- Email: [email protected]
Medical science and social values
International Journal of Obstetric Anesthesia (2004) 13, 167–173 Ó 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijoa.2004.02.002
FRED HEHRE LECTURE, 2003
Medical science and social values D. Caton Professor Emeritus, Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA SUMMARY. Social Values, no less than medical science, have shaped the medical management of the pain of childbirth. Nineteenth century feminists fought for greater use of anesthesia in obstetrics at a time when physicians held back for fear of its effects on labor, hemorrhage, rates of infection and the condition of the child. A century later, after physicians became comfortable with the use of anesthesia, a new generation of feminists challenged the use of such drugs, once again citing social considerations. The personalities of colorful and charismatic obstetricians such as James Young Simpson and Grantley Dick-Read played a strong part in the outcome of each confrontation. Ó 2004 Elsevier Ltd. All rights reserved. Keywords: Anesthesia; Obstetrics; Childbirth; Pain; Simpson; Dick-Read; Natural childbirth; Feminists
More than that, however, Fred developed a wonderful working relationship with obstetricians and with the nursing staff. In quality and style it reminded me of the obstetric anesthesia service I had observed as a medical student at Columbia Presbyterian Hospital, as overseen by Drs. Sol Shnider and Frank Moya. During the late 1960s the Obstetrics Department at Yale was among the premier units in the country. Ted Quilligan, someone you may know as a long-time editor of the American Journal of Obstetrics and Gynecology, chaired the department. Also on the faculty was Dr. Ed Hon, the electrical engineer turned obstetrician who developed techniques for fetal heart monitoring that we all use today. Together, Quilligan and Hon formed ‘Corometrics,’ the firm that manufactured the first monitors. Frequent visitors to the unit were German obstetricians Sahling and Kubli, pioneers in the development of techniques for fetal scalp sampling. The obstetrics unit at Yale stayed busy, testing and evaluating these innovations. Fred Hehre was right in the middle of all this activity, as a facilitator. When I left my fellowship I used Fred Hehre’s unit as a model for the division that I was to build at the University of Florida. Completely unknown to me during my fellowship was that the Yale obstetrical department had been instrumental in establishing the natural childbirth movement in the United States. How useful that information might have been! Knowing that I would have spent more time with Fred Hehre, to learn how he had managed to establish such a fine anesthesia service in the midst of a
INTRODUCTION It is both an honor and a great pleasure for me to give this lecture. I attended my first Society for Obstetric Anesthesia and Perinatology (SOAP) meeting more than 30 years ago. Accordingly, I was pleased to receive the invitation from SOAP president, Dick Wissler, a longtime friend and colleague. I was particularly pleased to give a lecture named for Fred Hehre (Fig. 1). I suspect that few people today knew Fred Hehre. I am one of the fortunate few. After I finished my clinical training at the University of Virginia I went to Yale for a fellowship. Most of my two years at Yale I spent in the laboratory with physiologist Donald H. Barron, a student of the English physiologist Sir Joseph Barcroft and one of the founders of the field of ‘Reproductive Physiology.’ While there, however, I also came to know Fred Hehre, to observe his work and to learn how he organized and ran his obstetric anesthesia unit at Yale New Haven Hospital. Fred ran his unit quite well. Women received quality care and superb anesthesia coverage for their deliveries.
––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Accepted February 2004 Dr. Donald Caton delivered the Fred Hehre lecture at the annual meeting of the Society for Obstetric Anesthesia and Perinatology at Phoenix, Arizona in May 2003. Correspondence to: D. Caton, Department of Anesthesiology, PO Box 100254, Gainesville, Florida 32610-0254, USA. Tel.: +352-846-1315; fax: +352-392-7029; E-mail: [email protected] 167
168 International Journal of Obstetric Anesthesia
Fig. 1 Dr. Fred Hehre
bastion of natural childbirth. Dealing with natural childbirth advocates was to be my biggest challenge during my first years at the University of Florida. At Florida, I quickly learned that natural childbirth activists did not approach anesthesia for childbirth as a medical issue but rather as a social issue. For example, they were not interested in the effects of anesthesia on the oxygen metabolism of the neonate or rate of equilibration of drugs across the placenta, some of the issues that concern us as clinicians. On the other hand they had a keen interest in personal and social aspects of childbirth: ways in which a woman’s experience during childbirth might affect subsequent interactions among members of the family. Given this orientation they were not the least bit impressed with my clinical training or my background in reproductive physiology. Often they saw patterns of contemporary anesthesia practice as inimical to their social goals. Without realizing it I had stepped into a clash between medical science and social values. Nothing in my training in medicine or in science had prepared me to deal with this. As I started to explore the history of this problem I learned that the conflict was as old as obstetric anesthesia itself and that the clash had taken some strange twists and turns over the previous 150 years. This report will thus focus on this issue. Perhaps learning something of the history will help you with your work as it has helped me.
first anesthetic for childbirth on January 17, 1847 and then did so much to popularize it. You may also recall that Simpson’s influence was mainly with the public, women wanted anesthesia for childbirth and Simpson convinced them that they should have it. Simpson had far less influence on physicians. Most of them opposed the use of anesthesia on medical grounds, not for religious reasons as popular stories often tell. Physicians were not convinced that anesthesia was safe. They feared its effects on the child, on uterine contractions and on the incidence of hemorrhage and infection. Given what we know about the pharmacology of ether and chloroform, their fears were well grounded. In the end, however, it was Simpson, and women, who prevailed. In no small part this was due to Simpson’s personality. Simpson was colorful, influential, gregarious, and charming. He also had a commanding physical presence. One friend described him as having the head of Jove and the body of Bacchus. In short, he was larger than life, the kind of person who dominates a room when he walks in and begins to speak. At the time of his death, 40 years after the introduction of obstetric anesthesia, many colleagues acknowledged Simpson as the most influential physician in all of Europe.
