Satire in Eighteenth-Century Medical Discourse: Elizabeth Nihell, Tobias Smollett and the Advent of Man-Midwifery

ABSTRACT This paper examines Tobias Smollett’s scathing assessment in the Critical Review of Elizabeth Nihell’s midwifery treatise, Treatise on the Art of Midwifery (1760), a polemic against the use of instruments in childbirth and the increasing popularity of man-midwifery. This continues with Nihell publishing a response to Smollett’s review, and then Smollett responding to Nihell’s response. The Nihell-Smollett exchange brings discourses surrounding two concomitant medical controversies – the use of instruments in childbirth and the presence of men in the birthing chamber – to the fore, and it is particularly remarkable due to the satirical tone adopted in this exchange, particularly by Smollett. Using Simpson’s model of satirical discourse, this paper explores the textual-linguistic practices adopted by both Smollett and Nihell and elucidates how satire both construes and is construed by rival medical ideologies in mid-eighteenth-century England.


Introduction
The eighteenth century bore witness to one of the most significant changes underwent in the field of midwifery: increased involvement of medical men in the care and delivery of parturient (labouring) women during normal childbirth where only minor or no complications arose.Before this period, childbirth was a woman-centred affair overseen exclusively by (female) midwives; male surgeons would only become involved if there were major complications that fell beyond the purview of the midwife (such as a stillbirth).However, due to the advent of birthing instruments like the forceps in the late seventeenth century, as well as broader advancements in medicine during the period, an increasing number of male practitioners became more and more involved in normal childbirth throughout the eighteenth centuryhence the term man-midwife. 1 It should come as no surprise that these changes caused quite a stir in the field of medicine on a number of levels, not the least because this increased access of non-familial men to the female body upset a long-standing social taboo.
One of the fiercest critics of man-midwifery was the London-based midwife Elizabeth Nihell, who in 1760 published her Treatise on the Art of Midwifery, an invective against the increasing male encroachment on a previously gynocentric space and a refutation of practices recommended by William Smellieone of the most famous and influential man-midwives of the eighteenth centuryand a number of other man-midwives.This text did not go unnoticed by the medical community, and shortly after its publication, it was met with a scathing response in the Critical Reviewa periodical featuring a new genre, the book review, and edited by Tobias Smollettauthor of picaresque novels and former medical man (including man-midwifery).Smollett is also the presumed author of the review in question, which was quickly met with an elaborate response from Nihell, which itself was then countered by anotheralbeit tersereview from Smollett.This textual exchange between Nihell and Smollett brings the controversy surrounding man-midwifery and the use of instruments into stark relief, but it also provides a remarkable illustration of how satire, purportedly humourous plays on language used to counter opposing ideologies, 2 played a noteworthy role in eighteenth-century medical discourse.This is no doubt due to Smollett's background as a novelist and desire to write entertaining (sellable) book reviews, but his wit is equally matched by Nihell in her response to his critique.It is the aim of this paper to both uncover the particular textual-linguistic practices employed by Smollett and Nihell in their construction of satirical discourse, as well as place this discourse in its broader milieu of medical controversies and the emergent book review culture.
I will discuss the broader sociohistorical context of midwifery practice during the eighteenth century as well as the mid-century advent of review publications such as the Monthly Review and the Critical Review in the next section.Then I will provide an overview of the model of satirical discourse I am using to analyse the Nihell-Smollett exchange, which will then be examined in depth.Some final remarks will conclude the discussion.

