Living and Dying in Georgian London’s Lying-In Hospitals

This article uses previously untapped archival sources to revise the dominant, negative view of London’s eighteenth-century maternity hospitals, by reconstructing daily life at the British Lying-in Hospital. Though the hospital in fact helped to support women’s work as midwives, its institutional practices altered the experience of childbirth both negatively and positively, which inspired rumors, criticism, and inflammatory published attacks. The article illuminates how two unrecognized events in 1751—the hospital’s first epidemiological crisis, and the arrival of a new man-midwife who used instruments—may have become intertwined in the public imagination and helped to shape the terrible reputation of lying-in hospitals, despite their overall positive eighteenthcentury record.

Naturally, the mid-eighteenth-century founders and their charitable supporters and early historians emphasized the humane and superior care that these institutions offered. 2 Yet detractors have charged otherwise, beginning with the eminent physician and professor of anatomy Frank Nicholls, whose anonymous, semisatirical Petition of the Unborn Babes (December 1751) claimed "that one in Fifteen of all the Children . . . born" at the British Lying-in Hospital "are drag'd dead into the World," while "it is reserved a Secret how many more of the Fifteen die soon after of the Wounds and Bruises there received, as also how many of the Mothers remain alive, after passing through such Experiments, as are there try'd on miserable Mortals." 3 Not surprisingly, the Petition's dramatic claims inflamed the hospital's board of governors, who placed advertisements defending their institution's record and its place in boosting the British national population. 4 But the self-defense failed to prevent Nicholls's original imputation of hospital men-midwives' brutality from echoing through 250 years of discussions about the hospitals and the rise of professional male obstetrics-or "man-midwifery," as it was then known. 5 Because the lying-in hospitals appeared to offer clinical advantages to the rising cadre of menmidwives, female midwives and their defenders have long viewed these institutions as contributing to a broader male medical campaign to destroy the autonomy and prestige that early modern midwives once enjoyed. Some present-day critics, including Margaret Connor Versluysen in a seminal 1981 article, have argued that these were primarily patriarchal institutions that not only undermined female practitioners but also wrested the control of birth from the mothers. 6 While Nicholls and others since then have characterized the lying-in hospitals as helping to marginalize or subordinate female midwives, they have also condemned these institutions for their mortality rates, a charge that has stuck through the centuries. Even such modern medical historians as Roy Porter and Irvine Loudon, who have rehabilitated the reputation of leading Georgian obstetricians, have dismissed Georgian maternity hospitals as havens of disease and death. 7  described lying-in hospitals as consistently less safe than birth in women's own homes, presumably because of endemic and epidemic levels of deadly "puerperal fever," the devastating postpartum cluster of symptoms now understood to result from Streptococcus pyogenes. Though nineteenth-century hospitals indeed had appalling mortality rates, such as La Maternité in Paris with a death rate of 18 percent in the early 1860s, 8 it remains contended how much deadlier eighteenth-century hospital births were compared to home deliveries. Loudon has argued that the lying-in hospitals significantly increased new mothers' likelihood of dying in childbirth, but he bases his study on the period after 1770, especially during the nineteenth century, when hospital mortality rates were at a far higher level than in the eighteenth century. Epidemiological sleuthing by Margaret DeLacy has shown quite contrarily that in the eighteenth century, "hospital epidemics of puerperal fever were in fact unusual events in Britain and did not account for a large number of deaths," in large part because Georgian disease theory, compared to that of the Victorians, promoted more hygienic practices that reduced some bacterial transmission. 9 Statistically, according to DeLacy, eighteenth-century women fared reasonably well in Georgian maternity hospitals: even though these institutions, with a 3.3 percent mortality rate between 1751 and 1755, had death rates nearly three times as high as the citywide average of 1.3, during other intervals-say, between 1756 and 1759-the hospitals' rate at 1.26 percent compared favorably with the metropolitan rate of 1.30. 10 Historians of both midwifery and epidemiology have built their arguments by relying solely on published materials, but these sources are severely limited, especially when we wish to evaluate what the level of care actually was and whether hospital practice subordinated female midwives and diminished women's control over their reproductive experiences. To analyze these problems I have, almost uniquely, 11  surviving archival records-particularly those of the British Lying-in Hospital, the largest and most successful of London's five philanthropic maternity facilities. The surviving archival sources of weekly minutes, the quarterly governors' courts, patient registers, and even receipts from merchants and plumbers at the British Lying-in Hospital reveal daily life in astounding detail: every pound of mutton and yard of diaper cloth purchased, every pipe cracked and repaired, whether windows were kept open or shut, the names of every employee hired and every mother and child supported by the institution, and sometimes detailed descriptions of many of the 138 eighteenth-century women who trained at this hospital as midwives. The material details of this particular philanthropyadmittedly the most financially solvent of London's five maternity institutions-reveal wards filled with clocks, books, bibles, birth chairs, mirrors, dressing gowns, feather beds, coals, candles, and baby clothes, and a bustling program in training women to carry on the business of midwifery.
On the one hand, these archival sources revise the entirely negative evaluations of Georgian maternity hospitals. The minutes' discussion of the matron's powerful role and the female midwifery students' qualifications challenge any sweeping conclusions that this hospital contributed to a professional marginalization of Georgian midwives. The abundance of food, clean linens, and concern about making mothers and babies comfortable also contradicts modern assumptions about these hospitals' having been mean and harsh. By the material standards of the patient population-generally categorized as "the respectable working poor"these were rich and comfortable institutions in which to give birth and lie in for a month. On the other hand, however, the debates over ventilation, problems with a copper pot in the kitchen, and the issue of whether hospital staff and pupils could have visitors obliquely point to tensions otherwise hushed up as this very new institution and its men-midwives attempted to establish themselves on the London scene. 12 By pressing into service the most mundane of archival and institutional recordsincluding shopping lists recorded in the minutes, rumors on the street, accusations in pamphlets, and advertisements in the press-I have been able to gauge the tension between what actually happened and what was believed to happen in London's Georgian lying-in hospitals.
A reconstruction of life on the wards shows how the British Lying-in Hospital faced a crisis beginning in July 1751 that resulted in the death of negative appraisal of eighteenth-century hospitals and obstetrics: see Evenden, Midwives (n. 6), esp. pp. 193, 195, 197, 199. 12 eight mothers and ten newborns by the time Nicholls published the Petition in December. While Nicholls and, more recently, the historian of seventeenth-century midwifery Doreen Evenden have charged that hospital mortality was generally due to surgical instruments or male doctors' "bungled deliveries," 13 the archival record challenges these assertions. First, the neonatal mortality rate that Nicholls attacked in 1751 of "one in fifteen," or 6.6 percent, was actually significantly lower than what the Cambridge School of demographers have recently estimated as the metropolitan neonatal death rate of about 10 percent in mid-century London. 14 Second, the archival records clarify that maternal deaths at the British Lying-in Hospital did not result from instruments, but from the necessarily crowded conditions that amplified and accelerated the spread of disease on the wards. Neither Nicholls nor his contemporaries could see what was "really" happening in 1751-but we can, when we collate and compare the various contemporaneous printed and archival documents. No one source can reveal the story in full, but as a collection they show exactly how material, institutional, philanthropic, and medical practices converged to create a new epidemiological and cultural landscape of birth, which Georgians attempted to decipher. From a modern cultural historian's perspective, the critics' specter of brutal men-midwives might be seen rather as a metaphor to capture what Georgians could not yet see: that mothers died because of invisible infectious agents, not because of forceps wielded by misogynistic men-midwives. 15 Women's Roles at the British Lying-in Hospital Though proponents of the lying-in hospitals always emphasized Christian benevolence as their primary motivation, and a desire to improve the British population as a close second, 16  cism, arguing that these institutions were designed to annex pregnant poor bodies for doctors and their students. 17 That may have been true with the Middlesex Lying-in Ward, founded in 1747 by hospital doctors clearly interested in learning the craft of midwifery as they established themselves as elite accoucheurs in the capital. 18 But the British Lying-in Hospital rarely relied upon its doctors to deliver infants, nor did it ever admit a male student before 1830-making the presumed connection between the rising power of eighteenth-century men-midwives and the establishment of lying-in hospitals more nuanced than generally assumed. Nor did these institutions downgrade the status of female midwives nearly as much as is generally argued. In fact, as this article will suggest, it is not even clear that an eighteenth-century institutional birth "medicalized" the experience of birth or ruptured all the traditional customs surrounding pregnancy and lying-in, as some historians have argued. In truth, the eighteenth-century lying-in experience varied between hospitals, and the picture I draw here is admittedly of the hospital perhaps least concerned with replacing female midwives with male practitioners.
