Abstract
An early administration of anaesthesia for childbirth occurred on 19 January 1847, when Scottish obstetrician James Young Simpson administered diethyl ether to facilitate the delivery of a child to a woman with a deformed pelvis. Simpson advocated for its use to reduce pain both in surgery and in childbirth. Obstetric anaesthesia was controversial for many reasons, and objections came not only from fellow obstetricians, but also from the public and members of the clergy. While James Young Simpson shed light upon religious objections to obstetric anaesthesia, modern scholars have debated whether such objections truly existed. The aim of this study is to determine whether religious objections to obstetric anaesthesia were endorsed by medical professionals in France during the mid-19th century. A search of the Bibliothèque Nationale de France (National Library of France) was conducted. Primary source documents reveal that French physicians were interested in studying the effects of ether and chloroform during labour and delivery. Nevertheless, the introduction of obstetric anaesthesia was controversial for many reasons, including concerns about its effect on natural labour. The evidence suggests that these objections were not endorsed by the medical community. Much of the controversy surrounding obstetric anaesthesia involved the perceived necessity of the practice during low-risk vaginal deliveries. It appears that French physicians were aware of religious objections to the use of anaesthesia in childbirth but did not endorse them. The use of obstetric anaesthesia in France was guided by scientific evidence and clinical experience, without interference from religious leaders.
Introduction
An early administration of anaesthesia for childbirth occurred on 19 January 1847, when Scottish obstetrician James Young Simpson (1811–1870) administered diethyl ether to facilitate the delivery of a child to a woman with a deformed pelvis. 1 A strong proponent of anaesthesia, Simpson advocated for its use to reduce pain both in surgery and in childbirth. 1 Obstetric anaesthesia was controversial for many reasons, including concerns about the effects of anaesthetics on labour, the infant and the mother. 2 Objections came not only from fellow obstetricians, including Charles Delucina Meigs (1792–1869), but also from the lay public and members of the clergy. 2 While James Young Simpson shed light upon religious objections to obstetric anaesthesia in his pamphlet Answer to the religious objections advanced against the employment of anaesthetic agents in midwifery and surgery, modern scholars have debated whether such objections truly existed. 3
The premise of religious objections to use of anaesthetics during childbirth was the Bible verse Genesis 3:16, quoted here from the King James version: ‘Unto the woman he said, I will greatly multiply thy sorrow and thy conception; in sorrow thou shalt bring forth children; and thy desire shall be to thy husband, and he shall rule over thee.’
In his pamphlet, Simpson reported religious objections both from patients and from physicians. 4 He wrote that these individuals ‘found their objections principally on the words of the primeval curse which God pronounced after the temptation and fall of our first parents.’ 4 Following publication of Simpson’s pamphlet, Canada’s first rabbi, Abraham De Sola, was consulted by a Canadian medical journal to give his interpretation. 5 He agreed that the correct interpretation of the passage was ‘that with toil or labour shall women bring forth children, rather than in pain.’ 5 But while the translation that Simpson selected for his pamphlet did not use the word ‘pain’, many other versions do. Several different translations, both from the Jewish and the Christian traditions, specifically use the word ‘pain’. 5
In his pamphlet, Simpson wrote extensively regarding the meaning of the words in Genesis 3:16, a debate that continues to this day. After Dr John Snow used chloroform to deliver Queen Victoria’s eighth child in 1853, religious objections within the British Empire dissipated. Since the English monarch led the Anglican church, use of chloroform on the Queen represented a powerful statement against religious objections. Nevertheless, religious objections continued to manifest throughout the 20th century. Obstetric anaesthesiologist Donald Caton’s seminal work What a blessing she had chloroform examined the issue through a more contemporary lens. 6
While controversies surrounding the introduction of surgical anaesthesia in France have previously been studied, 7 less is known about the use of anaesthesia in France for labour and delivery. The aim of this study is to determine whether religious objections to obstetric anaesthesia were endorsed by medical professionals in France during the mid-19th century. The origins of these objections and their impact on clinical practice will be explored.