EARLY HISTORY Obstetric anesthesia began with James Young Simpson, the Edinburgh obstetrician (Fig. 2). He administered the
Fig. 2 Dr. James Young Simpson
Medical science and social values 169 But it was not just Simpson’s personality that helped establish anesthesia for childbirth. Nineteenth century social values also put a high priority on the relief of pain and suffering, including that of childbirth. Women attributed many of the social and physical ills that plagued them later in life to the destructive effect of pain that they experienced during repetitive deliveries. Better obstetric care, including anesthesia for childbirth, became part of the feminist movement of the late nineteenth and early twentieth century. Women who fought for the vote also fought for hospitalization for their deliveries; care by physicians rather than by midwives, and anesthesia. The social agenda of these early feminists brought them into direct conflict with medicallyconservative physicians, who preferred to wait until they had appropriate medical studies to show whether the use of anesthesia was safe for normal deliveries.1 In effect, this was the first conflict between medical science and social values over the treatment of pain during childbirth. It was the social values of patients that prevailed however: women campaigned for the use of anesthesia long before physicians could evaluate medical effects of ether, chloroform, narcotics or spinal anesthesia. With this brief history of the first conflict between medical science and social values, I will move ahead a century to the second conflict. Like the first, this too involves a colorful and influential obstetrician, Grantly Dick-Read, founder of the natural childbirth movement. English by birth, Dick-Read was no less charismatic than Simpson, but there are other similarities. Like Simpson, Dick-Read appealed directly to the public, and it was with the public that he had the most influence. Like Simpson, he had far less impact on physicians. DickRead, however, nearly undid all that Simpson achieved to establish anesthesia as part of obstetric practice.2 Grantly Dick-Read (Fig. 3) was born and raised on a farm in Northern England. He studied at Cambridge where he was a mediocre student, but a fairly good heavy-weight boxer. Shortly after medical school he served with the British forces in World War I (WWI). He later wrote that two experiences in the service did much to shape his thinking. In Greece, he watched a woman “drop a quick one” in the field (his words) and then promptly and cheerfully return to work. He thought to himself “This is natural. This is the way that childbirth is supposed to be.” The other experience was with an Indian non-commissioned officer, who introduced him to techniques of mental-relaxation to help him deal with the stress of trench warfare; techniques that would later become part of his system of natural childbirth. After the war, while in training to become an obstetrician, Dick-Read wrote a book describing his ideas about natural childbirth. His professors suggested that it might be prudent at least to finish his training before he
Fig. 3
Dr. Grantly Dick-Read
published. He acceded and the book finally appeared in 1943 under the title Revelation of Childbirth.3 It had little impact. In 1954 he republished the book with the now familiar title Childbirth Without Fear.4 This time the public was ready and Dick-Read began his climb to fame.
DICK-READ’S THEORY OF NATURAL CHILDBIRTH Dick-Read reminded us that childbirth is a natural, in other words a physiological, process. He also believed that “There is no physiological function in the body which gives rise to pain in the normal course of health.” As childbirth is a physiologic process, he concluded that pain is not a normal part of the process. The pain that so many western women seemed to experience he attributed to ignorance and fear and a longstanding cultural tradition that taught that sex was sinful and that pain was a punishment for sin, a reiteration of the Adam and Eve story from the third book of Genesis. Ignorance and fear, Dick-Read argued, caused “activation of the nervous system” and dysfunctional contraction of circular muscles surrounding the cervix. Dick-Read used as his model “natural deliveries” that he had observed during WWI. This is how he described it: “Primitive women are rarely troubled by anxiety states or toxic manifestations. The primitive knows that she will have little trouble when her child is born. She knows that it will be small and healthy. . . .There are no fears in her mind. No midwives spoiling the natural process, she has no knowledge of the tragedies of sepsis, infection and hemorrhage. To have conceived is her joy; the ultimate result of her conception is her ambition. Eventually, and probably whilst even yet at her work, labor commences. . .there is unquestionably a sense of satisfaction when she feels the first symptoms and
170 International Journal of Obstetric Anesthesia receives the impatiently awaited indications that her child is about to arrive. . .she isolates herself, and in a thicket, quietly and undisturbed, she patiently waits.”4 How do they cope with their fear of death? “Those who die, two, three or four percent of some tribes, do so without any sadness realizing if they were not competent to produce children for the spirits of their fathers and for the tribe, they had no place in the tribe.” Educate women about childbirth, Dick-Read said, their fear will diminish and their uterine contractions will return to a normal state. Their labors will be shorter and they will be free of pain. The response to Dick-Read’s theory After WWII, Dick-Read’s method had increasing appeal to the public. There probably were several factors contributing to this. Childbirth had become complicated and very aggressive, with the routine use of forceps (e.g. the so-called “prophylactic forceps” as advocated by DeLee), episiotomy, and anesthesia.5 Women were heavily drugged throughout labor with various combinations of barbiturates, narcotics, tranquilizers, and inhalation agents, often combined with spinal anesthesia for delivery.6 These changes had not been undertaken capriciously. In part they were a response of obstetricians to continuing high risk of death and permanent physical damage associated even with normal deliveries. In part, however, they were also a response to the social goals of early feminists, who expected improvements and innovation in obstetric care. Regardless of the cause, some medical historians have described this era of obstetrical practice as an “orgy of interference.” After WWII, however, the public developed an increased distrust of invasive medical procedures and of drugs as they learned of congenital problems associated with diethylstilbestrol, thalidomide and ionizing radiation. Coincidentally, Virginia Apgar’s score refocused attention on the condition of the neonate. With this, patients showed increasing concern for the use of drugs during childbirth. For such people, Dick-Read’s theory of natural childbirth had great appeal. In short, it was a new era and the mood and social goals of the public began to shift. Even conservative physicians were less enthusiastic about Dick-Read’s theories than the public. Many were outright critical. They asked: If childbirth is so ‘natural,’ why does it require so much education? They saw no scientific basis for Dick-Read’s ideas. They challenged his assertion that his methods improved outcome and they asked for evidence, medical studies and statistical analysis. Most significant, perhaps, they recognized that Dick-Read’s method undercut a style of obstetric practice that they understood and that had given good results, up to that time. Physicians also feared that widespread
