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What a Blessing She Had Chloroform: The Medical and Social Response to the Pain of Childbirth from 1800 to the Present

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Overview

This book describes in fascinating detail the history of the use of anesthesia in childbirth and in so doing offers a unique perspective on the interaction between medical science and social values. Dr. Donald Caton traces the responses of physicians and their patients to the pain of childbirth from the popularization of anesthesia to the natural childbirth movement and beyond. He finds that physicians discovered what could be done to manage pain, and patients decided what would be done.
Dr. Caton discusses how nineteenth-century physicians began to think and act like scientists; how people learned to reject the belief that pain and suffering are inevitable components of life; and how a later generation came to think that pain may have important functions for the individual and society. Finally he shows the extent to which cultural and social values have influenced "scientific" medical decisions.
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Editorial Reviews

Library Journal
The use of anesthetics to alleviate pain associated with childbirth is controversial. This book, written by a physician specializing in obstetric anesthesia, is an attempt to understand and explain women's reactions to this pain. He explores several interesting subjects in the process. The development of anesthesia occurred during a period of political, social, and scientific change. Physicians had to learn to think like scientists as they mastered the use of a new tool. The social reactions to childbirth were also changing as the feminist and suffrage movements liberated women from religious doctrines associating pain with sin and punishment. The interaction between medical practice and social values, between physicians who see pain as a scientific problem and women who view childbirth as a social, political, and/or personal issue, is fascinating. Physicians discover what can be done, but patients decide what will be done. Unlike Judith Leavitt's Brought to Bed 1986, which discusses the history of childbearing in America, this book deals with the development of anesthesia, its use in childbirth, and the colorful personalities involved in these events. Recommended for health science, medical history, women's studies, academic, and large public libraries.--Barbara M. Bibel, Oakland P.L., CA Copyright 1999 Cahners Business Information.
Perri Klass
The book's foremost strength is its intelligent combination of the science of pain relief - which remains one of the great gifts of modern medicine - with a rich matrix of social history.
The Wilson Quarterly
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Product Details

  • ISBN-13: 9780300075977
  • Publisher: Yale University Press
  • Publication date: 6/28/1999
  • Pages: 308
  • Product dimensions: 5.50 (w) x 8.50 (h) x 0.81 (d)

Read an Excerpt




Chapter One

The position of woman in any civilization is an index of the advancement of that civilization; the position of woman is gauged best by the care given her at the birth of her child." So wrote H. W. Haggard in 1929. If so, western European society made a significant advance on January 19, 1847, when James Young Simpson, a Scottish obstetrician, administered diethyl ether to facilitate delivery of a child to a woman with a deformed pelvis. This is the first known administration of anesthesia for childbirth. On the same day, Simpson received notice of his appointment as Queen Victoria's "Physician in Scotland." A comment to his brother shows the relative value that Simpson placed on the two events: "Flattery from the Queen is perhaps not common flattery, but I am far less interested in it than in having delivered a woman this week without any pain while inhaling sulphuric ether. I can think of naught else." Considering everything that had happened to Simpson that day, his lapse in syntax is understandable.

    Simpson recognized the medical and the social implications of his achievement and what it offered women. Descriptions of labor pain have always been heartrending. The author of the Book of Jeremiah, for example, notes the "cry of a woman in travail, the anguish of one bringing forth her first child, gasping for breath, stretching out her hands crying `Woe is me!'" Homer in The Iliad refers to "the sharp sorrow of pain [that] descends on a woman in labour, the bitter ness that the hard spirits of childbirth bring on." Comments from modern authors are no less moving. The novelist DorisLessing describes how "the warning hot wave of pain swept up her back [and] she entered a place where there was no time at all. An agony so unbelievable gripped her that her astounded and protesting mind cried out it was impossible such pain should be. It was a pain so violent that it was no longer pain, but a condition of being." The poet Sylvia Plath described labor as a "long, blind, doorless and windowless corridor of pain waiting to open up and shut her in again," and the poet Judith Hemschemeyer calls the delivery "that moment when I knew if I pushed I would die and if I didn't push I would die but it would still be inside me." Simpson's innovation offered women an opportunity to avoid an extremely painful experience.