Two anonymous, very detailed diaries covering the period 1751 to 1754 at the British Lying-in Hospital provide the earliest glimpse of what exactly hospital men-midwives did in the 1750s, and this source, combined with the hospital minutes and patient registers, contradicts some contemporary and historical assumptions that male doctors used the lying-in hospitals to keep midwifery out of women's control. The physician author-whose identity will become apparent later in this articlerecords how he easily spent two or more hours on the wards whenever medical complications arose, visiting patients and ill staff, and prescribing medications. His several hundred entries describe postpartum complications, for which he ordered medications, rest, compresses, or certain diets. 19 Neither he nor William Hunter or the other medical men at the British Lying-in Hospital delivered babies in routine cases, although they helped the matron and nurses in difficult deliveries and took over in rare cases of extremely complicated, lengthy labors. In his practice at the British Lying-in Hospital, this doctor managed only five births between July 1751 and September 1754. This comports with the estimates made by the hospital secretary in January 1752: medical men delivered only somewhere between 14 and 18 of the first 545 infants born at the British Lying-in Hospital. 20 This pattern of men handling only emergencies was followed at all the other London maternity facilities-even the Middlesex doctors, who had originally attended all of their hospital patients' births, appointed a female matron in October 1752 and shifted toward managing only the difficult deliveries. 21 It was women, then, who performed the grueling labor of delivering some forty infants a month and caring for them and their mothers day and night at the British Lying-in Hospital. By 1752, each of London's lying-in facilities relied on two experienced and highly recommended midwives who served as matron and assistant matron. In addition to delivering babies and caring for mothers in their reproductive needs, the matrons ran all day-to-day affairs in the hospital, including managing the nurses and other staff, the storerooms, and the linen-the latter an allconsuming task for them and all the female employees, and sometimes for the patients. Reading the often matter-of-fact references in the minutes to the matrons' unrelenting activities attending births, supervising the kitchen, purchasing fabric, and making the linens and baby-clothes helps to buttress the suspicions of Versluysen, Evenden, and others that these hospitals exploited women's labor.
The matron and her assistant delivered between thirty and forty babies a month in 1751, an enormous and probably exhausting caseload. The minutes do not mention whether the board members considered hiring more midwives permanently, but perhaps they viewed additional salaried employees as a luxury at an institution that survived solely through small, private donations. The board ultimately developed a solution to expand the hospital's workforce and its treasury by establishing a training program in female midwifery in the spring of 1752, for which female pupils paid the substantial sum of about thirty-five pounds. 22 20. The secretary stated that the matron and her assistant "deliver the Women in all Natural Labours, and the Men-Midwives are called in where these cannot deliver them, or where there is any appearance of Danger, which does not happen on the whole above once in thirty or forty Cases; so that the Midwifery Business of this Hospital is certainly as much in the Hands of Women Midwives as it can or ought to be" (BLHM, H14/BLI/A1/1, 23 January 1752).
21. Croxson, "Foundation" (n. 11), p. 37. 22. The students' fees included both the twenty guineas paid to the man-midwifery staff for instruction and 10s. paid "per week to the Treasurer for . . . Board and Lodging, Exclusive of Tea, Sugar & washing" (BLHM, H14/BLI/A1/1, 27 August 1752). Both the The rigorous six-month residential stay included assisting the matron to deliver babies and hearing lectures by the staff doctors, who provided the students with models, plaster casts, books, and anatomical illustrations. 23 In 1767, when Mrs. Oakes retired after fifteen years as matron, she "made a present to this Charity of Dr. Smelly's Book of Plates on Midwifery" for the students to use-suggesting that at this hospital, at least, both midwives and male practitioners found medical anatomy useful in their work as birth attendants. 24 What role did the British Lying-in Hospital have in the status of eighteenth-century midwives? Many historians who have proved that in the seventeenth century English midwives were widely respected, literate, and from upper middling and professional households, have argued that this profile changed negatively in the eighteenth century as Georgian men-midwives, especially through the lying-in hospitals, colluded to marginalize midwives. 25 It is widely assumed that by 1800, female practitioners attended only the poor and were themselves from the lower classes. 26 Midwives unquestionably lost ground against men-midwives in the second half of the eighteenth century among an elite clientele, 27 and increasingly found themselves the employees of parishes and outpatient Middlesex Lying-in Wards and the City of London Lying-in Hospital established their programs in 1758; for the City of London, see the notice in the London Chronicle, 10-12 August 1758, p. 138; Croxson, "Foundation" (n. 11), p. 37 charities. 28 Yet the pool of women who came to the British Lying-in Hospital to train as midwives from 1752 forward suggests that midwifery nonetheless remained a lucrative field, attracting highly qualified and financially secure women. While this particular training program may be unrepresentative in attracting a financially affluent and socially sophisticated student population because of the high cost of its tuition, even the smaller pools of women who applied for the job of matron at the British Lying-in Hospital in 1749, 1750, and 1752 show that London's eighteenthcentury midwives were extremely capable and experienced practitioners. 29 The hospital minutes usually recorded the age, marital status, location, and husband's occupation of each of the 186 female students who arrived at the British Lying-in Hospital between 1752 and 1820. The average age for the pool of 138 women who trained between 1752 and 1800, was 34.7 years, with only three women over the age of 50. Thirty-six were widows (28 percent of the 129 whose marital status is recorded), who were on average 37.5 years old. That is, these were women at the prime of life-probably healthy, and likely mothers themselves, but none of them elderly or infirm. Three women of the total pool of eighteenthcentury women were identified as spinsters, but these single women were 28. Stanley A. Seligman, "The Royal Maternity Charity: The First Hundred Years," Med. Hist., 1980, 24: 403-18. I am grateful to archivist Pat Want for allowing me access to the minutes and records of the Royal Maternity Charity, which are now at the Royal College of Obstetricians and Gynaecologists, London. The society paid female midwives only 1s. 6d. per out-patient delivery, compared to the typical 5s. and more that local magistrates had customarily paid to midwives to deliver destitute women in the parish in the seventeenth and eighteenth centuries. For a typical parish example with several disbursements, see Accompt of Disbursements, on Behalf of the Overseers of the Parish, . . . St. Martin in the Fields, London, 1688-1689, Add. MS 44934, British Library Manuscripts, London. By the end of the eighteenth century, some parishes moved toward paying a parish midwife an annual salary, no matter how many babies were born. For instance, the vestry of St. George Bloomsbury paid one midwife £20 a year by the 1770s; but in an especially busy year in which she delivered 108 infants she was given an additional five guineas gratuity, suggesting that the parish assumed she should earn around 5s. per delivery: St. George Bloomsbury Vestry Minutes, P/GB/M/1 (1730-1828), 25 June 1787, Local Studies and Archives, Holborn Library, London.
29. The names of pupils and candidates for the position of matron, plus details about their ages, marital status, geographical background, and husbands' names and occupations, are noted throughout the BLHM. The program continued into the nineteenth century, but beginning in the 1820s the hospital accepted women to train as not only midwives, but also monthly nurses. This development raises questions about the nineteenth-century status of female health practitioners beyond the parameters of this article. Data on London's eighteenth-century midwives at the British Lying-in Hospital, the Royal Maternity Charity, and elsewhere are available through my Webpage: http://hist .claremontmckenna.edu/lcody. only accepted as pupils from the 1780s forward when the hospital no longer saw this as an impediment to becoming a midwife. 30 To afford the hospital's high tuition, the pupils necessarily either came from economically solid households or had well-off sponsors. Over onethird of the women's husbands who were identified were occupied as professionals, merchants, farmers, or skilled craftsmen, such as jewelers. Thirteen women had husbands who were either surgeons or apothecaries, and one woman, Ann Yewd, was the wife of the secretary for the lying-in hospital in the 1760s. The hospital board acknowledged that their pupils were of higher status than the patients and lower-level staff by making the program as comfortable as possible with separate, well-furnished quarters, and by seating them at the steward's table for meals. Equally significant was the number of women whose husbands were servants or soldiers: thirty-five pounds, ten times the annual wages of typical domestic female servants, 31 was an enormous sum, but one that clearly must have been viewed as a good investment with excellent returns. Although such interpretations are inferential, this suggests that midwifery remained a lucrative female profession into at least the early nineteenth century.
