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Dana Schwartz
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Dana Schwartz
Learn more@intuit.com ERP welcome to Noble Blood, a production of iHeartRadio and Grim and Mild from Erin Menke. Listener discretion advised. This is part two of our episode on James Young Simpson, and if you haven't listened to Part one yet, you should probably start there. On November 8, 1847, James Young Simpson successfully used chloroform for the first time for a pain free delivery of a baby. Just two days later, he was ready to share his successes with the rest of the medical community. He invited colleagues into his own home for a demonstration where a dentist used chloroform for a tooth extraction in front of an audience of scientific observers. One of the observers was a surgeon in the Edinburgh Royal Infirmary, and he was so impressed by the painless tooth extraction that Simpson managed to convince him to try using chloroform in surgery. Two days later, with Simpson overseeing, that surgeon used chloroform to amputate a diseased forearm on a five year old boy. After the operation, the surgeon recalled that the patient was found in bed like a child newly awakened from a refreshing sleep with a clear, merry eye and placid expression of countenance wholly unlike what is found to obtain after ordinary etherization. Within a week, Simpson had successfully tested chloroform on 30 patients and in a frenzy wrote a paper for publication in the Lancet. He wrote about the chemical with flowery enthusiasm, saying that it had an agreeable, fragrant Fruit like odor and a saccharine pleasant taste. This might seem over the top and more pertinently premature given that the chemical had only been in use for about a week and a good number of those that had tried it had taken it recreationally in Simpson's dining room. But it was clear even by that point that chloroform had distinct advantages, especially when compared with ether. Chloroform was cheaper and more portable than ether and easier to use. Physicians could hold up a handkerchief to their patients faces rather than using a cumbersome, imposing inhaler. Chloroform didn't have a noxious smell that irritated the throat. Physicians needed far less of it to sedate their patients and it worked much more quickly and reliably than ether. Simpson was so confident about the efficacy of chloroform that he wrote a pamphlet promoting the chemical intended for general audiences, titled On a New Anesthetic Agent More Efficient than Sulfuric Ether. By the end of the month, that pamphlet had sold 1500 copies. On December 15, Edinburgh Hospital convened a meeting that unanimously concluded that they should use chloroform instead of ether in all operations at the hospital. Moving forward, one committee participant recalled, there was no instance on record where the discovery of a remedy had been so rapidly made known and and its employment so universally adopted as that of the inhalation of chloroform. Before the end of 1847, established manufacturers were unable to keep up with demand and new firms were springing up to cash in on the rush. But not every doctor was as enthusiastic about chloroform as such. Simpson. There was a dark fear around chloroform for both philosophical and medical reasons. And Simpson would need to navigate those fears when faced with his most important patient yet, a woman who certainly knew her way around childbirth. Queen Victoria. I'm Dana Schwartz and this is noble blood. One strain of criticism against chloroform arose from broader concerns about whether pain had any biological purpose. At the time, it was common medical practice that the physician should not interfere with the body's natural processes and should instead leave the body alone to heal itself. Because pain was considered a natural function, many doctors thought that suppressing it with anesthesia might cause more harm to the patient. Simpson had no patience for that argument. He rebutted that pain was unnecessary and destructive. In an early paper he quoted the 2nd century Greek physician Galen. Pain is useless to the pained. He also had statistics to back it up. He found that the mortality rate associated with amputation of the thigh decreased from 50% to 25% when the patients were anesthetized, suggesting that taking away patients pain improved their healing rather than inhibiting it. This line of reasoning, buttressed by data, convinced some doctors that chloroform was safe to use in surgery. After all, surgery is an inherently invasive, unnatural process. The body cannot naturally amputate a limb or biopsy by itself. And even though early anesthetics were unreliable, opiates and other forms of pain reduction had been used in surgery for centuries without much controversy. But many physicians balked at Simpson's use of chloroform during routine childbirth. Unlike surgery, childbirth is a process that the body can undergo without medical intervention. Doctors and midwives alike thought that they should facilitate so called natural labor without getting in the way. A common adage was a meddlesome midwifery is bad because to meddle in any of the natural