Midwifery
Until the early modern era in England (and no doubt beyond), childbirth was a nonmedical, woman-centred event overseen by midwives and a few of the parturient woman's closest associates; men were banned from the birthing chamber, save in the event of an emergency, in which case a (male) surgeon would be called in.During the seventeenth century, a small number of male surgeons became increasingly involved in caring for women during the prenatal period through childbirth and beyond, most notably the Chamberlensa family of surgeons who devised instruments (namely forceps) during the early part of the century but kept their invention a secret until the late 1600s.Once these and other instruments (like the vectis and crochet) became public, these new man-midwives increased in number during the eighteenth century and became a recognisable competitor of the traditional female midwife, even though the latter was still the more common choice at the end of the century.Nevertheless, given these medical men's claim to an expertise that combined both scientific knowledge gained through university education (unavailable to women during this era) as well as first-hand experience, the eighteenth century was the time in which normal childbirth began to be seen as a medical(ised) event. 3On the other hand, the publication of printed vernacular midwifery treatises since the sixteenth century has been almost exclusively a male-centred affair; the earliest texts, such as The Birth of Mankind (a translation of a German-language treatise via an intermediary Latin translation, published in 1540 by Richard Jonas), were based on an older, scholastic-style of medical learning and published either by learned physicians or other men who had no experience in the birthing chamber, or by surgeons whoas stated aboveintervened only in an emergency.It wasn't until the seventeenth century that female midwives began publishing their own texts, although these are few and far between the ample number of texts published by men.More women published in the eighteenth century, but this was matched by a far greater number of men-midwives entering the publication fray, particularly during the latter half of the century. 4ne of the most influential of these eighteenth-century man-midwives was William Smellie (1697-1763), in terms of his booming London-based practice, his educational offerings (to both male and female students) and his influential The Theory and Practice of Midwifery, a series of his observations and case studies, published in three lengthy volumes between 1752 and 1764. 5Smellie had his share of critics, among whom the midwife Elizabeth Nihell (1723-1776) was happy to include herself.Born to French Catholic parents in London, she trained at the Hôtel Dieu in Paris and eventually returned to London to practice midwifery. 6In 1760, she published her Treatise on the Art of Midwifery, in which she objects to the practices of William Smellie, particularly his recommended use of instruments, and she also voices disagreement with a number of prominent French accoucheurs (man-midwives); superimposed on these critiques is Nihell's more fundamental objection to man-midwifery: she believes women qua women are more suitable midwives because they are supposedly more gentle and supple in their use of their hands (whereas men are more brutish in technique and lack a necessary degree of grace).In today's terms, Nihell could be said to have an essentialist view of the sexes, and she was quite conservative in terms of her view of women's nature as "modest, highly emotional, and centred on pregnancy and maternity",7 although this was a common view of the time.Indeed, such beliefs were also echoed by several man-midwives in their writings, some of whom argued that (female) midwives

6
The controversy surrounding the use of instruments in midwifery practice did not revolve solely around medical technique; political and religious affiliation also played a significant role in the demarcation of certain positions on the issue, particularly if one was trained on the Continent where religious affiliation overshadowed the location of the medical schools, e.g., Protestant Leiden vs. Catholic Louvain.The fact that both William Smellie and Tobias Smollett hail from Scottish Presbyterian backgrounds, whereas Elizabeth Nihell was Catholic, may or may not be significant here; this issue is never overtly referenced in any of the textual exchanges discussed, although it is worth remembering as being significant in the larger medico-cultural milieu.See Wilson, The Making of Man-Midwifery; cf.Cunningham and French, The Medical Enlightenment.
lacked the requisite scientific knowledge to assist with childbirth safely, and that this should be left in the purportedly more capable hands of medical men. 8It is also worth noting that this increased access of medical men to the previously woman-centred space of childbirth, especially since it involves contact with sexual/reproductive organs, threatened a massive breach of eighteenth-century sensibilities. 9 The Emergent Book Review Culture Aside from the increasing number of man-midwives and associated publications, the latter half of the eighteenth century also saw the emergence of a new genre of writing and publication: the book review.In 1749, bookseller Ralph Griffiths published the first volume of his Monthly Review (hereafter MR) in an effort to provide the reading public with an informative overview of the sometimes unwieldly number of new publications (both literary and non-literary) hitting the book market in rapid succession. 10Contributions to MR were fairly short and gave a succinct overview of the publication in question; the focus was generally on content summary, although reviewers were hard pressed not to include some sort of assessment as well. 11Around this time, aspiring litterateur and medical man (including midwifery) Tobias Smollett (1721-1771) was focusing his attention more on literaturemainly picaresque novelsand less on medicine, 12 although he had a close association with William Smellie and helped him edit his Theory and Practice of Midwifery.In fact, historian Lisa Forman Cody goes so far as to suggest Smollett actually ghost-wrote this text. 13And in 1751, Smollett even published a pre-emptive review of Smellie's text in MR, in which he claims that Smellie "asserts nothing that is not justified by his own experience" and lauds his colleague for improving the design of the forceps and describes his instructions as "clear and perspicuous, his remarks judicious and happily deduced, his general method of practice unexceptionable; and there is an air of candour, humanity and moderation through the whole book, which cannot fail to engage the reader's favour and esteem". 14This no doubt proved beneficial to Smellie, and although he was a contributor to Griffith's new publication, the two had a falling out not long after this review appeared, 15 and in 1756, he released the first volume of his Critical Review (hereafter CR).
