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September 1997
Volume 61 |
Number 9
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| Analgesia in Labor
Becomes Respectable: The Role of John Snow |
David A.E. Shephard, M.B.
In 1591, Lady Euframe MacAlyane of Edinburgh, Scotland, was bold
enough to ask a midwife to relieve the pains of labor.1
So roundly was analgesia in labor condemned then that she was
put to death. Physicians, of course, had long sought to relieve
the pains of labor, but it was not until an event of catalytic
import occurred on April 7, 1853, that opposition to labor analgesia
began to fade. That event was the administration of chloroform
by John Snow, M.D., to Victoria, Queen of England for childbirth.
All went well, and the Queen's approval of "that blessed
chloroform"2 sent
the message that pain relief was acceptable, even respectable,
for women in labor.
In celebrating the 150th anniversary of the use of chloroform
in obstetrics, it is timely to consider how John Snow became an
agent of change in the acceptability of analgesia in labor.
Objections to Analgesia in Labor
Why apparently intelligent physicians and churchmen should have
objected to analgesia in labor is not easy for us to appreciate
today. These objections, which raged on both sides of the Atlantic,
cannot be detailed here, but the two major aspects were the opposition
to anesthesia itself and the opposition to analgesia in labor.
Opponents of anesthesia had two main arguments: first, in its
initial decade, anesthesia was hazardous and sometimes fatal (particularly
in inexpert hands); and second, in abolishing pain, which was
regarded as the main stimulator of life and healing, the manifestations
of anesthesia seemed to be uncomfortably like those of death.
As for analgesia in labor, pain was held to be necessary for the
normal progress of labor, while churchmen (and some physicians)
held that anesthesia, in abolishing the pains representing God's
punishment on womankind for tempting Adam's fall, was sinful because
it circumvented the chastisement inflicted by a Higher Power.
One of the first to use anesthetic agents to relieve the pains
of labor was Sir James Young Simpson of Edinburgh. He gave ether
as early as January 19, 1847,3
and chloroform on November 8 that year.4
He was the prime target of the anesthesia critics, who branded
him as a heretic. But Simpson most capably refuted the opponents'
arguments, most of which were based on an interpretation of the
Bible that differed from Simpson's. Among the points he made,
two are memorable.5 First,
the word "sorrow" in Genesis 3:16 ("in sorrow
thou shalt bring forth children") should be properly translated
as meaning labor, toil or physical exertion rather than pain,
so that to use the quotation as an argument against analgesia
was invalid. Second, the fact that the Lord had permitted Adam
to sleep while undergoing the first operation in history meant
that anesthesia was surely respectable. With his agile mind and
broad shoulders, the outgoing Simpson blunted the attacks of the
critics and so made easier the path for his London compatriot,
John Snow, to trod when he, albeit unwittingly at the time, became
an agent of change in obstetric anesthesiology.
How John Snow Came to Be an Agent of Change
It was not by chance that John Snow, with Queen Victoria, became
the agent of change whereby analgesia in labor became acceptable.
Snow's work in anesthesia had begun at the beginning of 1847.
His clinical competence, his ready understanding of the problems
of the new discipline and particularly his research, conducted
from 1848 to 1851,6 established
him as the leader of the new discipline. Quietly and systematically,
he had laid the scientific foundations of anesthesia7
long before he was called to Buckingham Palace, and the knowledge
he thus gained contributed to his clinical mastery, mastery reflected
in the fact that only one of his 4,000 patients died under chloroform.
No one else, anywhere, was in so strong a position to rebut the
few complaints and criticisms that were leveled at him and at
anesthesia, and no one else was so well-fitted to be an agent
of change.
The nature of Snow and his enormous contributions to medicine
have been discussed elsewhere,8
and comments here will be restricted to Snow's work in obstetrics.
Three points should be made. First, Snow was the "complete"
physician, with a deep knowledge of medicine and the training
and credentials of an internist, which were confirmed when he
solved the problem of the transmission of cholera in 1854. Second,
for all of his 20 years in practice, he was a general practitioner
and was familiar with obstetrics, delivering many of his own patients.
And, third, as his great text On Chloroform9
so clearly shows, he had an acute understanding of the anesthesiologist's
role in obstetrics.
In particular, he knew when chloroform should be used to induce
anesthesia (to facilitate operative procedures such as version)
and when it should be used to produce analgesia (which he did
in the majority of cases of uncomplicated labor). Of special note
is his ability to use, equally well, his own inhaler, which he
favored overall because he could accurately estimate the delivered
concentration, or just a handkerchief, also with uncanny accuracy
(or chloroform a la reine, so termed because this was the
way he administered it to the Queen on April 7, 1853, and again
on April 14, 1857). It was his preeminence, born of a profound
knowledge of all aspects of anesthesia, that enabled him to help
make analgesia in childbirth acceptable and, together with the
Queen of England, even respectable.
Snow as an Obstetric Anesthesiologist
To highlight this commentary on Snow as an agent of change in
obstetric analgesia, three excerpts are taken from the three casebooks
in which he recorded the details of virtually all the cases he
saw from 1848 until his death in 1858.10
Many of these records related to the anesthetics he gave, and
a significant number related to the use of chloroform in childbirth.