functions of labor, including relieving pain, might cause things to go wrong. But disbelief in the importance of labor pain was just as moral as it was medical. Victorian women were expected to to show their femininity by suffering for the greater good. Popular women's conduct manuals from the 1840s, like the women of England and the Wives of England by Sarah Stickney Ellis, argued that women's moral authority came from being patient, self sacrificing and disciplined. Childbirth was considered the ultimate display of virtue, as being able to suffer through pain for the good of a child was the ultimate symbol of sacrifice. It also had biblical precedence with the in sorrow thou shalt bring forth children from Genesis 3:16, proving that pain during childbirth was a part of God's higher purpose. Even though doctors rarely brought out their Bibles to justify labor pain, many physicians critical of chloroform used religious language to talk about the medical utility of women's physical suffering. As one physician put it at the time, the agonies of delivery were an indicator of safety and a well nigh holy accompaniment of childbirth. Another doctor wrote that it was ultimately more ethical to convince their patients to endure labor pain because relieving it would deny their biological destiny as daughters of Eve. An obstetrician from Liverpool suggested that women who wanted chloroform for childbirth were shirking their natural duty and thus were so ethically dubious that that they were in no fit state to make decisions and thus should be ignored. Are we going to allow the patient to tell us what to do? He wrote. Most of these early and influential critics of chloroform did not only have ethical concerns. They also worried about chloroform's safety, since this was an experimental drug that had gone from a niche chemical solvent to a pretty popular anesthetic in a little over a month. These critics were also suspicious of how Simpson advertised chloroform directly to the public before it had been properly tested. One physician wrote, I did not expect that Dr. Simpson would have appealed so generally and through so many channels to the feelings and imperfect knowledge of society in general. For it is, I am happy to say, still very uncommon in our profession to find those of its members who would give tone to its bearing and conduct. Professors, for instance, of our ancient universities, going about from one city to another to announce and exhibit the wonder effects of new gas, and as I am informed, somewhat after the fashion of a showman, to demonstrate them personally at dinner parties and in drawing rooms. Simpson replied personally, writing, my blood feels chilled by the cruel inhumanity and deliberate cruelty which you and some members of the profession are openly. Have not yet had time to get rid of some old professional caprices and nonsensical thought. Simpson invited that physician to stay with him, perhaps to try out chloroform himself, but the physician declined. That doctor did have a point, though. Throughout 1847, Simpson was still riding the high of his discovery, both metaphorically and literally. He hawked chloroform to anyone who would listen and pushed the drug on unwitting dinner guests. While his sister in law was a bit cautious after her first experiment with it on November 4, Simpson used to joke that he would chloroform her and. And he chased her around the house with a bottle, laughing. Once, Simpson made a cocktail with chloric ether and aerated water, which he called chloroform champagne, and served it to a dinner party. They found it nice but heady. The butler offered some to the cook, who downed it and immediately collapsed. The butler ran upstairs, announced that he had poisoned the cook, and the guests rushed to the kitchen to find the cook on the floor, snoring loudly. The incident was not fatal, but it did disturb Simpson's guests. Simpson, however, was completely undeterred. As one widow of an Edinburgh physician later recalled, the professor used to try his experiments with chloroform on us girls. He was then just introducing it, and with some of the liquid simply poured onto a handkerchief, would have half a dozen of us lying about in various stages of sleep. Our mother feared nothing and was only too delighted to sacrifice, if unavoidably, a daughter or two to science. Chloroform's critics listed their reasonable practical objections alongside more philosophical ones about the nature of pain and the feminine virtue of suffering. This rhetorical strategy majorly backfired. Simpson couldn't effectively undermine his critics concerns about the safety of chloroform because it was still so early, so no one had the data to prove anything substantial either way. And so he went after his critics and moral arguments instead, which were on more shaky ground. Simpson was willing to fight directly with his critics in pamphlets, articles and published letters directly responding to their points. In December 1847, Simpson published a pamphlet entitled Answers to the Religious Objections Advanced against the Employment of Anesthetic Agents in Midwifery and Surgery and Obstetrics. In the pamphlet, Simpson