adoption of natural childbirth methods would undercut their own campaign for better private and governmental support of obstetric services. In other words, medical science and social goals again were at loggerheads. This time, however, it was physicians who wished to maintain their more aggressive forms of obstetrical practice: patients now began to demand a return to an earlier, more ‘natural’ style of practice. Dick-Read was stunned by the apathy and hostility that he detected among his colleagues. As far as he was concerned, he had simply suggested returning to a traditional form of obstetric practice. In this regard he was right. The approach that he claimed as new was, in fact, very similar to that advocated in many older textbooks. For example, early in the nineteenth century Thomas Denman wrote, “She, the midwife, is to direct her (the laboring patient) to walk about the chamber, from room to room: to sit or lie down, as she finds most agreeable to herself; and if she can, to sleep between pains. . .. The principal object, therefore, of the midwife’s care in this stage of labor is to regulate her patient’s conduct, to soothe her sufferings, to calm her fears, and above all things to avoid fatigue.” Denman’s tract, I believe, could well serve as a manual for a present day Doula.7 I spent considerable time reading Dick-Read’s papers and letters and I came to believe that a great deal of obstetricians’ resistance to Dick-Read’s ideas of natural childbirth was, in fact, a reaction to his style. Patients may have found him charismatic, but with physicians and other professionals he often appeared confrontational and abrasive. Let me illustrate aspects of DickRead’s style with some quotations. First, Dick-Read was inconsistent. For example, with respect to religion he once wrote: “The greatest book upon health is the New Testament. Christ’s teaching is the most advanced and complete treatise upon the interaction of the mind and body ever written.”8 But then he also wrote: “When reviewing the Bible and the teachings of the Church, we find nothing that could give comfort or courage to women who are to become mothers, but today a vast number of women know these ancient representations of childbirth to be entirely fallacious. . .”9 Similarly, having extolled Christianity he also said, “We found the Pagan the best religion we had met, immutable, unchangeable; the laws of their gods saw childbirth as the greatest gift of woman and her greatest accomplishment.”10 Dick-Read was equally inconsistent about anesthesia. On the one hand he could write: “I do not wish to disagree with advocates of applied anesthesia, whether it is caudal, inhalation or parenteral, for pain must be prevented or relieved. Every effort to make childbirth a painless function should be carefully considered. . .”11 But then he could also write: “The whole question of pain relief in labor by anesthesia and analgesia is in a state of chaos, which would be
Medical science and social values 171 laughable if it were not so serious. I experienced a peculiar urge to uncontrolled mirth after 10 days intensive search for stability in this branch of our science. Walt Disney could barely do justice to this Silly Symphony of Obstetric Anaesthesia.” Dick-Read disparaged the work of other physicians: “Robert H. Hingson had done magnificent work upon the use of anaesthesia injected either around or within the spinal cord. In many abnormalities and illnesses his methods have been a lifesaving service, but unfortunately, enthusiasts incarcerated in the overnight cobwebs spun with all technical brilliance of scientific arcane endeavor to simulate his genius before they pass into nothingness. Thousands of normal labors have been subject to this dangerous and unjustifiable procedure, How long, oh how long will this nonsense go on? Why do not at least some of our first class brains settle down to try some really harmless methods of preventing pain in childbirth?” Curiously, Dick-Read also attacked people who might have helped him, leaders of the National Birthday Trust Fund, for example. Leading this organization was a group of politically sophisticated and influential women of the British upper class. Many had worked for several decades to improve medical care for women and children. They had a wonderful track record of working productively with physicians and politicians to attain their goals. Many of the improvements in education of physicians and the care of patients could be traced to members of this organization. Initially, many were interested in Dick-Read’s theories and were willing to support his work. If there was any group that he should have cultivated, this was it. Yet of them he wrote: “The administrators of the Birthday Trust should look into these matters if they are working seriously for pain relief in childbirth and not be guided by political motives of gynecologists who rarely attend normal labor. What sorts of people rob women of the full joys of motherhood because of prejudice or worse?. . .. Surely the safety of mothers and babies carries greater political capital than ministerial statistics of unwanted stupor?” Needless to say, leaders of the National Birthday Trust saw in Dick-Read a person bent on undermining the social and medical goals that had occupied them for half a century. Dick-Read even made statements that were medically incorrect: “Caudal anesthesia robs a woman of all nerve sensations below the waist. She has the baby without sensation, in the same way as a woman paralysed below the waist by poliomyelitis can give birth without experiencing any feeling.” He seemed not to understand that polio affects only motor nerves. Dick-Read’s self destructive tendencies are nicely described in a letter by Eardley Holland, an influential obstetrician, long-time friend and staunch supporter of Read. “I would urge you, though, with respect, to take
more thought to win the sympathies of the Profession as distinct from the Public, and give more time and take more trouble in doing so. It is true that Browne and Claye and I happen to be comparatively liberally minded men and to be your professional sympathisers and backers. But you seem to have alienated the sympathies of the rest of the gynecological world. Have you even considered that you, yourself, may be to some extent to blame for the state of affairs? You have sometime tried even me very severely.”12 Failure and success It was a bad year for Grantly Dick-Read in 1949. He had made little headway establishing his method. He divorced his wife. His partners in private practice ousted him from their group, accusing him of unethical advertising. The newly formed National Health Service declined to appoint him as a consultant in obstetrics because he never sat the examination after completing his training. In a typical response Dick-Read said that he was so well known that he shouldn’t have to take the examination. When this perfunctory appeal failed, he left England to establish a practice in South Africa. There, however, be became embroiled in another mess when he was denied medical licensure because he had not followed the proper procedures. Just as both his personal and professional life seemed ready to disintegrate, help appeared from two unlikely sources: Fernand Lamaze and the Pope. Lamaze was chief of obstetrics in the Metal Workers Union Hospital in Paris. After WWII he made two trips to Moscow to learn how Russian obstetricians had used Pavlovian training techniques to provide women a ‘pain free’ delivery. Lamaze was probably a communist: it was post WWII Europe, at the height of the cold war. The politics of nations were to figure in the ensuing battle over ‘natural childbirth.’ He described the Pavlovian method in a book, which was quickly followed by two clones, one written by his assistant, the other by Majorie Karmel. Lamaze attacked Dick-Read’s method for being unscientific, difficult to learn, and ineffective.13–15 Dick-Read, the former heavy-weight boxer, responded predictably. He struck back. He said that Lamaze had stolen his ideas and then distorted them. Noting that the Russians claimed authorship of every major idea from Shakespeare to Marconi, Dick-Read said that he wasn’t surprised that they also claimed his methods of natural childbirth. The squabble between the two obstetricians soon became public. Dick Read’s approach became known as the English method; the Lamaze technique became the Russian method. In true ‘Cold War’ fashion, patients began to debate the relative merits of the Russian and the English approach. In this debate Dick-Read did not
