Allopathology in Medical Rhetoric and Maternal Health Care: Discursive (Mal)Practice and the Female Body

Monica Chiu

Childbirth is not an illness, nor is it a disease. The rhetorical construction of laboring patients renders the birthing scene and its female subject pathological. Strapped to a table and commanded to push or subjected to a variety of unexplained needles and examinations, women in labor are denied choice in hospital settings and experience a variety of negative reactions: frustration, anger, disappointment. Medical concerns about the safety of the woman and her unborn child do not always incorporate either the woman's own concerns or her informed demands. This produces conditions inimical to a harmonious staff-patient relationship. Medicalized childbirth can be allopathological, where one action (over medicalizing childbirth as an avenue toward safety) produces a concomitant reaction (that of dissatisfied female patients). Women may have been successfully and safely delivered of a child, but often do not feel that they have subjectively experienced their own labor. [1] The tension between these poles recasts normal labor and delivery, within the medical arena, as a dis-ease.

In the medical (con)text of labor and delivery, women's experiences are described within and prescribed by gendered medical theories concerning women's sex, their bodies, and their health. Women's disappearance in medical rhetoric is the background for this paper, which explores the politics of labor and delivery, where well-intended medical 'care' can produce unexpected, negative results. I trace the allopathological nature of this model through two types of texts: the medical Williams Obstetrics, edited by a collection of doctors and considered the definitive instructional guide for health care professionals on labor, delivery, and obstetrics; and two lay texts, What to Expect When You're Expecting (1991), written by Arlene Eisenberg, Heidi E. Murkoff, and Sandee E. Hathaway and A Good Birth, A Safe Birth: Choosing and Having the Childbirth Experience You Want (1992) by Diana Korte and Roberta Scaer. The latter two texts take medical practices such as those in Williams to task. These are easily found on commercial bookstore shelves, while Williams is usually only requested by those in the medical field. These lay texts serve as mouthpieces for women's negative reactions to medical actions.

Using Williams and the two lay texts as grounds for examining discursive struggles over defining childbirth, I focus on medical representations of women, tracing their histories and their translation into particular cultural situations. I compare these findings with nonmedical, or women- and family-centered texts that have their roots in feminism. Both what is written and what is obscured in textbooks for health care professionals and in popular guidebooks for pregnant women and their families, dictates women's care within and against gendered and institutionalized standards during normal labor and delivery. [2]

A text, no matter what its origin and audience, reflects and reproduces the attitudes and assumptions of the culture in which it is produced. Williams Obstetrics is produced not only within the medical realm, but for it as a training manual that naturalizes the roles medical ideology has created for female patients. [3] Laboring women, like any other patients, become the object of medical practices. Outside the medical profession there may be increasing acknowledgment of female subjectivity and agency, but because of its social prestige, medicine remains insulated from larger ideological changes. Behind the laser surgery, laporoscopy, and fetal monitoring of the late-twentieth century lies a nineteenth-century ideology about women.

Since Williams' first publication in 1903, according to Robert A. Hahn, it has eliminated the definitive member of the birthing team: the female patient (1987: 262). Strapped to a table and commanded to 'push,' the woman in this medical tome becomes only the object upon which the staff works and from which it delivers what is often perceived as the primary patient, the baby. Hahn criticizes the role of the physician as 'the conductor of physiology and reproduction, with the woman a faintly discernible participant' (1987: 262). Thus, when medical theory becomes medical practice [4], women appear as a passive form between hospital sheets from which a child is born.

During his investigation of Williams, Hahn has been 'repeatedly confronted by attitudes and practices that [he] find[s] repugnant: essentially the reduction of the personal experience and the interpersonal relations of childbearing to an operation on the body in which the childbearing woman and her women friends are deprecated and ignored' (1987: 258). Lay guides also exhibit anger at frequent insensitivity toward women in labor. These authors instruct and inform pregnant women of strategies for warding off the standard set of needles and scissors brandished by some of their medical staff. If medical actions are produce angry female reactions, then medical writing has similarly prompted a spate of books reacting to its objectification of women.

Physicians must retain their authority over medical processes for the moral and legal integrity of the profession. If not -- or if all patients are to be viewed as experts on their conditions -- then what would be the purpose of seeing a physician? Traditionally, nurses have mediated between patient and doctor, especially in conveying patients' frustrations. However, because they have not earned a doctorate of medicine, nurses must defer to physicians' authority. Thus, a book such as What to Expect, with a nurse on its editorial board, unsurprisingly speaks for her female patient to her physician through this written avenue.

