“Uma hora pequenina!” – The emergence of pain in modern Portuguese obstetricsIsabel Freire
“Pain, which almost always lacks justification, does have a history” writes Spanish historian Javier Moscoso (2012). It is a little fragment of the history of pain, or better of the history of childbirth pains in Portugal, that I aim to share in this text. Specifically, I would like to consider on what basis a modern obstetrical knowledge of pain historically developed.
While the mechanisms of childbirth labour had already interested physicians for over a century, it was in fact only after the discovery of anaesthesia (1846) that pain emerged an issue of obstetricians’ attention. As to say, pain became an object of modern scientific interest only through its possible disappearance.
Obstetrics manuals, over the previous decades, treated pain as an inevitable outcome of childbirth development, formulating different causal explanations and reading through its expressions – the cries, the agitation, the spasms – as signs that could guide the man midwife (o parteiro) through the progress of labour.
With the disappearance of pain from the birthing scene thanks to anaesthesia (1847), and the appearance of an unconscious, still labouring body, the coincidence of pain with contractions was put into question, together with the reasons for pain to still exist.
In Lisbon, it was in the Infirmary Santa Barbara, situated in a narrow attic on the fifth floor of Hospital São José – that obstetrician Alfredo da Costa (1906) will later address as “the antechamber of a female hell” – that the first experimentations with anaesthetic substances took place, starting in 1848. Magalhães Coutinho was the first obstetrician to attempt to test parturition under “the suspension of the phenomena of sensitivity” (Coutinho 1857: 329). Situating this efforts within the international debates over the utility or necessity to medically deliver women from pain during childbirth, he asserted that “it was not with the aim to generalize these applications, that we started the testes in the clinic. What we wanted, was simply to judge through our own experience the reasons that have been given not to multiply these attempts” (Coutinho 1857: 329 italics added). Nevertheless, in the spam of a few decades, trials with anaesthetic substance in the Infirmary Santa Barbara multiplied, and by 1880 beside ether and chloroform, had already appeared amylene, nitric ether, aldehyde, Dutch Liqueur, benzene, carbon disulphide, laudanum, morphine and chloral (Salgado 1880; Paiva 1916; Jesse 1933).
While the clinical interest in experimenting the effects of anaesthetic agents on labour was clear, the articles and medical thesis where these experimentations are reported give us an invaluable insight not only on the developing obstetrics’ understanding on pain, but on the moral and ethical basis on which this knew knowledge was grounded.
The possibility to control the pain of childbirth in the delivery room brought about the necessity, for the obstetricians, to confront emerging issues. A pressing problem was the responsibility to motivate the intervention on normal (as in non-pathological) deliveries. Religious controversies over labour pain’s suppression – the biblical admonishment “in pain you will bring forth child” – were tackled through a counter argument that “God was the first anaesthetist”, stressing how the first surgical operation contained in the Bible, God’s extraction of Adam’s rib to create Eve, was performed after putting him in a deep sleep. The argumentations in defence of anaesthetizing childbirth pain were ascribed mainly on secular reasons, producing a morality of the suffering woman that was initially configured in terms of medical compassion and as a necessity to prevent the trauma related to parturition, that prevented women to give birth to more than one child (Santos 1870; Soares 1925; Salgado 1880; Villar 1892).
Another focal aspect of the debate was the encounter with a new corporeality – and unconscious and still labouring woman – that challenged previous frameworks for the interpretation of pain and decorum. French obstetrician Magendie had critically argued that anaesthesia not only stole the patient’s conscience, but could even evoke erotic dreams in women. In his pioneering experimentations in Lisbon, Magalhães Coutinho dismissed these accusations, though he noted in one of his early cases that “when the woman woke up (…) she said that not only she hadn’t felt any pain, but also that the remedy we gave her had produced a very enjoyable sleep. Could had happened, in this case, what Magendie complained about?” (Coutinho 1857: 329). Faced with immobility, occasional groans and amnesia upon waking, the obstetrician inquiry into what really happened in that senseless abandon was filled with uncertainties and innuendos. “Some obstetrician argue that it is not chloroform but childbirth itself that can give pleasant sensations to the parturient” – continues Coutinho – “Apart from the sensations of maternity, we don’t accredit any others”.