172 International Journal of Obstetric Anesthesia fare well. Women seemed to prefer the ‘painless’ birth offered by Lamaze over the ‘natural’ birth promised by Dick-Read. At just this point the Pope entered the fracas. In 1957 Pope Pius XII gave a major address at the Convocation of Italian Obstetricians about natural childbirth. It was a thorough historical review of the pain of childbirth and a thoughtful analysis of methods used to alleviate it. The Pope noted that pain had been associated with childbirth since time immemorial, thereby contradicting Dick-Read’s assertion that primitive women experience no pain. He stated that the church had never objected to any medical innovation that might improve the lives of human beings, including the use of anesthesia for childbirth, thereby undermining another of Dick-Read’s assertions. He mentioned the methods of Dick-Read and Lamaze, but said that he personally saw little difference between them. For women concerned about childbirth with ‘Christian Values,’ however, he favored the English method because it seemed ‘less materialistic.’16 The world press took note. A report of the Pope’s address appeared on the front page of the Washington Post. A translation of the entire address even appeared in the New York Times. Newspapers around the world responded predictably. Headlines read: “Painless Birth Techniques” (The Times); “Painless Childbirth not Opposed” (The Daily Telegraph); “Pontiff approves System of Painless Childbirth” (The Washington Post); “Pope approves Soviet Method of Painless Birth, no moral objection.” (The Daily Record of Glasgow). Grantly Dick-Read was ecstatic. He acted as if the Pope had addressed his method and his method alone. He took the Pope’s address as a vindication of his life, and an endorsement of his work, over that of his arch rival, Fernand Lamaze. Dick-Read was even happier a year later when the Pope gave him a special audience and presented him a silver medal for his work. Both the Pope and Dick-Read seemed to have forgotten that for years Dick-Read had ascribed all of the travails of laboring women to the teachings and misinformation given out by the very Church that the Pope led, a situation that appeared to bother neither man. End of life Following his triumph at the Vatican, Dick-Read undertook an extensive speaking tour in the United States. He made several stops. He received a rather cool reception at Johns Hopkins from Nicholson Eastman, one of the leading figures in American obstetrics. He also got a skeptical response in New York, from Alan Guttmacher, another leading American obstetrician. It was in New Haven, however, that he had his greatest success. The chair of the department at Yale, Herb Thoms, was enthusiastic about Read’s ideas, and this spurred
acceptance in the United States. (This was the unit that Fred Hehre was to staff a few years later.) Dick-Read returned to South Africa, where he finally was licensed after a court challenge. He produced a long play record album called The Sounds of Natural Childbirth. It came complete with instructions for a ‘natural birth’ on the record jacket. He televised a live birth, the first such showing ever. A year later, he died. His only regret, his widow said, was that he had not received the Nobel Peace Prize for his work. He believed that he deserved it. An evaluation Grantly Dick-Read was a visionary and a reformer. He helped to bring obstetrics back towards a more restrained, less aggressive style of practice. On the other hand, he was a very disruptive person. Like James Young Simpson, he instigated change by appealing directly to the public. Like Simpson, Dick-Read appeared to have a good sense of the mood of the public. He was in tune with the social values of his patients, and he was willing to bend medical science to fit his theories. Was he right in his theories? I believe that he was, in part. In fact, we now have clinical studies that substantiate some of his ideas. For example, we now know that higher levels of ‘anxiety’ among pregnant women are associated with longer labors, and a higher incidence of cesarean sections and forceps deliveries. Similarly, we have data that shows beneficial effects of having supportive friends and family with a woman during labor. Often, however, simply ‘being right’ is not enough. Nor does it suffice to be ‘in tune’ with current social values. In medicine, it is also necessary to demonstrate the validity of an idea, and it was in this area that Dick-Read failed. He himself never undertook studies to validate his ideas. More than that, however, he often disparaged the work of those who did.17–21 Right or not, any evaluation of Dick-Read must note that his flamboyant style did much to undermine his credibility among physicians. In an obituary published in the New York Times, Frank Slaughter, an American surgeon and writer in the mold of Sherwin Nuland, wrote the comment that best sums up Dick-Read’s life and career: “After it was announced, the Read method was taken up as a sort of cult with considerable mumbo-jumbo and much popular discussion. For some of the official medical opposition to his theories, Read was himself responsible. He advocated principles of relaxation akin to yoga, which he had learned from an Indian noncommissioned officer in World War I. The methods were effective but such an approach spelled quackery to a suspicious medical profession. . .It illustrates a very important truth that those who get rid of existing shibboleths must be careful how they go about it, lest the opposition they create keep the truth from being widely known.”22
Medical science and social values 173 With respect to natural childbirth, I think that the truth did not emerge for several decades after Grantly Dick-Read’s death.23 I believe that the Dick-Read story serves as an important reminder of the interaction between medical science and social values. We are trained in science, and that prepares us to evaluate data. On the other hand, there is little in our medical education that attunes us to social values. All medicine is a balance between medical science and social values. Nowhere is this more apparent than in the delivery suite. Childbirth is not simply a medical or physiological event. It is a time of great personal and social import for the parents, but also for all other members of the community. Simpson and Dick-Read understood the social import of their practice, and that is an important lesson that we should learn from them. At the same time, however, we should not lose our base in science. Most importantly, we must make appropriate efforts to educate patients in this aspect of our work. Striking an appropriate balance between medical science and social values may be our most difficult task.
REFERENCES 1. Caton D. Obstetric anesthesia: The first ten years. Anesthesiology 1970; 33: 102–109. 2. Caton D. Who said childbirth is natural? The medical mission of Grantly Dick Read. Anesthesiology 1996; 84: 955–964. 3. Dick-Read G. Revelation of Childbirth. London: Heinemann, 1943. 4. Dick-Read G. Childbirth without Fear. London: Heinemann, 1954.
5. DeLee J B. The prophylactic forceps operation. Am J Obstet Gynecol 1920; 1: 34–44. 6. Gwathemey J T. Obstetrical anesthesia: a further study based on more than twenty thousand cases. Surg Gynecol Obstet 1930; 51: 190–195. 7. Denman T. An Introduction to the Practice of Midwifery. Brattleborough: W. Fessenden, 1807. p. 187–190. 8. Dick-Read G. Revelation of Childbirth. London: Heinemann, 1943. 1–52. 9. Dick-Read G. Unpublished autobiography. 10. Dick-Read G. Account of a visit to USA (unpublished manuscript). 11. Dick Read G. Childbirth without Fear. New York: Harper, 1944. 12. Holland E. Letter to GDR (dated Jan 8, 1949). 13. Lamaze F. Painless Childbirth: Psychoprophylactic Method [Celestin LR, Trans.] London: Burke, 1956. 14. Vellay P. Childbirth without Pain [Lloyd D, Trans.] London: Hutchinson, 1959. 15. Karmel M. Thank You Dr. Lamaze: A Mother’s Experiences in Painless Childbirth. Philadelphia: Lippincott, 1959. 16. New York Times, Oct 6, 1957. 17. Lederman R P, Lederman E, Work Jr B A et al. The relationship of maternal anxiety, plasma catecholamines and plasma cortisol to progress in labor. Am J Obstet Gynecol 1978; 132: 495–500. 18. Zuspan F P, Cibils L A, Pose S V. Myometrial and cardiovascular responses to alterations in plasma epinephrine and norepinephrine. Am J Obstet Gynecol 1962; 84: 841–851. 19. Kennell J, Klaus M, McGrath S et al. Continuous emotional support during labor in a US hospital: a randomized controlled trial. JAMA 1991; 265: 2197–2201. 20. Scott J R, Rose N B. Effect of psychoprophylaxis (Lamaze preparation) on labor and delivery in primiparas. N Engl J Med 1976; 294: 1205–1207. 21. Wolman W L, Chalmers B, Hofmeyr G J et al. Postpartum depression and companionship in the clinical birth environment: a randomized, controlled study. Am J Obstet Gynecol 1993; 168: 1388–1399. 22. Slaughter F. To ease the pangs. New York Times, New York, Oct. 6, 1957. 23. Caton D. What a Blessing She Had Chloroform. New Haven, CT: Yale University Press, 1999. p. 289.