In the bestseller What to Expect When You're Expecting, a reversal occurs; a physician speaks from a lay text. Dr. Richard Aubry endorses the entire text in two short forewords called 'A Word From the Doctor' and 'Another Word From the Doctor' (Eisenberg et al. 1991: xvii-xix). 'Pleased and excited,' Aubry highly praises the comprehensive quality of this book concerned with normal and problem pregnancies. Women love it and physicians respect it, according to Aubry: 'It's not only recommended ... to new patients by many ob/gyns, but used by those physicians.... My young residents read it to learn what patients are wondering and worrying about' (Eisenberg 1991: xvii). Already Aubry colors the knowledge presented, shifting its emphasis from the pregnant women at the text's center to the practicing and learning medical staff.

The text is authored by three women: one a nurse, none of them physicians. Therefore, Aubry's forward, which reinforces the necessity of introducing birth through the medical field is worrisome. It signifies the necessity to validate women's birthing experiences through the traditional, patriarchal realm of medicine. Emily Martin's The Woman in the Body: A Cultural Analysis of Reproduction shows that what is defined as scientific and objective is also defined as masculine, Thus so-called emotional and subjective women are alienated from the hard sciences. Quoting Kenneth R. Niswander, Martin says that 'science presents a male-biased model of human nature and social reality,' and therefore infuses the scientific/hospital experience for laboring women with male-oriented ways of seeing (Martin 1987: 21). In fact, Aubry's published affirmation illuminates a commonplace in medical literature where the health care provider's 'masculine' authority is privileged over women's experiences. Is this carried over from the infantalized woman of the nineteenth century, nursed back to health by imposing paternal figures? Or is this merely modern medicine ensuring a safe labor and delivery?

As a member of the privileged medical arena, Aubry accords authority to the lay text. Once in the hospital setting the hierarchizing of physicians over patients eradicates any negotiated understanding between clinical and other opinions so optimistically expressed in What to Expect. [5]

A Good Birth is written by two mothers; it opens with this disclaimer, nearly erasing the boldness of a text critiquing overmedicalized births: 'The authors of this book are not physicians. All matters regarding your health require medical supervision. The suggestions contained in this book are not substitutes for professional medical advice' (viii). The marginal, represented in this lay text, highlights some of the problems in mainstream medicine. The authority accorded to physicians is not subverted in this text, but rather mildly subdued. [6]

Comparing Williams with the opinions offered in these lay texts shows the medical field's view of childbirth as a risk to women and their unborn babies as a stark contrast to its 'natural' designation as a process in which women have engaged for centuries. Defining of what is 'good' and 'bad' for the laboring woman remains hotly contested.

Approaches to Pain in Labor and Delivery

Both popular texts and Williams begin chapters about labor and delivery by listing questions women ask regarding birth. Popular texts redefine traditional notions of excruciating or debilitating labor pains through parallels to sexual and psychological pleasures. Williams, however, dwells upon a negative understanding of pain. Hahn writes, 'While Williams does not mention pleasurable and satisfying experiences in childbearing, he is greatly concerned with the 'excruciating' pain that patients often suffer during the course of delivery,' thus rendering anesthesia desirable in order to erase the experience from memory (1987: 270-271).

In fact, degrees of pain, categorized by levels of pleasantness or unpleasantness, are totally divorced from feelings of success and satisfaction during childbirth (Salmon et al. 1990: 258). In other words, Williams' insistence on completely eliminating pain takes precedence over women's emotional reactions to delivery, which account more strongly for satisfaction in and involvement during birth. 'Pain has been a label indiscriminately applied to the range of sensations during labor, a label which appropriates and denies the complexity of the individual woman's physical experience' (Rich 1976: 159). Does the forced elimination of pain evoke other symptoms, mainly the emotional dissatisfaction of those women who desire a less invasive birth?

