Sudden Infant DeathSudden Infant Death

Prosecutorial zeal, intellectual arrogance, scientific uncertainty—a fascinating admixture, indeed! These elements are documented extensively in The Death of Innocents, a thoroughly researched and meticulously detailed historical account of several instances of multiple infant deaths in each of three families in upstate rural New York during the 1960s, 70s, and 80s. The principal incidents portrayed in this book relate to the deaths of five children of Tim and Wanda Hoyt between 1964 and 1971, all of which were originally ascribed to sudden infant death syndrome (SIDS). The authors, husband and wife award-winning journalists, use the extensive investigation of these bizarre deaths and the eventual murder conviction of Wanda Hoyt in 1995 as a vehicle for an in-depth historical review and analysis of SIDS research in the United States during the last two decades.

In October 1972, the journal Pediatrics published an article by Alfred Steinschneider, MD, PhD, entitled "Prolonged Apnea and the Sudden Infant Death Syndrome: Clinical and Laboratory Observations." The author theorized that prolonged apnea was the major physiological component leading to these inexplicable deaths, and that "infants at risk might be identified prior to the final tragic event." The presentation of this concept in such a prestigious medical journal soon spawned a large industry of home monitor manufacturing. By 1990, it was estimated that 60000 babies throughout the world were hooked up to such monitors with sales surpassing $40 million, 65% of which was accounted for in the United States. Ironically, by that time, the vast majority of SIDS researchers and clinical experts had concluded that apnea was not a proven etiological factor in SIDS, and, therefore, the use of home monitors was a needless expense and, more important, a source of false hope and unwarranted comfort for parents whose infants for one reason or another were considered to be at risk. Still, Dr Steinschneider persisted in defending and advancing his apnea theory and succeeded in obtaining large federal grants at different academic institutions for his extensive research projects. Ultimately, at the Hoyt murder trial in 1995, he was confronted with overwhelming evidence that in some of the families with two or more deaths originally attributed to SIDS (including several individual cases that he had personally reviewed), the deaths were almost certainly the result of homicidal suffocation.

A dramatic awakening regarding these inexplicable infant deaths occurred in 1977 when a British pediatrician, Dr Roy Meadow, adduced substantive clinical information that led to his coinage of a phrase in Lancet that year in an article entitled "Munchausen Syndrome by Proxy: The Hinterland of Child Abuse." (Another British physician, Dr Richard Asher, had first advanced the concept of Munchausen syndrome in 1951 for people who invented or contrived their own illnesses to gain attention and sympathy.)

Firstman and Talan do not limit their criticism to Steinschneider among SIDS physician-researchers and scientists. Their exhaustive study of the manner in which this lingering medical mystery has been seized upon by various prominent figures for self-aggrandizement, academic recognition, and solicitation of direct or indirect funding for local empire building is highly revealing and quite deflating to say the least. For example, Dr Richard Naeye, the chairman of pathology at the Milton S. Hershey Medical Center, had published his findings in the New England Journal of Medicine in 1973, in which he claimed to have discovered the cause of SIDS. Subsequently, no other researcher was able to replicate Naeye's findings, and his so-called seven tissue markers joined Steinschneider's apnea theory on the pile of discredited etiological explanations for SIDS that were initially proclaimed to the world with much publicity and no equivocation.

It is also significant and relevant to note that several forensic pathologists in medical examiner's and coroner's offices, as well as some eminent pediatric pathologists, had either performed the original autopsies in a few of these cases or subsequently reviewed the microscopic tissue slides, postmortem protocols, medical and hospital records, social and family reports, and, in some instances, police investigative reports. All of them over many years had failed to note or even suggest the possibility of foul play.

In October 1997, Pediatrics published an editorial¹ that repudiates the Steinschneider study of a quarter of a century ago and laments the damage done to SIDS research as a result. A supplemental commentary² excerpts notices about The Death of Innocents, and the editorial urges its subscribers to read the book. Studies continue to reassess spurious SIDS.^{3 - 4}

The American Academy of Pediatrics, "reversing long-held conventional wisdom, had recommended the new sleep position in 1992, after concluding that studies around the world had demonstrated an association between SIDS and the prone position." In June 1996, the National Institute of Child Health and Human Development announced that "in the four years since American pediatricians had begun instructing parents to put their newborns to sleep on their backs or sides rather than on their stomachs, the SIDS rate had plummeted 30 percent." This is the first significant decrease of these tragic deaths ever officially noted and represents an estimated 1500 infant lives saved each year. Will this trend continue and be substantiated in future years? We can only hope so.