Ether: A Tale of Three Cities


The sequence of events that prompted Simpson to administer ether had started just a few weeks earlier. On October 16, 1846, William Thomas Green Morton, a dentist in Boston, gave the first successful public demonstration of a modern anesthetic for surgery in a room at the Massachusetts General Hospital, now preserved as the "ether dome." News of Morton's success traveled quickly. Within two weeks a description appeared in the Boston Medical and Surgical Journal. One man who had witnessed the event, Dr. Jacob Bigelow, wrote to Francis Boott, an expatriate American physician practicing in London. By December 19 Boott and James Robinson, a dentist, had designed an apparatus to administer ether and had used it for a tooth extraction. Two days later in London the surgeon Robert Liston used ether to anesthetize a man for amputation of an infected leg. Simpson knew Liston, having worked for him as a wound dresser when Simpson was in medical school. On December 26 Simpson traveled to London to speak with Liston about ether. Presumably Simpson used this information three weeks later when he anesthetized his obstetric patient in Edinburgh. Not a person to hide his accomplishments, Simpson promptly described the delivery in an article that appeared in March 1847.

    The interval between Morton's demonstration of ether for surgery and Simpson's application of it for obstetrics barely exceeded three months. Given the ship-borne communications of the day, physicians disseminated the news and acted on it with extraordinary speed. Simpson, too, responded quickly. He and the others hardly had time to assimilate the information, much less test it, before they began to use ether in their practices.

    The incorporation of anesthesia into medical practice appears especially rapid when compared with the slow and methodical testing procedures of today. The difference reflects changes in medicine over the past century and a half. Contemporary medicine is a highly technical multidisciplinary field. Physicians undergo extensive training in science, mathematics, statistics, and the critique of scientific papers. Not only do private and government organizations oversee and regulate all aspects of medical care, but the public also questions drugs and testing procedures.

    In 1847, however, training in science and in critical analysis was not part of medicine. Medicine as we now know it had hardly taken shape. Physicians were only a few decades from medical theories inherited from the ancient Greeks. Physiology, pharmacology, and pathology were in their infancy, and the bacterial origin of disease was unknown. Except for a handful of progressive schools, medical education consisted of an unstructured apprenticeship or a stint reading medical textbooks. No rules or conventions governed the testing of drugs. Anyone could tout the miracles of a new therapy to a public that had little experience evaluating such claims. Anesthetics were among the first potent drugs that physicians or the public had to evaluate.

    Events in Boston, London, and Edinburgh presented a formidable challenge. For the first time physicians had an effective way of obliterating pain, something everyone had ostensibly wanted for centuries. But physicians suddenly felt compelled to ask whether it was wise to use that power. As they soon would learn, various answers had social and religious implications. The use of anesthesia for obstetric pain proved to be especially vexatious, and physicians and patients responded in every way possible. Some called anesthesia "God's gift." Others considered it a needless danger and even an abomination. These differences were eventually reconciled, but not without rancor and debate.

    Simpson was an active participant in the debate. He not only introduced anesthesia to obstetrics but almost single-handedly effected its use, and for this he deserves great credit. Medical historians who assert that no other physician could have done this as quickly or as well cite his professional stature and extraordinary personality as factors critical in his success. No less important was the character of the times. In 1847 all elements of society, including the medical profession, were in the midst of tremendous change. The prevailing mood was buoyant and optimistic, and there was an eagerness to implement new ideas. The incorporation of anesthesia into obstetric practice represents a fortuitous confluence of the right person, the right place, and the right social climate.


Simpson's Life


Many events in Simpson's early life prepared him for the role of medical innovator. Born on June 7, 1811, in Bathgate, a small town on the coach route between Edinburgh and Glasgow, Simpson was the eighth and last child of David and Mary Jarvis Simpson. His father was a baker whose business never quite achieved success. His mother died when James was nine years old, so his care devolved on the eldest sibling, a sister.

    James studied in a village school directed by a man named Taylor, a teacher of some talent who prepared several of his students to become university professors. On the strength of Simpson's early performance and his aptitude for study, his family pooled their resources so that James might obtain more education—a common practice among poor Scottish families. At age fourteen he began studies at the University of Edinburgh, eighteen miles from home.