Methods
A search of available online primary source French medical literature was conducted. Previous research indicated that the French Academy of Sciences played an integral role in the introduction of anaesthesia in France. Transcripts of French Academy meetings, published in Comptes Rendus hebdomadaires des séances de l’Académie des Sciences, the official publication of the French Academy of Sciences, were examined for evidence of religious objections to the use of obstetric anaesthesia. Also examined were the Bulletin de l’Académie de Médecine and the Gazette Médicale de Paris, and the Bibliothèque Nationale de France (National Library of France) was searched for other documents containing evidence of religious thoughts regarding obstetric anaesthesia. Translation of French language documents and qualitative analysis were used to place the findings in historical and contemporary context. Translation was performed by one author (RC).
Results
Discussions surrounding obstetric anaesthesia began in February 1847. Figure 1 illustrates the key dates and physicians who were involved in the introduction of obstetric anaesthesia into clinical practice in France.
Timeline of key events in the introduction of obstetric anaesthesia in mid-19th century France.
Objections to the use of anaesthesia during childbirth stemmed from concerns regarding the effects of anaesthesia on the course of labour, the mother and the infant. Though Simpson suggested in the Answer to the religious objections advanced against the employment of anaesthetic agents in midwifery and surgery that religious objections were widespread, review of French sources does not support this assertion.
The first mention of the use of anaesthesia for childbirth occurred at the Academy of Sciences meeting on 1 February 1847 by Alfred-Armand-Louis-Marie Velpeau (1795–1867) (see Figure 2).8,9
Woodburytype portrait of Alfred-Armand-Louis-Marie Velpeau created by Pierre Petit (1832–1909) before 1867. From Getty Museum Collection. 9
Velpeau supported the use of ether in ‘certain cases of difficult deliveries’, describing instances when ‘one must go and search for the infant in the uterus’. 8 His hypothesis was that ether inhalation would result in the cessation of uterine contractions. 8 Velpeau’s commentary on the use of ether for difficult deliveries was followed by François Magendie’s (1783–1855) infamous rebuke of surgical anaesthesia. 8 Magendie spoke extensively regarding his concerns about experimentation with surgical anaesthesia. His arguments questioned the scientific merit and novelty of the discovery, the safety of anaesthesia, the appropriateness of operating on an ‘intoxicated’ patient, and the speed at which the use of anaesthesia was adopted into clinical practice. 7
Conversations surrounding obstetric anaesthesia continued later in the month at the Academy of Medicine meeting on 23 February 1847. 10 The Medical Gazette of Paris recorded a lengthy discussion on the application of ether inhalation to the practice of deliveries. 10 Paul Antoine Dubois (1795–1871), Philibert Joseph Roux (1780–1854), Joseph Capuron (1767–1850), François-Joseph Moreau (1789–1862), Pierre Nicolas Gerdy (1797–1856), Alfred-Armand-Louis-Marie Velpeau, Philippe-Frédéric Blandin (1798–1849), Jean Zuléma Amussat (1796–1856) and Joseph-François Malgaigne (1806–1865) participated in the discussion. 10 Paul Dubois presented a case series (see Figure 3). 11
Paul Dubois, the first French obstetrician to present a case series on the use of ether in childbirth illustrated by Victor Frond in Le panthéon des illustrations françaises au XIXe siècle, vol. 5. 11
The first case was an 18-year-old primigravid whose delivery required the use of forceps. Dubois reported that the use of ether enabled him to perform the procedure painlessly and extract the infant more easily than in a typical delivery. 10 The second case was another delivery requiring forceps. While the procedure produced cries and agitation, the patient had no memory of it. 10 A major concern, however, was whether ether impacted uterine contractions, which physicians recognised as essential to the labour process. Dubois then presented a third case, a woman who had been in labour for 2 h. He observed that the administration of ether caused conjunctival injection and foaming saliva in the mouth. 10 He noted, however, that despite the adverse reaction in the mother, the foetal heart rate remained at 160 beats/min, and he observed that while the infant came out more quickly, there was a smaller than expected perineal laceration. 10