In the meantime, as a result of the Hoyt case (and the Van Der Sluys case in 1986, and the Tinning case in 1987, each of which involved three dead infants), there has developed a "maxim in forensic pathology: One unexplained infant death in a family is SIDS. Two is very suspicious. Three is homicide." This is dangerous and scientifically shaky dogma. Each and every case of sudden, unexpected death of an infant (just as with a child or adult) should be carefully and thoroughly evaluated by a fully trained, experienced forensic pathologist. If no plausible cause of death can be ascertained, then other circumstances and factors can be considered and given some credence. But after all, just as one death in a family may have been a case of infanticide, so two or three deaths in the same family do not automatically mean that the babies were homicidally smothered. There is still a presumption of innocence until proven guilty in America—suspicious police, prosecutors, and pathologists notwithstanding. Few knowledgeable people involved in these cases believe that homicides account for more than 1% or 2% of all SIDS cases.

The harsh truth and sad fact are that as we prepare to move into the next millennium, we still do not know why thousands of seemingly normal, healthy infants die suddenly and inexplicably, without any clinical warning whatsoever. SIDS is perhaps the greatest single medical mystery confronting scientists. It is no wonder or surprise, therefore, that The Death of Innocents , with homicides and courtroom battles thrown in for extra flavor, is such a fascinating and provocative book.

When Pierre the lascivious priest amorously propositions a beautiful young widow named Beatrice who comes to his church, she reacts pragmatically: "What if you make me pregnant?" He replies, "I have a special herb."

Pierre's and Beatrice's testimony, introducing Eve's Herbs , is especially important to the history of contraception and abortion because it comes from an unimpeachable Inquisition court transcript from Montaillou, France, dated 1320. The exuberant sexuality of the renegade priest and lover teaches us what legal adversaries thought about the same sexy subject. A man's professional requirement for successful contraception, often as significant as a woman's, forced him to initiate birth control. "Ordinary" people, not simply the powerful, regulated fertility by chemistry.

Eve's Herbs depends on legislation, court transcripts, medical texts, pharmacology books, philosophical disquisitions, theological treatises, historical artifacts, and other valid documents of the past. Dr Riddle demonstrates, as in his earlier Contraception and Abortion From the Ancient World to the Renaissance (Harvard University Press, 1992), that knowledge about fertility control existed and women had access to it lost to them in modern times.

Both proabortion and antiabortion advocates equally will find these books important, instructive, and maybe prescriptive. Law influences medicine. Law motivates a culture to unlearn what it has known. When vigilance sleeps, mischief works.

Without political polemic, Riddle proves the following: (1) Successful contraception and abortion are not modern phenomena. (2) Women and men in ancient Greece, Rome, Egypt, medieval and Renaissance Europe, and colonial, Victorian, and modern America wanted to control childbirth by law, chemistry, and physical acts. (3) In all these times and places a huge pharmacopeia of herbal abortifacients and contraceptives prevented pleasures of sex from producing unwanted babies. (4) Knowledge existed and was "lost." (5) National politics, medical organizations, and churches wrested control over fertility from women, midwives, and "wise women" and transferred it to physicians. (6) Legislation and litigation, such as the 1873 Comstock Law, criminalized birth control as obscenity. (7) Criminalization of knowledge of contraception and abortion by prosecuting early midwives as witches, and by later legislating abortion as criminal felony, created politically correct ignorance.

A scholarly sleuth, Riddle permits historical texts to speak. Does the Hippocratic Oath prohibit all abortions or only abortion by pessary? What did medieval and Renaissance physicians know about abortion and contraception? What is our American "tradition" of fertility regulation? Were Victorian attitudes toward birth control as tightly laced as women's corsets? Did Catholic clergy always say "Never!" to abortion? What about Protestants? Jews? Was there a Golden Age when women and men coupled only to breed or only to delight? What did pre-20th century women (rich or poor, young or old, married or single, urban or rural, learned or unlettered) know about regulating conception? Did methods work? What did physicians know? Did politics always control bed behavior?

Riddle argues that the long chain of abortion and contraception knowledge from antiquity to the present essentially was forged with invisible links made from female vocal cords. Orally transmitted knowledge became women's secrets, first persecuted as woman-craft, later viciously prosecuted as witchcraft. Church, medical, and political institutions claimed, then gained, control over women's bodies. Yet information about fertility control seemingly lost after the 16th- and 17th-century witch trials survived to modern times as coded secret knowledge, passed from woman to woman. Folk tradition still transmits it.