8 Historical scholarship has shown that most maternal deaths associated with childbirth were not due to the act of giving birth itself, but rather to cases of postpartum infection (puerperal, a.k.a.childbed fever), see Evenden, The Midwives; Read, Maids, Wives, Widows; Allison, Midwifery.The advent of instruments also had no net benefit on the infantmaternal mortality rate until the discovery of bacteria and antiseptics in the late nineteenth century, and it was not until after World War II that significant strides were made in reducing these mortality rates (thanks to further improvements in antiseptic techniques and anaesthesiology).Indeed, the maternal-infant mortality rate of early twentiethcentury England differed little from the Tudor period, see McIntosh, A Social History of Maternity Care; Allison, Midwifery.9 See Porter, "A Touch of Danger"; Gilman, "Touch, Sexuality, and Disease"; Lawrence, "Educating the Senses"; Porter, "The Rise of the Physical Examination"; Wilson, The Advent of Man-Midwifery; Keller, "The Subject of Touch." 10 Taavitsainen, "Medical Book Reviews 1665-1800", has shown that reviews of medical texts go as far back as 1665, in line with the inauguration of the Royal Society's flagship publication, The Philosophical Transactions.These reviews were initially summative in nature and always collegial in tone, in contrast to those appearing in the MR or CR.Of course, Philosophical Transactions was not devoted exclusively to book reviews and mainly featured write-ups of scientific observations and experiments. 11Forster, "Review Journals"; Forster, "Avarice or Interest"; Jones, "The Eighteenth-Century Review Journal." 12 For overviews of Smollett's life and career, see Knapp, Tobias Smollett; Rousseau, Tobias Smollett; or Basker, Tobias Smollett.Given his background in medicine, it should come as no surprise that medicine and the human body feature substantially in Smollett's literary works, see Rousseau, Tobias Smollett, 160ff.or Douglas, Uneasy Sensations. 13Cody, Birthing the Nation, 152-3. 14Smollett, "The Theory and Practice of Midwifery," 465-6.
In late 1755, Smollett placed a notice in the Public Advertiser announcing the inauguration of the CR, in which he stated: This Work will not be patched up by obscure Hackney Writers, accidentally enlisted in the Service of an undistinguishing Bookseller, but executed by a Set of Gentlemen whose Characters and Capacities have been universally approved and acknowledged by the Public: Gentleman, who have long observed with Indignation the Production of Genius and Dullness; Wit and Impertinence; Learning and Ignorance, confounded in the Chaos of Publication; applauded without Taste, and condemned without Distinction; and who have seen the noble Art of Criticism reduced to a contemptible Manufacture subservient to the most sordid Views of Avarice and Interest, and carried on by wretched Hirelings, without Talent, Candour, Spirit, or Circumspection. 16re Smollett is attacking Griffiths and his alleged substandard practices at the MR, and promising a more sound and learned form of book reviewing in his CR.Although there was little difference in actual practice between MR and CR, 17 Smollett is clearly attempting to edge Griffiths out of the market, most notably through the biting satirical tone of this texta hallmark of Smollett's picaresque novels visible in his non-literary writings as well. 18Indeed, although book reviews were meant to inform the reading public, the marketability of publications such as the MR and CR was at least partly dependent on the contributors' ability to entertain the reading public as well. 19It is within this context of Smollett's close connection with Smellie, his personal and professional stake in Smellie's text, and his ambitions with the new CR that Elizabeth Nihell publishes her Treatise on the Art of Midwifery in 1760.Smollett's review of Nihell is no less fierce than his attack on Griffiths above; if anything, it is more intense. 20He also devotes an exceptionally lengthy piece to Nihell (10 pages), which appears almost solely focused on defending Smellie's reputation, even though Nihell's text itself is hardly concentrated on Smellie. 21The content and style of this review and Nihell's response will be discussed below, although first a few comments about satirical style are in order.

Satire as Discursive Practice
Satire is conventionally held to be a hallmark of the literary domain, and the eighteenth centuryheralding authors such as Jonathan Swiftis of particular interest to literary scholars of satire. 22Simpson, however, has shown that instead of confined to the domain of literature, satire is in fact a discursive practice that transcends genre.It is, in short, the "configuration … of subject placements and humour communities within orders of discourse", 23 with the overarching goal of some sort of script subversion (i.e., deviation from readers' expectations) and ideological critique. 24And it is satire's subversive and critical nature that situates it as a trans-generic phenomenon: associated phenomena like puns and word play occur at the level of lexico-grammar, whereas parody occurs at the level of genre and register, 25 although all of these can be subsumed within a broader satirical discourse. 26Such discursive practice occurs in a triadic exchange between the satirist, the satirised (the target) and the satiree (the addressee) in "orders of discourse in social, cultural and political organisation". 27Simpson's conception of discourse and ideology is drawn from Critical Discourse Analysis, 28 in which "meaning in the service of power" 29 is "located … both in structures which constitute the outcome of past events and the conditions for current events, and in events themselves as they reproduce and transform their conditioning structures"language (and texts) being one means by which such ideologies are "conditioned" and "transformed". 30Even so, Simpson acknowledges that the use of humour has rarely if ever come into focus in CDA. 31 Nevertheless, his framework can help augment an application of CDA to discourses with a satirical component, such as the medical controversy in focus here.