What impressions did these midwifery pupils have of their time in the hospital? Jane Wright, a former pupil at the hospital and wife of a London wine-merchant, published a small midwifery pamphlet in 1798 in which she thanked "the physicians and surgeons of the British Lying-in Hospital . . . to whom, for their goodness and able instructions, I shall always feel the sincerest obligations; and to the intelligent matrons of that useful charity, I also offer my honest acknowledgements." 32 Such encomia no doubt helped Wright win her post as the matron of the Westminster Lying-in Hospital in 1805. 33 Though her praise should be read cautiously, her perspective counters that of the better-known criticisms by such contemporaries as Elizabeth Nihell, whose 1760 Treatise on the Art of 30. In 1773, an unnamed woman "of a proper age and of good character and well recommended but not . . . married . . . or [a] widow" was rejected after two weeks of discussion: BLHM, H14/BLI/A1/3, 21, 28 May 1773; but after the 1780s, "spinsters" did not generate comment in the minutes. Between 1800 and 1820, at least six more single women were accepted out of a pool of forty-five. 31 Midwifery has been used to show that all midwives were professionally marginalized by the hospitals and by the men-midwives who ran them. 34 Bronwyn Croxson has argued that procedures at the lying-in hospitals established a hierarchical divide between midwives who were allowed to manage only routine deliveries, and doctors who handled all the difficult labors. 35 However, the number of times that doctors actually were called to help deliver women in the first years at the British Lying-in Hospital was far below the rate of "difficult births," according to both contemporary and modern sources. William Smellie estimated from his practice in London in the 1740s, for instance, that almost 8 in 100 deliveries required more than routine assistance, and Robert Bland estimated that 5.5 percent of London births among the poor between 1774 and 1781 were "laborious," difficult, or dangerous. 36 Yet the evidence from the archives indicates that doctors at the British Lying-in Hospital did not attend hospital deliveries nearly so frequently, and that they actually arrived late in very long labors. If the rate of difficult deliveries was between 5 and 8 percent, and if it is assumed that the hospital doctors would be called to attend all difficult deliveries, it would be statistically anomalous for the hospital's men-midwives to have attended only between 14 and 18 deliveries out of 545. Given that the doctors claimed not to have attended even twenty births, then, it appears likely that the matron, her assistant, and her students managed about half of the difficult deliveries at the British Lying-in Hospital themselves, and successfully so, without inspiring any negative remarks in the hospital minutes about their midwifery skills.
Some historians have claimed that the teaching programs at these eighteenth-century lying-in hospitals benefited male students. The archival evidence shows that this is false for three of the five early lying-in institutions, and probably not true for the other two. The British and City of London Lying-in Hospitals clearly prohibited male pupils from entering their wards until 1830, and the Middlesex wards, which survived until 34 1786, never allowed male students. 37 The spokespersons from the General Lying-in Hospital also advertised that men, other than staff doctors and clergymen, were banned from the wards 38 -yet this was apparently not exactly true, because in his advertisements for his lectures as a manmidwife, Felix MacDonough promised to offer "frequent Opportunities of feeling and performing real Labours at the Lying-Inn Hospital, German-street, where his Pupils are privileg'd to attend on all such Occasions." 39 Similarly, the Westminster's weekly minutes recorded barring male pupils until 1815 40 -but as early as the 1770s, John Leake, the founding man-midwife, advertised that male students would have access to hospital patients. 41 MacDonough's and Leake's hospitals were the only two of five facilities to accept single mothers and place them in separate wards from the 1770s onward, and perhaps it was these unmarried women who were exposed to pupils of both sexes, while married women were protected from all "Persons of the Male-Sex." 42 In addition to supporting women as midwives, institutional practices at the British Lying-in Hospital also surprisingly helped to preserve many of the traditional, communal features of birth and lying-in that promoted female bonding and authority. First, in its stringent regulations prohibiting men's presence on the wards, the hospital preserved the customary notion that delivery and recovery should occur in segregated, female spaces. 43 Indeed, compared to their own crowded and cramped homes that afforded little privacy, even during childbirth, 44 patients may have found the most notable aspect of the hospital stay to be its exclusion of men and children. Though female relations apparently could visit mothers on the wards, the hospitals decreed that despite "the Affection of Husbands" and "the curiousity of Particular Persons" no men could do so. 45 Husbands and male relatives could, however, see the new mothers in the downstairs hallway, but only between three and seven o'clock during the summer and between two and four o'clock in the winter. 46 For most of the hours of the day, then, patients would see only each other and the female staff.
Close relationships developed between the female employees and the mothers, apparently so frequently that the British Lying-in Hospital board passed a rule banning former patients from visiting nurses on duty. 47 Though this rule highlights the board's frustration with those relationships, the need to prohibit suggests the frequency with which female bonds were forged during the hospital stay. According to the comments of a man-midwife at the City of London Lying-in Hospital, the enclosed hospital ward produced close-knit conviviality, even during delivery itself. At a 1769 City of London board meeting, Dr. Hulme proposed that beds with casters should be made for the purpose of removing women in labor to separate delivery rooms when they were "seized with Fits or Madness . . . or in difficult Labours where the Woman is obliged to be delivered by Instruments or when [she] is attacked with a raging fever or the like"; he admitted, however, that this might not be necessary, because despite the "Cries of those in Labour," "the good women do not mind much the Noise of their Fellow Sufferers in Labour as they know it is in general soon over and as soon forgotten." 48 He noted, too, that "sometimes there is more Merriment at a Labour than at a Feast," which indicates how little eighteenth-century men-midwives perceived the lying-in hospitals as altering the customary female celebration of birth. 49 Reading hospital minutes helps to illuminate how, paradoxically, an institutional lying-in experience ultimately closely resembled the early modern ideal of birth occurring in a distinctive space segregated from 44 males and the obligations of household routines. Elite women had long created such recuperative and supportive experiences for themselves through the support of female relatives, paid midwives, and lying-in nurses, but this ideal would have been out of reach for many poor women-unless they gave birth in one of these new hospitals.
Living in the Lying-In Hospitals The abundance of women and the exclusion of men from the lying-in wards were not the only novel features of these new institutions. The mothers who won places in these hospitals would have found them to be materially rich places. Each woman theoretically had her own freshly made bed (though in fact there were often fewer beds than mothers, which led to occasional doubling up). 50 At the British Lying-in Hospital, mothers were given petticoats and gowns during their stay, and their infants received "two clean dresses per week . . . on Sundays and Thursdays," a rare luxury for the poor. 51 The doctors had "wrapping Gowns" and "easy chairs" made for use during delivery. 52 The hospitals offered women the traditional postlabor fortified caudle, gruel, and muttonbroth, but for most of their lying-in they were offered meat, cheese, milk, porridge, plain caudles, bread, and "a pint of strong Beer a day"-a varied and wholesome diet that exceeded the standards of many poor Georgians who rarely could afford meat other than fat bacon. 53 While enjoying the material pleasures of essentially a middle-class lying-in, the patients were also expected to comport themselves like middling and elite mothers. Not only were board members aghast that these impoverished women and their visitors stole "several small articles of linnen" at the British Lying-in Hospital, 54 and sometimes stole from each other, 55 they were surprised that these new mothers wanted to hasten the lying-in period and even leave their babies behind in the hospital while they went out on "business." The boards passed several rules restraining new mothers from leaving the wards during the lying-in period, 56 but they also corrected what seemed to be their obvious spiritual, moral, and parental deficiencies through sermons, demonstrations, and special pamphlets. Because Dr. Underwood, a hospital man-midwife and specialist in children's care, described the "Women of the Class usually admitted into this Hospital [as] having very improper ideas of the management of infant Children," the board decided in 1787 to write a parenting pamphlet and print 1,500 copies for immediate distribution. 57 While historians have focused on elite mothers' preference for the use of wet-nurses over breast-feeding their own children, Georgian doctors also found this to be a problem with women of the urban working poor, whose occupations sometimes prevented them from being able to both nurse and continue working. To discourage the hospitals' new mothers from relying on "dry-nursing" or sending their newborns out to nurse, staff men-midwives mandated that they hold and sleep with their infants, and breast-feed them as well. 58 They even attempted to link the hospital patients to more-affluent new mothers searching for wet-nurses, an arrangement that provided the patients with some income and guaranteed that they would breast-feed their own children. 59 Hospital spokesmen always emphasized their institutions' abilities to improve the poor spiritually. Mothers had access to religious materials, although whether they wanted to read The Great Importance of Religious Life or the Bishop of London's Serious Advice is entirely another question. The board and benefactors brought women and newborns into the Anglican fold through providing elaborate public christenings, placing bibles in the wards, and locating dependable ministers to give weekly sermons on the wards. Perhaps surprisingly to modern observers, these activities preoccupied the board and governors in the eighteenth century as much as any procedures related to pregnancy or child delivery. 60 Such an emphasis on spiritual matters actually provided a powerful point of continuity with old birth and lying-in customs and with the traditional role of female midwives in the home, who in early years had been respected not just for their obstetric skill, but also for their piety and ability to baptize dying babies in emergencies. 