FRED HEHRE LECTURE, 2003
Medical science and social values D. Caton Professor Emeritus, Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA SUMMARY. Social Values, no less than medical science, have shaped the medical management of the pain of childbirth. Nineteenth century feminists fought for greater use of anesthesia in obstetrics at a time when physicians held back for fear of its effects on labor, hemorrhage, rates of infection and the condition of the child. A century later, after physicians became comfortable with the use of anesthesia, a new generation of feminists challenged the use of such drugs, once again citing social considerations. The personalities of colorful and charismatic obstetricians such as James Young Simpson and Grantley Dick-Read played a strong part in the outcome of each confrontation. Ó 2004 Elsevier Ltd. All rights reserved. Keywords: Anesthesia; Obstetrics; Childbirth; Pain; Simpson; Dick-Read; Natural childbirth; Feminists
More than that, however, Fred developed a wonderful working relationship with obstetricians and with the nursing staff. In quality and style it reminded me of the obstetric anesthesia service I had observed as a medical student at Columbia Presbyterian Hospital, as overseen by Drs. Sol Shnider and Frank Moya. During the late 1960s the Obstetrics Department at Yale was among the premier units in the country. Ted Quilligan, someone you may know as a long-time editor of the American Journal of Obstetrics and Gynecology, chaired the department. Also on the faculty was Dr. Ed Hon, the electrical engineer turned obstetrician who developed techniques for fetal heart monitoring that we all use today. Together, Quilligan and Hon formed ‘Corometrics,’ the firm that manufactured the first monitors. Frequent visitors to the unit were German obstetricians Sahling and Kubli, pioneers in the development of techniques for fetal scalp sampling. The obstetrics unit at Yale stayed busy, testing and evaluating these innovations. Fred Hehre was right in the middle of all this activity, as a facilitator. When I left my fellowship I used Fred Hehre’s unit as a model for the division that I was to build at the University of Florida. Completely unknown to me during my fellowship was that the Yale obstetrical department had been instrumental in establishing the natural childbirth movement in the United States. How useful that information might have been! Knowing that I would have spent more time with Fred Hehre, to learn how he had managed to establish such a fine anesthesia service in the midst of a
INTRODUCTION It is both an honor and a great pleasure for me to give this lecture. I attended my first Society for Obstetric Anesthesia and Perinatology (SOAP) meeting more than 30 years ago. Accordingly, I was pleased to receive the invitation from SOAP president, Dick Wissler, a longtime friend and colleague. I was particularly pleased to give a lecture named for Fred Hehre (Fig. 1). I suspect that few people today knew Fred Hehre. I am one of the fortunate few. After I finished my clinical training at the University of Virginia I went to Yale for a fellowship. Most of my two years at Yale I spent in the laboratory with physiologist Donald H. Barron, a student of the English physiologist Sir Joseph Barcroft and one of the founders of the field of ‘Reproductive Physiology.’ While there, however, I also came to know Fred Hehre, to observe his work and to learn how he organized and ran his obstetric anesthesia unit at Yale New Haven Hospital. Fred ran his unit quite well. Women received quality care and superb anesthesia coverage for their deliveries.
––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Accepted February 2004 Dr. Donald Caton delivered the Fred Hehre lecture at the annual meeting of the Society for Obstetric Anesthesia and Perinatology at Phoenix, Arizona in May 2003. Correspondence to: D. Caton, Department of Anesthesiology, PO Box 100254, Gainesville, Florida 32610-0254, USA. Tel.: +352-846-1315; fax: +352-392-7029; E-mail: [email protected] 167
168 International Journal of Obstetric Anesthesia
Fig. 1 Dr. Fred Hehre
bastion of natural childbirth. Dealing with natural childbirth advocates was to be my biggest challenge during my first years at the University of Florida. At Florida, I quickly learned that natural childbirth activists did not approach anesthesia for childbirth as a medical issue but rather as a social issue. For example, they were not interested in the effects of anesthesia on the oxygen metabolism of the neonate or rate of equilibration of drugs across the placenta, some of the issues that concern us as clinicians. On the other hand they had a keen interest in personal and social aspects of childbirth: ways in which a woman’s experience during childbirth might affect subsequent interactions among members of the family. Given this orientation they were not the least bit impressed with my clinical training or my background in reproductive physiology. Often they saw patterns of contemporary anesthesia practice as inimical to their social goals. Without realizing it I had stepped into a clash between medical science and social values. Nothing in my training in medicine or in science had prepared me to deal with this. As I started to explore the history of this problem I learned that the conflict was as old as obstetric anesthesia itself and that the clash had taken some strange twists and turns over the previous 150 years. This report will thus focus on this issue. Perhaps learning something of the history will help you with your work as it has helped me.
first anesthetic for childbirth on January 17, 1847 and then did so much to popularize it. You may also recall that Simpson’s influence was mainly with the public, women wanted anesthesia for childbirth and Simpson convinced them that they should have it. Simpson had far less influence on physicians. Most of them opposed the use of anesthesia on medical grounds, not for religious reasons as popular stories often tell. Physicians were not convinced that anesthesia was safe. They feared its effects on the child, on uterine contractions and on the incidence of hemorrhage and infection. Given what we know about the pharmacology of ether and chloroform, their fears were well grounded. In the end, however, it was Simpson, and women, who prevailed. In no small part this was due to Simpson’s personality. Simpson was colorful, influential, gregarious, and charming. He also had a commanding physical presence. One friend described him as having the head of Jove and the body of Bacchus. In short, he was larger than life, the kind of person who dominates a room when he walks in and begins to speak. At the time of his death, 40 years after the introduction of obstetric anesthesia, many colleagues acknowledged Simpson as the most influential physician in all of Europe.
