Simpson and assistants discovering anesthetic effect of chloroform

Next to Pitocin, obstetric anesthesia is probably the second-most hated intervention among the natural birth community. Like Pitocin, obstetric anesthesia is blamed for excess Cesarean deliveries and various other obstetric complications, and it is also claimed by many that women who undergo pain relief during delivery simply don’t bond with their children as much as they should or even love them as much as those mothers who don’t receive anesthesia during delivery. Doctors and hospitals are seen as pushing epidurals and pain meds on laboring women, leading to unspeakable ills.

The history of obstetric anesthesia is actually quite amazing, and is still relevant today in helping understand what we think about pain relief during labor.

One of the greatest differences between ancient medicine and surgery and modern medicine and surgery is the ability to control pain. As I discussed in the first appendix of my new book about vaginal hysterectomy, anesthesia before 1850 usually involved opium derivatives like Laudanum or simply alcohol (or both). Many cases involved nothing at all. Scottish obstetrician James Young Simpson first used chloroform on humans for anesthesia in 1847, administering it to a laboring woman after experimenting on himself. Two years before, in 1845, American physician Crawford Long administered ether to his own wife during labor. He had been experimenting with ether for a few years and began using it in surgery, but he didn’t publish his results until 1849.

The availability of anesthesia suddenly made surgery much safer and certainly more humane, and led to the emergence of a controlled environment that allowed for better hemostasis, aseptic and antiseptic techniques, and a dramatic decline in morbidity and mortality. Surgery became a science and a wonderful tool to improve our quality of life instead of a desperation-filled act of barbarity. It started with inhalation gases.

The Gases

Nitrous oxide, laughing gas, or “factitious airs” as it was originally called, was first synthesized by Joseph Priestly in 1772. Humphy Davy, who experimented with the gas for a variety of uses, first noted that it might have an anesthetic quality in 1799 and published this result in 1800 after trying the gas on himself when he had pain after a wisdom tooth extraction. However, it was not until December 11, 1844 that Horace Wells famously used it on a patient while performing a dental extraction in Hartford, Connecticut. Wells killed himself in 1848, after becoming depressed and despondent when one of his patients died from nitrous oxide. Nitrous oxide didn’t induce a potent enough effect for major surgery, but the idea that a gas could be used as an anesthetic quickly led to the use of diethyl ether.

Crawford Long was a physician in Danielsville, Georgia. He had read Davy’s work about nitrous oxide and decided to try to use ether (because it was more available) in 1842 to remove a cyst from a patient’s neck. Long continued to experiment with ether for many years before he published his results in 1849 in The Southern Medical and Surgical Journal. William Morton made the first public demonstration of ether as a surgical anesthetic in October, 1846. A year before, in 1845, Crawford Long administered ether to his wife during her labor, making Caroline Swain Long the first woman to receive inhalation anesthesia during labor.

In 1847, James Young Simpson, the famous Scottish obstetrician, first demonstrated the anesthetic properties of chloroform. Simpson had been searching for a compound that might prove effective, trying various chemicals on himself and his assistants. He actually lost consciousness after inhaling the gas and luckily woke up the next morning. On January 17th, he first administered chloroform to relieve the pain of childbirth to a woman called Jane Carstairs, in Edinburgh. She was the wife of a physician and had a contracted pelvis due to rickets. Mrs. Carstairs’ first pregnancy had ended with fetal destruction after a three day, agonizing labor failed to produce delivery due to her contracted pelvis. The doctor had perforated the fetal head and removed the dead baby from the obstructed labor. In her second pregnancy, Simpson administered chloroform to her and the baby delivered on its own in about 25 minutes after she became completely dilated. She woke up in disbelief that she had delivered when she was presented her “own living baby.” Simpson went on to use chloroform for most of his laboring patients in the months that followed, publishing his results in the forerunner to the British Medical Journal. He said,

Obstetricians may oppose it, but I believe our patients will force the use of it upon the profession … I most conscientiously believe that the proud mission of the physician is distinctly twofold – namely, to alleviate human suffering, as well as preserve human life.