Effectively, the new corporeality of the anaesthetized parturient had robbed the obstetricians of those key signs on which they had historically constructed a reliable interpreting frame.
Yet, the appeal of anaesthesia in disciplining bodies was an explicit agenda of the obstetricians, so that “putting an end to the disordered movements of the suffering woman, and relaxing the abdominal muscles, constitute one of the best adjuvant of the surgeon” (Sarmento 1898). The compassionate quest to nullify pain cannot be separated by the side-track outspoken effort to contain the overly emotional parturient, a gendered embodiment recounted as anxious, delirious, hysterical, the liminal expression of the feminine corporeality (Joaquim 1997).
In contrast with this obstetrical approach, in the intimate and often exclusively feminine context of home birth, as Teresa Joaquim argued in “Dar à Luz” (1983), childbirth was a painful act whose meaning reflected a vision of pain that was semantically integrated in women’s life. The harshness of living conditions, the stark possibility of death in childbirth, laced with the feminine role’s path through life – girl, wife, mother – reverberated through a gendered, spread sentiment of suffering, “for a pleasure, a thousand pains” (por um prazer, mil dores), of married life, of bringing forth life (1983: 25–30). These expressions reveal an understanding of pain that encompassed all aspects of a woman´s life, englobing childbirth pain and attributing to it a pedagogical character: “pain teaches to give birth” (a dor ensina a parir). Constitutive of a gendered life, disseminated through female lineage, pain was a mark that endorsed the translation from the role of woman/wife to that of mother: “Giving birth without pain, rearing without love” (Parir sem dor, criar sem amor) (1983: 68). The dynamics of childbirth within the enclosed space of a feminine universe, when labour was accompanied by laments, chants and echoes of the birthing memories of the surrounding women produced, according to Giacomini (1985), a “pain-based, excitatory model of birth where the expression of pain, encouraged by the other women, was at once a liberation from anguish and an assertion of the reality of childbirth” (1985: 49).
To conclude, if we assert with the German philosopher Wittgenstein (1953), that the experience of pain is based on the (shared) meanings attributed to it, the historical emergence and spread of anaesthetic management of pain could be read as the sign of an impoverishment of traditional significances of suffering in childbirth, but also as the rise of a new vision of birth that implied the possibility of control – of pain, of the gendered labouring body, ultimately of life.
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GIACOMINI, Mariuccia, 1985, “La Donna e il suo parto: rituali e pratiche di assistenza tra passato e presente” in Le Culture Del Parto, 47–53. Milano, Feltrinelli Editore.
JESSE, Thomas Theodor, 1933, “A analgesia no parto”. Universidade de Lisboa.
JOAQUIM, Teresa, 1983, Dar á Luz. Ensaio sobre as práticas e crença da gravidez, parto e pós- parto em Portugal. Lisboa, Publicações Dom Quixote.
JOAQUIM, Teresa, 1997, Menina e Moça. A construção social da feminilidade. Séculos XVII-XIX. Lisboa, Fim de Século.
PAIVA, Jakobus Artur Bota Ferreira de, 1916, “A analgia em obstetricia: Mistura de Schleick – Eutocina Laurent”, Universidade de Lisboa.
SALGADO, Joaquim Antonio, 1880, “O Clorofórmio No Parto”, Escola Médico-Cirúrgica de Lisboa.
SANTOS, Clemente José dos, 1870, “O Cloral durante o trabalho de parto”, Escola Médico-Cirúrgica de Lisboa.
SARMENTO, Evaristo Moraes de, 1898, ‘A Etherisação Em Obstetricia.’ A Medicina Contemporânea 1 (11): 85-86.
SOARES, Pedro Paulo de Mendonça, 1925, “Contribução Ao Estudo Do Parto Sem Dôr”, Universidade de Lisboa.
VILLAR, Luiz, 1892, “O Clorofórmio No Parto”, Escola Médico-Cirúrgica de Lisboa.
WITTGENSTEIN, Ludwig, 1953, Philosophical Investigations, Oxford, Basil Blackwell.