The first paragraph of Williams chapter 'Conduct of Normal Labor and Delivery' begins: 'Most pregnant women have two major fears: 'Will my baby be all right?' and 'Will labor and delivery be extremely painful?' Williams addresses what physicians assume that women fear most -- pain -- reinforcing its existence by implication (Williams 1993: 371). An explanatory paragraph follows soon after, in which a Dr. Cook, in 1982, discovered that 'the natural order [of childbirth] results in very high maternal, fetal, and neonatal death rates and uncounted forms of morbidity. ... [Thus,] the medical intervention [to control pain] in this natural process . . . resulted in the dramatic drop in maternal and prenatal mortality' (1993: 371, emphasis in text). Using such evidence, Williams provides itself with a convenient medical model in which the 'parents' desire for a meaningful experience' is secondary to 'the needs of the fetus-infant' (Williams 1993: 371, emphasis in text), wresting decision-making from women and placing it in the hands of medical providers before the chapter even begins.

While not all women desire pain relievers, and not all births necessitate them, this section makes their administration routine. Nowhere does Williams indicate that the choice for pain relief rests with laboring women; the health care provider reads patients' levels of pain and prescribes appropriate medical remedies. Too often, a provider's attempt to eliminate a woman's pain does not necessarily emanate from compassion, but rather, from the staff's desire to control perceived pain. This suggests that women in labor will undergo as much pain as their medical staff deems acceptable: 'Doctors believe that they alone know what women need' (Korte and Scaer 1992: 94). Williams underscores an observation by 'the founding 'father' of the twentieth-century natural childbirth movement,' [7] who says, 'Fear is in some way the chief pain-producing agent in otherwise normal labor' (Williams 1993: 371, emphasis in text). Gena Corea, in The Hidden Malpractice: How American Medicine Treats Women as Patients and Professionals, writes, 'When, in the hospital environment, women do not know what is happening to them or why, they can become frightened. A number of studies have shown that fear, leading to tension, increases the length of labor' (1977: 191). Doris Haire, in 'The Cultural Warping of Childbirth,' adds, 'Research indicates that fear adversely affects urine motility and blood flow,' ultimately making labor and delivery more painful and more difficult (1972: 13). Such results re-emphasize the sometimes allopathological implications of forced pain control.

The emergence of such symptoms may suggest to the medical staff that fearful women create their own pain, and consequently their own delivery problems. When 'imaginary' pain results in necessary analgesics sometimes harmful to the fetus, women bear the blame. They are guilty, culpable, the fetuses' most threatening enemies. The medical team then privileges children over women, often creating animosity between parent and child as well as between women and medical staff (Hahn 1987: 262).

The medical scrutinizing of the laboring woman encourages her to acquiesce to its authority. Consistent medical questioning about pain can convince women that they are experiencing such pain . Thus the voice of medical authority can mediate and eventually appropriate women's reactions into its paradigms. Medicalized birthing practices become 'natural' agreements between patient and physician. The medical discourse constructs its object, which consequently conforms to the demands of the discourse.

By reducing women's experience of childbirth to pain, Williams erases all possibility of asking questions such as Rich poses: Can childbirth pain be satisfying? What is the difference between creative and destructive pain? Who or what is responsible for pain? What other sensations accompany labor and delivery? Addressing these concerns transforms pain 'into something usable, something which takes us beyond the limits of the experience itself into a further grasp of the essentials of life and possibilities within us' (Rich 1976: 158).

Throughout passages on stages of labor, What To Expect includes recurring subsections called 'What You May Be Feeling or Noticing' and 'What You Can Do,' addressing different kinds and levels of pain: varying degrees of leg and back discomfort, cramping and fatigue (Eisenberg et al. 1991: 271-308). Not simply euphemisms for pain, What to Expect dismantles Williams' myth of a single, overarching pain. In addition, What To Expect includes methods of relief other than quick, pain relieving injections offered at women's first grimaces of discomfort.

While childbirth traditionally has been associated with all-inclusive pain, its more pleasant sensations and emotions have been overlooked. Women must remain sensitive to their physical and psychic pain in relation to the changes in the body during delivery (Rich 1976: 159). A Good Birth equates childbirth pain with sexual pleasure through parallels to the rhythmic contractions of labor and orgasm. After delivery, the erect nipples and the pleasant sensation as the child sucks heighten women's emotions and often stimulate their sexual desire, establishing an erotics of breast feeding (Korte and Scaer 1992: 30-31). Emphasizing such connections enhances and complements the birthing experience, making birth easier, calming and encouraging expectant women and allowing them to enjoy the experience. Negotiating medical practicality with lay desires seems the logical solution to 'good' labor and delivery.