wrote that the traditional interpretations of the biblical in sorrow thou shalt bring forth children did not mean that women were to experience pain, but that they were to work during childbirth. He dismissed the moral arguments about a woman's inherent predisposition towards sex suffering as ought else than indications of a strange degree of eccentricity of thought. He dismissed any objection to the use of chloroform as prejudice. But soon chloroform's dangers would be impossible to ignore. In Newcastle, on January 28, 1848, a surgeon showed up at the home of a 15 year old girl named Hannah Greener for a routine procedure. She had an infected ingrown toenail and the surgeon had arrived to remove it. While it was a minor surgery, the nail bed can be surprisingly painful. So the surgeon put a teaspoon of chloroform onto a cloth and held it toward her nose. She took two breaths before pulling the cloth away, but the doctor told her to keep going. After the first incision, Hannah flailed until the doctor gave her more chloroform. When the doctor pulled up an eyelid to check if she was anesthetized, her eye stayed open. She turned pale and didn't respond when the surgeon splashed water on her face. Two minutes after the surgeon administered chloroform, she was dead. An autopsy revealed that congestion of the lungs after inhaling chloroform had caused Hannah's death, but did not blame the surgeon. The coroner wrote, no human foresight, no human knowledge, no degree of science could have forewarned any man against the use of chloroform in in this case. After a report about Hannah's death appeared in the Lancet, news spread quickly about the case. It was tragic but commonplace for patients to die after surgery from infection or blood loss. But it was nearly unheard of for a patient to die while surgery had barely begun, let alone a young and healthy patient dying during a minor operation. Headlines like Death by Chloroform appeared in newspapers across England. But the medical establishment could not reach consensus on what exactly had killed her. It was still unclear how exactly chloroform worked, so no one knew how it had suffocated her to chloroform. Skeptics, the episode proved that the drug was dangerous and had been adopted too quickly. But chloroform supporters thought that these results were inconclusive and that perhaps she died not because chloroform was inherently dangerous, but instead because she had been given too much of it or it was administered improperly. Some even thought that Hannah's death had nothing to do with chloroform at all, and that she instead died because of the shock of the surgical operation. One physician was unconvinced by all of these hypotheses. John Snow, a surgeon from London. Like Simpson, Snow was interested in the burgeoning field of anesthesiology. But temperamentally, these two men could not have been more different. Snow was known for being methodical and reserved. He didn't drink, eat meat, read novels or consume any water that hadn't been distilled. Unlike Simpson, Snow was a research scientist. He had published a paper about how to properly administer ether in 1847 and had been conducting animal studies on chloroform throughout the rest of the year to compare fatal and non fatal doses. According to historian Linda Stratman, he was the personification of order, keeping a diary of every case in which he administered an anesthetic and detailed notes of his experiments. His familiarity with anesthesia meant that he found the most common explanation. Explanation that the chloroform had suffocated Hannah. Improbable. Usually, deaths from asphyxiation were slow and involved a lot of visible struggle. But Hannah had rapidly collapsed, indicating to him that something else was going on. Snow studied the inquest testimony and medical reports and found that Hannah had not been suffocated. Instead, she had overdosed from having been given too much chloroform too quickly. Even though Hannah had only been given 1 teaspoonful of chloroform, it was undiluted, so it was in its strongest form. Snow emphasized that this made it dangerously easy for a patient to overdose. He also found that the surgeon's method, holding a handkerchief dipped in chloroform up to Hannah's nose and mouth was too imprecise. There was no way to control exactly how much chloroform Hannah was getting. Even small factors like the temperature and air circulation in the room or how close the handkerchief was to the patient's face could change how the drug worked. Worse, from his animal studies, Snow had found that chloroform vapor continued to accumulate in the lungs even after it had already been administered, making it even more difficult to control. Luckily, Snow had a an inhaler. Snow even had developed a a large metal can connected to a gas mask with a hose. With this kind of a device, Snow could mix the chloroform with air and introduce the drug gradually to make sure patients weren't getting too much too quickly. These findings should have comforted Simpson, since they suggested that chloroform wasn't inherently dangerous, but it was so powerful that it just had to be administered carefully. This wasn't