History of Obstetric
Anesthesia
S. Ramanathan, M.D.
Inhalational
Analgesia
Since time immemorial, women were
expected to bring forth their babies in pain. According to the Holy Scriptures,
childbirth was meant to be a painful process as shown from the quotation from
the book of Genesis 3: Unto the woman he said “ I will greatly multiply thy
sorrow and thy conception; in sorrow thy shalt bring forth children.” Thus, there has always been a moral opposition
from the Church against providing any kind of pain relief for child birth. The
pioneers of obstetric anesthesia had to try their innovations in this
unfavorable climate. However, the pioneering work of James Young Simpson (1811-1870), an obstetrician, introduced
inhalation analgesia for childbirth. He
used ether for pain relief for the first time on January 19, 1847 and
chloroform on November 8, 1847 in Edinburgh. He used to sit around the dinner
table with his friends and used to experiment with various anesthetics in
“sniffing” parties. In order to silence his critics, Simpson used the Bible
cleverly by quoting the Scriptures (Genesis 2:21) “And the Lord God caused a
deep sleep to fall upon Adam, and he slept and He took one of his ribs and closed
up the side instead, thereof”. Thus, Simpson made the God the first
anesthetist, demonstrating that it is the primary duty of the physician to
relieve pain.
The next innovator is John Snow (1813-1858). During his career, Snow 
anesthetized obstetric patients
with chloroform. His most famous patient was Queen Victoria and Snow
administered open drop chloroform for the births of Prince Leopold and Princess
Beatrice. Typically, he would delay inhalation until they entered second stage
and they were able to push on command. Snow suggested that the anesthetic
administration should be left to a dedicated anesthesia provider. It was not
too long ago, in this country, that the obstetricians were administering their
own epidural and spinal blocks. Snow was also a leading epidemiologist of that
time. He is the founder of the first epidemiological society in the world. From mere observations of where deaths
occurred, he postulated that the cholera epidemic of central London of 1854 was
caused by contaminated water.
Walter Channing (1786-1876), an
obstetrician, published the first comprehensive report on ether use for
childbirth in North America, in 581 cases (A Treatise On Etherization In
Childbirth, 1848). He received a dual appointment as professor of Obstetrics
and Medical Jurisprudence at Harvard. He faced opposition from religious people
who believed that pain in childbirth was punishment for Eve's sin. Professor
Charles D. Meigs was critical of his etherization techniques as he felt that
pain relief was not essential for childbirth.
Other
Inhalational Agents
Nitrous oxide
was first prepared by Joseph Priestly in 1776 and used in obstetrics in St.
Petersburg in 1880. In the USA, Guedel first designed an apparatus for
self-delivery of N2O and in 1934, Minitt introduced a machine which
would deliver 35% N2O in room air. The problem with these machines
was they sometimes delivered hypoxic gas mixtures. In 1961, Turnstall of
Aberdeen introduced an apparatus for self-inhalation capable of delivering
oxygen 50% and N2O 50%, contained in a single cylinder (Entonox),
which is still being used in midwifery practice in UK. Methoxyflurane was also
used for self-administration, but its use was abandoned, because of the
possibility of nephrotoxicity.
Methoxyflurane whistles were strapped to the patient’s wrists and they
were encouraged to breath through the whistle during contractions. If they
became unconscious, the arm fell to the side and further self-administration of
the agent stopped. Specially designed
vaporizers were also introduced for the self-administration of methoxyflurane
and trichloroethylene. The problem with most self-operated devices was the
uncontrolled trace-anesthetic pollution of the ambient air.
Regional
Analgesia and Anesthesia
Caudal epidural anesthesia was first attempted by Fernand
Cathelin (born May 1873), a French urologic 
surgeon. Jean Athanase Sicard (a
French radiologist, 1872-1929), used lipiodol for the first time as a contrast
medium and he also used it to outline the caudal space. Caudal epidural was
first used in a parturient in 1909 by von Stockel. In 1930, John Cleland of
Oregon first described the pain pathways in labor and his work mainly focused
on caudal blocks and paravertebral blocks. Robert Hingston described continuous
caudal techniques in parturients in 1942. Lumbar approach to epidural space was
described by Fidel Pages in 1921.
Hingston and Charles Flowers (a staff obstetrician at the Johns Hopkins
University at Baltimore) described continuous lumbar epidural techniques. They
inserted plastic catheters into the 
epidural
space. Hingston is also known for his invention of jet-driven mass vaccination
system.
Spinal block was first introduced by August Karl Gustav Bier (1861-1949). Bier also introduced intravenous regional anesthesia (Bier block). In the USA, the spinal block was popularized by Pitkin, in 1928. However, Adriani in 1943 popularized the technique. Regional anesthesia has gained widespread popularity in obstetrics, both for analgesia and anesthesia mainly because of synthesis of newer local anesthetics and availability reliable equipment.
Non-Pharmacologic methods: Hypnosis has been used periodically since it was introduced by Anton Mesmer in 1777.
Sedatives
and analgesics:
Morphine was
isolated by Serturner, but the drug could not be administered parentally until
the invention of the hypodermic syringe in 1845. In the USA, Fordyce Baker
first used a hypodermic syringe in 1856. Kormann, from Germany, suggested
hypodermic injection of morphine to control the pain of labor. By 1906, Gaus of
Frieburgh had introduced the twilight sleep using a mixture of morphine and
scopolamine, which often produced maternal and neonatal respiratory depression
and maternal delirium. However, the parturients had total amnesia of all the
peripartal events and the practice continued until the Second World War.
Meperidine was introduced in Germany, in 1940 by Benthin. Meperidine use for
labor analgesia was started in this country in 1948.
Other important contributions
Virginia Apgar was one of Columbia University's first female M.D.s
(1933). Frustrated by chauvinism during her internship, Apgar changed her
focus to anesthesiology, which became a specific and separate medical
discipline thanks to her. In 1949, she became Columbia's first-ever full
Professor of Anesthesiology. Apgar's research on anesthesia and childbirth led
her to her greatest contribution: the Newborn Scoring System---better known as
the "Apgar Score", which was published in 1953 (Appearance, Pulse,
Grimace, Activity and Respiration).
References
1 Schaer HM, Marx GF, Bassell GM: History of Pain relief in Obstetrics.
Obstetric Analgesia
and Anaesthesia, 1980; pp 1-19.
2.
Atkinson RS, Rushman GB, Lee A: A Synopsis of Anaesthesia Ed. A John Wright and
Sons
Publication, 1977: pp 676-679.