Early contraception and abortion knowledge of midwives and "wise women" agitated rationalists and scientists who deplored women's knowledge as dangerous, magical, and unscientific. The church, prosecuting midwives as witches, took control from women over private beds and birthing chambers. Early medical and surgical guilds, and, later, the American Medical Association, eliminated midwives' strong competition for women patients.

The long sexual record merits reading. Almost 2000 years ago Juvenal wrote, "we have surefire contraceptives." He was not lying. Historians customarily assuming that antiquity's antifertility agents could not have worked erroneously concluded they did not. But the classical, medieval, and Renaissance brilliance that built aqueducts and bridges, cathedrals and castles, and composed masses, madrigals, and magnificent monuments to intellect in philosophy, theater, and theology also created contemporary medical recipes and case histories of contraceptives and abortifacients. These were not charlatanry or empty hope. They successfully regulated conception and birth.

Riddle integrates modern chemical, pharmacological, and medical confirmations that what the ancients said worked probably did. Most premodern plant and mineral estrogenic and biochemical properties were as potent then as now. Now we can explain chemical effectiveness that was earlier only empirically understood. When tested in modern labs, some historical substances disrupt or desynchronize preovulatory and preimplantation events in animals and human beings. Variously exerting antifertility effects chemically, some are isoflavones or uterine contractors or estrogenic steroids that act on the hypothalamus and pituitary gland or prostaglandin stimulants inhibiting sperm transport or uterine implantation. Since antiquity, people have known how to upset the delicate hormonal balance necessary to postovulatory reproduction.

Dramatic drops in birth rates occurred in classical antiquity and the Middle Ages. Nine factors could have enabled men and women to control births: sexual restraint, late marriage, coitus interruptus, condoms, nonfertile intercourse (oral, anal, or homosexual), the rhythm method, infanticide, oral or vaginal contraceptives, and abortion. Riddle brilliantly highlights contraception and abortion.

He courageously confronts basic textual questions. What does Hippocrates' oath prohibit? Who swore that oath? Hippocrates prohibited abortion by suppository or pessary. Hippocrates expressly did not forbid abortion by mechanical means or by surgery or by abortive drugs. Accidentally or intentionally, the oath proscribing an abortifacient pessary has been transmuted to a total ban on abortions.

Classical prescriptions distinguish among abortifacients terminating pregnancy and agents that produce abortion: ecbolics, oxytocics, and emmenagogues. An emmenagogue provoked menstruation whether or not a fertilized egg was present and whether or not implantation occurred. Abortifacients included any agent that interfered with ovum transport, before or after coitus, and that prevented or impaired implantation.

Dioscorides in De materia medica distinguishes among contraceptives, menstruation provokers, and abortifacients. He further classifies plants for drying out the menses, purging the afterbirth, killing an embryo, and aborting the conceptus. Dioscorides and the physician Soranus agree on the powers of such emmenagogues and abortifacients as artemisia, cardamom, fenugreek, iris, laurel, lupine, myrrh, opopanax, pepper, rocket rue, wallflower, and wormwood. Soranus recommends the oral contraceptive and abortifacient Cyrene Juice, from the plant silphium. It made the Greek city of Cyrene in North Africa rich and famous. Popularity probably drove silphium to extinction.

Modern scientific curiosity about old drugs can lead to valuable new products. Pharmaceutical companies pay me handsomely to lecture to their scientists on medieval and Renaissance drugs. Beyond exuberant intellectual adventure, my audiences expect possible practical direction. Drugs thought efficacious in the past might profitably be synthesized today.

Ancient law and literature preserve abundant references to abortion and contraception in the writings of Plautus, Juvenal, Ovid, Philo, Lucretius, and Seneca, as well as such early Christian writers as Clement of Alexandria, John Chrysostom, Lactantius, Ambrose, and Jerome. Classical court cases and legislation restricting abortion never refer to a fetus's "rights" but rather the rights of the parent deprived of an heir.

Scholarly Bishop Macer's 11th century influential herbal De virtutibus herbarum describes medical qualities of 71 plants. He lists menstrual regulators, abortifacients, and contraceptives. Artemisia stimulates menstrua and expels a conceptus. Among menstrual stimulators he includes southernwood, wormwood, betony, camomile, fennel, lily, chervil, mustard, marjoram, thyme, peony, cinnamon, and spikenard. Spearmint is a good contraceptive applied directly to the womb before coitus.