A Woman's Choice versus Hospital Routine

Many practices once considered routine during delivery have recently been dismissed as unnecessary or only beneficial to the busy staff: shaving the pubic area to create a clean, surgical surface; administering an enema to prevent women from defecating while pushing; attaching women to fetal monitors to record babies' heartbeats [8] ; and performing episiotomies, which involves cutting the space between the vagina and the rectum (perineum) to prevent tearing during birth and to enlarge the vaginal opening for a faster delivery. A Good Birth advises its reader to question these practices in 'What Women Want' (Korte and Scaer 1992: 7-25), 'Obstetricians' Beliefs About a 'Safe Birth' (88-103), 'The Obstetrician's Black Bag of Interventions' (104-131) and 'The Cesarean Epidemic' (132-165).

While many studies discount the necessity of such procedures, Williams presents most as exigent and non controversial. The textual explanation of enemas, for example, suggests its routine application: 'Early in labor, a cleansing enema usually is given to minimize subsequent contamination by feces' (1993: 374, emphasis mine). 'Usually' keeps the authors from saying that all hospitals routinely administer this procedure, while still implying its common practice. The same conclusion can be drawn from the textual presentation of shaving women's pubic hair: 'In many hospitals the hair on the lower half of the vulva and the perineum is removed either by shaving or clipping' (1993: 374, emphasis mine). 'Many' similarly implies that these procedures are always performed. Haire writes, 'Research involving 7,600 mothers has demonstrated that the practice of shaving the perineum and pubis does not reduce the incidence of infection. In fact, the incidence of infection was slightly higher among those mothers who were shaved' (Haire 1972: 14). [9] Williams' rhetoric implies an uncomplicated acceptance of this medical norm: 'Except for cutting the umbilical cord, episiotomy is the most common operation in obstetrics. The reasons for its popularity among obstetricians are clear. It substitutes a straight, neat surgical incision for the ragged laceration that otherwise frequently results' (1993: 389). This surgical incision makes suturing easier and quicker for the physician and prevents lacerations of the rectum (1993: 389). Ease of medical treatment comes at the cost of acknowledging women's desires. Strangely, Williams suggests that episiotomies need not remain a standard procedure in normal labor and delivery (1993: 389); both 18th and 19th editions cite several opponents to the procedure and their reasons (1989: 323, 1993: 389). Given this admission, it is curious that Williams excludes directions for the perineal massage, an episiotomy alternative where regularly massaging the perineum during the latter stages of delivery render it more flexible -- thus more resistant to ripping -- as the baby stretches the skin. Ease of surgery, or a surgeon's ease.

Throughout the chapter, photographs depict women during delivery as supine, strapped to the delivery table, her legs firmly secured in the stirrups. 'The kind of bed or delivery table used, the labor and delivery position of the woman, and the temperature of the delivery room are all designed to contribute to his [the physician's] convenience and comfort, not to that of the mother-to-be or the newborn infant' (Korte and Scaer 1992: 94). In both popular texts, birthing while squatting or standing where gravity is an additional aid in expelling the child, are recommended over the usual lithotomy (supine) position. The 19th edition of Williams boldly admits that 'actual delivery of the fetus can be accomplished with the mother in a variety of positions' (1993: 380). This addition, a milestone in the medical tome's progression toward women-centered inclusion is ironically, followed by a thorough recommendation of the dorsal lithotomy position and instructions on placing the patient comfortably into the stirrups (1993: 380). No wonder a discussion on leg cramping immediately follows. A Good Birth says, 'The supine position is the worst one for labor and delivery.... [While] the upright position, with the assistance of gravity, increases the strength of contractions and dilates the cervix faster. Women report less pain in the upright position' (Korte and Scaer 1992: 105, emphasis in the text). What to Expect includes drawings of various labor positions (Eisenberg et al. 1991: 289).

The two women-centered texts fail to warn readers of numerous medical students and residents using female patients as teaching material. Diana Scully's chapter on 'Women as Teaching Material,' in her book, Men Who Control Women's Health: The Miseducation of Obstetrician-gynecologists (1980) investigates how lower class patients (often women of color) are used as experimental material, how their treatment, compared to that of white middle- and upper-class patients who are able to pay for health care services, is of inferior quality. [10] Scully says, 'Teaching hospitals, usually associated with medical schools, have always been organized primarily to train physicians. Since the health care system was never intended to provide the same services and care for the poor that is available to the middle class, teaching institutions are at liberty to structure services so that staff needs, rather than patient needs, are satisfied' (1980: 120-40). [11]

Middle- to upper-class women can afford private physicians, avoiding student examiners and observers. 'According to my research,' says Ellen S. Lazarus, 'choices and control are more limited for poor women, who are overwhelmed with social and economic problems' (1994: 26). Such women often exchange the use of their bodies -- as training tools -- for necessary medical care. Overlooking such hospital dangers, the authors of What to Expect and A Good Birth are assuming a particular readership, namely white and middle class.