EARLY HISTORY Obstetric anesthesia began with James Young Simpson, the Edinburgh obstetrician (Fig. 2). He administered the
Fig. 2 Dr. James Young Simpson
Medical science and social values 169 But it was not just Simpson’s personality that helped establish anesthesia for childbirth. Nineteenth century social values also put a high priority on the relief of pain and suffering, including that of childbirth. Women attributed many of the social and physical ills that plagued them later in life to the destructive effect of pain that they experienced during repetitive deliveries. Better obstetric care, including anesthesia for childbirth, became part of the feminist movement of the late nineteenth and early twentieth century. Women who fought for the vote also fought for hospitalization for their deliveries; care by physicians rather than by midwives, and anesthesia. The social agenda of these early feminists brought them into direct conflict with medicallyconservative physicians, who preferred to wait until they had appropriate medical studies to show whether the use of anesthesia was safe for normal deliveries.1 In effect, this was the first conflict between medical science and social values over the treatment of pain during childbirth. It was the social values of patients that prevailed however: women campaigned for the use of anesthesia long before physicians could evaluate medical effects of ether, chloroform, narcotics or spinal anesthesia. With this brief history of the first conflict between medical science and social values, I will move ahead a century to the second conflict. Like the first, this too involves a colorful and influential obstetrician, Grantly Dick-Read, founder of the natural childbirth movement. English by birth, Dick-Read was no less charismatic than Simpson, but there are other similarities. Like Simpson, Dick-Read appealed directly to the public, and it was with the public that he had the most influence. Like Simpson, he had far less impact on physicians. DickRead, however, nearly undid all that Simpson achieved to establish anesthesia as part of obstetric practice.2 Grantly Dick-Read (Fig. 3) was born and raised on a farm in Northern England. He studied at Cambridge where he was a mediocre student, but a fairly good heavy-weight boxer. Shortly after medical school he served with the British forces in World War I (WWI). He later wrote that two experiences in the service did much to shape his thinking. In Greece, he watched a woman “drop a quick one” in the field (his words) and then promptly and cheerfully return to work. He thought to himself “This is natural. This is the way that childbirth is supposed to be.” The other experience was with an Indian non-commissioned officer, who introduced him to techniques of mental-relaxation to help him deal with the stress of trench warfare; techniques that would later become part of his system of natural childbirth. After the war, while in training to become an obstetrician, Dick-Read wrote a book describing his ideas about natural childbirth. His professors suggested that it might be prudent at least to finish his training before he
Fig. 3
Dr. Grantly Dick-Read
published. He acceded and the book finally appeared in 1943 under the title Revelation of Childbirth.3 It had little impact. In 1954 he republished the book with the now familiar title Childbirth Without Fear.4 This time the public was ready and Dick-Read began his climb to fame.
DICK-READ’S THEORY OF NATURAL CHILDBIRTH Dick-Read reminded us that childbirth is a natural, in other words a physiological, process. He also believed that “There is no physiological function in the body which gives rise to pain in the normal course of health.” As childbirth is a physiologic process, he concluded that pain is not a normal part of the process. The pain that so many western women seemed to experience he attributed to ignorance and fear and a longstanding cultural tradition that taught that sex was sinful and that pain was a punishment for sin, a reiteration of the Adam and Eve story from the third book of Genesis. Ignorance and fear, Dick-Read argued, caused “activation of the nervous system” and dysfunctional contraction of circular muscles surrounding the cervix. Dick-Read used as his model “natural deliveries” that he had observed during WWI. This is how he described it: “Primitive women are rarely troubled by anxiety states or toxic manifestations. The primitive knows that she will have little trouble when her child is born. She knows that it will be small and healthy. . . .There are no fears in her mind. No midwives spoiling the natural process, she has no knowledge of the tragedies of sepsis, infection and hemorrhage. To have conceived is her joy; the ultimate result of her conception is her ambition. Eventually, and probably whilst even yet at her work, labor commences. . .there is unquestionably a sense of satisfaction when she feels the first symptoms and
170 International Journal of Obstetric Anesthesia receives the impatiently awaited indications that her child is about to arrive. . .she isolates herself, and in a thicket, quietly and undisturbed, she patiently waits.”4 How do they cope with their fear of death? “Those who die, two, three or four percent of some tribes, do so without any sadness realizing if they were not competent to produce children for the spirits of their fathers and for the tribe, they had no place in the tribe.” Educate women about childbirth, Dick-Read said, their fear will diminish and their uterine contractions will return to a normal state. Their labors will be shorter and they will be free of pain. The response to Dick-Read’s theory After WWII, Dick-Read’s method had increasing appeal to the public. There probably were several factors contributing to this. Childbirth had become complicated and very aggressive, with the routine use of forceps (e.g. the so-called “prophylactic forceps” as advocated by DeLee), episiotomy, and anesthesia.5 Women were heavily drugged throughout labor with various combinations of barbiturates, narcotics, tranquilizers, and inhalation agents, often combined with spinal anesthesia for delivery.6 These changes had not been undertaken capriciously. In part they were a response of obstetricians to continuing high risk of death and permanent physical damage associated even with normal deliveries. In part, however, they were also a response to the social goals of early feminists, who expected improvements and innovation in obstetric care. Regardless of the cause, some medical historians have described this era of obstetrical practice as an “orgy of interference.” After WWII, however, the public developed an increased distrust of invasive medical procedures and of drugs as they learned of congenital problems associated with diethylstilbestrol, thalidomide and ionizing radiation. Coincidentally, Virginia Apgar’s score refocused attention on the condition of the neonate. With this, patients showed increasing concern for the use of drugs during childbirth. For such people, Dick-Read’s theory of natural childbirth had great appeal. In short, it was a new era and the mood and social goals of the public began to shift. Even conservative physicians were less enthusiastic about Dick-Read’s theories than the public. Many were outright critical. They asked: If childbirth is so ‘natural,’ why does it require so much education? They saw no scientific basis for Dick-Read’s ideas. They challenged his assertion that his methods improved outcome and they asked for evidence, medical studies and statistical analysis. Most significant, perhaps, they recognized that Dick-Read’s method undercut a style of obstetric practice that they understood and that had given good results, up to that time. Physicians also feared that widespread