The German physician canonized as Saint Hildegarde of Bingen enumerates in De simplicis medicinae seven plants as emmenagogues or abortifacients including tansy, oleaster, and nasturtium for a woman not menstruating for "so long a time that it hurts." Another 12th-century woman physician and medical writer, Dr Trotula of Salerno, recommends artemisia wine as an abortifacient or, if that fails, a potent drink combining hemlock, castorene, artemisia, myrrh, century plant, and sage.

Popular medieval antifertility plants such as artemisia, myrrh, pennyroyal, rue, squirting cucumber, and, especially, Queen Anne's lace, endure today as folk abortives. Rural North Carolinian women "wishing not to be with child" after sexual intercourse drink a glass of water mixed with a teaspoonful of crushed seeds of Queen Anne's lace. In mice, rats, guinea pigs, and rabbits, Queen Anne's lace seeds apparently via terpenoids prevent ovum implantation, inhibit ovarian growth, and disrupt the estrus cycle.

As a child I learned to chant a traditional English nursery rhyme celebrating Queen Ann's lace while bouncing a ball. One lifted a leg over the ball at each line's last words without breaking rhyme or rhythm:

Queen Anne's Lace
Saves women's place.
I love that flower
To keep my power.

Politically vulnerable ideas have fragile mortality. In England and America the church fought both contraception and abortion in various periods with more or less intensity. But separation of church and state enabled secular authorities to tolerate what the church would not. However, in the 19th century, federal and state governments criminalized abortion and contraception. Women "forgot" what they knew. Midwives forgot their inherited lore when they were pushed out of birthing chambers into ignominy, dishonored by accusations of superstition and stupidity. Scientifically trained physicians, almost all men, taught to disdain folk medicine and "old wives' tales," probably never learned enough about fertility control to forget.

England's Ellenborough Act of 1803 made abortion illegal. Physicians risked professional license and personal freedom for giving abortifacients. Drug contraceptives virtually disappeared from British medical literature.

America's federal Comstock Law of 1873 and later state laws transformed the commercially successful market for contraception and abortion information, products, and services into a clandestine industry. Forgetfulness of fertility control was expedient when state laws called "Little Comstocks" prohibited dispensing, advising, and publishing of any recipes or prescriptions (as a Colorado statute stated) for drops, pills, tinctures, or other compounds for contraception or abortion. Louisiana law forbade sale or advertisement of any drug or nostrum exclusively "for the use of females." "For the use of females" or items "important to ladies" in laws were code phrases for birth control. Clandestinely, birth control thrived. "Folk" remembered because some folk won't sway when political winds change.

These momentous books demonstrate that antiabortion and anticontraception laws were not integral to earliest American tradition. European and Colonial American women and men used venerable techniques for contraception and abortion traceable to antiquity. Both knowledge and use were criminalized in the 19th century. Late Victorian attacks on midwives controlling fertility attempted to complete the unfinished medieval and Renaissance trials of secret knowledge of witches.

In 10 chapters and a very useful introduction by Geoffrey Cocks, this collection brings together some of the best recent scholarship about the rise and spread of an increasingly professionalized and scientific medicine that has had a profound influence around the world. As indebted as we are to Rudolf Virchow, Robert Koch, et al, the tragedies of two world wars begun by Germany and the horrors of the Holocaust are never far from our consciousness, and to the credit of the scholars represented in this book, those tragic events are not far from their work. Like a black hole, as Geoffrey Cocks notes in the introduction, everything eventually is drawn toward the events during the Third Reich.

The essays are arranged in chronological order, beginning with Johanna Blecker's discussion of hospitals and care for the poor, 1820 to 1870. This was the half century before the startling discoveries in bacteriology, but what Blecker shows is that physicians began to make increasing use of hospitals both for practice and for their teaching and research, prior to the advent of the more scientifically based medicine of the late 19th century.

Alfons Labisch writes about German health insurance between 1883, when Bismarck coaxed the Reichstag into some social responsibility, and 1931—though, as Henry Sigerist noted more than 50 years ago, Bismarck's motives were more fueled by political control than by social amelioration.

In a historiographic article, Richard Evans, the author of an important book about the 1892 cholera epidemic in Hamburg, traces the concept of social Darwinism in Germany. Evans notes two phases. The earlier, in the 1860s and 1870s, was tied to evolutionary thought, in which mutual aid was as prominent as ruthless competition. A later phase, in the 1890s, superseded the earlier version and stressed the struggle for the survival of the fittest. A vulgarized form of this Darwinism came forth as Nazi ideology. But one should certainly not blame the horrors of the Nazis on Charles Darwin. Social Darwinism, Evans notes, was not even popular among most Nazis or the German middle classes. What is interesting for the reader of this essay is that Evans nicely summarizes how contending historical explanations take shape and are defended.