As if to punctuate racial and socio-economic divisions, the majority of Williams photos highlighting cervical dilation or vaginal examinations use African-American women as their subjects, sanctifying the white, female body as too pure for exposure. In addition, all of the practitioners represented are white. In this respect, the egalitarian objectivity of the hard, cold sciences is visually obliterated.

Medicalized (Mis)Representations of Woman

Equally suggestive of the medical staff's free play over the defined and confined laboring women is the pictorial disappearance of their faces. Staff and infant are shown most frequently as complete human bodies. Paging through an edition of Williams written by the physician who assisted her mother, Adrienne Rich says, 'Nowhere was the face of a laboring mother visible in its photographs; all was perineum, episiotomy, the nether parts I recognized as like and unlike my own, stretched beyond belief by the crowning infant head' (1976: 166, emphasis in text). Visually, women's bodies are fragmented upon the page; they are only part of a medical, nonexistent (w)hole.

Educational materials other than Williams contribute to women's disappearance on the delivery table. In the videotape 'Human Birth Series,' an instructional tool on delivery methods for nursing and medical students, the camera's focus remains between the woman's legs and upon the emerging infant. [12] She has been draped, routinely shaved, and prepared for surgery, as if birth were a surgical event. Because the video camera refuses to acknowledge her voice, her face, and her body, except as two bent knees and a vagina, visually, the video suggests that despite her absence, the baby can still be born. Typical of videotapes or photographs highlighting surgical procedures for use in/as instructional materials, this emphasizes the point that the clinical eye relinquishes the human element in its approach to the human body.

All delivery room noise has been eliminated throughout the video; the 'operators' (as the attending staff is called in this tape) perform in a vacuous silence while the male narrator drones on, describing routine procedures in the staff's, not the woman's, delivery of the baby. The woman's efforts at expelling the baby remain obscured; the male operator delivers the child, with or without forceps, with or without a cesarean, i.e. seemingly without the woman Re-emphasizing the invisibility of female patients, the narrator consistently informs viewers when the fetus is a boy, which occurs in over 90% of filmed births. If the is female, no such similar announcement is made.

Agents of Control

In Williams, the chapter on normal labor and delivery is divided into numerous subsections, three of which are called 'Management of the First Stage of Labor,' 'Management of Second Stage of Labor,' and 'Management of Third Stage of Labor.' 'Manage' emerged in the sixteenth century to mark the success of one who dominates over another. The Oxford English Dictionary offers the following definitions: 'to handle, train, or direct (especially horses)'; 'to handle, wield, make use of a weapon'; 'to control, cause to submit to one's rule'; 'to adulterate, sophisticate, to 'doctor'; 'to cope with difficulties of, to succeed in using' (1971: 1711). In its evolution from the management of horses to its reference to medical doctoring, 'manage' in this context disturbingly suggests the usurpation of 'the active, leading role' (Hahn 1987 265).

In their managerial role, health care professionals allow themselves the liberty (or luxury) of arriving only when delivery is imminent, pure testimony to the continuity of their control even when they are absent. The staff asserts its presence upon laboring women through frequent, although often unnecessary and painful vaginal examinations. The latest edition of Williams admits that 'the need for subsequent vaginal examinations ... will vary considerably' (1993: 377). Sometimes these are performed by medical students and residents, who need opportunities to practice. Medical staff and students merge into one, part and parcel of the metonymic 'examining finger' prevalent in the pages of Williams (1993: 372). And with the frequent use of fetal monitoring, Williams itself concedes: 'Electronic monitors are merely extensions of doctors' and nurses' eyes and hands' (1993: 376), rendering the 'man'agement of the entire medical staff all-pervasive and intrusive. With an increase in surveillance, a word used frequently in the text, monitoring equipment is now the clinic eye replacing the medical hand.