Simpson worked to popularize the use of chloroform as an anesthetic, not just for laboring women but for surgeries in general. He administered it to a four year old boy while his broken bone was set later in 1847. In the United States, in April of 1847, Nathan Cooley Keep administered ether to Fanny Longfellow, wife of Henry Wadsworth Longfellow, during her delivery. Critics of anesthesia sprung up immediately and Simpson spent a great part of the next several years of his career defending anesthesia on several fronts.

Surgery was viewed as so deadly that it was thought that adding something that weakened the pulse or sedated the patient would just lead to further deaths. To combat this notion, Simpson collected data on amputation patients and showed that only 1 in 3 died with chloroform compared to 2 in 3 without it. It was similarly argued that when used in childbirth, chloroform would produce higher risks of maternal morbidity and mortality (again with the general idea that “pain” was necessary to keep the patient vigorous); Simpson once against used data to show that this idea was wrong as well. Simpson was keen on using statistics and probability theory to aid in his medical decision making, a sentiment not shared by his contemporaries (or mine).

It was generally believed at the time that the pain of childbirth was natural and served a natural function; that God had created pain during the conduct of childbirth to make childbirth safer, and therefore removing the pain would necessarily make childbirth more dangerous. Harvey Graham, in Eternal Eve, found this quotation from the time about Simpson:

That he did not think anyone in Dublin had as yet used anesthetics in midwifery; that the feeling was very strong against its use in ordinary cases, merely to avert the ordinary amount of pain, which the Almighty had seen fit – and most wisely, no doubt – to allot to natural labor; and in this feeling he – the writer – most heartily concurred.

To which Simpson responded,

I do not believe that anyone in Dublin has as yet used a carriage in locomotion; the feeling is very strong against its use in ordinary progression, merely to avert the ordinary amount of fatigue, which the Almighty has seen fit – and most wisely, no doubt – to allot to natural walking; and in this feeling I most heartily concur.

Simpson’s breakthrough in the twin aim of alleviating suffering and preserving life was being criticized as unnatural just as today many of the extraordinary breakthroughs that have made humans live longer and better lives than at any point in human history are criticized as unnatural. The argument is made today that unless a woman experiences all of the pain in childbirth she cannot appreciate her child in the fullest nor love it completely; to which Simpson might point out that unless you write a letter by hand and carry it by foot to its recipient after fashioning the paper from raw material and creating the ink and pen from scratch, the recipient might not fully appreciate the message being delivered nor value it completely.

This idea is still promulgated among the “natural-birth” community. The (unfortunately) influential Michel Odent has said,

The pain of labor is part of the physiologic process … You cannot extract the pain and keep the rest. It’s a chain of events (quoted in Pushed by Jennifer Block).

There is, of course, absolutely no scientific basis for such a perverse claim, and one wonders if Odent just enjoys watching women suffer.

The last and biggest objection facing Simpson and other early practitioners of obstetric anesthesia was the idea that giving anesthesia specifically to women while they labored violated the biblical decree that women must suffer pain during childbirth as recorded in Genesis 3:16:

To the woman he said, “I will greatly increase your pangs in childbearing; in pain you shall bring forth children, yet your desire shall be for your husband, and he shall rule over you.” (NRSV)

The Church of Scotland had long since taken a stand against the use of anesthesia during childbirth. In 1591, a Scottish woman named Eufame Macalyane was pregnant with twins and sought some pain relief during delivery from a woman named Agnes Sampson. Because she attempted to provide pain relief to a woman in labor, Agnes Sampson was tried for heresy before King James; she was convicted, and burned to death on the Castle Hill in Edinburgh. Howard Haggard (The Story of Anesthesia) records one clergyman’s thoughts about Simpson:

Chloroform is a decoy of Satan, apparently offering itself to bless women; but in the end it will harden society and rob God of the deep, earnest cries which arise in times of trouble for help.