    Simpson undertook the arts curriculum at the university, a standard course of study that included rhetoric, mathematics, literature, Greek, and Latin. He enjoyed this work and later put it to good use, but he did not excel. During his first year of study, a friend and fellow student from Bathgate, John Reid, took Simpson to anatomy lectures by Robert Knox, curator of the museum of the College of Surgeons. Knox, a gifted speaker and popular teacher, was an "extra academic" lecturer. Students could satisfy degree requirements by attending courses given by either university faculty or by such extra academics—teachers who taught privately. Stimulated by Knox's lectures, Simpson started formal medical studies in 1828. His professors included the obstetrician James Hamilton, the pathologist John Thomson, and Robert Liston, an extra-academic surgeon from whom Simpson later learned about ether anesthesia.

    After finishing his medical coursework in 1830, Simpson assisted at a local dispensary while preparing his doctoral thesis. The thesis, "Death from Inflammation," attracted the attention of his former pathology professor, John Thomson, who offered Simpson work as an assistant. When Thomson later suggested that he consider a career in obstetrics, Simpson studied seriously in that field. Having slept through most of Hamilton's lectures as a student, Simpson sat through them again, this time more motivated to listen than to sleep. On completion of his formal coursework, he visited medical centers in Paris, Liège, Brussels, Ghent, London, and Oxford, a common pattern of postgraduate study. After the tour, he returned to Edinburgh to begin obstetric practice and to lecture as an extra-academic teacher.

    Simpson's reputation as an exceptional physician and teacher grew quickly. When he was elected president of the Royal Medical Society in 1835, his inaugural address drew favorable comments, was printed in the Edinburgh Medical and Surgical Journal, and was subsequently translated into French, Italian, and German. But in spite of a heavy clinical load, Simpson's income remained limited, and he felt professionally unsatisfied.

    In 1839 James Hamilton resigned from the university chair of midwifery. Even though Simpson's youth, limited professional experience, lack of reputation, unmarried status, and modest social origins all militated against success, the twenty-eight-year-old Simpson applied for the post. Professional obscurity may have been the most significant impediment. Local success notwithstanding, Simpson was unknown outside the city. Edinburgh merchants depended on the "medical trade" for income. The economy of the city depended in part on the reputation of the medical school and its professors to attract students and wealthy patients from other cities and countries. Responsibility for selection of Hamilton's replacement lay with the lord provost, the city magistrates, and the thirty-three members of the town council, not with a university committee. Involvement of the town council probably worked in Simpson's favor, for most members of the medical faculty supported his opponent, Philip Syme. In fact, Syme campaigned against Simpson in support of another candidate.

    Simpson worked aggressively for selection. He solicited more than seventy testimonials from physicians who knew him, aided no doubt by the contacts made during his study tour of European clinics—Simpson was not easily overlooked or forgotten. Simpson quieted criticism of his bachelorhood by proposing marriage to Jessie Grindlay, whom he had known for several years. Jessie was a distant relative and the daughter of a Liverpool merchant who had helped Simpson during his training. To demonstrate his preparedness for the university post, Simpson collected books, anatomic casts, illustrations, medical equipment, and other paraphernalia that he would need to teach midwifery—more than seven hundred items in all—and set his new wife to the task of cataloging the material for presentation to the town council. Simpson told the council that his lack of reputation did not matter, because, once appointed, he would quickly rise to the top of his profession. Faced with such bravado, the council apparently chose to overlook Simpson's youth, inexperience, and lower-class origins. On February 14, 1840, the council elected him "Professor of Medicine and Midwifery and of the Diseases of Women and Children" by a margin of one vote. He was twenty-nine years old and in serious debt from costs accrued in competing for the post. But the status of a university appointment virtually ensured professional success and financial solvency. It also gave Simpson a platform from which he might be heard and seen.

    Simpson used the opportunity that came with his appointment to advantage. An indefatigable worker and an excellent publicist, he quickly became one of the best-known physicians in western Europe. He wrote many professional papers, devised new surgical procedures, and developed a set of obstetric forceps that is still used frequently today. In addition, he became a prominent spokesman for improvements in medical practice, medical education, hospital design, and new methods of care for patients with tuberculosis and leprosy. He also discovered the anesthetic properties of chloroform. Because this very potent, rapidly acting agent was much easier to administer than ether and less irritating to the lungs and throat, it gained in favor. Its popularity lasted for more than half a century before physicians recognized its potential to destroy the liver. Besides pursuing his career in medicine, Simpson developed an interest in archaeology, lecturing and writing on a variety of topics. Most important, Simpson's clinical reputation attracted patients from England and the continent and helped to keep Edinburgh hotel rooms filled with patients and the city solvent. At the time that Simpson administered the first obstetric anesthetic, he was near the crest of his career.


