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

What a Blessing She Had Chloroform: The Medical and Social Response to the Pain of Childbirth from 1800 to the Present. By Donald Caton, M.D. (New Haven: Yale University Press, 1999. xvi plus 288 pp. $30).

In recent years, social historians of medicine have illuminated how medical practice developed in the context of changing cultural and social values. Medical practice evolved historically in response to prevailing ideology and serious professional concerns. Nineteenth century physicians had to walk a fine line between what society deemed to be appropriate and what they chose to do to increase the credibility of their profession in a culture that did not necessarily value professional authority. Physicians had to contend with a highly competitive professional environment lacking standards and permitting multiple sectarian practitioners who governed their own practices. Caton, however, bemoans the fact that recent medical historians have "ignored scientific and medical ideas that shaped practice," (p. xiii) implicitly granting tremendous significance to the "great" physicians, and their scientific discoveries, which he feels had a major impact as agents of change in obstetrical practice. This emphasis tends to obscure his primary argument that the pain of childbirth has cultural and social significance that has been severely altered by the use of anesthesia.

Caton relies mainly on primary sources generated by physicians and literary figures as well as secondary sources, but also uses the unpublished papers of Grantly Dick Read and the National Birthday Trust Fund. He utilizes a plethora of published articles from the medical and scientific literature. In order to augment the work of social historians of medicine, he draws from the literature of poets, playwrights and novelists who he feels are "unusually sensitive to the mood of the public" (p.xiii), assuming that their literature reflected the values of the readers. The thoughts and feelings of women are, therefore, deduced primarily through the eyes of male physicians and popular writers.

In Part I, of three parts, Caton describes the history of the medical management of the pain of labor, focusing primarily on influential physicians who advocated, opposed or researched the use of anesthesia in labor. James Young Simpson who "not only introduced anesthesia to obstetrics but almost single-handedly effected its use" (p.6) is highlighted as well as his opponents. Nineteenth century opposition was generally due to concerns regarding safety, the medical significance of pain and uncertainty regarding the adverse effect of anesthesia on the process of labor. Caton's focus is clearly placed on the individual men, although a brief discussion of medical education and the influence of Paris and Germany are included for background. It is difficult, however, to clearly understand nineteenth century practitioners' attitudes without placing them in the context of physicians' struggle to gain credibility over the sectarian practitioners, very prevalent at the time.

Caton, in Part II, discusses different ways society has felt about and dealt with pain, including philosophical, religious and humanitarian viewpoints. Utilizing primarily secondary historical monographs and literary sources, the author notes that views regarding pain were, at first, grounded in religious beliefs. During the eighteenth and nineteenth centuries, partially due to the influence of philosophers and scientists, prevailing ideology began to change, reflected in the social and humanitarian movement occurring during the first half of the nineteenth century. Noting that "anesthesia could develop and survive only in a culture that valued the relief of pain" (p.92), he concludes that this explains society's willingness to accept the new methods. The last three chapters in Part II are devoted to specific campaigns designed to reform the childbirth experience, including American women's campaign for twilight sleep, the National Birthday Trust Fund Campaign in Great Britain, and the Natural Childbirth Mov ement. Caton concludes that women's interest in natural childbirth signifies a decline in the public's faith in science and medicine.

In Part III the author attempts to analyze how medical practice and social values interact; this is by far the shortest section of the book, comprising only thirty-four pages. Studies of the effects of drugs on fetal development as well as increasing concern over chemical toxins in the environment, more generally, resulted in increasing skepticism regarding the use of anesthesia in childbirth, all of which reflected a waning faith in science. Moreover, Western cultural traditions were disrupted when pain was eliminated from human experience. Without addressing crucial cultural and societal changes, Caton declares that "the medical discoveries that increased the comfort and safety of women may have inadvertently disrupted important social patterns"(p.216). By the midtwentieth century, women perceived childbirth as an impersonal, unfavorable experience. As well as being a rejection of medical authority, and a reflection of women's unwillingness to take risks, the return to a more natural childbirth was, theref ore, an attempt to preserve the meaning in childbirth, which had diminished as pain was removed from the experience. It is noteworthy, however, that rates of anesthesia use in obstetrics have risen rapidly on a national level in recent years, generally in response to consumer demand, a rather interesting conundrum in light of the author's argument.

Caton discounts current critics of medical practice who say that it fosters gender stereotypes, without understanding problems posed by pain itself. Implicit in this entire work is support for the thesis that medical practice, past and present, does indeed foster gender stereotypes. Caton rightfully notes that "conflicts between medical science and social values became a recurrent theme during most of the twentieth century"(pp.86-87). But Caton himself, by neglecting to analyze those social values, has reduced this to a polarization between educated male doctors and idealistic female patients. When referring to the Twilight Sleep debate, for example, he states that "the social idealism of American feminists finally collided with the analytic methods of physicians" (p.l32). Caton fails to address these conflicts between physicians and their patients which represent much broader issues. Doctors needed to raise the standards of their profession, and women attempted to maintain some control over their lives in a society that relegated them to being caretakers of children and tending the hearth in the cult of domesticity. Further, the response of male physicians to the assertive feminists may reflect male concerns in a society undergoing change in the traditional male-female relationship. Physicians, in their attempt to gain professional credibility and cultural authority, often did promote prevailing ideology by confining women to specific designated roles, and thereby perpetuating the stereotype.

This is a well-written, quite readable monograph that poses a number of interesting questions. As with all research this study serves as a starting point for additional investigation.