The first excerpt is from a record of a patient he saw on November
1, 1848:
I found the os uteri thrown backwards and as large as half
a crown, the head lying above the brim. The pains were irregular
and distressing. I went backwards and forwards till about twelve
o'clock when she was still in much the same state, the pains
being increased in force and regularity and the os uteri in
the same state. She was very much distressed, out of patience
and wished to know if something could not be done for her relief.
Of course it could, particularly by Snow, who was much more liberal
in his use of anesthesia, even in patients who were very ill.
High-flown objections to analgesia in labor carried little weight
with Snow; in contrast, the well-being of his patients carried
a great deal of weight.
The next entry is for a patient he treated on January 24, 1849.
The patient:
... complained very much of the pain ... and the administration
of chloroform was commenced in small quantity with each pain
with very good relief. Consciousness was not removed at first
but in the second state of labour, what began about 9 when the
pains were stronger, a larger quantity was given and consciousness
was once or twice removed for a short time ... [She] was much
pleased with the effects of the chloroform.
Snow's patients were all satisfied with the effects of chloroform.
His careful administration of chloroform, tailored to the demands
of his patient's condition, met with great success.
The final excerpt related to a patient Snow saw on October 20,
1853, not long after he had anesthetized Queen Victoria. His patient
was ill, with:
... extensive cavities of the lungs ... [and] had been kept
alive for some time by cod liver oil ... She sent me word that
she was likely to want me and a little before six I was sent
for ... The os uteri was about half dilated and the pain getting
rather severe. The chloroform was commenced at once. The patient
had a little difficulty in breathing it at first, on account
of the tendency to cough, but in a few minutes she experienced
and expressed, great relief from it ... Her convalescence was
very favourable.
This record is a significant one, overshadowed only by the historic
one of April 7, 1853. The patient was the daughter of one of the
most respectable citizens in the land, the Archbishop of Canterbury.
The Queen's approval of labor analgesia had undermined the disapproval
of analgesia based on flimsy obstetric arguments and it stood
for what childbearing women wanted. The Archbishop's approval
now discounted the disapproval of the clerics' Pecksniffian arguments.
Conclusion
By 1853, objections to analgesia in labor could no longer be
seriously entertained, and the provision of analgesia in labor
by anesthesiologists had become respectable. As the doyen of anesthesiology,
John Snow had taken the lead in this aspect of anesthesiology.
By applying what he knew to be right, he helped bring about a
victory for society over the dark forces of prejudice and hypocrisy.
About the Author:
Dr. Shephard's historical interest during his visits to the Wood
Library-Museum as a Paul M. Wood Fellow centered on John Snow's
influence on the development of anesthesia and on the influence
of American anesthesiology on organized anesthesiology in Canada.
As a result, Dr. Shephard published a biography of John Snow (John
Snow: Anaesthetist to a Queen and Epidemiologist to a Nation -
A Biography. Cornwall, PE: York Point Publishing; 1995). He
is currently Chair of the Committee on Archives of the Canadian
Society of Anaesthetists. On display at the Wood Library-Museum
is Dr. Snow's ether vaporizer, a rare treasure described in great
detail by the late Roderick Calverley, M.D., in an article published
in the Proceedings of the 3rd International Symposium on the
History of Anesthesia (Park Ridge, IL: WLM, 1992:91-99).
References:
- Heaton CE. The history of anesthesia
and analgesia in obstetrics. J Hist Med Allied Sci. 1946;
1:567-571.
- Royal Archives. Queen Victoria's
Journal, April 23, 1853.
- Simpson JY. Notes on the Inhalation of Sulphuric Ether
in the Practice of Midwifery. London, Edinburgh: Sutherland
& Knox; 1847.
- Simpson JY. On a new anaesthetic agent,
more efficient than sulphuric ether. Lancet. 1847; 2:549-550.
- Simpson JY. Answer to the Religious
Objections Advanced Against the Employment of Anaesthetic Agents
in Midwifery and Surgery. Edinburgh: Sutherland & Knox;
1847.
- Snow J. On Narcotism by the
Inhalation of Vapours. Facsimile Edition with an Introductory
Essay by Richard H. Ellis. London: Royal Society of Medicine
Services, Ltd.; 1991.
- Shephard DAE. From empirical craft
to scientific discipline: The contributions of Claude Bernard
and John Snow to the foundations of anesthesia. In: Fink BR,
Morris LE, Stephen CR. eds. The History of Anesthesia: Third
International Symposium. Park Ridge, IL: Wood Library-Museum
of Anesthesiology; 1992:360-366.
- Shephard DAE. John Snow: Anaesthetist
to a Queen and Epidemiologist to a Nation - A Biography.
Cornwall, Prince Edward: York Point Publishing; 1995.
- Snow J. On Chloroform and Other
Anaesthetics: Their Action and Administration. London: 1858:318-329.
Facsimile Edition: Park Ridge, IL: Wood Library-Museum of Anesthesiology;
1989.
- Ellis RH. ed. The Case Books
of Dr. John Snow. London: Med Hist. (Suppl. 14) and
Wellcome Institute for the History of Medicine; 1994.
David A.E. Shephard, M.B., is
Staff Anesthesiologist at Queen Elizabeth Hospital, Charlottetown,
Prince Edward Island, Canada. He was twice awarded the Paul M.
Wood Fellowship by the Wood Library Museum (1991, 1993) to conduct
historical research.
E-mail the author.
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