adoption of natural childbirth methods would undercut their own campaign for better private and governmental support of obstetric services. In other words, medical science and social goals again were at loggerheads. This time, however, it was physicians who wished to maintain their more aggressive forms of obstetrical practice: patients now began to demand a return to an earlier, more ‘natural’ style of practice. Dick-Read was stunned by the apathy and hostility that he detected among his colleagues. As far as he was concerned, he had simply suggested returning to a traditional form of obstetric practice. In this regard he was right. The approach that he claimed as new was, in fact, very similar to that advocated in many older textbooks. For example, early in the nineteenth century Thomas Denman wrote, “She, the midwife, is to direct her (the laboring patient) to walk about the chamber, from room to room: to sit or lie down, as she finds most agreeable to herself; and if she can, to sleep between pains. . .. The principal object, therefore, of the midwife’s care in this stage of labor is to regulate her patient’s conduct, to soothe her sufferings, to calm her fears, and above all things to avoid fatigue.” Denman’s tract, I believe, could well serve as a manual for a present day Doula.7 I spent considerable time reading Dick-Read’s papers and letters and I came to believe that a great deal of obstetricians’ resistance to Dick-Read’s ideas of natural childbirth was, in fact, a reaction to his style. Patients may have found him charismatic, but with physicians and other professionals he often appeared confrontational and abrasive. Let me illustrate aspects of DickRead’s style with some quotations. First, Dick-Read was inconsistent. For example, with respect to religion he once wrote: “The greatest book upon health is the New Testament. Christ’s teaching is the most advanced and complete treatise upon the interaction of the mind and body ever written.”8 But then he also wrote: “When reviewing the Bible and the teachings of the Church, we find nothing that could give comfort or courage to women who are to become mothers, but today a vast number of women know these ancient representations of childbirth to be entirely fallacious. . .”9 Similarly, having extolled Christianity he also said, “We found the Pagan the best religion we had met, immutable, unchangeable; the laws of their gods saw childbirth as the greatest gift of woman and her greatest accomplishment.”10 Dick-Read was equally inconsistent about anesthesia. On the one hand he could write: “I do not wish to disagree with advocates of applied anesthesia, whether it is caudal, inhalation or parenteral, for pain must be prevented or relieved. Every effort to make childbirth a painless function should be carefully considered. . .”11 But then he could also write: “The whole question of pain relief in labor by anesthesia and analgesia is in a state of chaos, which would be
Medical science and social values 171 laughable if it were not so serious. I experienced a peculiar urge to uncontrolled mirth after 10 days intensive search for stability in this branch of our science. Walt Disney could barely do justice to this Silly Symphony of Obstetric Anaesthesia.” Dick-Read disparaged the work of other physicians: “Robert H. Hingson had done magnificent work upon the use of anaesthesia injected either around or within the spinal cord. In many abnormalities and illnesses his methods have been a lifesaving service, but unfortunately, enthusiasts incarcerated in the overnight cobwebs spun with all technical brilliance of scientific arcane endeavor to simulate his genius before they pass into nothingness. Thousands of normal labors have been subject to this dangerous and unjustifiable procedure, How long, oh how long will this nonsense go on? Why do not at least some of our first class brains settle down to try some really harmless methods of preventing pain in childbirth?” Curiously, Dick-Read also attacked people who might have helped him, leaders of the National Birthday Trust Fund, for example. Leading this organization was a group of politically sophisticated and influential women of the British upper class. Many had worked for several decades to improve medical care for women and children. They had a wonderful track record of working productively with physicians and politicians to attain their goals. Many of the improvements in education of physicians and the care of patients could be traced to members of this organization. Initially, many were interested in Dick-Read’s theories and were willing to support his work. If there was any group that he should have cultivated, this was it. Yet of them he wrote: “The administrators of the Birthday Trust should look into these matters if they are working seriously for pain relief in childbirth and not be guided by political motives of gynecologists who rarely attend normal labor. What sorts of people rob women of the full joys of motherhood because of prejudice or worse?. . .. Surely the safety of mothers and babies carries greater political capital than ministerial statistics of unwanted stupor?” Needless to say, leaders of the National Birthday Trust saw in Dick-Read a person bent on undermining the social and medical goals that had occupied them for half a century. Dick-Read even made statements that were medically incorrect: “Caudal anesthesia robs a woman of all nerve sensations below the waist. She has the baby without sensation, in the same way as a woman paralysed below the waist by poliomyelitis can give birth without experiencing any feeling.” He seemed not to understand that polio affects only motor nerves. Dick-Read’s self destructive tendencies are nicely described in a letter by Eardley Holland, an influential obstetrician, long-time friend and staunch supporter of Read. “I would urge you, though, with respect, to take
more thought to win the sympathies of the Profession as distinct from the Public, and give more time and take more trouble in doing so. It is true that Browne and Claye and I happen to be comparatively liberally minded men and to be your professional sympathisers and backers. But you seem to have alienated the sympathies of the rest of the gynecological world. Have you even considered that you, yourself, may be to some extent to blame for the state of affairs? You have sometime tried even me very severely.”12 Failure and success It was a bad year for Grantly Dick-Read in 1949. He had made little headway establishing his method. He divorced his wife. His partners in private practice ousted him from their group, accusing him of unethical advertising. The newly formed National Health Service declined to appoint him as a consultant in obstetrics because he never sat the examination after completing his training. In a typical response Dick-Read said that he was so well known that he shouldn’t have to take the examination. When this perfunctory appeal failed, he left England to establish a practice in South Africa. There, however, be became embroiled in another mess when he was denied medical licensure because he had not followed the proper procedures. Just as both his personal and professional life seemed ready to disintegrate, help appeared from two unlikely sources: Fernand Lamaze and the Pope. Lamaze was chief of obstetrics in the Metal Workers Union Hospital in Paris. After WWII he made two trips to Moscow to learn how Russian obstetricians had used Pavlovian training techniques to provide women a ‘pain free’ delivery. Lamaze was probably a communist: it was post WWII Europe, at the height of the cold war. The politics of nations were to figure in the ensuing battle over ‘natural childbirth.’ He described the Pavlovian method in a book, which was quickly followed by two clones, one written by his assistant, the other by Majorie Karmel. Lamaze attacked Dick-Read’s method for being unscientific, difficult to learn, and ineffective.13–15 Dick-Read, the former heavy-weight boxer, responded predictably. He struck back. He said that Lamaze had stolen his ideas and then distorted them. Noting that the Russians claimed authorship of every major idea from Shakespeare to Marconi, Dick-Read said that he wasn’t surprised that they also claimed his methods of natural childbirth. The squabble between the two obstetricians soon became public. Dick Read’s approach became known as the English method; the Lamaze technique became the Russian method. In true ‘Cold War’ fashion, patients began to debate the relative merits of the Russian and the English approach. In this debate Dick-Read did not