The same passage in Genesis that seems to demand that women suffer pain in childbirth goes on to state that men should toil and sweat and struggle with farming; but in the 19th century, air-conditioned tractors and harvesters had not yet been invented so men saw no apparent parallel. Simpson responded to the religious objections against obstetric anesthesia in an 1847 paper entitled Answers to the Religious Objection Against the Employment of Anesthetic Agents in Midwifery and Surgery. He pointed out several issues. He argued that, even then, farmers were using horses and tillers to make the work of farming easier; he pointed out that physicians should not attempt to save lives, since the same passage ends by stating, “For you are dust, and to dust you shall return.” He discussed the meaning of the Hebrew word translated pangs or sorrow and argued that toil or labor is a better translation; he further argued that since humans have a more difficult time delivering than other animals (due to the large head-to-pelvis ratio seen only in humans), then the principle of suffering is fulfilled. Simpson also argued that God himself used anesthesia when he caused “a deep sleep to fall upon the man, and he slept; then he took one of his ribs and closed up its place with flesh” (Genesis. 2:21).

Simpson methodically destroyed the various objections to anesthesia, both health and side-effect related and religious. But it didn’t matter. The medical community vilified Simpson and others who dared use chloroform. In 1848, The Lancet published a theologic response to Simpson’s paper written by a Dr. Ashwell, and the medical literature of the time was suddenly filled with theological papers and even papers written by Hebrew scholars about the meaning of the words in the verse.

The Queen

For six years the debate raged on, until April, 1853. On April 7th, 1853, Queen Victoria was in labor with her eighth child, the future Prince Leopold, Duke of Albany. She asked Dr. John Snow to give her chloroform (which she received from him again in 1857 with the birth of her last child, Beatrice). Snow administered chloroform 77 times in his career to women in the second stage of labor, but it was this administration to the Queen that would largely silence the religious objections to its use.

Well, eventually any way. The initial response was one of disbelief and ridicule. On April 15th, a week later, the Association Medical Journal reported the birth:

We understand that chloroform was administered by Dr. Snow during the latter part of the labour, with very satisfactory effect; and that the Queen expressed herself as grateful for the discovery of this means of alleviating and preventing pain.

The responsible position, and the acknowledged skill of the physicians who sanctioned the inhalation of the chloroform, the Royal Majesty of the patient, and the excellence of her recovery, are circumstances which will probably remove much of the lingering professional and popular prejudice against the use of anaesthesia in midwifery, even when sanctioned by competent authority, and induced with requisite precaution. It is for this reason that we chronicle the recent accouchement of Her Majesty as an event of unquestionable medical importance.

Despite this early report, in the May 14, 1853 edition of The Lancet, the editors wrote a lengthy screed seemingly denying that chloroform had even been used on the Queen:

A very extraordinary report has obtained general circulation connected with the recent accouchement of her most gracious Majesty Queen Victoria. It has always been understood by the profession that the births of the Royal children in all instances have been unattended by any peculiar or untoward circumstances. Intense astonishment, therefore, has been excited throughout the profession by the rumour that her Majesty during her last labour was placed under the influence of chloroform, an agent which has unquestionably caused instantaneous death in a considerable number of cases. Doubts on this subject cannot exist. In several of the fatal examples persons in their usual health expired while the process of inhalation was proceeding, and the deplorable catastrophes were clearly and indisputably referrible to the poisonous action of chloroform, and to that cause alone. These facts being perfectly well known to the medical world, we could not imagine that any one had incurred the awful responsibility of advising the administration of chloroform to her Majesty during a perfectly natural labour with a seventh child. On inquiry, therefore, we were not at all surprised to learn that in her late confinement the Queen was not rendered insensible by chloroform or by any other anaesthetic agent. We state this with feelings of the highest satisfaction. In no case could it be justifiable to administer chloroform in perfectly ordinary labour; but the responsibility of advocating such a proceeding in the case of the Sovereign of these realms would, indeed, be tremendous. Probably some officious meddlers about the Court so far overruled her Majesty’s responsible professional advisers as to lead to the pretence of administering chloroform, but we believe the obstetric physicians to whose ability the safety of our illustrious Queen is confided do not sanction the use of chloroform in natural labour. Let it not be supposed that we would undervalue the immense importance of chloroform in surgical operations. We know that an incalculable amount of agony is averted by its employment. On thousands of occasions it has been given without injury, but inasmuch as it has destroyed life in a considerable number of instances, its unnecessary inhalation involves, in our opinion, an amount of responsibility which words cannot adequately describe. We have felt irresistibly impelled to make the foregoing observations, fearing the consequences of allowing such a rumour respecting a dangerous practice in one of our national palaces to pass unrefuted. Royal examples are followed with extraordinary readiness by a certain class of society in this country.