61 What was new about the hospitals' policies regarding religion, however, was their imposition of high-church Anglican conformity. The some 13 percent of the first five 57 Catholic and Nonconformist mothers may have felt the conflict between the religious demands of the lying-in hospitals and their own spiritual beliefs more acutely than other women did, but all of the mothers, no matter what their faith, confronted additional new, bureaucratic expectations. Waking, sleeping, and eating were dictated by the clock and the house rules posted in each ward. The nearly five hundred hours that a typical woman spent at these hospitals were also deliberately committed to moral, spiritual, and cultural improvement, with hospital rules prohibiting the drinking of tea, 64 swearing, playing "Cards, Dice . . . smoak [ing] in their Wards," and drinking gin. 65 Mobility was highly limited: the women were banned from visiting fellow patients in other wards, and they needed special permission to leave the hospital. 66 When patients "misbehaved," the matron watched and warned them; Mary Perry, for example, shaped up within a week and "behaved very well" once the matron had complained about her to the board in 1760. 67 If all of these rules seemed exercises in "social control," as some critics have charged, they did not prevent impoverished women from seeking admission, always in numbers greater than could ever be accepted. 68 68. A few desperate women lied that they were married, procured blank recommendations, or even cheated during the weekly lottery for admission; see BLHM, H14/BLI/A1/1, 2 May 1751; H14/BLI/A1/2, 25 January 1765; 10 December 1767. Bronwyn Croxson has tabulated the numbers of women who applied for but could not gain admission at the British Lying-in Hospital beginning in 1768, when the Middlesex Lying-in Ward no longer took pregnant women on an in-patient basis; that number ranged from 144 to 871 mothers Discontents The hospitals were always financially precarious institutions, and subsequently the boards did what they could to guarantee as good a public reputation as possible. Bureaucratic rituals, such as the moment at which patients were required to "give thanks" before exiting, were designed not simply to enforce polite behavior, but also to elicit complaints: after mothers gave thanks, the board quizzed them about their stays. Patients' disappointment over rancid caudle, bedbugs, and neglect by the female staff led to immediate investigations and remedies, including firing negligent staff found to be guilty or, on the other hand, prohibiting the complainant from receiving future charity if her charges were discovered to be exaggerated or false. 69 One woman's anger with two nurses' "disregard and want of Tenderness," for instance, led to a six-hour-long discussion during a regular Thursday board meeting and required an additional Saturday meeting to resolve; it ultimately resulted in the nurses' dismissal. 70 The board members surely were concerned about the welfare of the mothers and newborns, but they appeared especially solicitous when patients' disappointment or aggravation might lead to gossip beyond the hospital walls. 71 In fact, patients sometimes complained to their recommenders, who periodically wrote anxious letters inquiring about stories they had heard. Some especially dramatic reports traveled further, even appearing in city newspapers and in texts hostile to man-midwifery. 72   Another story told how a heartless man-midwife grew angry that a new mother had asked for additional servings of caudle, slapped her, and then threw her and her newborn out of an unidentified hospital at "nine o'clock at night, and the sixth day of her delivery," which led to their catching cold and the child's dying. 74 Before such stories, whether true or false, could reach the public, the British Lying-in board tried to quell discontent by reprimanding patients, employees, and even visitors for having "spake disrespectfully of the charity." 75 When Susanna Rackford, a cook-maid whom the matron fired, returned one night at eleven and "came to the door of the hospital, and beat upon it in a violent Manner, so as to alarm the Neighbourhood and greatly disturb the Patients," the board decided to prosecute her in court. 76 Even the mere possibility of negative comments warranted action. The City of London board decided that Mary Watson could not be admitted for any future pregnancies because she had "go[ne] out of this House before the time prescribed, which might have proved detrimental to her health, and thereby brought an Odium to this Hospital." 77 Once the stories circulated through the city or appeared in the press, the hospital boards published self-defenses, as in their response to Nicholls's pamphlet. 78 The General Lying-in Hospital, which was perpetually assaulted for accepting unmarried mothers, defended itself in the press that unspecified rumors traveling through the city in 1766 were "all absolutely false, malevolent, and utterly groundless, founded in the deepest Malice, and wickedly calculated and set on foot by some evil- Despite negative gossip, the lying-in hospital boards had no reason to fear repelling potential patients-their numbers always surpassed the available spaces-but their more material concern was to guarantee a steady stream of charitable revenue to support these expensive enterprises. These foundations lacked adequate donors to support the patient population, whose stays at the British Lying-in Hospital, for example, cost £4.10 per typical lying-in patient. 80 The British Lying-in board almost immediately recognized that their costs were nearly double their revenue, for each governor or governess gave £3.3 annually but was permitted to recommend two patients per year. Because subscribers' fees could not pay the bills, the hospitals tried to appeal to a broader public who would attend charitable benefit nights at the opera, or even give large benefactions. To that end, the lying-in hospital boards often inserted notices advertising the great numbers of babies they contributed to the nation, and established annual sermons and published various pamphlets to assure the public of their good work. To guarantee that current benefactors would continue to support the hospital, the secretary wrote letters to governors, assuring them that all was well, despite rumors surrounding the death of infants or angry testimonials from former patients about nurses' negligence or noisy squabbles between doctors who wished to win elections to the hospital staff. 81 These complaints particularly preoccupied governors and the board in the autumn of 1751, in the months preceding the appearance of Frank Nicholls's Petition of the Unborn Babes in December. In September the hospital's most illustrious patron, the Duke of Portland, wrote the board, demanding an explanation for the "many Complaints made about the Ill management and Neglect of the Patients therein"; he also criticized the outcome of an election to choose one of the hospital physicians that summer, arguing that had they appointed his particular candidate the institution would "avoid Publick Censure which will certainly be the ruin of the Hospital." 82 The board stood by the results of the election, but the debate over George Macaulay, the physician man-midwife who won, and Dr. Trotter, who lost, had far-reaching ramifications that may have even led Frank Nicholls to involve himself in the politics of the British Lying-in Hospital.

Frank Nicholls and the Rise of Man-Midwifery
When The Petition of the Unborn Babes anonymously appeared in late 1751, its author was not a great mystery. Indeed, Frank Nicholls himself hinted as much in a later deposition at King's Bench in which he proudly recounted his ongoing campaign against man-midwifery, including boasting about having goaded the accoucheur Dr. Robert Nesbitt into hitting him with his cane by calling him names one evening at the Royal College of Physicians. 83 Even the reviewers in the press immediately recognized the Petition as one of several salvos in the notorious dispute between Nesbitt and Nicholls. 84 London's men-midwives, including William Hunter, also quickly identified him as the author of this and other antiobstetrical pamphlets, and it was said that Mrs. Kennon, the royal midwife who delivered the future George III, gave Nicholls £500 "when she lay upon her death-bed" in 1755 in gratitude for his attack on male practitioners. 85 While Nicholls won for himself thanks from Georgian midwives and twentieth-century historians of gender, he was no feminist. Nor was he even particularly appreciative of midwives' skills: he argued in a 1753 deposition that though childbirth was a natural, not pathological, condition, contemporary midwives required additional instruction, which the Royal Society of Physicians should control by appointing an eminent lecturer-perhaps Nicholls himself-to edify female practitioners. 86 (In other words, Nicholls's goals resembled the much-maligned and unsuccessful attempts of the seventeenth-century Chamberlen family of doctors and inventors of the obstetrical forceps to regulate London's midwives through the Royal College of Physicians.) 87 Nicholls viewed the new eighteenth-century specialization of manmidwifery as an invented, interloping field, and he treated the British Lying-in Hospital as helping to establish a new era of reproductive care. He was right to see an obstetric watershed at mid-century, for male 83 practitioners had indeed extended their reach beyond emergency deliveries by 1750 to include serving a growing clientele of elite women who booked them in advance for normal deliveries. 88 This shift in gender relations was unfathomable to Nicholls, for he viewed men's entering a traditionally female occupation as tantamount to their "assum[ing] the Character and Discourse of Old Women"-unless, of course, they masqueraded themselves so that they could seduce their pregnant clients. 89 Nicholls described man-midwifery as a categorically impossible, even disgusting occupation: it was simply "a Kind of Excrescence that had grown out of the Midwives," and "no more considered . . . a profession than Kennel Rakers." 90 Nicholls also was unable to shed the long-standing assumption that any medical man who attended childbirth necessarily relied upon deadly surgical tools. His Petition of the Unborn Babes appeared only days after the first appearance of William Smellie's Treatise on the Practice of Midwifery, 91 which Nicholls described as offering "express directions . . . to cut and twist off the arms of Children, and to lessen their heads (which cannot be done without extracting or squeezing out the brain)" 92 -but he did not mention or even directly allude to either Smellie or his work in the Petition. Instead, the focus of his attack was on specific other London practitioners and, in one very long sentence, the infant mortality rate at the British Lying-in Hospital; he had learned of the latter through the hospital's own publications that proudly announced their success rate but also happened to describe one-fifteenth of the infants born there as dying.