172 International Journal of Obstetric Anesthesia fare well. Women seemed to prefer the ‘painless’ birth offered by Lamaze over the ‘natural’ birth promised by Dick-Read. At just this point the Pope entered the fracas. In 1957 Pope Pius XII gave a major address at the Convocation of Italian Obstetricians about natural childbirth. It was a thorough historical review of the pain of childbirth and a thoughtful analysis of methods used to alleviate it. The Pope noted that pain had been associated with childbirth since time immemorial, thereby contradicting Dick-Read’s assertion that primitive women experience no pain. He stated that the church had never objected to any medical innovation that might improve the lives of human beings, including the use of anesthesia for childbirth, thereby undermining another of Dick-Read’s assertions. He mentioned the methods of Dick-Read and Lamaze, but said that he personally saw little difference between them. For women concerned about childbirth with ‘Christian Values,’ however, he favored the English method because it seemed ‘less materialistic.’16 The world press took note. A report of the Pope’s address appeared on the front page of the Washington Post. A translation of the entire address even appeared in the New York Times. Newspapers around the world responded predictably. Headlines read: “Painless Birth Techniques” (The Times); “Painless Childbirth not Opposed” (The Daily Telegraph); “Pontiff approves System of Painless Childbirth” (The Washington Post); “Pope approves Soviet Method of Painless Birth, no moral objection.” (The Daily Record of Glasgow). Grantly Dick-Read was ecstatic. He acted as if the Pope had addressed his method and his method alone. He took the Pope’s address as a vindication of his life, and an endorsement of his work, over that of his arch rival, Fernand Lamaze. Dick-Read was even happier a year later when the Pope gave him a special audience and presented him a silver medal for his work. Both the Pope and Dick-Read seemed to have forgotten that for years Dick-Read had ascribed all of the travails of laboring women to the teachings and misinformation given out by the very Church that the Pope led, a situation that appeared to bother neither man. End of life Following his triumph at the Vatican, Dick-Read undertook an extensive speaking tour in the United States. He made several stops. He received a rather cool reception at Johns Hopkins from Nicholson Eastman, one of the leading figures in American obstetrics. He also got a skeptical response in New York, from Alan Guttmacher, another leading American obstetrician. It was in New Haven, however, that he had his greatest success. The chair of the department at Yale, Herb Thoms, was enthusiastic about Read’s ideas, and this spurred
acceptance in the United States. (This was the unit that Fred Hehre was to staff a few years later.) Dick-Read returned to South Africa, where he finally was licensed after a court challenge. He produced a long play record album called The Sounds of Natural Childbirth. It came complete with instructions for a ‘natural birth’ on the record jacket. He televised a live birth, the first such showing ever. A year later, he died. His only regret, his widow said, was that he had not received the Nobel Peace Prize for his work. He believed that he deserved it. An evaluation Grantly Dick-Read was a visionary and a reformer. He helped to bring obstetrics back towards a more restrained, less aggressive style of practice. On the other hand, he was a very disruptive person. Like James Young Simpson, he instigated change by appealing directly to the public. Like Simpson, Dick-Read appeared to have a good sense of the mood of the public. He was in tune with the social values of his patients, and he was willing to bend medical science to fit his theories. Was he right in his theories? I believe that he was, in part. In fact, we now have clinical studies that substantiate some of his ideas. For example, we now know that higher levels of ‘anxiety’ among pregnant women are associated with longer labors, and a higher incidence of cesarean sections and forceps deliveries. Similarly, we have data that shows beneficial effects of having supportive friends and family with a woman during labor. Often, however, simply ‘being right’ is not enough. Nor does it suffice to be ‘in tune’ with current social values. In medicine, it is also necessary to demonstrate the validity of an idea, and it was in this area that Dick-Read failed. He himself never undertook studies to validate his ideas. More than that, however, he often disparaged the work of those who did.17–21 Right or not, any evaluation of Dick-Read must note that his flamboyant style did much to undermine his credibility among physicians. In an obituary published in the New York Times, Frank Slaughter, an American surgeon and writer in the mold of Sherwin Nuland, wrote the comment that best sums up Dick-Read’s life and career: “After it was announced, the Read method was taken up as a sort of cult with considerable mumbo-jumbo and much popular discussion. For some of the official medical opposition to his theories, Read was himself responsible. He advocated principles of relaxation akin to yoga, which he had learned from an Indian noncommissioned officer in World War I. The methods were effective but such an approach spelled quackery to a suspicious medical profession. . .It illustrates a very important truth that those who get rid of existing shibboleths must be careful how they go about it, lest the opposition they create keep the truth from being widely known.”22
Medical science and social values 173 With respect to natural childbirth, I think that the truth did not emerge for several decades after Grantly Dick-Read’s death.23 I believe that the Dick-Read story serves as an important reminder of the interaction between medical science and social values. We are trained in science, and that prepares us to evaluate data. On the other hand, there is little in our medical education that attunes us to social values. All medicine is a balance between medical science and social values. Nowhere is this more apparent than in the delivery suite. Childbirth is not simply a medical or physiological event. It is a time of great personal and social import for the parents, but also for all other members of the community. Simpson and Dick-Read understood the social import of their practice, and that is an important lesson that we should learn from them. At the same time, however, we should not lose our base in science. Most importantly, we must make appropriate efforts to educate patients in this aspect of our work. Striking an appropriate balance between medical science and social values may be our most difficult task.
REFERENCES 1. Caton D. Obstetric anesthesia: The first ten years. Anesthesiology 1970; 33: 102–109. 2. Caton D. Who said childbirth is natural? The medical mission of Grantly Dick Read. Anesthesiology 1996; 84: 955–964. 3. Dick-Read G. Revelation of Childbirth. London: Heinemann, 1943. 4. Dick-Read G. Childbirth without Fear. London: Heinemann, 1954.
5. DeLee J B. The prophylactic forceps operation. Am J Obstet Gynecol 1920; 1: 34–44. 6. Gwathemey J T. Obstetrical anesthesia: a further study based on more than twenty thousand cases. Surg Gynecol Obstet 1930; 51: 190–195. 7. Denman T. An Introduction to the Practice of Midwifery. Brattleborough: W. Fessenden, 1807. p. 187–190. 8. Dick-Read G. Revelation of Childbirth. London: Heinemann, 1943. 1–52. 9. Dick-Read G. Unpublished autobiography. 10. Dick-Read G. Account of a visit to USA (unpublished manuscript). 11. Dick Read G. Childbirth without Fear. New York: Harper, 1944. 12. Holland E. Letter to GDR (dated Jan 8, 1949). 13. Lamaze F. Painless Childbirth: Psychoprophylactic Method [Celestin LR, Trans.] London: Burke, 1956. 14. Vellay P. Childbirth without Pain [Lloyd D, Trans.] London: Hutchinson, 1959. 15. Karmel M. Thank You Dr. Lamaze: A Mother’s Experiences in Painless Childbirth. Philadelphia: Lippincott, 1959. 16. New York Times, Oct 6, 1957. 17. Lederman R P, Lederman E, Work Jr B A et al. The relationship of maternal anxiety, plasma catecholamines and plasma cortisol to progress in labor. Am J Obstet Gynecol 1978; 132: 495–500. 18. Zuspan F P, Cibils L A, Pose S V. Myometrial and cardiovascular responses to alterations in plasma epinephrine and norepinephrine. Am J Obstet Gynecol 1962; 84: 841–851. 19. Kennell J, Klaus M, McGrath S et al. Continuous emotional support during labor in a US hospital: a randomized controlled trial. JAMA 1991; 265: 2197–2201. 20. Scott J R, Rose N B. Effect of psychoprophylaxis (Lamaze preparation) on labor and delivery in primiparas. N Engl J Med 1976; 294: 1205–1207. 21. Wolman W L, Chalmers B, Hofmeyr G J et al. Postpartum depression and companionship in the clinical birth environment: a randomized, controlled study. Am J Obstet Gynecol 1993; 168: 1388–1399. 22. Slaughter F. To ease the pangs. New York Times, New York, Oct. 6, 1957. 23. Caton D. What a Blessing She Had Chloroform. New Haven, CT: Yale University Press, 1999. p. 289.