Friday, April 22, 2016

The debate over the use of anaesthetics in childbirth

Victoria, Alfred and their children
The nineteenth century, and particularly the Victorian years, saw enormous advances in medicine. New procedures were developed, standards of cleanliness improved and for the first time pain relief was possible with the development and use of anaesthetics.  Progress, however, did not come cheaply.  Reputations were made but, equally, reputations were lost. For every group that argued for progress, there was another group to argue against it.

On 7 April 1853 Queen Victoria was delivered of a son, Prince Leopold. During the birth, she was anaesthetised with chloroform by Dr John Snow.* “The inhalation lasted fifty-three minutes.  The chloroform was given by on a handkerchief, in fifteen minim doses.”** Four years later, in 1857, John Snow was in attendance again and  again employed chloroform in the delivery, this time, of Princess Beatrice.

The Queen's decision to have chloroform administered during the birth was not made lightly.  There had been discussions as early as 1848, with Prince Albert who strongly supported the use of the anaesthetic, and the Queen’s physicians, who apparently had reservations about it. While it had not been used in the delivery of either Princess Louise (1848) or Prince Arthur (1850), when it was finally employed for the birth of the Queen’s seventh child, Her Majesty was delighted.  Writing in her Journal, she had nothing but praise. “Dr Snow administered ‘that blessed Chloroform’ & the effect was soothing, quieting & delightful beyond measure.” Indeed, as she noted, she had “never recovered better.”

Just a little over a month after the Queen gave birth to Prince Leopold, an article appeared in the Lancet, criticising the administration of chloroform to the Queen.  Although not named in the article, it was clearly an attack on Dr John Snow by the owner/editor of the journal, Thomas Wakley. The article was mildly hysterical in tone claiming that
Intense astonishment … 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. … 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.
Much of the literature related to the consequences of the use of chloroform in the birth of Prince Leopold emphasised the wider acceptance of anaesthetics as a result. While the Royal approval of the use of chloroform might have provided what was at least an informal imprimatur, not all of the medical profession was accepting of the use of anaesthetics, especially chloroform, in childbirth. As The Lancet went on to point out, certainly incorrectly in the face of the Queen’s own statement, the so-called administration of chloroform was all a pretence employed because “some officious meddlers about the Court so far overruled her Majesty’s responsible professional advisers as to lead to the pretence…”

H and T Connor have suggested that it is unlikely that lay opinion was influenced since the press reports of the birth did not, in general, mention the use of anaesthetics. That may indeed have been the case, but by the time of the Queen’s accouchement, the use of chloroform in parturition was common enough for one correspondent to write to the Association Medical Journal shortly after the Queen’s delivery,
Your announcement, a few weeks ago, of the Queen’s accouchement under chloroform and that, under no other than ordinary circumstances, the royal child-birth had been treated by anaesthesia, doubtless gave rise to considerable emotion and excitement both in the professional and the female world. … For some time, however, before this, it was well known that, in certain districts, the married—especially the young married—women, even of respectable society, had been in much agitation respecting the recent discussions upon chloroform, and had become so solicitous for its administration in their own cases…
The debate continued and seems to have accelerated after the Queen gave birth to her seventh child.  The all-male medical profession engaged in rather convoluted arguments to justify the pain of childbirth.  To offer succour to women in labour was, some argued, “meddling or interference” and could not be defended.
If labour be undeniably a physiologic process for the birth of human offspring, and if anatomy and physiology have proved that this process cannot be obtained without fulfilling the Divine enunciation, ‘that in sorrow and pain woman should bring forth’, the whole of this being notwithstanding perfectly consistent with the health of mother and child,--what doctrine can be an excuse for mischievous meddling with such a miracle of contrivance?
Some of the criticism was undeniable valid.  There had been deaths with the use of chloroform. Indeed, its popularity was such as to lead to inexperienced, and even those totally untrained in medical procedures, to act as anaesthetists. Beyond that, even those with a degree of medical training were not necessarily conversant with the best means of administering chloroform and in some cases may have been dangerously enthusiastic in its use. 

John Snow, however, was meticulous and careful.  He was concerned about regulating the dosage and even developed a mask for proper administration of chloroform although this was not used with Victoria. Instead he employed the “open-drop” method where the chloroform was dropped onto a cloth covering the face of the Queen.

Snow was not the first doctor to use chloroform.  It was first used in childbirth by James Young Simpson, Professor of Midwifery in the University of Edinburgh, who had discovered its properties in 1847. Simpson reported his cases in The Lancet, detailing nine of these in the issue of 11 December 1847. In the first case it was the mother’s second birth. “In her first confinement she had been three days in labour, and the infant had at last been removed by craniotomy.”*** Of the effect of the chloroform in the first case he wrote; the patient
...did not awake till after the placenta was removed, and then spoke of having “enjoyed a very comfortable sleep.” She was not in any degree aware that the child was born; and when, in a few minutes, it was brought in . . . I was a matter of no small difficulty to persuade the astonished and delighted mother  that the child … was really her own infant.
It was the work of Simpson and Snow that effectively changed the nature of childbirth through the introduction of the use of chloroform.  Questions as to its safety were effectively laid to rest in 1853 with its use by Queen Victoria, and by the time of his death in 1858, at the age of 45, He had, according to Sir Peter Froggatt,
… no deaths in over 4000 chloroform cases, often bad risk ones, … he anaesthetised for over 30 leading London surgeons and included the Queen and members of the social and commercial élite among his cases …

**A minim is 1/60th of a fluid dram or about the equal of one drop.

***Craniotomy involved the reduction in the size of the unborn child’s head and was used where labour was obstructed.  It was used in cases of foetal death and made vaginal delivery possible rather than run the far greater risk of performing a caesarean section before the advent of anaesthetics.