Simpson the Man


Simpson had a memorable appearance. A contemporary wrote:


The chair was occupied by a young man whose appearance was striking and peculiar. As he entered the room his head was bent down and little was seen but a mass of long tangled hair, partially concealing what appeared to be a head of very large size. He raised his head and his countenance impressed one as that of a pale face, massive bent brows from under which stone eyes now piercing as it were to your innermost soul, now melting into almost feminine tenderness. And finally, now his mouth would seem the most expressive feature of the face. Then his peculiar rounded soft body and limbs, as if he had retained the infantile form in adolescence. All this presented an ensemble which even if we had never seen it again, would have remained indelibly impressed on our memory.


Similarly impressed but less respectful, another acquaintance quipped that "Simpson had the head of Jove and the body of Bacchus." Even as a child, Simpson's head size had attracted attention. The fascination continued after death. Reflecting a Victorian preoccupation with phrenology, Simpson's obituary included detailed measurements of his brain, which weighed fifty-four ounces.

    Simpson's personality also impressed observers. Contemporaries described him as a man of immense physical energy, enthusiasm, and charm, mighty passions and strong beliefs. Some said that in conversation he had an almost hypnotic effect on both men and women. Simpson inspired great loyalty and affection but also great enmity. One lifelong adversary was Philip Syme, the famous surgeon who had opposed Simpson's appointment to the medical faculty. The feud continued unabated to their deaths.

    Simpson's home in Edinburgh was a center of excitement and activity. No one, including the family and staff, ever knew how many he would bring home as last-minute dinner guests. He enmeshed friends and acquaintances in his projects. When searching for an anesthetic to replace ether, he invited friends for dinner and then asked them to test compounds, which he would pass around the table. According to one story, he recognized the anesthetic potential of chloroform, a very strong agent, when he awoke after one such incident and found himself on the floor flanked by guests who were as unconscious as he had been.

    When Simpson died in 1870, many considered him to be among the most famous and influential physicians of the century. More than thirty thousand people filled the streets of Edinburgh for his funeral, according to newspaper reports. The two thousand people who followed the hearse included representatives from the university, from the Colleges of Physicians and of Surgeons, and from other professional societies. An announcement in the Medical Times Gazette read, "One of our greatest men has passed from amongst us; Simpson is dead!" The Lancet published "Prometheus," a poem dedicated to Simpson. Friends placed a memorial in Westminster Abbey, commissioned a larger-than-life statue to be erected on Princess Street, and attached a brass plaque to the door of his house at 52 Queen Street. The memorial, statue, house, and plaque remain.


Medical Education in the Early Nineteenth Century


Simpson rose to prominence at a time when medicine had little basis in science. Professional advancement depended on rhetoric, political alignments, and the ability to repel the verbal and even physical attacks of rivals. A contemporary described Simpson's Edinburgh as "a city where controversy and partisanship attended portentous developments, where elections [were] fierce battles, and their intervals, times not so much of peace as of preparation." In this atmosphere, Simpson competed and thrived.

    Chief among Simpson's advantages was his education. In 1825, when Simpson began his university studies, education in Scotland had a long tradition of excellence. Social historians attribute this excellence to the Reformed religious tradition, which made each person responsible for his or her own soul. Clerics believed that personal knowledge of the Scriptures enabled people to recognize the importance of God's word and to act accordingly. The church, therefore, placed high value on original and independent thought and encouraged development of state support of education. Village schools offered excellent training, as did the universities, which cost the student relatively little to attend. Higher education was accessible to even students with little money, like Simpson. As a result, the people of Scotland were among the best educated in western Europe.

    Medical education in Scotland also excelled. By 1800 four of its cities boasted schools: Glasgow, Saint Andrews, Aberdeen, and Edinburgh. What distinguished these medical schools from their English counterparts was their association with a university, medical curricula that emphasized scholarship, the low cost to the student, and freedom from a religious test for matriculation. Most medical schools in England were associated with a hospital or clinic. Their teaching was utilitarian but not inspired. Oxford and Cambridge did have medical programs, but they were small and weak, for these universities gave more emphasis to preparing students for church or government service than for a medical profession. Nor were scholarship and investigation part of the tradition in English medical schools. Original work was most likely to be done by practicing physicians, such as Richard Bright and Thomas Sydenham; or by curious pastors, such as Stephen Hales and Joseph Priestley.