From his observations, Dubois drew the following conclusions: ether can prevent pain during obstetric procedures; ether can suspend the natural pains of labour; ether does not suspend uterine contractions or abdominal muscle contractions; ether may decrease perineal resistance; and ether had no unfavourable impacts on the health of the child. 10 Throughout 1847 and 1848 articles focused on the use of ether for difficult deliveries, such as those requiring the use of forceps, breech extraction and twins.12–14 Jules Roux (1807–1877), Chief Naval Surgeon in Cherbourg, reported the successful use of ether during a twin delivery (see Figure 4).15,16
Jules Roux, military surgeon, Director of the Toulon School of Medicine. 16
He reported using forceps to deliver the first twin, and then performing a breech extraction of the second twin. 13 He reported obtaining 10 min of effect with the use of his ‘ether sack’, and he concluded that ether was very useful during difficult deliveries, but not necessary for ordinary deliveries. 13 Reports of ether used in the setting of forceps delivery continued throughout 1848.13–15 Observations demonstrated that there were no adverse effects on the infant. 15
Though French physicians were interested in studying the effects of ether on labour and delivery, evidence of religious objections to its use is limited. In Des effets physiologiques et thérapeutiques des éthers, Dr Henri Chambert of the Faculty of Medicine of Paris discussed religious objections to the use of obstetric anaesthesia. He expressed surprise that some obstetricians continued to doubt the many observed advantages of ether inhalation ‘in favour of certain words in the Bible.’ 17 His mention of the Bible suggests that religious objections may have existed at the time; however, they were not supported by current scientific evidence. He stated that such individuals ‘are restrained by a commendable prudence, without doubt.’ 17 He expressed hope that this prudence would spark new experimentation, and enable a greater understanding of the effects of ether. 17
During the annual public meeting and award ceremony for the French Academy of Sciences on 4 March 1850, Philibert Joseph Roux announced that the Prize for Medicine and Surgery for the years 1847 and 1848 was awarded jointly to Charles Jackson (1805–1880) and William Thomas Green Morton (1819–1868). 18 After prizes for all sections of the Academy were awarded, Velpeau concluded the ceremony with a review of surgical anaesthesia and the current state of knowledge. 18 He discussed the use of anaesthesia for surgical procedures, challenging delivery manoeuvres, as well as other medical uses, including in the treatment of epilepsy, hysteria, certain mental problems, and neurological disorders. 18 He then turned his attention to the topic of obstetric anaesthesia. Velpeau named Chailly, Devilliers, Paul Dubois, Bodson (in Paris), Joseph-Alexis Stoltz (in Strasbourg) and Villeneuve (in Marseille) as pioneers in the use of anaesthesia for childbirth. 18 Velpeau reflected, ‘this is perhaps neither the time nor the place to consider such an application of anaesthesia.’ 18
He stated that obstetric anaesthesia would have to overcome numerous obstacles to be admissible in clinical practice. Velpeau specifically stated, ‘one encounters first of all the divine law which, for Israelites and Christians, wants according to Genesis, for the woman to give birth with pain.’ 18 He continued, ‘some theologians maintain, in fact, that to shield a woman from this unfortunate consequence of her first weakness would be a sacrilege. Also, in England, a country where religious principles retain so much power, we see Mr Simpson, exposed to the liveliest attacks from doctors of the faith, obliged to enter a struggle with bishops, and to seriously discuss the articles of the Bible.’ 18 Because Velpeau’s explanation of the religious objections to obstetric anaesthesia occurred at a public meeting of the Academy of Sciences, his remarks carried immense influence.
The cholera epidemic and the political turbulence in France led to an abrupt halt of anaesthesia-related research. 7 In the years following Velpeau’s public address, a few authors mentioned religious objections to the use of obstetric anaesthesia.
Étienne-Frédéric Bouisson (1813–1884), Professor of Surgery of the Faculty of Medicine of Montpellier and Chief of Surgery of the Civil and Military Hospital of Saint-Éloi, published Traité théorique et pratique de la méthode anesthésique in 1850. 19 The final chapter of his comprehensive text refutes objections to anaesthesia. He specifically mentions religious objections to the use of anaesthesia in childbirth faced by Simpson in England. Bouisson argues that ‘God gave the first example of anaesthesia’ by producing a ‘profound sleep’ during the removal of Adam’s rib and the creation of Eve.