When the hospital board met in January 1752 to discuss Nicholls's pamphlet, members denounced him for having not examined the hospital registers and minutes. Nicholls's vivid imagery of "Hooks, Pincers, and other bloody Instruments" 93 seemed a gross mischaracterization to the board: these tools symbolized the surgical violence of the emergency male surgeon, but men-midwives at the lying-in hospitals explicitly em- phasized how they very rarely needed to use them. 94 As the British Lyingin Hospital secretary stated in a January 1752 advertisement responding to Nicholls's accusations: "Instruments capable of hurting have been used but twice," and then only in stillborn cases. 95 While the rhetoric in The Petition of the Unborn Babes evoked every imaginable violent obstetrical instrument, the phrase "one in fifteen . . . are drag'd dead into the world" hinted at a newer, far more controversial tool of the men-midwives: the obstetrical forceps. 96 Smellie, usually considered the most enthusiastic proponent of forceps, stated in his Treatise that only one in a hundred births required forceps or some other instrument 97 -an estimate that contrasts dramatically with Nicholls's impression of the text. No eighteenth-century man-midwife, including Smellie, ever entered into print the argument that forceps should replace a natural delivery, 98 but Nicholls could not transcend the assumption that men attended births only when their surgical tools were required-or, if they were not required, that they would use them anyway. Like many other critics of male practitioners, including midwife Elizabeth Nihell, 99 he conflated men-midwives with the instruments that emergency surgeons had used to kill the fetus in utero in order to save the life of the mother, and he thereby suggested that all the infant deaths at the British Lying-in Hospital were entirely attributable to men's surgical interventions.
Nicholls's charge that the British Lying-in Hospital doctors practiced barbaric instrumental and forceps deliveries would appear to be a red  Another piece of evidence points to Macaulay as one of Nicholls's targets. In the Petition, Nicholls derided certain London men-midwives, whom he nicknamed "Barebones," "Pocus," and "Maulus." Adrian Wilson has identified Barebones as John Bamber, who used the vectis (an obstetrical tool akin to the forceps), and Pocus as Robert Nesbitt, the man-midwife with whom Nicholls brawled and whom he ultimately took to King's Bench for battery. Maulus, however, has remained a mystery among medical historians, not least because the contemporary manuscript keys to the pamphlet's pseudonyms do not decipher this nickname. Wilson and others have proposed Dr. Morley, 102 a London manmidwife sued for professional incompetence when he neglected a private patient two years later, and who was the defendant in an adultery case in the 1740s for apparently seducing one of his pregnant patients. 103 Yet whether Morley was a forceps practitioner is unknown, and he was not connected to the lying-in hospitals.
Perhaps the more likely candidate for "Dr. Maule" is instead George Macaulay, a Scottish physician with a 1739 Padua M.D., and an estab- was extremely fierce and bitter, with attacks against Macaulay from the other candidate's supporters continuing for many months. 105 The most important reason why Macaulay may have been Nicholls's target was that he used obstetrical instruments, including forceps, and their usage seems to have caused conflict with at least one other hospital doctor, Francis Sandys.
From the evidence in his diary, Macaulay seems to have been reluctant to use the instruments and avoided doing so for many hours when he attended complicated deliveries at the hospital. 106 While both Adrian Wilson and Bronwyn Croxson have characterized many Georgian menmidwives, especially at the lying-in hospitals, as not deviating from specific techniques and tools, Macaulay defies this trend: he was an obstetrical polyglot, willing to try the manual techniques of the Deventerian school, the vectis of the Bamber camp, Smellie's forceps, and even complete nonintervention as advocated by William Hunter. In one delivery with the baby's jaw caught on the pelvis, for example, Macaulay first tried "pushing back the Ox Coccyes," the method promoted by the Dutchman Hendrick Deventer and men-midwives opposed to forceps deliveries; when this stalled, he tried other manual maneuvers, but these too failed to progress the birth, and he finally turned to the forceps to deliver a living child seemingly with no pain to the mother: "The Woman recovered without any bad Symptoms and the child is very well," he noted. 107 But he added a nota bene in September 1759: "I am now of opinion that this Woman wou'd have been delivered with out the use of the Forceps; only by waiting and assisting with the hand in her pains." 108 In another difficult delivery involving the use of a "blunt hook," Macaulay and Sandys delivered a living child who survived; yet he added later, in 1759: "I am inclined to think from the many Cases I have seen since that time that this Woman would have been delivered without any such operation as was put in practice," and he also noted that "Dr. Sandys has misrepresented what I mentioned in this case about a hook in a M.S. Note in one of his Books," revealing how divided hospital men-midwives were in their obstetric techniques and opinions. 109 No record survives of the dozen births that doctors other than Macaulay attended at the hospital before 1752, but three out of Macaulay's four deliveries were lengthy, complicated, and perhaps unusually painful (and loud). He resorted to instrumental interventions in the presence of other patients for the women were delivered on the wards, and the surrounding mothers could have easily reported later to the outside world what they had heard and seen of his work. None of these women or their infants delivered by Macaulay died while at the hospital, but other mothers and babies did: the archival evidence indicates that Macaulay and his instruments had little or nothing to do with this, but perhaps the surge in maternal death and illness at the hospital from his arrival in July 1751 onward was blamed on him by Nicholls and even by other governors at the hospital.

Living and Dying in 1751
Reading only the hospital's pamphlets and the weekly minutes of the British Lying-in Hospital would not reveal an exact reason why Nicholls blamed this particular hospital alone in his attack on man-midwifery. The few events that stand out include Sandys's attack on a nurse for having "the Blisters to be pulled off" of an unnamed patient who had "a Fever with dangerous Symptoms" and who later died. 110 In October 1751, the secretary noted that the board should inform governors when the patients whom they had recommended had died and created "a Vacancy in the hospital," so that the governors were "at Liberty to recommend another Patient whenever they shall think Proper." 111 The wards were soon overcrowded, forcing the board to lodge surplus patients in neighborhood homes and to place them in newly outfitted garrets. 112 Throughout 1751 the board attempted to eradicate bedbugs, to stop the chimneys from smoking, and to air the wards. 113 Though these were all slightly 110. BLHM, H14/BLI/A1/1, 3, 10 October 1751; BLHPR, patient # 396 (Grace Smith). Smith had a stillbirth, which correlated highly with maternal mortality and was obviously a more likely cause of her death than the nurse's pulling off of the blisters. See Audrey Eccles, "Obstetrics in the Seventeenth and Eighteenth Centuries and Its Implications for Maternal and Infant Mortality," Soc. Hist. Med. Bull., 1977, 20: 8-11 unusual events, the minutes do not register them as alarming the board members or medical staff.