And given the time period involved, the Discourse-Historical Approach (DHA) to CDA provides additional analytical insights complimentary to Simpson's satirical model. 32In terms of discursive phenomena explored to see how textual-linguistic practices betray particular ideologies, DHA focuses on nomination (how persons/objects etc. are referred to or named, particularly nouns with either positive or negative denotations or connotations), predication (characteristics attributed to said persons/objects etc., usually in the form of pre-or postmodifiers like adjectives), argumentation (what arguments are employed in a given discourse), perspectivisation (the point of view from which such nominations, predications and arguments are made) and mitigation/intensification (whether the utterances involved are downtoned (mitigated) or intensified in any way, usually with adverbs or hedges such as possibly or certainly). 33Within Simpson's satirical framework, then, these strategies would generally integrate some sort of humorous component into the discourse (whether the expressions are actually funny or appropriate is another matter entirely), and in sum, some particular ideology is construed.To illustrate this, let us return briefly to Smollett's thinly veiled attack on Ralph Griffiths and his associates in his announcement of the CR's advert above.Smollett refers to Griffiths by his job title Bookseller, and his associates similarly as Writerstheir role at MR (nomination). 34This is unremarkable, although Smollett's use of predication is where his attack his realised: Griffiths is "undistinguishing", these writers are "obscure" and "Hackney", and the latter's association with the former is "accidental".
CR, on the other hand, will be intentionally overseen by "Gentleman"a contrastive nomination indicative of a (positive) social as opposed to a (neutral) professional standingin possession of "approved and acknowledged" characteristics.In this instance, Smollett's discourse is situated in a struggle for both intellectual and financial supremacy in the marketplace of publications in mid-eighteenth-century London.
The more elaborate and satirical textual exchange with Elizabeth Nihell is of a different order, featuring rival ideologies surrounding maternity care: who are the most suitable to care for parturient women?; what practices should be adopted or discouraged?; and what kinds of knowledge are superior or inferior in midwifery practice? 35In order to place this discourse in its proper medico-and sociohistorical context, Simpson's punningly named SMUT model of satire is quite suitable: 36 Setting: The "preparatory preconditions necessary for the construction of satirical discourse". 37Included here are Smollett's medical and literary background, extant literary and social conventions regarding textual practice, the context of eighteenth-century midwifery and book review culture (discussed in Section 2), Smellie and his treatise, and Nihell and her treatise.

Method:
The textual-linguistic component of satirical discourse, which can include "the creation of grotesques or caricatures through exaggeration of features associated with the object of attack; the merging and inversion of scripts and schemata; the transition between positive and negative polarities; the alteration between normal and abnormal scripts; and the opposition of possible and impossible discourse worlds". 38This is at least partly accounted for by the DHA components discussed above, and it will be the focus of the analysis below.
Uptake: The addressee of satire's ability to comprehend the target (see below) of satire. 39here is little we can do here, aside from gauging Nihell's perception of and response to Smollett's review, as well as Smollett's response to Nihell's response.Without extant texts containing an explicit discussion of Smollett and Nihell's exchanges, it is impossible to determine how the readers of CR responded to either of these authors' texts. 40In any case, such an investigation lies beyond the scope of the current discussion.
Target: The focus of satire.This can be episodic (an event or action in the public sphere), personal (an individual, often generalised to broader stereotypes or archetypes), experiential (more general aspects of the human condition or experience), or textual (aspects of the "linguistic code"), or a combination of these. 41The exchange discussed here is above all personal in nature, first with Nihell and then Smollett finding themselves in each other's respective line of satirical attack.Also at play is the textual, insofar as both authors sometimes comment on each other's use of language choices or argumentation strategies.
Simpson has self-reflexively critiqued this model as being too broad to be applicable solely to satirical discourse. 42However, I disagree and believe that this model's generalisationsalthough perhaps not fully satisfactoryare broad enough to allow application 35 See Whitt, "Language, Labour and Ideology." 36Simpson, The Discourse of Satire, 69-71. 37Ibid., 70. 38Ibid., 70. 39Ibid., 70. 40Although author Philip Thicknesse, in Man-Midwifery Analysed (1763)a short treatise critical of man-midwiferycondemns Smollett's defense of Smellie in MR and CR (4-5).He does not, however, address the particulars of the Nihell-Smollett exchange. 41Simpson, The Discourse of Satire, 71. 42Ibid., 71.across a broad range of time periods and contexts.Properly augmented with other approaches (such as DHA), it serves as a useful apparatus in a larger historical pragmatic toolkit in the analysis of satirical discourse.
On a final note, given that the eighteenth century is generally regarded as the Age of Sensibility or Sentiment, 43 it seems obvious that, when the target is personal, satirical discourse breaches one of the great social values of the era: politeness.Through its unabashed face-threatening acts of word play, satirical discourse can impune one's reputation, related to positive face. 44However, Andreas Jucker is quick to remind us that, during the eighteenth century, politeness itself was an emerging ideology with different face concerns than today. 45Politeness strategies were used primarily for purposes of class identification (with the upper, or at least upwardly mobile, classes, in contrast to the vulgar and base lower classes) rather than for fostering day-to-day pleasantries.Nevertheless, the notions of face and face-threatening acts can still serve as useful concepts when analysing (im)politeness in historical contexts, 46 and where relevant, they will be discussed here as well.