    The high quality of medical education in Scotland attracted many students from outside the country. At a time when Edinburgh awarded almost two hundred doctor of medicine degrees each year, Cambridge awarded fewer than four, and Oxford's medical school was virtually defunct. The year that Simpson administered the first obstetric anesthetic, 1847, more physicians practicing in England had a degree from a medical school in either Scotland or the continent than from one in England.

    Of the four medical schools in Scotland, most people thought Edinburgh to be preeminent in instruction. It had been founded in 1726 by five former students of the Leiden physician Hermann Boerhaave, one of the most influential medical educators in Europe. The reputation and influence of the Edinburgh Medical School reached its zenith in the last decades of the eighteenth century. Graduates staffed a disproportionate number of teaching posts in medical schools and biology departments in England, Ireland, and Scotland. Edinburgh graduates also had an enormous influence on medical education in America. William Shippen (1736-1808) and John Morgan (1735-1789) founded the first medical school in America, at the University of Pennsylvania. Benjamin Rush (1745-1813), also an original member of the faculty at the University of Pennsylvania, signed the Declaration of Independence and wrote America's first textbook on mental illness. Samuel Bard, a New York physician, founded King's College Medical School, the second medical school in the colonies; and David Hosack started the College of Physicians and Surgeons, the medical school of Columbia University.

    Appointment to the Edinburgh faculty gave Simpson one more important advantage, tenure in the oldest and possibly the most prestigious chair of midwifery in the world. Founded in 1726, the chair grew in reputation with each of its incumbents. This growth in status was important, for obstetrics was not a highly regarded specialty in 1847. That honor went to medicine, although surgery was fast closing the gap. Even though family practitioners delivered a high proportion of babies, particularly in cities, medical schools in England did not require a course in obstetrics for graduation. Scottish medical schools did, however, and their graduates influenced the development of the specialty in other countries. Shippen, for example, made a course in obstetrics part of the original medical curriculum at the University of Pennsylvania and taught it himself. Appointment to the chair of midwifery at Edinburgh, therefore, gave Simpson a bully pulpit, which he used to establish obstetric anesthesia.


Simpson's Contribution to the Acceptance of Anesthesia


In 1847 anesthesia needed strong advocates. Although some physicians recognized its potential immediately, many harbored doubts. Criticism fell into two categories. The first concern involved the medical significance of pain—whether pain was a deleterious and unnecessary part of disease or whether it was a necessary component of healing. The second concern was the safety of anesthesia, the nature and magnitude of the risks associated with its use, and the worth of taking those risks. In light of the information available at the time, both concerns were reasonable. Physicians had little information to guide them.

    Simpson, unlike many others, had no doubts. To him pain was unnecessary and destructive. In an early paper he quoted the second-century Greek physician Galen: "Pain is useless to the pained." Simpson also pointed out the inconsistency of those who argued that the relief of pain with ether might be detrimental. He reminded his colleagues that physicians had used opium for centuries to relieve pain and suggested that no reasonable distinction could be drawn between the effects of a remedy that was swallowed and the effects of one that was inhaled.

    Simpson even claimed that anesthesia itself could be beneficial, suggesting that surgical patients recovered faster if they had been anesthetized. To support this contention, he published statistics showing that the mortality rate associated with amputation of the thigh decreased from 50 to 25 percent when patients were anesthetized. He attributed this difference to the ability of anesthesia to protect the patient from the nervous shock that often occurred during surgery without anesthesia:


I have already shown, from evidence of statistical returns, that some of the graver operations of surgery are so much less fatal in their results when patients are operated on under anaesthesia, and consequently without any pain, than the same operations were formerly, when patients were submitted to all the agonies of the surgeon's knife in their usual waking state. The prevention of pain in surgical operations is, in other words, one means of preventing danger and death to those operated on: the saving of human suffering implies the saving of human life. And what holds good in relation to pain in surgery holds good in relation to midwifery.