The editors simply could not accept that the Queen had chloroform or that her doctors could be such quacks. The editors of the Association Medical Journal replied on May 27 with this conclusion:

We would remind the Lancet that anaesthesia may be induced without loss of consciousness. To those accoucheurs who are in the habit of using chloroform in labour, we would refer, for final decision, the question of its being a safe or a dangerous practice. From a careful perusal of most of that which has been written on the subject, as well as from some personal experience of the practice, we may in the meantime state, as our own humble opinion, that the cautious inhalation of the vapour of chloroform during labour is entirely free from danger, and calculated to afford merciful relief from pain, in one of the most agonizing trials of humanity.

The explicit religious objections were not mentioned by the editors of The Lancet; instead, the objections were dressed up in non-scientific concerns about safety, particularly after the Queen had herself requested the medicine. But the safety concerns were a losing argument.

A year later, in 1854, the daughter of John Bird Sumner, the Archbishop of Canterbury, received chloroform during her delivery; finally, the religious objections seemed to be over. Well, almost. In the late 1850s, Prince Leopold, the child born to Victoria under the influence of chloroform, was diagnosed with hemophilia. He was the first member of the royal family to carry this diagnosis. In retrospect, Victoria must have been a carrier; the disease is X-linked. But as soon as Leopold received the diagnosis that would eventually take his life at age 30, many were quick to blame chloroform. Hemophilia was either a long-delayed side effect or the result of God’s curse upon Victoria for having her suffering alleviated.

Charles Meigs, in his textbook of Obstetrics from 1856, summarizes his objections thusly:

…never have I given, nor will I ever give any person chloroform…I am still quite convinced that the discovery of anesthesia in midwifery, has done more harm than good, and I believe its use will define, and not increase. I think it is declining already.

Boy, was he wrong. Soon, a variety of narcotics, often combined with scopolamine, gave rise to what was called “twilight birth.” Simpson was right; it was the patients who demanded and made obstetric anesthesia commonplace. The feminist movement of the early 20th Century actively worked to move pregnancy care from midwives to obstetricians, and from the home to the hospital. They also demanded that delivering women be given obstetric anesthesia, even as some of the obstetricians continued to question its safety, particularly the sedation of the newborn due to systemic narcotics.

Feminists and Suffragettes formed the National Twilight Sleep Association in 1914 to fight against the “primal curse” and “relieve one-half of humanity from its antique burden of a suffering which the other half of humanity has never understood.” Even more so than with inhaled gases, women became completely sedated and unconscious with twilight birth, and children did have an increased risk of neonatal depression. But safe general anesthesia, as well as spinal, epidural, and local anesthesia were eventually developed, which allowed women to experience the joy of delivery without the pain. It also allowed for safe operative vaginal deliveries and Cesarean deliveries, making fetal destruction a thing of the past and helping to relegate death during delivery to the history books. Ironically, many feminists today oppose obstetric anesthesia and the arguments against its use (false claims of safety issues, for example) are reminiscent of claims fought long ago by James Young Simpson. Certainly, not every woman wants or needs anesthesia; but for the majority of women, safe obstetric anesthesia has helped transform birth into a joyous event to be excited about, not a dreaded and dangerous inevitability.