The Nihell-Smollett Exchange
We now turn our attention to a detailed examination of the satirical elements of the exchange between Elizabeth Nihell and Tobias Smollett.Coming in at just under 500 pages, Nihell's text is a polemic against the general unsuitability of medical men involved in childbirth, especially concerning their use of instruments, but also regarding those man-midwives favouring more manual techniques.The first part of the treatise contains a number of self-formulated "objections" about the suitability of manmidwives, the inferiority of female midwives, the benefits of instruments, and other such matters, to which Nihell provides a detailed response.In the second part of the treatise, Nihell details a number of labours and deliveries that went amiss, thanks to the incompetence of man-midwives and their instruments.Throughout the text, Nihell draws on her extensive experience as a midwife to undergird her arguments, both in terms of her first-hand experience and knowledge of other cases.She engages with a number of authors, including not only William Smellie, but also several French and Dutch man-midwives.She is often critical of their practices and recommendations; however, she does not universally condemn their writings and will praise certain authors where she is in agreement with them (although she never seems to agree with Smellie).Nihell's technique both appeals to contemporary sensibilities concerning conventional roles for men and women, and it is also one of reasoned and evidence-based argumentation.Her writing style is noteworthy in its directness and in its use of evaluative lexis; Nihell does not shy away from providing gory details of botched deliveries or describing matters in extreme terms.For example, early in her text, Nihell discusses the general state of affairs: 43 See, for example, Jucker, Politeness, 118. 44Brown and Levinson, Politeness; see also Culpeper, Impoliteness. 45Jucker, Politeness, 120. 46Jucker and Taavitsainen, "Diachronic Speech Act Analysis"; Taavitsainen and Jucker, "Speech Act Verbs"; Alonso-Almeida and Álvarez-Gil, "Impoliteness." Many out of a distrust inspired them of midwives, have thrown themselves into the hands of men, who have promised them infinitely more than they were able to perform; and who behind all the tender alluring words, of superior skill and safety in the employing of them, conceal the ideas with which they are full, of cutting, hacking, plucking out piecemeal, or tearing limb from limb. 47 the one hand, Nihell describes these men-midwives' self-presentation using positively evaluated lexis (tender, alluring) that suggests a placid and affectionate disposition, but then immediately contrasts this using verbs that frame these men's actions in violent, murderous terms (cutting, hacking, plucking, tearing).She acknowledges that female midwives have been "liable to error" 48 and have indeed been responsible for horrific outcomes on occasion, but regarding men, "they are all of them, as will be more fully demonstrated hereafter, naturally incapable of the exercise of this profession". 49It is this thesis which underlies Nihell's argument throughout her treatise.When Smollett published his initial response to Nihell's text in the March 1760 edition of CR, he provided this general assessment: If a pun may be allowed in discussing a ludicrous subject, we would advise Mrs. Nihell to take, for a motto, in the next edition of this work, should it ever attain a reimpression:

Ex nihilo nihil sit!
In the dedication and preface of this curious performance, there is nothing very extraordinary but a few preliminary flashes of that explosion against man-midwives, which makes such a dreadful noise through the whole body of the work, and the author's declaration, that her husband is, unhappily for her, an apothecary: for our parts, we cannot conceive a more natural conjunction than that of an apothecary and a midwife, who, should they club their understandings in order to entertain the public, will hardly ever fail of producing a fine gossiping performance, like that which now lies before us. 50ollett immediately signals the satirical tone of his review by making recourse to a Latinate "pun" which roughly translates "from nothing is nothing".Aside from the clear implicature of rendering Nihell's text worthless, another possibilityespecially given the subject matteris a double entendre referencing female genitalia (men have "something", women have "nothing", cf.Shakespeare's Much Ado About Nothing).Simpson sees the use of negation in metonymic terms, remaining within one conceptual domain (in this instance, textual value, biological sex, or both simultaneously) and presenting an inverse in a ludicrous fashion. 51Nihell's text is worthless, and in a more cynical readingwhat else would one expect proceeding from the mind of a woman, especially in the scientific domain?Smollett then proceeds into the metaphorical by describing this text as a mere "performance" that results in a detonation (flashes, explosion) with unpleasant acoustic affects (dreadful noise through the whole body).Nihell's text is at once embodied, theatrical and combustible. 52Smollett then returns to negation, this time countering Nihell's skittish claims about her husband's profession 47 Nihell, A Treatise, 4. 48 Ibid., 8. 49 Ibid., 8-9; see van Leeuwen, "The Representation of Social Actors," 46-8. 50Smollett, "A Treatise," 187. 51Ibid., with positive polarity, seeing the union as a source of entertainment, noting the potential for a gossiping performance, hence a redeployment of the theatre metaphor and another less-than-subtle disparagement of Nihell's female sex.In a more overt attack on Nihell's positive face (sense of self or reputation), 53 Smollett comments on the latter's intellectual capacities: With respect to our author's ignorance, it might be detected in many articles both of omission and commission … of all the defective treatises on the art, this is the most deplorably deficient.Indeed it appears the author's aim was abuse, not instruction … The very basis of her performance is either a gross mistake arising from ignorance, or a wilful misrepresentation flowing from a worse motive. 