247 m SPECIAL ARTICLE Anesthesiology 2000; 92:247–52 © 2000 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc. John Snow’s Practice of Obstetric Anesthesia Donald Caton, M.D.* IN 1847, obstetrician James Young Simpson won last- many suppose, but John Snow, the London physician ing fame for suggesting that physicians regularly use who anesthetized the Queen. anesthesia to abolish the pain of childbirth. To Simp- son’s surprise, his suggestion evoked more criticism than praise.1–3 Virtually every leading obstetrician in Simpson’s Failure Western Europe and the United States argued that anesthesia was dangerous and unnecessary for normal By rights, James Young Simpson’s opinion should have deliveries. Many women also objected, either from carried more weight. The year in which he introduced obstetric anesthesia he also discovered the anesthetic fear or because they thought anesthesia was un- properties of chloroform, an accomplishment for which seemly. he earned a commemorative plaque in Westminster Ab- Within 10 yr, however, medical opposition to ob- bey. Only 36 yr old, he was one of Europe’s best-known stetric anesthesia faded. Historians attribute this to the physicians, already having served 7 yr as Professor of influence of patients who coerced physicians when Midwifery at the University of Edinburgh, the oldest and they learned that prominent women, such as Fanny most prestigious chair of its kind in the Western world. Longfellow and Queen Victoria, had demanded anes- 4,5 Hard working, charismatic, and an excellent publicist, thesia for delivery of their newborn infants. Al- Simpson was a leader in a movement that sought more though appealing, this explanation seems simplistic. active management of childbirth. Its goals included care Medical opposition to obstetric applications of anes- by physicians rather than by midwives and more fre- thesia had been too acrimonious and widespread to quent use of ergots to stimulate labor and of forceps to dissipate so quickly simply from social pressure. More- facilitate delivery. Anesthesia was a natural adjunct to over, it overlooks the issue of safety, the primary such practices. In theory, the mitigation of pain was also concern of physicians who opposed Simpson’s inno- a popular social message. Sustained by faith in progress vation. Evidence suggests that opposition to obstetric and imbued with ideals of humanitarianism, mid century anesthesia disappeared only when physicians began to Victorians believed it their duty to abolish suffering believe that it was safe and that the person who did wherever they found it.6 most to change their minds was not James Simpson, as Why did such a popular message fail? First, many conservative physicians disagreed with Simpson’s ag- gressive style of practice. They argued that childbirth e This article is featured in “This Month in Anesthesiology.” was a “natural,” not a pathologic, process and that anes- Please see this issue of ANESTHESIOLOGY, page 5A. thesia represented just one more form of “meddling.” Second, many distrusted Simpson. One London physi- cian criticized him personally for indiscriminately taking up every new idea or technical innovation.7 Another * Professor of Anesthesiology and Obstetrics and Gynecology. decried Simpson’s blatant use of publicity: Received from the Departments of Anesthesiology and Obstetrics I did not expect that Dr. Simpson would have ap- and Gynecology, University of Florida College of Medicine, Gainesville, pealed so directly, and through so many channels, to Florida. Submitted for publication June 7, 1999. Accepted for publica- tion September 14, 1999. Support was provided solely from institu- the feelings and imperfect knowledge of society in tional and/or departmental sources. general, for it is, I am happy to say, still very uncom- Address for reprint requests to Dr. Caton: c/o Editorial Office, De- mon, in our profession, to find those of its members partment of Anesthesiology, PO Box 100254, Gainesville, Florida who would give tone to its bearing and conduct, 32610-0254. Address electronic mail to: [email protected]fl.edu professors, for instance, of our ancient universities, Key words: Chloroform; ether; history; Queen Victoria; Simpson. going about from one city to another to announce and Anesthesiology, V 92, No 1, Jan 2000 248 DONALD CATON exhibit the wonder effects of a new gas, and, as I am on Great Windmill Street. Still not satisfied, he earned a informed, somewhat after the fashion of a showman, doctorate from the University of London and then be- to demonstrate them personally, at dinner parties, and came a licentiate of the Royal College of Physicians, the in drawing rooms.8 highest level of professional attainment available for a Simpson dismissed such criticism, attributing it to pro- physician who had not studied at Oxford or Cam- fessional jealousy and chauvinism. In 1850, at the height bridge.11–13 of the controversy, he wrote, “London physicians have, Snow’s reputation grew in part from his involvement on several occasions, specially distinguished themselves with the Westminster