Macaulay's diary and the patient registers, on the other hand, suggest that the hospital experienced a grave situation. Macaulay began his notes in July 1751 and wrote 143 pages through April 1752 (but only another 18 pages through January 1753), describing mothers' routine postpartum discomfort, his prescriptions, his examination of staff, the difficult deliveries he attended, and details regarding his Old Bailey testimony about one woman's death and autopsy, which showed she had died of "fever," not the wounds inflicted by her abusive husband. 114 Throughout, he tracked waves of disparate symptoms among patients and the female staff, including fevers and delirium, which suggest that the hospital was experiencing its first epidemiological crisis. The registers also reveal a cluster of three women dying in four weeks shortly before the board decided to start informing governors of patient deaths, and both Macaulay's diary and the patient registers show that overcrowding occurred because women were sick with fever and needed to stay longer than the former average of just under three weeks. 115 Several deaths occurred before Macaulay began describing symptoms in detail. The patient registers and minutes record that one woman died of a fever in June, three postpartum women died in late July and August, and another died of a fever in September, perhaps resulting from a stillborn delivery. Yet these deaths, and the likely symptoms of fevers and physical pain, generated little comment in Macaulay's notes until 18 October. That day, Deborah Reiser, nine days postpartum, was "taken with a shivering which was succeeded by a vomiting and purging which held her all night accompanyed with violent pains in her belly," which seems to have led Macaulay to begin taking much more detailed notes about many more patients than before. 116 On the same day, four other 114. In June 1752 Macaulay and another unnamed hospital doctor "opened" the body of Mary Atkinson (or Adkerson), who had died after complaining that "her husband had kicked her in the stomach and belly and that she was sure she shou'd never recover this Lyeing-In" ([Macaulay], Lying-in Hospital Book [n. 19], 16-21 June 1752, 1: 145-46; BLHPR, patient # 848). The husband, a soldier, was tried for willful murder at the Old Bailey, but was acquitted, perhaps because Macaulay's testimony led the jury to conclude "that she new mothers, including one who had given birth to twins, began complaining of headaches, chills, fevers, thirst, and severe pain in their genitals and abdomens, and some became delirious. As the days went by, other women manifested similar symptoms; and though most of them recovered, on 26 October 1751 Reiser "died early this morning, she was in a clammy sweat yesterday and delirious. . . . at about 2 o'clock this morning her sweat stopt. She was then outrageous for about 2 hours more, and very unmanageable but sensible. She died about nine." 117 On the 29th, another woman, Elizabeth Wright, died after manifesting similar symptoms, and on 5 November Macaulay wrote that Mrs. Jones, the assistant matron, was "taken yesterday with a shivering vomiting and purging her pulse quick." 118 Other extreme symptoms continued on the ward throughout November. Margaret Cheyne felt pains after delivering on 1 November. She declined throughout the month: on the 12th "in a strange half delirious way [she] complains of great pain in the Vagina, sleeps none, a slow fever," 119 but by the 15th was "extreamly noisey and troublesome to the other patients, for last night she was so outrageous that the Nurses were obliged to strap her down to the bed"; Macaulay and the board ordered her to leave and gave "our weekly allowance for 2 weeks . . . to her husband." 120 (The patient register simply noted, in the "Day of Discharge" column: "Mad.") 121 Another woman, Sarah Smiler, developed a red rash and pains, also on the 15th, three days postpartum; but she "beg'd hard to have leave to go out that night. I told her with how much hazard that wou'd be attend & that it was the height of folly for her who had lain in a week, & who had such an eruption." 122 She left and never returned. In total, from mid-October to late January, when the board decided to address Nicholls's pamphlet, Macaulay had continuously described twenty-two patients suffering from such symptoms as "Feverish fits and headaches" 123 and six members of the staff complaining of, for example, "an Eruptive fever . . . shivering vomiting and purging . . . quick pulse, head ack and had a violent pain of her back." 124 On 9 December, after suffering from weeks of fever, aches, sore throat, skin eruptions, and weakness, Sarah Steven died, and Macaulay asked himself: "Had the Case of this woman any thing to do with her Lying-in? Or was it meerly a low nervous fever?" 125 It may be apparent to us, as it would have been to observers only twenty years later in the early 1770s, that Macaulay was describing women suffering and dying from puerperal fever. This devastating cluster of symptoms, with a death rate ranging from 30 percent in sporadic and endemic cases to 80 percent in epidemic, usually resulted from one of seventy strains of Streptococcus pyogenes. Streptococcal bacteria invaded a parturient mother's reproductive tract through even minuscule lacerations or tears when asymptomatic nose and throat carriers coughed or sneezed, or attendants with unwashed hands touched them. Victims of puerperal fever suffered from convulsions, excruciating abdominal pain, faintness, headaches, swelling, delirium, sometimes thrashing, and, in many cases, death, as the bacteria invaded the uterus and the abdominal cavity and penetrated the circulatory system. 126 Though Macaulay and others could describe these symptoms, they apparently had no idea how hospital practices helped to create an ideal environment for heightened levels of disease and death.

Hospital Spaces
From early July to mid-December 1751 when Nicholls's pamphlet appeared, a total of 188 mothers resided in the British Lying-in Hospital, with seven deaths among women, but only eight among babies. 127 The increased maternal mortality rate during 1751 was not evidence of an epidemic, because no source described most mothers and infants as experiencing illnesses severe enough to warrant mention, and the overall numbers, though heightened, reflected reasonably well on the hospital, as Margaret DeLacy has argued. The acknowledged and published death rates at the hospital were annual aggregates, however, which helped to mask dramatic weekly variations. The registers and Macaulay's diary show that most mothers in 1751 died in a concentrated, four-month period, and that they had succumbed to the very same symptoms that many other mothers experienced and survived. The minutes and annual 125. Ibid., 9 December 1751, 1: 95. 126. Loudon, Tragedy (n. 7), p. 6; DeLacy, "Puerperal Fever" (n. 8), pp. 523-26; White, Treatise (n. 15), p. 141.
127. I am counting the number of patients actually at the hospital during this period, according to the BLHPR; this includes patients who arrived before July and left after mid-December, about the time Nicholls's pamphlet appeared. statistics hide the experience on the wards, but the other sources show that in the months preceding Nicholls's attack there was always a mother in extreme pain and potentially on the verge of death. Fevers, sore throats, abdominal and vaginal pain, and even skin infections were omnipresent, and from May 1751 until Nicholls published his pamphlet, at least one woman died each month, with two dying in August, October, and December. In fact, not more than forty-two days went by between deaths. Considering that patients typically stayed in the hospital for three to four weeks, most women who came to the British Lying-in Hospital in 1751 would have witnessed the death of another mother, and certainly two or more cases of infant mortality.
Lying-in hospitals transformed the experience of birth-not so much by "medicalizing" birth through the frequent use of forceps, or by replacing female midwives with men-midwives in routine deliveries, but by dramatically and immediately altering the epidemiological landscape. At the eighteenth-century British Lying-in Hospital, approximately forty women were housed together for nearly a month each; since ten women were admitted and discharged weekly, each new mother actually cohabitated with approximately seventy other women during her month. These seventy women and seventy children, housed together in a small building, created a perfect opportunity for any disease introduced by a doctor, midwife, visitor, or mother to spread rapidly.
Georgians did not know that whitewashing walls had little effect on preventing fevers; nor did they recognize that their own medical staff, including staff surgeon and anatomist William Hunter in the 1750s, could serve as disease vectors when they moved between patients and even between their dissecting work and their consultations at the hospital. The British Lying-in board attributed the disease and death that did occur at their hospital as resulting instead from the patient population itself: they viewed these women as inherently unhealthy, capable of spreading contagion to others and likely to suffer from difficulties in addition to pregnancy when they arrived at the hospital. The general ill health of the mothers was so striking that the board even decided in June 1751 to add a staff physician who would address only symptoms that "do not relate to childbearing." 128 In 1767, one hospital pamphlet explained that "of the 156 Women who have died in the Hospital, most of them came in, not only under Circumstances of Distress and Poverty, in common with the Rest of the patients, but also affected with dangerous 128. BLHM, H14/BLI/A1/1, 27 June 1751.
Disorders, exclusive of their state of Pregnancy." 129 The interviews and physical examinations of patients by the matron at weekly board meetings eliminated many of those petitioners with visible venereal diseases, 130 "the Itch or any other Contagious Distemper," 131 or vermin, 132 and the "very dirty ragged and others of bad behaviour." 133 Though the interrogations and looking under women's skirts and caps 134 certainly support the modern criticism that the board "policed" the patient population, these measures also reflected the institutional and philanthropic desire to protect the healthiest poor mothers from others who might imperil their safe deliveries.
When the nearly two hundred women who resided in the British Lying-in Hospital during the second half of 1751 ended their stays, they would have been able to report to others stories of sickness, other women's deliriously "outrageous" behavior, and even death. When Sarah Smiler returned to her home, presumably with a very red face from her rash, her neighbors may have blamed the hospital. And if Margaret Cheyne left the hospital exhibiting the psychotic behavior characteristic of very advanced puerperal fever, what must her neighbors have thought? Especially if she could tell them she was tied to her bed?