54e attack on the treatise continues here (it is defective and deplorably deficient), but there are now more explicit characterisations of Nihell's ability as stemming from ignorance and her motives as abuse due to either said ignorance or a worse motive (which remains unspecified).Through these nomination and predication strategies, Smollett establishes a satirical tone that continues throughout his review. 55e now turn to an examination of specific points of contention between Tobias Smollett and Elizabeth Nihell.Smollett appears to spend most if not all of his review in defending the reputation of William Smellie even though, as stated earlier, Nihell's treatise is not devoted exclusively or even primarily to a refutation of Smellie's arguments.However, in order to see exactly how the Nihell-Smollett exchange plays out, we have to return to Nihell's text and see how she handles disagreement with Smellie.Consider the following, in which she takes issue with Smellie's treatment of the pelvis and recommended use of instruments: Dr. Smellie in his enumeration of the cases, by which laborious labors are occasioned … has intirely omitted this case of obliquity [distortion of the pelvis] … I take to be comparatively infinitely rarer than an obliquity of the uterus … Why then such an omission by these writers?I cannot conceive, unless that they were aware of the consequence, obvious to be drawn from thence, that women, by the superior fitness of their hands, must be the properest to apply the topical remedy; and that their iron and steel instruments could not so well be set to work in such a case … those very lingering labors, I say, which shall have thus arisen from the want of skill or prevention, furnish the men-practitioners with a pretence to dispatch them with their instruments.Thus they, often murderously for the child, and injuriously to the mother, terminate many a delivery, which a gentle and constant reduction of the uterus would have so much more safely and less painfully accomplished. 56 in essence, Nihell accuses Smellie (and others) of focusing excessively on pelvic distortion, a less common phenomenon, while ignoring the far more frequent uterine distortion because the former allows an easier and more straightforward justification for the use of instruments.Smellie's priority here, she argues, is ultimately the promotion of instruments rather than women's health; and even where pelvic distortion is at play, female midwives are fully capable, whereby instrumental interventions generally have resulted in worse outcomes for both mothers and children.To this claim, Smollett responds in his review by making the general claim that there are cases of pelvic 53 Brown and Levinson, Politeness; see also Culpeper, Impoliteness, 155ff. 54Smollett, "A Treatise," 191-2. 55Reisigl and Wodak, Discourse and Discrimination; Reisigl and Wodak, "The Discourse-Historical Approach (DHA)." 56Nihell, A Treatise, 333-5.
distortion where manual intervention simply will not suffice, and that the only way to save the mother and child is through the use of instruments.He continues: Whoever denies this, must either be dead to common sense, or lost to common candour; and may as reasonably affirm, that when a child is born without a perforated anus, it must be left to nature, assisted by the shrewd fingers of the midwife.Whoever understands midwifery in any tolerable degree, must know that in some cases the concurrence of a very narrow pelvis in the mother, and a very large head in the child, render the birth absolutely impossible, without the aid of instruments … Many other examples might be specified, to prove that this female critic either does not speak candidly, or is not at all acquainted with her business in its full extent … we pronounce that she is but half learned in her profession … . 57re Smollett levels a number of positive face-threatening implicatures that, similar to above, draw Nihell's competency into question (whoever denies this, whoever understands midwifery), and then asserts forthrightly she does not speak candidly and is but half learned in the practice of midwifery.A grotesque equivalence is drawn between distorted pelvises and babies born without anuses, 58 and Nihell's own words (shrewd fingers) are repeated in further equivalence of Nihell's (hypothetically recommended) solution. 59ihell responded quickly to Smellie's scathing CR review with the publication of a tract, An Answer to the Author of the Critical Review (42pp.), in which she returns to this particular point: … but I have never had reason either from sense, or especially from my own experience, to form the Reviewer's conclusion from such ricketiness to the distortion of the pelvis.On the contrary, I have delivered many richety women, many outwardly distorted women … but never found that it in the least affected the bones of the pelvis … I own then, that without the least pretention to more anatomy than is competent to my profession, I look on that ingenious argument, in the Reviewer, of bones softened by a rickety disorder … to be absolutely void of foundation, and to be even as false in theory, as I have found it in practice.For the truth however of this, I appeal with due submission to surgeons, not men-midwives. 60 contrast to Smollett, who supports his reasoning with a description of women with pelvic distortions in need of an instrumental delivery in general, hypothetical terms, Nihell draws on her own observations and experience to claim she has never dealt with a case so hopeless as the way Smollett described it.Although her focus is generally on the insufficiency of his claims (the sarcastically phrased ingenious argument which is void of foundation and false), she then resorts to implying a possible lack of expertise by deferring to surgeons, not man-midwives.Smollett then presents a terse response to Nihell's tract in the May 1760 issue of CR, although this will be discussed below after a further illustration is made.
