obstetric anaesthesia and analgesia in england and wales 1945-1975. richard barnett university ...

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OBSTETRIC ANAESTHESIA AND
ANALGESIA IN ENGLAND AND
WALES 1945-1975.
RICHARD BARNETT
UNIVERSITY COLLEGE LONDON
DOCTOR OF PHILOSOPHY (PhD)
2007
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UMI Number: U591B66
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DECLARATION OF ORIGINALITY
I, Richard Barnett, declare that the work presented in this thesis is my own, and that any
ideas, quotations or other material taken directly or indirectly from the work of other authors
have been properly acknowledged and referenced.
Signed:
Date:
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THESIS ABSTRACT
This thesis addresses the history of obstetric anaesthesia and analgesia in Hngland and Wales
between 1945 and 1975. It is based on an analysis of archival material from the Ministry of
Health Department for Health and Social Security, the C entral Midwives Board, the Medical
Research C ouncil, the Royal C ollege of Obstetricians and Gynaecologists, the Obstetric
Anaesthetists* Association and the National Birthday Trust Fund. Other sources used include
the popular and medical press, British governmental publications, oral history interviews and a
prosopography of the Obstetric Anaesthetists' Association.
In this period the management and elimination of the pain of childbirth became the subject of
great interest not only for mothers and anaesthetists, but also for obstetricians, midwives,
clinical scientists, healthcare administrators, politicians and the press. Broadly speaking,
existing work on the history of obstetric anaesthesia and analgesia treats this subject in two
contrasting ways. Practitioner-historians of anaesthesia have characterised it as one of co­
operation between mothers and medical practitioners, but many historians of obstetrics and
midw ifery have preferred to emphasise the role of obstetric anaesthetists in medicalising and
hospitalising birth.
This thesis places the development of obstetric anaesthesia and analgesia in the context of
three related narratives. These narratives emerged in the First half of the twentieth century, but
after 1948 operated within wider debates over the centralisation and hospitalisation of state
healthcare under the NHS. First, the emergence and consolidation of anaesthesia as a hospital-
based clinical speciality. Second, the demographic shift from home to hospital birth. Third,
arguments over the role of midwives in birth. It uses four case-studies to explore these
narratives: the Analgesia in Childbirth Bill, 1949; the development of new analgesics for use by
unsupervised midwives; obstetric anaesthesia and analgesia in the governmental Reports on
Confidential Enquiries into Maternal Deaths', and the early history of the Obstetric
Anaesthetists' Association and its role in debates over epidural analgesia.
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CONTENTS
Title page 1
Declaration of originality 2
Thesis abstract 3
Contents 4
Acknowledgements 7
Abbreviations in main text 9
Additional abbreviations in footnotes 12
List of figures in main text 13
List of tables in main text 13
List of tables in Appendix 1 14
List of tables in Appendix 2 14
1. Introduction. IS
1.1. Literature review. 16
1.2. Aims and methodology. 34
1.3. Chapter outline. 40
2. Medical, political and demographic contexts for obstetric anaesthesia and 42
analgesia in England and Wales in the twentieth century.
2.1. Obstetrics, midwifery and anaesthesia in England and Wales c. 1900 - c. 43
1950.
2.1.1. Obstetric analgesia and the Midwives Act, 1902. 44
2.1.2. Maternal mortality, obstetric anaesthesia and a national maternity 47
service 1919-1939.
2.1.3. The NBTF and analgesia for domiciliary midwives 1928-1945. 59
2.1.4. Anaesthetists and obstetric anaesthesia in England and Wales before the 65
Second World War.
2.1.5. Obstetrics, midwifery and anaesthesia in England and Wales during the 70
Second World War.
2.1 6 Anaesthesia and the NHS 1948-1953. 72
. .
2.2. The hospitalisation of birth in England and Wales 1945-1975. 75
2.3. Conclusion: contexts for obstetric anaesthesia and analgesia in England and 83
Wales 1945-1975.
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3. ‘A radical alteration in the midwifery situation': obstetric analgesia and health 86
serv ice reform 1945-1949.
3.1. The N’BTF and the working party on midwifery. 87
3.2. The NBTF and nationalised analgesia. 94
3.3. The NBTF and the Analgesia in Childbirth Bill, 1949. 98
3.4. Conclusion. 107
4. On their own responsibility: testing and approving new' methods of obstetric 110
analgesia for unsupervised midwives in England and Wales, 1945-1975.
4.1. Trilene. 112
4.2. Pethidine. 131
4.3. Nitrous oxide and oxygen. 141
4.3.1. The Lucy Baldwin machine. 144
4.3.2. Hntonox. 157
4.3.3. Bringing nitrous oxide / oxygen analgesia into clinical service. 161
4.4. Conclusion. 169
5. ‘Showing up the gaps in the maternity services'?: obstetric anaesthesia in the 175
Confidential Enquiries into Maternal Deaths in England and Wales 1945-1975.