so different from the arguments Simpson was making himself at the time. He had maintained that just like familiar anesthetics like opiates or ether, chloroform wasn't risk free, but safe in moderation. And yet Simpson was up in arms about Snow's result. Simpson thought that Hannah's death had nothing at all to do with chloroform. Instead, he fixated on another detail. The surgeon had given Hannah some brandy in addition to the chloroform. This was relatively common practice at the time to calm nervous patients. But Simpson thought that Hannah Greener had drowned from having brandy poured into her mouth while she was unconscious. But this hypothesis did not make any sense. The surgeon gave her brandy before she was given the chloroform, and the autopsy showed no signs of drowning. Still, Simpson wasn't the only one who disagreed with Snow's findings. Physicians published scathing letters in the Lancet and the London Medical Gazette arguing that Snow was overcomplicating this whole anesthesia business. They thought that all a surgeon had to do to safely use chloroform was watch the patient and stop when they fell unconscious. It was still unclear whether the chloroform had killed Hannah through the heart or the lungs, or whether the chloroform affected some undiagnosed pre existing condition that reared its head for the first time during the surgery. Ever the methodical researcher Snow reluctantly agreed with those conclusions. These findings could not be the final word on the safety of chloroform. His sample size was too small. Hannah was just one case. Snow would have to wait for more deaths. Before he could make a definite conclusion. Unfortunately, he did not have to wait long. Within months, reports appeared from across Europe and North America of patients dying in surgery after taking chloroform. By the early 1850s, Hannah Greener's death no longer seemed like a freak accident. Snow put out a paper in 1852 comparing 21 documented chloroform deaths. He advanced essentially the same argument as the Greener case, that these deaths were a result of the surgeons using handkerchiefs to administer the drug and ending up giving patients too much chloroform too quickly. Still, Snow's paper did not make that big of a splash. The medical establishment was still fighting tooth and nail about every aspect of climate chloroform, whether you needed to measure how much of the drug you used, whether it was safer than ether, whether pain relief should be used in surgery at all. But one very important person did take note of Snow's new paper. Queen Victoria. Even though Queen Victoria had nine children, she hated pregnancy and childbirth, which she called wretched. During her sixth pregnancy in 1847, the Duchess of Sutherland sent Victoria a pamphlet about the obstetric potential of chloroform. In 1850, when she was pregnant with Prince Arthur, she sent her royal accouche to meet with Jon Snow about potentially using the drug in her own labor. But in the end, she was too cautious to go through with it. By the time she was pregnant again in 1853, she had snow administer chloroform to one of her ladies in waiting during a tooth extraction. After seeing proof that he had administered the drug safely and successfully, Victoria invited Snow to court for an interview. Snow put on a court suit with a sword and flattened hat and met up with Prince Albert, Victoria's husband and the cause of all of these painful pregnancies. On the way there, Snow ran into a friend's wife and child on the street. He recalled that the child threw up her hands and exclaimed, oh, isn't Dr. Snow pretty, Mama? Snow was short, balding and self professed to be plain. So he repeated this story as a self deprecating anecdote for the rest of his life. Upon meeting Prince Albert, Snow and the consort talked through the Queen's concerns. Snow was impressed by the Prince's interest in the sciences and Albert was comforted by Snow's caution, expertise and and humility. Then and there. Albert approved Snow to administer chloroform to the Queen for the birth of her eighth child on Apr 7, 1853 at 12:40pm According to Snow's, detailed notes, Snow arrived at the Queen's bedside. She had been in labor for a few hours, but wanted to relieve her pain for the final step ages. And really, who can blame her? Ironically, given how much he railed against the use of handkerchiefs in anesthesia. Snow gave Victoria a chloroform dipped handkerchief to relieve her pain. But Snow figured it was safe to use a handkerchief because he was only using a tiny bit of chloroform. He had noted that women in labor often require required a smaller dose of anesthetic, and he aimed to anesthetize his patients so lightly that most of them remained conscious and responded to commands without remembering the labor pain. He used the same method to relieve Victoria's pain, and it worked. Between contractions, Snow reported that there was complete ease. At 1:13 in the afternoon, Leopold was born. Victoria was reported to have said that the experience of using chloroform was soothing, quieting and delightful beyond measure. The next day, she wrote to her uncle, I can report most favorably of it myself, for