Medical Society, an organization by their determined and prejudiced opposition to all formed for clinical presentations and scientific demon- innovation in practice not originating among them- strations. Snow served as an officer and frequently spoke selves.”9 at meetings. Early issues of The Lancet often quote com- There was, however, more to the criticism than jeal- ments that he made at various meetings. Snow also ousy and chauvinism. Simpson failed to allay concern published original articles. In 1841, for example, he about the safety of anesthesia. Advocacy of obstetric wrote, On Asphyxiation, and on the Resuscitation of anesthesia may have won Simpson praise for his com- Still-Born Children, in which he described a method for passion, but when he claimed that chloroform made ventilation of the newborn and discussed recent discov- childbirth safer, skeptical colleagues asked for proof. As eries concerning the physiology of neonatal respiration, medical historian Richard Shryock observed, humanitar- oxygen consumption, hypoxia, and effects on changes ian sentiments may have motivated nineteenth century of body temperature.14 The article illustrates Snow’s physicians, but science shaped their practice.10 understanding of scientific principles and his talent for Simpson’s arguments for obstetric anesthesia con- applying them to clinical problems. tained very little science. His initial paper described only Anesthesia quickly became the focus of all Snow’s six patients. His method for administering anesthesia work. He was systematic and thorough. Within a year of was crude, unmodified from the technique first used for the introduction of ether anesthesia to Great Britain, he surgery. He simply poured ether, or chloroform, onto a published a short treatise entitled, On the Inhalation of cloth draped over the patient’s face. He initiated the the Vapor of Ether.15 Simultaneously, he began a series anesthetic during the first stage of labor and kept his of papers in which he reported his clinical experience patients unresponsive until after delivery of the placenta. with anesthesia, commented about the pathophysiology He paid little attention to dosage and discounted the of adverse reactions, speculated about mechanisms of possibility of any harmful effect on uterine contractions action, and described original experiments in which he or the newborn. Thus, he neither acknowledged nor measured physical, chemical, and pharmacologic char- resolved any of the medical issues that concerned his acteristics of various agents.16 His second book, On colleagues. Furthermore, he did not persist with this Chloroform and Other Anesthetics: and Their Action work. After an initial flurry of papers and letters, Simp- and Administration, appeared in 1857, the year after his son turned from obstetric anesthesia to other issues, a death.17 In addition, Snow kept notes about the more criticism often raised by his detractors. than 4,000 anesthetics that he administered during his career. They fill four books. The first disappeared, but the rest survive and may be read in a transcription John Snow’s Success prepared by the late Richard Ellis.18 Clearly, both as a scientist and a clinician, Snow spoke with authority, a John Snow began his work in anesthesia with few of fact that must have been as apparent to his contempo- Simpson’s advantages. He was a practitioner, not the raries as it is to us today. incumbent of a prestigious chair at a famous university. He was, however, known and respected in London, a remarkable feat considering the inauspicious start of his John Snow’s Practice of Obstetric Anesthesia career. Born in Yorkshire in 1813, the son of a common laborer, Snow began medicine apprenticed to a local The absence of the first casebook precludes us from physician. After completion of this training, he moved to knowing anything of Snow’s early practice of obstetric London, where he practiced and studied, eventually anesthesia. The first entry in the surviving casebooks earning a degree from the Hunterian School of Medicine bears the date July 17, 1848, but the first description of Anesthesiology, V 92, No 1, Jan 2000 249 JOHN SNOW’S PRACTICE OF OBSTETRIC ANESTHESIA an obstetric anesthetic is October 16, 1848, almost a year that it would be safer if that responsibility were dele- and a half after Simpson’s landmark article. By that time, gated to some other person.26 several other authors had already written articles about Precision was a hallmark of Snow’s work. He designed obstetric anesthesia for prestigious journals.19–22 Be- experiments to learn the clinical signs associated with cause of Snow’s interest in anesthesia, his familiarity different concentrations of anesthetics. To achieve bet- with medical events, his curiosity, and his propensity to ter control over inspired concentrations, he built a brass experiment, it seems unlikely that he waited that long to vaporizer that he immersed in water to stabilize the anesthetize his first obstetric patient, but this is specu- temperature and, thereby, the vapor pressure of the lation.