Because puerperal fever had not yet been articulated as a specific disease entity in 1751, critics like Frank Nicholls lacked an epidemiological framework to explain how the hospital environment amplified childbed mortality. Instead, Nicholls relied on what he and his contemporaries viewed as new and controversial: the violence of instruments dragging "one in fifteen" was used to explain the infant mortality rate, and unknown "Experiments" on mothers' bodies were invoked to describe maternal death in childbirth. Though the British Lying-in Hospital doctors were not performing the sorts of experiments that Nicholls and others imagined, they tried every conceivable remedy when confronted with surging death rates. William Hunter described the desperation and futility in the 1760 epidemic at the hospital: "some . . . were bled, some were 129 treated with cooling medicines, others with warm medicines and cordials, but everything proved equally unsuccessful." 135 Similarly in 1751, Sandys and Macaulay prescribed spermaceti and opiates, ordered bleeding and blistering, and had convulsively hysterical patients strapped to their beds. Maternity hospitals were new institutions in Georgian London, and despite their very public presentation in pamphlets and in orchestrated Sunday baptisms, in practice they were private, enclosed spaces guarded by doormen in livery. Their wards were open for very few hours to family and governors, and in the case of the British Lying-in Hospital, the curious had to travel to the heart of the crime-ridden parish of St. Giles's to visit-in fact, the hospital paid for chairs for any doctors who attended the patients at night. 136 The difficulties faced by patients' families and the governors, let alone the broader public, in gaining access to these hospitals and seeing what actually happened there were much greater than the printed pamphlet literature would ever indicate. For a public newly adjusting to both man-midwifery and this particular form of institutional benevolence, former patients' reports of hysterical mothers strapped to beds, bleeding, blisters, rigid schedules, and rules prohibiting movement could easily have reinforced the conviction of critics, including perhaps Nicholls, that hospital man-midwifery was experimental and cruel.
Twelve women died in 1751, but neither the hospital minutes and registers nor Macaulay's diary show that any of these women died directly at the hands of men-midwives, as Nicholls and (more recently) Doreen Evenden have claimed. Evenden has asserted: "I suspect, because of their silence on this point, that the male midwives [at the British Lying-in Hospital] were, indeed, in attendance when bungled deliveries occurred. The doctors never hesitated to place the blame on female attendants whenever possible." 137 This is simply unsubstantiated. Contemporary records do not support the claim that the men-midwives at this hospital took part in a conspiracy to cover up experiments and "bungled" mishaps. Nor, with one exception-when Sandys blamed and no doubt humiliated the female nursing staff for disobeying his orders 138 -does evidence survive that the hospital board and doctors singled out the female staff as causing the deaths of mothers and babies. Instead, members of the board focused on eradicating bedbugs and smoky chimneys, and airing the wards-all signs that they viewed the wave of fevers and sore throats as resulting from the environment. 139 Over the years, the nurses, laundresses, and cooks found their way into the hospital minutes for drunkenness or negligence, and in the case with Sandys a nurse was noted as being reprimanded publicly for disobeying the doctor's orders; yet in light of the thousands of hours these women gave to the hospital, the doctors and board members appear to have complained very little about the female staff. They also happened to reprimand male employees and governors, from the back-talking steward and slow-moving messenger boys to the gossip-stirring Duke of Portland and Francis Sandys. 140 Indeed, it appears that in cases of conflict the board even backed the matron against the male employees. 141 The symptoms that Macaulay described, the brief notes sometimes including cause of death in the patient register, and oblique comments in the minutes indicate that puerperal fever was endemic on the wards soon after Macaulay joined the staff, and that it lasted far into the winter, after the appearance of Nicholls's pamphlet. The sources do not reveal who or what the vector was. It cannot be said with certitude whether Macaulay or another doctor introduced the disease through their examinations of postpartum women, or whether it was spread through the air from a member of the female staff or a visitor suffering from that year's epidemic "sore throat," which DeLacy has shown correlated with known puerperal fever epidemics. 142 The records suggest, however, that most, if not all, of the women who died of or suffered from symptoms associated with streptococcal infections-fever, severe postpartum pain in the reproductive tract, sore throats, skin rashes, delirium-were delivered by one of the hospital midwives without the assistance of medical men. The four women whom Macaulay attended, in three cases with instruments and the other with internal manual intervention, were not recorded as manifesting any of the puerperal-fever-like symptoms that occurred contemporaneously on the wards.
Although I am defending the male obstetrical staff at the British Lying-in Hospital in its early years, I am not doing so in order to shift the blame back toward the female staff, who offered extraordinarily good care overall and performed nearly all of the work at the hospital as 139 midwives in not only routine deliveries, but probably also some difficult ones. The hospital matron, her assistant and nursing staff, and the female pupils in midwifery were in fact the unsung heroes of these early lying-in hospitals. They deserve modern recognition not only for successfully attending hundreds of London's poor mothers, but also for keeping midwifery largely in the hands of female practitioners-despite the growing use of men-midwives among elite mothers.

Conclusion
Where does this exploration of the internal life of the hospital leave us? First, in terms of disease at the hospitals: aside from Margaret DeLacy, most historians have treated the eighteenth-century lying-in hospitals as extremely dangerous. Irvine Loudon, for example, has argued that the lying-in hospitals were from the early years plagued by recurrent epidemics of puerperal fever with appalling mortality rates. By choosing delivery in a lying-in hospital, women . . . were exposing themselves to a risk of dying that was many times higher than if they had stayed at home in the worst of slums and been attended in their birth by none except family and an untrained midwife. The lying-in hospitals were such a disaster that, in retrospect, it would have been better if they had never been established before the introduction of antisepsis in the 1880s. 143 While this might be true of the mid-nineteenth century, and while there were indeed some very bad years-1760, for one, with a mortality rate of 6 percent-the eighteenth-century lying-in hospital experience was statistically as safe as or safer than a home delivery in some years, including 1750, 1756-59, 1765-69, 1771-73, 1776-77, 1779, 1783, and 1789-1800. This success rate is not surprising given the outstanding qualifications of the hospitals' matrons and their midwifery students. 144 In terms of neonatal mortality-which was the more salient concern in Nicholls's Petition of the Unborn Babes-the British Lying-in Hospital was an extremely successful institution. According to E. A. Wrigley and his coauthors, the metropolitan rate of newborn deaths was 10 percent, which was significantly higher than the hospital's publicized rate of "one in fifteen" perishing, or 6.7 percent. 145 When Nicholls published his pamphlet in late 1751, 39 children had died out of the 521 babies delivered at the hospital-or 7.4 percent-in the two-year period from its founding in late 1749; the patient registers record that 27 of these were stillbirths, and 12 were postnatal deaths, only 4 of which occurred after the first seven days. 146 Considering that at least some portion of the stillbirths would have involved fetal death before the mother arrived at the hospital, and that deaths in the first week of life highly correlated with endogenous causes such as genetic defects, 147 the rate of neonatal death potentially attributable to poor care or an unhealthy environment at the hospital was exceptionally low. The hospital's consistently impressive record of infant survival was due to excellent midwifery, twenty-fourhour attendance by several nurses, and abundant clean linens provided by the hospital laundresses. At the same time, the stringent regulations excluding pregnant women with obvious communicable diseases, limiting new mothers' mobility, preventing visitors from entering the wards, and mandating that mothers breast-feed and sleep with their newborns also contributed to this infant population's high survival rate while at the hospital.
Second, I have emphasized here that the critical perceptions of Georgians like Frank Nicholls and many modern historians of gender that eighteenth-century hospital men-midwives were coercive, violent, and the cause of dramatically high death rates among mothers and babies cannot be substantiated by the archival record-or the demographic facts-at the British Lying-in Hospital. Yet I have also suggested that previously untapped sources might explain why these critics' charges have stuck through the centuries. The Georgian hospitals relied on strikingly "modern" bureaucratic and institutional procedures that reinforced social hierarchies: from demanding that potential patients follow a lengthy and complex process in order to gain hospital admission, 148  148. To gain admission, a woman needed to locate a governor who could give her a recommendation; she had to have proof of her marriage, or go to the Old Bailey to have an affidavit made out; and then she was interviewed at a Thursday board meeting, where she was asked about her menstrual cycle and other matters, examined by the matron, and, if determined a clean, proper object of charity, was allowed to ballot for a place. If she won a place, she was scheduled for admission on a particular day, although she could come into the house sooner if in labor. mothers who had snuck through the system. 149 Each one of these (and many other) institutional features appeared in the press or gossip, reinforcing many contemporaries' curiosity and their suspicions that these philanthropic endeavors were not entirely charitable and exacted a heavy toll from the poor women they supposedly served. 150 In terms of the tension between the perceptions and facts of death at the hospital, lying-in hospitals quickly magnified London mortality rates, but contemporaries like Nicholls did not view this as resulting from the amplification of disease in crowded, enclosed spaces. Rather, they blamed the institutional authority of men-midwives, who in fact did not serve the hospitals primarily as birth attendants, as both Georgians and historians have believed, but rather as bureaucrats attending meetings, raising funds, and reprimanding visitors for defying house rules. Before the dramatic epidemics of 1770, when Manchester physician Charles White and several other lying-in hospital doctors codified the cluster of symptoms as puerperal fever, Georgians were unsure just what caused maternal death at the lying-in hospitals, and so Nicholls, Nihell, and others pointed to what seemed novel in the mid-eighteenth century: the rise of routine man-midwifery, the use of forceps, and the establishment of hospitals for normal pregnancies and deliveries. Though at the British Lying-in Hospital men-midwives neither routinely delivered babies nor did three out of four of them defend the obstetrical forceps, both contemporaries and historians have cast blame for the periodic deaths of mothers and babies on the novelties rather than what was at the time entirely unknowable and invisible: the pathogenic amplification of a very crowded birth room.