Although the general tone or aim of Nihell's treatise is not satirical in nature, she occasionally makes use of the satirical style in her defenestration of man-midwives. 57Smollett, "A Treatise," 192-3. 58Simpson, On the Discourse of Satire, 139-40. 59See also the discussion of "echoic" irony in Simpson, On the Discourse of Satire, 91ff.Here, Simpson is adopting Sperber and Wilson's distinction between standard irony, where the irony simply appears as is without any previous trigger in the discourse context, whereas echoic irony is the particular use of something already mentioned, modified in some sort of way to achieve the ironic.See Sperber and Wilson, "Irony." 60Nihell, An Answer, 7-8.
Here, she recommends a manual technique of pain relief while simultaneously detailing why men are fundamentally unsuitable for the task: I have myself known women in pain, and even before their labor-pains came on, find, or imagine they found, a mitigation of their complaints, by the simple application of the midwife's hand; gently chasing or stroaking them: a mitigation which, I presume, they would have been ashamed to ask, if they had been weak enough to expect it, from the delicate fist of a great-horse-godmother of a he-midwife, however softened his figure might be by his pocket-night-gown being of flowered callico, or his cap of office tied with pink and silver ribbons; for a I presume he would scare, against Dr. Smellie's express authority, go about a function of this nature in a full-suit, and a tie-wig. 61 this short extract, Nihell makes use of both a grotesque image of a man-midwife as a great-horse-godmother, which crosses domains between human and equine, and a caricature of Smellie's recommended attire for a man-midwife. 62Smollett responds to this point with unabashed ribaldry: 63 How far Mrs.Nihell's shrewd, supple, sensitive fingers, may be qualified for the art of titillation, we shall not pretend to investigate.But those women who are pleased with this operation before the pains come on, may certainly chuse their own operator, without affecting the art of midwifery: we cannot help thinking, however, that in this case the male-practitioner would not be the most disagreeable, unless our author has talents that way which we cannot conceive. 64re Smollett implies both lesbian inclinations on the part of Nihell and a valorisation of sexual prowess on the part of man-midwives; both are in clear breach of contemporary sensibilities.But that is exactly the point.Nihell does not specify precisely where the midwife's hand should chase or stroke the parturient women, although this is presumably in the abdominal region rather than on or near the genitals.And it is Nihell's lack of precision that Smollett seizes on to provide yet another satirical counter-claim to Nihell's oft repeated accusation of sexual impropriety on the part of man-midwives, instead suggesting such impropriety is the domain of female midwives -Nihell especiallyand that any sort of sexual capabilities on the part of men are not the most disagreeable.Smollett is thereby subverting and critiquing the extant and oft-used cultural scripts of midwifery-as-female-art and the sexual taboos surrounding female contact with male medical professionals by bringing an extreme, albeit implied, inversion of these scripts into focus. 65This is done through the use of echoic ironyin direct response to Nihell's textwith seemingly positive predications (shrewd, supple, sensitive) in the service of sexually loaded implicatures, as well as the repeated use of negation (we shall not, we cannot, would not be).In her Answer to the Author of the Critical Review, 61 Nihell, A Treatise, 325. 62As man-midwifery progressed through the eighteenth century, a number of man-midwives adorned themselves in colourful attire with various accoutrements; they sometimes even made themselves confidants of the women they were treating.Nihell offers a retort to this point, also making use of satire and an additional opportunity to further critique the practices of William Smellie: In which passage I own I cannot well pronounce which is the greatest, the modesty of it, or the delicacy of compliment to the women … there is one use to which I hope a true midwife will, for her own sake, as well as for that of her patient, never put her fingers, though the practice of it is recommended by Dr. Smellie, in more parts than one of his work, I mean, the practice of running the fingers up the fundament or anus [direct quote from Smellie's treatise omitted here] … But how such a thought could enter into a man's head I cannot conceive, as thrusting his fingers there, for any beneficial purpose.In the first place, it can be absolutely of no service, and may do infinite mischief: to say nothing of the torture to which it must put the woman, especially if she should happen to have … the hemorrhoids.In short, I do not conceive that there can be imagined a more nauseous, ridiculous, cruel, absurd management; and if such are the triumphs of the men's learning over the women's ignorance, may the women continue their ignorance still of such curious practice! 