    Simpson made a great leap when he equated the pain of childbirth with the pain of surgery. Unfortunately his claim that anesthesia had a beneficial effect was far less well substantiated for obstetrics than for surgery. He said that "the mortality accompanying labor is regulated principally by the previous length and degree of the patients' sufferings and struggles," but he gave no supporting arguments or evidence. Similarly, it was pure supposition for him to write "as in surgery, [ether's] utility is certainly not confined to the mere suspension and abrogation of conscious pain, great as by itself such a boon would doubtless be, but in modifying and obliterating the state of conscious pain, the nervous shock, otherwise liable to be produced by such pain ... is saved to the constitution, and thus an escape gained from many evil consequences that are too apt to follow in its train." Inasmuch as Simpson had anesthetized only six women when he wrote this, it is difficult to imagine what experience warranted this conclusion. Closer examination of the data from his own institution might have given him cause for thought. Even though maternal mortality was high by today's standards—one death for every 134 deliveries in Simpson's own unit—it was nowhere near the 50 percent mortality that he had reported for leg amputations without anesthesia. Statistics would have been more convincing than rhetoric.

    Simpson acknowledged the need to evaluate the safety and side effects of anesthesia. In an early paper he had written: "A careful collection of cautious and accurate observations will no doubt be required before inhalations of sulfuric ether is adopted to any great extent in the practice of midwifery. It will be necessary to ascertain its precise effects both upon the action of the uterus, and on the assistant abdominal muscles; its influence, if any, upon the child: whether it gives a tendency to hemorrhage or other complications; the contraindications peculiar to its use; the most certain modes of exhibiting it; the length of time it may be employed, etc." In this one passage, Simpson astutely predicted the problems with anesthesia that would occupy obstetricians for the next century and a half. Simpson, however, did not act upon his own advice. He continued to extol the benefits of anesthesia without offering further proof. He said that he never had "observed any harm whatever, to either mother or infant" but that he had seen "no small amount of maternal suffering and agony saved by its application."


    It is hard to say how much longer women would have had to wait for anesthesia had it not been for Simpson's advocacy. He had the wit to recognize the potential of anesthesia, the courage to apply it to an old medical problem, a reputation that made others listen, and the persistence to see that his innovation took hold. He was aided by his charisma, a keen eye for publicity, and a talent for sensing the mood of patients and winning them to his cause.

    In 1847 success seemed close at hand. Writing about ether to a fellow obstetrician, Charles D. Meigs of Philadelphia, almost a year after his first use of the gas, Simpson said, "In midwifery most or all of my brethren in Edinburgh employ it constantly.... In London, Dublin and elsewhere it every day gains converts to its obstetric employment; and I have no doubt that those who most bitterly oppose it now will be yet, in ten or twenty years hence, amazed at their own professional cruelty. They allow their medical prejudices to smother and overrule the common dictates of their profession and of humanity." Ironically, Meigs became one of the loudest and most effective opponents of obstetric anesthesia. No doubt Simpson would have been more amazed if he could have foreseen the hostility of some women to obstetric anesthesia one hundred years later.

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Table of Contents

Preface
Acknowledgments
Pt. I Physicians and the Pain of Childbirth
1 "The Head of Jove and the Body of Bacchus": James Young Simpson and the Beginning of Obstetric Anesthesia 2
2 "A Cup of Circe": The Opposition to Obstetric Anesthesia 20
3 "Bled, Leeched, Salivated": The Transformation of Medical Practice by Science 38
4 "The Queen in Her Confinement": John Snow's Approach to Anesthesia 54
5 "The Tender Organization of the Newborn": Balancing the Risks of Pain and Anesthesia 70
Pt. II Women and the Pain of Childbirth
6 "The Sin of Our First Parents": The Social Connotations of Pain 90
7 "This Blessed Chloroform": Pain as Biological and Anesthesia as Necessary 108
8 "There Ought to Be No Pain": The American Women's Campaign for Twilight Sleep 130
9 "Labor Is Pathogenic": The National Birthday Trust Fund Campaign in Great Britain 152
10 "As God Intended": Grantly Dick Read and the Natural Childbirth Movement 172
Pt. III In the Delivery Room: Physicians and Women Together
11 "Pain Makes Things Valuable": The Danger of Drugs and the Social Value of Pain 198
12 "The Greatest Misery of Sickness Is Solitude": Current Controversy 220
Notes 235
Index 279
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