Third, in terms of the history of gender, some historians and feminists have drawn a correlation between men-midwives' use of forceps and misogyny. It has long been appealing, at least from Frank Nicholls's pamphlet forward, to link instruments with an "artificial," unnatural medical intrusion on a traditionally female space. 151  doctors at a formative moment in the rise of male obstetric medicine, these linkages appear less tenable. Further archival and demographic research will be needed in order to show whether the policies and experiences at the British Lying-in Hospital were emblematic or exceptional in the history of maternity hospitals. This hospital's archival records show that board members and male doctors generally supported both the female staff and the patient population, and that they encouraged the continuation of female midwifery as a profession. The board early on established an intensive and rigorous-albeit institutionally profitabletraining program for women eager to learn midwifery. The board paid the hospital matron between thirty and forty pounds annually at midcentury, and they and the governors consistently expressed concern about the welfare of the patient population. The British Lying-in Hospital was unquestionably a hierarchical institution that helped to enforce rituals of class obedience and male authority, but the doctors and male board members rarely seem to have been as brutal as contemporary and modern critics have charged.
I have here examined George Macaulay's role, proposing that he, as the sole forceps practitioner at the hospital in the first few years, came under pseudonymous attack from Frank Nicholls as "Dr. Maulus," an instrument-wielding, sadistic monster. What remains of Macaulay's diary and his presence in the hospital minutes, however, shows a doctor concerned about his patients and the female staff. It was he in December 1751 who was the first medical man to request that the female staff be given more frequent and regular breaks from work because "the Nurses [have been] Extreamly Fatigued with Sitting up Night and Day on account of the Wards being full of patients." 152 The election that led to Macaulay's appointment was close among the male governors, but he won a landslide number of female governesses' votes, some forty-two to Dr. Trotter's sixteen. 153 He would also soon wed Catherine Sawbridge Macaulay, the eminent historian and later advocate of female rights; when George died in 1766, she wrote of his "Ineffable sweetness of Temper" and "good Heart and a Sound Understanding with the peculiar Graces of Genius and Learning and every social Virtue in the highest degree of Perfection" 154 -perhaps not surprising words from a widow, but this particular high praise suggests that at least this early feminist had 152 little problem with her husband's occupation as a man-midwife. However, George Macaulay was, at least until 1759 when he wrote criticisms of his earlier use of instruments, a forceps practitioner. He also was one of the leaders of the most "medicalized" forms of childbirth in mid-century London: he promoted, and successfully practiced, induced labors in the seventh month prepartum in second or later pregnancies in women who had small pelvic openings and had lost their earlier infants during delivery. Though some midwives and critics castigated such obstetrical techniques, medical proponents and some historians have considered that these steps saved infant and maternal lives that otherwise would have been lost. 155 On the other end of the spectrum at the hospital, Francis Sandys, who was an adamant critic of forceps and other obstetrical instruments, seems to have shown considerably less support for the women employees and the profession of female midwifery. As one of the founders of the Middlesex Hospital's Lying-in Wards in 1747, he was one of the men who explicitly designed those wards to exclude entirely the work of female midwives. When he defected from Middlesex to help establish the British Lying-in Hospital, he presumably supported the use of a hospital matron for routine deliveries, but he, more than the other doctors, left evidence of having criticized female staff-for instance, when he blamed a nurse for the death of a patient. 156 He also retired from his post in an exit seemingly riddled with controversies and disputes with other members of the hospital community; 157 we can only speculate at this point whether it was because this hospital gave the matron and female employees greater control over most mothers' pregnancies and deliveries than did the Middlesex Ward. These are only two examples of eminent men-midwives and their perhaps unexpected attitudes toward forceps and medical interventions in light of the few things we know about their attitudes toward women, but it seems that in these two cases there is no necessary correlation between obstetrical instruments and misogyny.
Finally, despite the facts of a rigid bureaucratic structure and an elevated maternal mortality rate in some years, and despite rumors of medical "experiments," women consistently came to these hospitals in enormous numbers, far beyond the institutions' capacities. Adrian Wil-son has argued that the only way to understand how Georgian menmidwives became the routine birth attendants among elite and middling women is to recognize these mothers as making choices, rather than assuming that they lacked agency and were easily manipulated by medical men. 158 Similarly, it would behoove us to reevaluate the choices that poor Georgian women made when given the opportunity to give birth in a hospital. The bureaucratic rules, clock-watching, mandated acts of deference and gratitude, and risks of sickness and death might seem to have made a hospital birth an unappealing and irrational choice-yet when these hospitals are placed in the broader context of an extremely hierarchical, economically polarized, and insalubrious city with high maternal and infant mortality rates, impoverished women must have come to the hospital believing that they were improving their prospects and those of their children.
Perhaps most surprisingly, reconstructing daily life inside these institutions shows that an institutional birth in Georgian London was not like a modern American hospital birth, in which mothers in fact did lose both consciousness through anesthesia and complete control and political agency over their reproductive bodies. 159 Eighteenth-century lying-in hospitals, unlike American obstetric practices in the 1950s, were communal spaces filled primarily with women who largely controlled the experience of birth as midwives, mothers, and "fellow sufferers." These hospital births rarely involved either instruments or even the attendance of menmidwives in most instances. The early lying-in hospital in the first decades actually promoted many early modern expectations for an ideal English birth: Christian succor, delivery by a female midwife while surrounded by other women, plentiful caudle, and weeks of postpartum rest away from routine household and family demands. From this point of view, an eighteenth-century hospital birth may have been an entirely rational choice.
While some women were expelled for having vermin, being rude, or even pretending to be pregnant 160 or claiming to be married simply because they "crave[d] the Aid of Charity," 161 hospital staff and philanthropic supporters were not exclusively an intrusive, moral police force, unsympathetic to the dirty and the unmarried. Benefactors consistently overrecommended and wrote anxious letters when the women they had recommended complained about their stays in the hospital. 162 Doctors and nurses pressed the board to allow women to extend their stays, and when women who had been accepted for entrance gave birth early at home, the hospital boards gave direct donations to them to cover the cost of a midwife and some necessities; everybody involved in the hospital knew of particularly lamentable cases and pushed hard in support of the pregnant women who had come to them for help. 163 The hospitals were far from perfect institutions, and as crowded, enclosed spaces they had unintended epidemiological effects. As new bureaucracies, they had wide-ranging cultural effects in the relations between the propertied and the poor, and between doctors and midwives, but in the early years, these hospitals were peopled with individuals who did not act only out of calculated self-interest or wanton cruelty, as Frank Nicholls and others once charged. In reality, the eighteenth-century lying-in hospital may have accomplished quite the opposite of what both critics and even its own doctors believed the hospitals were doing. It seems that the actual experience of giving birth and lying in on the wards helped to promote and codify the ideal of birth as a communal, female-centered, and largely natural experience among women of the urban working poor. 162. Ibid., 19 December 1751, and 16 January 1752, noting the hospital's being overwhelmed by "several unworthy Objects [who] have procured Letters of Recommendation the giving of which has been owing to the Humanity of Governors in relieving distress'd Objects in General without inquiring into their Characters." It is unclear what "unworthy" meant exactly, but it may have suggested that governors were trying to help unmarried mothers.
163. Both the minutes and the patient register record numerous women delivering unexpectedly at home before their scheduled due date, and in the early 1750s the hospital board gave these women money. In some cases the hospital men-midwives, including William Hunter, attended the women in their own homes before they made it to the hospital: BLHM, H14/BLI/A1/1, 19 September 1751.