66 Nihell employs echoic irony here as well, signalled graphologically through her own use of italics in describing Smollett's text (directly quoted in her response) as modest and a delicate compliment to women.But she then proceeds to counter Smollett's argument with an example of manual intervention she genuinely finds objectionable: Smellie's recommendation of digital anal penetration in assessing a child's position in the uterus.Unlike Smollett, however, she counters this in very literal, non-ironic and non-satirical terms.Where she objects to something, for example, she uses negatively evaluated lexis (nauseous, ridiculous, cruel, absurd).Her use of negations may mirror Smollett's (I cannot/do not conceive), although here it is meant literally and not ironically.There is one script inversion at the end, however, when Nihell ameliorates the oft-made description made by some man-midwives of their female counterparts' ignorance, transforming it into a virtue of being able to avoid the cruellest of these man-midwives' techniques.Thus reads most of Nihell's Answer to the Author of the Critical Review, countering Smollett's review point-by-point with sustained argumentation against the particulars of critique levelled in the CR.There is certainly some degree of satire present in this text as well (all echoic in nature), though not as extensive as in Smollett's original review.The exchange did not end here, however, as Smollett provided another review in the CR (May 1760), this one of Nihell's Answer (although much briefer, repeated here in its entirety): Pray be easy, good madam, we are ready to grant whatever you require; even to acknowledge that your tongue is sensible, shrewd, and voluble, as thy fingers.It was never our intention to enter the lists with a lady, especially with a lady of your profession of whose skill in the weapons of altercation we could not be ignorant.We confess that you have here brought to light, forty pages of profound argumentation, which, hackneyed as we are in debate, we cannot pretend to answer in less than as many volumes and had you have delivered yourself of a monstrous birth, that fully evinces your dexterity in the obstetric art: may it, however, be the last of our begetting!Heaven preserve us from the heinous crime of fornication!What a snarling, tattling, gossiping urchin must that be, who owns a critic for his father, a midwife for his mother, and an apothecary, perchance, for his sponsor, or, what is worse, a grub, who feeds and fattens on the spoils of character and fair fame?Withold thy insnaring arts good Mrs. Nihell!Tempt not frail virtue, and provoke not appetites 66 Nihell, An Answer, 18-20.
treatises of the eighteenth centuryincluding those written by womentended to focus on their own observations and experiences alongside instruction, Nihell's treatise, as a polemic against the use of instruments and man-midwifery more general, instead provides detailed arguments against instruments and men in the birthing chamber and examples or case studies are mustered only to support these broader arguments.The treatise rarely if ever orients itself as an instructional text.Nihell may well be aiming to distinguish herself as a competent midwife, but this was probably more to position herself as a credible critic of instruments and man-midwifery, whereby her actual promotion was of female midwives more generally.

Concluding Thoughts
This discussion has provided a snapshot of how medical discourse surrounding a controversy can enter the domain of the satirical, often believed to be confined to the purview of literature.The advent of instruments and man-midwifery went hand-in-hand, and the treatises published during the eighteenth century featured every possible position on the matter (pro/anti-instrument, pro/anti-man-midwife, pro/anti-female midwife, pro/ anti-professional collaboration between men and women), although it remains to be seen how often the discourse entered the domain of the satirical.None of the treatises themselves can be said to be satirical in nature, and what we have seen here probably depends more on the emergent book review culture and the literary connections of Tobias Smollett than it does with midwifery itself.Still, what remains to be seen is the degree to which satire featured in the broader controversies surrounding midwifery during the eighteenth century.That is, while satire might be absent in the treatises themselves, is it present in published reviews of other midwifery treatises, and where any other treatises met with as forceful a resistance as Nihell's?In particular, what responses did the other eighteenth-century female midwives such as Margaret Stephen or Jane Wright who published (non-polemical) treatises after Nihell encounter?The answer lies beyond the scope of this paper, although future research could make use of British Periodicals database to track how these other treatises were received in the review publications, 73 as well as the general stylistic orientation these reviews took.More broadly, the place of satire in historical medical discourse has yet to be examined in any substantial detail.There are certainly indications Smollett made use of the techniques discussed here elsewhere in his treatment of health and medicine in both literary and non-literary contexts, 74 although the more general connection between satire and medical discourse is less understood.The current study suggests that medical controversies in particular prove a fruitful starting point, given that contested ideologies are at the heart of both controversies and satire, and there is certainly a need for a better understanding of how such controversies play out in textual-linguistic termsespecially where they impact on current practice.

Disclosure Statement
No potential conflict of interest was reported by the author(s).

2Simpson,
On the Discourse of Satire.