Charles McClelland, whose The German Experience of Professionalization: Modern Learned Professions and Their Organization From the Early Nineteenth Century to the Hitler Era (1991) is a standard source, here asks whether there was not also some failure of professionalization and socialization. This question becomes especially important in the 1930s, when many German doctors seem to have been drawn to National Socialism. Were the German doctors more anti-Semitic than those elsewhere? The many Jewish physicians in Germany were deprived of their right to practice in the mid 1930s. While it is tempting to say there was a failure of professionalization because we know how the story ended so tragically, are those American physicians who limited Jewish medical school admissions in the 1930s similarly to be seen as a failure in professionalization? It is an intriguing question.

Two chapters about the treatment of psychiatric patients and two about the politics of abortion and sterilization tell us much about the social, political, and economic conditions in which medicine in Germany developed. The whole question of sterilization and euthanasia, their historical and political meaning, as Gisela Bock notes, continues to be contested.

Geoffrey Cocks provides a succinct summary of the Nuremburg Trials. He notes that the main ethical lesson we have learned from the Doctors Trial concerns the dangers of social corporatism. By this he means an exaggerated sense of duty and conformity, bordering on fanaticism. It seems the doctors in the camps followed orders with a vengeance.

The final chapter of the book is about what Michael Kater, whose 1989 Doctors Under Hitler has become a standard source for medicine and the Third Reich, here describes as the unwillingness of the German medical profession to acknowledge Hans Joachim Sewering's deep involvement with Himmler's SS and the Nazi Party as early as 1933 when he was a medical student. Yet nearly six decades later the Germans pushed for and were successful in Sewering's election as president of the World Medical Association. Kater probes the deftness with which Sewering was able to rise in the postwar German medical establishment. His success, of course, says even more about his colleagues' willingness to look the other way as it does about his own political skills. Alas, the German gift for denial seems unabated.

We have, then, very rich fare. Medicine and Modernity brings recent German medical history to life, making it conveniently available for readers not able to read the growing literature in German. If there are any lessons in history, this collection may be a good place to look for them.

Every physician knows the frustration of seeking information in a number of textbooks with incomplete and confusing indexes while patients are waiting. Now, with a few keystrokes, data are quickly available to practitioners in one CD-ROM: MAXX: The Electronic Library on CD-ROM contains Little, Brown Spiral Manuals covering over 20 specialties, and the numbers are increasing. Included also is the US Pharmacopoeial Convention's Drug Information, volume 1.

Installation of the program is standard, short, and easy. However, each quarterly update has to be reinstalled, which the publisher omits mentioning in the manual, and the new versions come with no instructions at all. More frustrating, in order to update, the previous database usually has to be erased. An "uninstall" icon is included, which removes most of the program but leaves traces in the hard disk, a nuisance. Finding the data from the disk could be more user friendly. Most of us with intermediate computer knowledge are accustomed to running a program by intuition, but this CD-ROM forces the physician to study the manual. Although short (20 pages), it still is an irritating waste of time.

To add to the annoyance, I found the database freezes easily when one presses the wrong icon, necessitating rebooting. Several blank pages confront the user. Backtracking through the pages is difficult. A simple "previous page" command would have been more practical, rather than "backtracking" and "trail" buttons, neither of which works very well.

After the initial problems, searching the database is rewarding. The material is presented in a comprehensive and clear manner and does not leave a practitioner without information. The hits are listed neatly by specific book. Queries can be accomplished by various methods, using phrase, proximity, wildcard, and Boolean searches. For fast answers, simple word or phrase queries of the entire database are most feasible. One can also read individual books from cover to cover—a simple convenience that many CDs have neglected to include.

The quality of the x-ray images is fair, about the same as in standard textbooks. With CD-ROM technology, it could have been better. Color plates in the dermatology section are somewhat dull and don't compare well with regular textbook photos.

Booknotes, "sticky notes," and highlights are available, but they are lost with every update, which severely limits their usefulness.

All in all, the program is comprehensive but user unfriendly. Technical support is good, by both e-mail and telephone, although a toll-free number is not available. At this time, I am not aware of any comparable software, so MAXX will remain in my office CD drive.