Sir, - I read with interest the letter from Peter Boylan and Tony Farmar (October 6th) on my article (Health, September 6th) about 1950s midwifery practice in the National Maternity Hospital.
The Boylan/Farmar letter asserts that the real motive for the introduction of symphysiotomy as an alternative to Caesarean section was concern for maternal mortality rather than Catholic ethics. I can only refer them to Dr Spain's pioneering article on this subject, in which he asserted his complete confidence in the safety of the Caesarean section even when done repeatedly on the same woman, but went on to say: "It will, however, be a long time before such a method of delivery will be accepted by the profession or by the community at large. The results will be contraception, the mutilating operation of sterilisation, and marital difficulty. . ."
Arthur Barry's argument was couched in similar terms. He is quoted by Tony Farmar as saying, in an address to the Sixth International Congress of Catholic Doctors: "The Caesarean is probably the chief cause for the practice by the profession of the unethical procedure of sterilisation, and furthermore it is very frequently responsible for encouraging the laity in the improper prevention of pregnancy or in seeking its termination."
The debate on symphysiotomy in Ireland was not focused on the question of maternal mortality; no figures were referred to or assembled that might have supported such an argument. Repeatedly in discussion, the doctors in question referred back to this perceived Catholic ethical basis for symphysiotomy.
Regarding infant mortality, Dr Barry freely discussed the matter and accepted that the symphysiotomy operation carried a greater infant mortality than the Caesarean section alternative. He estimated the infant mortality for symphysiotomy to be 10 per cent. Opponents of the operation also mentioned the risk of brain damage to surviving infants.
Of course, as the authors of the letters said, it is not surprising that doctors were influenced by their religious views, and perhaps by those of their patients. It would have been more surprising if they were not. The doctors in question were men of their time. They held the religious certainties of 1950s Ireland, and these certainties informed their consciences and their practice. They felt it their duty to counter practices in medicine that seemed to contradict their deeply held ethical views.
Dr Barry's opposition to the introduction of a clinic to Holles Street hospital giving "safe period" contraception advice in 1963 is another example. I doubt if any of the doctors in question would feel that the fact of pointing out their religious convictions and motivation was in any way a "denigration".
Dr O'Driscoll did indeed point to the over-diagnosis of disproportion, but it is noteworthy that in dropping symphysiotomy as advocated by Spain, Barry and others, he dropped it completely. No exception was made for any rare cases of disproportion which might arise. Nowhere since has symphysiotomy been adopted in the manner proposed in the 1950s.
Dr O'Driscoll stands out in particular for his application of scientific analysis to the data in question. To a modern reader, the way in which the symphysiotomy operation was introduced widely without small-scale trials or comparative studies seems particularly striking. As Tony Farmar himself said of Arthur Barry's arguments for symphysiotomy: "...his argument is a classic display of how personal predilections and medical evidence were used in obstetrical discussion, that is, before fully scientific studies such as that initiated in Holles Street by Dermot McDonald in the 1970s. ..became common".
On the other hand, it is clearly true that this was the common practice in obstetrics of the time, not confined to doctors of any specific nationality, religion or hospital. Ann Oakley, a sociologist who has made a study of this area, has made a long list of procedures that were introduced into obstetric practice in Britain without systematic evaluation of their effectiveness. The list encompasses many procedures routinely followed in British and Irish hospitals. - Yours, etc.,
Jacqueline Morrissey, Women's Educational Research and Resource Centre, UCD, Dublin 4.