In Essai sur l’anesthésie provoquée appliquée aux opérations chirurgicales et aux accouchement, Sixte-Guillaume Normand Dufié discussed the presence of moral and religious objections to obstetric anaesthesia, and referred to such attacks as ‘ridiculous’. 20 In De l’emploi du chloroforme dans les accouchements simples, dans les operations obstétricales, et dans l’eclampsie des femmes en couches, GE Fredet, intern in medicine and surgery in Paris, wrote, ‘In France, we had more common sense and reason, and one would by no means think to establish a religious controversy which is inappropriate in a purely medical and scientific question.’ 21 Religious objections to the use of obstetric anaesthesia in the 20th century have been studied extensively. Indeed, the use of anaesthetics during childbirth has been shaped more by social and political movements than by scientific evidence. 6
Discussion
The study of religious objections to the use of obstetric anaesthesia in mid-19th century France has rarely been considered. Evidence for religious objections to the use of anaesthesia in mid-19th century England has been studied extensively, with many researchers concluding that religious objections to the use of obstetric anaesthesia are merely a myth perpetuated by modern historians. The results of this study support the conclusion that religious objections to the use of obstetric anaesthesia in mid-19th century France were not widely supported by physicians.
In Another look at religious objections to obstetric anaesthesia, AG McKenzie analysed the question of religious objections to obstetric anaesthesia. 22 He argued that an absence of evidence for religious objections in written sources does not necessarily mean they did not exist. 22 Moreover, he found a statistically significant increase in the use of obstetric anaesthesia at Edinburgh’s only maternity hospital after the distribution of Simpson’s pamphlet. 22 This evidence suggests that Simpson’s pamphlet did contribute to a change in practice patterns. The results of this study support the conclusion that religious objections to the use of obstetric anaesthesia in mid-19th century France were not widely supported by physicians.
Ever since Simpson’s early use of ether for obstetrics, pain management in labour and delivery has been shaped largely by social, cultural and political movements. Though Simpson himself endorsed significant objections based in religious ideology, modern scholars have debated whether such objections truly existed. Perhaps Simpson sought to bolster his reputation by manufacturing such opposition. 3 Review of French medical literature and society transcripts revealed that religious objections to the use of anaesthesia in childbirth were considered by French physicians in the mid-19th century. Velpeau’s discussion of Genesis at the 1850 prize assembly gave the theory a significant platform. Physicians possessed an awareness of the perceived discordance between obstetric anaesthesia and the Bible; however, these objections did not impact its use on a larger scale. Indeed, scientific objections from influential obstetricians were perhaps the most significant opposition encountered. 3
The mid-19th century was a turbulent political period in French history. The French Revolution, which began in 1789, marked the beginning of republican idealism and rejection of the absolute monarchy. Napoleon Bonaparte’s (1769–1821) rise to power in 1804 transformed the French First Republic into a colonial empire, with Napoleon declaring himself Emperor of France, and waging a series of wars collectively known as the Napoleonic Wars (1803–1815). The monarchy was again restored after Napoleon’s defeat at the Battle of Waterloo, on 18 June 1815, and overthrown by liberal revolutionaries in 1848. Louis-Napoleon, nephew of Napoleon Bonaparte, was elected President of the Republic; however, since he was limited to one term under the constitution, he led a coup d’état in 1851 to remain in power. He led France’s Second Empire (1852–1870) as Napoleon III. The Third French Republic was established on 4 September 1870, after the collapse of the empire in the Franco-Prussian war.
The turbulent political situation in France during that era influenced religious sentiments. Prior to the French revolution in 1789, the Catholic Church maintained immense power and influence, and the idea of divine mandate was central to the traditional French monarchy. The cycling of government regimes throughout the 19th century meant that the Church was much less influential than in previous periods of French history. Revolutionaries favoured a secular republic, while monarchists supported the Catholic Church. Industrialisation and imperialism, rather than religion, were the main influences in French society.
Conclusion
The introduction of obstetric anaesthesia occurred in parallel with the introduction of surgical anaesthesia in France. It appears that French physicians were aware of religious objections to the use of anaesthesia in childbirth but did not endorse them. The use of obstetric anaesthesia in France was guided by scientific evidence and clinical experience, without interference from religious leaders.