Not only can the staff physically manage deliveries by ordering women to be wheeled from labor to delivery rooms, but it can also control them psychologically through textual definitions of length of labor. Barbara Katz Rothman, in her text In Labor: Women and Power in the Birthplace, says, 'Length of labor is not a basic, unchanging biological fact, but is subject to social and medical control' (1982: 263). She cites a typical case of negotiating definitions of labor, one that privileges the health care professionals' knowledge of labor over women's experience. If, for example, she presents herself to the hospital claiming that she is in labor, and by weeping, pleading, or just because she seems educated and middle-class, she is admitted, the medical acknowledgment that she is in labor will have been established. If she does not begin to dilate for twenty-four hours, and then twelve hours after that ... she delivers, that woman will have had a thirty-six-hour labor. The medical authorities will see it as a thirty-six-hour labor, and so will she. ... On the other hand, if she is denied or delays admission and presents herself to the hospital twenty-four hours later for a twelve-hour in-hospital labor, she will have had a twelve-hour labor preceded by a day of discomfort. (1982: 166-167)

Staff interpretations, more than women's perceptions of their conditions, determine admittance into the delivery room and the recommendation of analgesics or the administration of labor inducing drugs. Jordan clarifies, 'what the woman knows and displays, by virtue of her bodily experience, has no status ... she 'cannot' push until the doctor gives the official go-ahead' (1993: 157). [13] Women's interpretations of their conditions are not considered the same sort of 'authoritative knowledge' which would prompt action (Jordan 152-154).

The authors of A Good Birth realize that laboring women may be squeezed into the medical staff's schedule as it regulates numerous and near simultaneous births with the limited availability of labor and delivery rooms. Korte and Scaer, therefore, suggest numerous birthing alternatives to the predominant hospital birth:

A major Atlanta newspaper writes, 'Women who deliver their babies at the Rincon [birthing] center aren't strapped to hard tables equipped with metal stirrups, hooked to electronic monitoring equipment, dosed with powerful painkillers or subjected to surgical procedures considered routine in hospital delivery rooms' (Jingle Davis 1992: B1+). The article illuminates alternatives in which women find relief from medical monitors, medical authorities, and unnecessary medication.

Health care providers outside the traditional hospital setting, are also licensed to assist delivery or are willing and able to become involved: family practitioners, nurses, midwives, significant others, and doulas (pronounced DOO-las). A doula is 'another woman who has had a normal birth and offers continuous comfort, support, and encouragement to the woman' before, during, and after delivery (Korte and Scaer 1992: 19). Doulas, which have been around for centuries, '... are banding together to bring their services into the mainstream of American health care,' effectively instilling confidence in the laboring woman, offering constant comfort and, equally important, drastically cutting health care costs for expectant women and/or families (Marcia Ringel 1993: B4). Such providers 'are bringing back an essential ingredient of birth. ... This is humanizing maternal care' (Ringel B4). Williams, too, is now gravitating toward accepting such alternatives to the traditional physician in labor and delivery rooms: 'Given a choice, [an ambiguous statement itself about whether choice is offered] most women probably would prefer the reassurance of the nearly continuous presence of the obstetrician or a compassionate well-trained obstetrical associate [read: midwife or doula]' (Williams 1993: 376). 'Choice' is entering Williams' vocabulary.

Conclusion

Health care professionals must realize that laboring women, although written out of medical texts like Williams, link them to their specialty: gynecology. But within this interplay between patient and medical staff, where is the fair negotiation between the latter's knowledge and women's actual experiences? Who is paying attention to women's reactions to medical actions in the clinical arena? [15] In negotiating an experience shaped by medical discourse, women should expect a dialogue with the medical staff in opposition to monologues directed at them, reversing women's capitulation to authority. Good and DelVecchio Good illuminate how medical rhetoric derives from medical knowledge, itself shaped experientially in the field. They ask the important question, 'How are we to re imagine medicine in a manner that neither reproduces conventional ideological knowledge nor represents an ungrounded fantasy?' (104). How can medical texts, as well as lay texts, mediate between both the sciences and humanity? How can one view always incorporate the practical and 'good' suggestions (however these are mutually defined) of the other view? To avoid the construction of women as gaps in another's rhetorical control, both theory and practice across the board must privilege expertise and safety as well as women's experience and satisfaction.

Works Cited

Notes

Acknowledgments

I would like to thank Gayle Whittier for all her help on an earlier version of this paper, originally written for her graduate seminar, 'Literature and Medicine,' Binghamton University, Spring 1992. I would also like to thank Michael Strysick for his numerous readings and careful editing of former drafts. To those who offered suggestions, including Jana French, Robbie Davis-Floyd, and Margaret Cooney, I extend my gratitude.