I have never been better or stronger since. The use of chloroform was still controversial, Buckingham palace tried to keep it under wraps, but eventually news got out. Snow's patients begged him for details about the royal birth, but all he would say was that Her Majesty is a model patient. One of his patients refused to take any more chloroform until Snow told her what the Queen had said while she was under the influence. Snow said Her Majesty asked no questions until she had breathed very much longer than you have, and if you will only go in loyal imitation, I will tell you everything. The patient complied, and then when she woke up, Dr. Snow was already gone. Simpson, too, was elated about the successful royal birth. It illustrated chloroform's safety and efficacy more than any of his letters or pamphlets ever could have. If chloroform was good enough for the Queen, it was good enough for the public. Simpson still took every opportunity he could to promote the drug, and he would eventually become one of the most renowned physicians in in Britain. He was awarded a Baronetcy in 1866. When Sir James Young Simpson died in 1870, more than 30,000 people filled the streets of Edinburgh for his funeral. According to newspaper reports, Queen Victoria sent a personal message of sympathy to the family. Simpson's lectures to medical students at the University of Edinburgh compared chloroform to innovations like eyeglasses or coffee, which were initially dismissed by the church as offsprings of man's wicked mind, but eventually were accepted into daily life. But Simpson ended up getting that wrong. Concerns about chloroform's safety never went away. After physicians collected decades of statistics chloro about how many patients died under the influence of chloroform, it developed a bad reputation. By the late 19th century, chloroform also became a popular plot device in crime fiction, appearing in lurid tales of criminals incapacitating their victims with nothing but a handkerchief. As early 20th century doctors turned to alternative anesthetics, like nitrous oxide and eventually intravenous options, chloroform fell out of medical use almost entirely. James Simpson's most important contribution to medical science wasn't actually chloroform itself. Instead, as one contemporary wrote after his death, Simpson adopted obstetrics when it was the lowest and most ignoble of our medical arts. He has left it a science numbering among its professors, many of the most distinguished of our modern physicians. He made childbirth something to be taken seriously. There is no doubt that Simpson way oversold the benefits of chloroform and downplayed its dangers. His science was dubious. Throughout his life, Simpson often repeated the frankly ludicrous claim that no one had ever died from chloroform. But his dogged insistence that patients, particularly women giving birth, didn't need to undergo so much pain has stood the test of time. As historian Donald Caton put it, it's hard to say how much longer women would have had to wait for anesthesia had it not been for Simpson's advocacy. That's the story of James Simpson. But stick around to hear about how John Snow not only administered chloroform to the queen, but also helped solve one of the deadliest cholera outbreaks in London's history.
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Myles Gray
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Dana Schwartz
A year after John Snow gave chloroform to Queen Victoria in 1853, an outbreak of cholera tore through London. Tens of thousands of people died throughout the city. Most thought that the disease spread through the air. But John Snow had another hypothesis. Cholera was in the water. Snow had first developed that theory during a previous cholera outbreak in 1849 when he noticed that more people were dying of cholera that got their water from two specific companies in South London. And so in 1854, he started analyzing cholera deaths in a similar way to those that died of chloroform, looking for patterns. After marking out the cases on a map of the city, he noticed that deaths were concentrated around a pump at Broadwick street, where townspeople came to collect water for drinking, cooking and cleaning. Snow published his results and convinced the city to take away the pump handle. Soon, the cholera outbreak went away. Later, the authorities discovered that the pump had been contaminated by a leaky sewer, confirming Snow's theory. Today, there is a replica of the pump on Broadwick street without a handle, named after John Snow to commemorate his essential discovery. Noble Blood is a production of iHeartRadio and Grim Mild from Erin Manke. Nobleblood is hosted by me, Dana Schwartz. Writers for Noble Blood are Hannah Johnston, Hannah Zwick, Paul Jaffe, Natasha Lasky and ME, Dana Schwartz. The show is edited and produced by Jesse Funk and Gnomes Griffin, with supervising producer Rima Il Kayali and executive producers Erin Menke, Trevor Young and Matt Frederick. For more podcasts from iHeartRadio, visit the iHeartRadio app, Apple Podcasts or wherever you listen to your favorite.
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