5.1. Reforming the Confidential Enquiries 1946-1975. 177
5.1.1. Proposals for administrative reform 1946-1947. 180
5.1.2. Medical interest in mortality investigations 1946-1949. 181
5.1.3. Reforming the Confidential Enquiries 1949-1957. 186
5.1.4. The appointment of regional anaesthetics assessors 1969-1975. 191
5.2. Anaesthesia, hospital birth and maternal mortality in the Reports on 196
Confidential Enquiries 1957-1975.
5.2.1. The first seven Reports on Confidential Enquiries 1957-1975. 197
5.2.2.Chapters on anaesthesia in the Reports on Confidential Enquiries. 200
5.2.3. Anaesthesia in the prefaces and final chapters of the Reports on 203
('onfidential Enquiries.
5.2.4. Mendelson syndrome, anaesthetics practice and the Reports on 205
C 'onfidential Enquiries.
5.3. Conclusion. 208
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6. ‘A symposium of working people’: the Obstetric Anaesthetists’ Association 211
(OAA) 1969-1975.
6.1. An archival approach to the early history of the OAA. 213
6.2. A comparative prosopographical approach to the early history of the OAA. 220
6.2.1. Prosopography: aims and method. 222
6.2.2. Prosopography: discussion. 225
6.2.3. Prosopography: conclusion. 230
6.3. The OAA, the RCOG ad hoc committee on the relief of pain in labour and 231
anaesthetics staffing policy 1970-1975.
6.4. Conclusion. 246
7. Conclusion. 250
Bibliography. 257
Appendix 1 - Prosopography tables. 289
Appendix 2 - Ministers of Health, Chief Medical Officers and presidents of the 311
RCOG 1945-1975.
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ACKNOWLEDGEMENTS
This project has benefited enormously from the expert supervision of Dr Tilli Tansey, who
has provided a finely balanced synthesis of critical analysis and space for thinking. Dr Anita
Holdcroft, the second supervisor and my principal contact in the OAA, has been a constant
source of encouragement, and an indispensable guide to clinicians’ perspectives on this subject.
I am very grateful to the Wellcome Trust Centre for the History of Medicine at University
College London and the OAA for their generous joint funding of this project. I owe my
involvement in this project, and its subsequent smooth running, to Alan Shiel, the Centre
Administrator.
Once again, the staff and students of the Wellcome Trust Centre for the History of Medicine
at UCL have made historical research both a pleasure and a challenge. I am indebted to Prof
Roger Cooter, Dr Martin Edwards, Dr Lesley A Hall, Prof Anne Hardy, Dr Rhodri Hayward,
Prof Chris Law rence and Prof Vivian Nutton for comments and guidance in various forms over
the last three years. Nandini Bhattacharya, Karen Buckle, Dr Stephen Casper, Candice Delisle,
Theresia Hofer, Dr Khai Khuin Liew, Christos Papadopoulos, Prof Walter Robinson, Dr Leela
Sami, Dr Norberto Serpente, Jane Seymour and Dr Thea Vidnes have been companions, critics
and friends. Particular gratitude goes to Stephen and Jane for our conversations on British
medicine, and to Walter for our days out in Salem and Boston. The Wellcome Trust Centre’s
administrators and IT staff have, as usual, held everything together in exemplary fashion.
Outside the Centre, Prof Iain Chalmers, Dr Jean Donnison, Dr Irvine Loudon and Prof David
Williamson gave invaluable guidance in the early stages of the project. Exchanges with Dr
Stephanie Snow at the C’entre for the History of Science, Technology and Medicine, University
of Manchester, and Prof Jacqueline II Wolf at the Department of Social Medicine, Ohio
University, enlivened and sharpened my later drafts. Bonnie Evans, Dr Jette Mollerhoj, Julia
Moses and Sian Pooley of the Cambridge Health and Welfare History Workshop were kind
enough to allow an outsider to take part in their conversations on the history of maternal care.
The OAA’s history of obstetric anaesthesia sub-committee have supported and encouraged all
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aspects of this project, from conception to delivery. Faruq Noormohammed of the Chelsea and
Westminster Hospital generously arranged provision of the personal computer on which this
thesis was composed. Dr Thomas Bryson, Dr Len Carrie, Mary C'ronk, Dr Andrew Doughty, Dr
Sheila Duncan, Dr Derrick Holdsworth, Prof Felicity Reynolds, Prof Michael Rosen, Dr
Anthony Rubin and Dr Michael Tunstall kindly took part in oral history interviews. I am
particularly grateful to Dr Tunstall and his wife for putting me up for the night in Aberdeen, and
for providing copies of his correspondence relating to Hntonox.
Participants at the Society for the Social History of Medicine’s postgraduate conference
‘From the Cradle to the Grave’, held at the University of Glasgow in January 2006, heard and
commented on early versions of chapters 3 and 4, as did the Group of Obstetric Anaesthetists in
London and the obstetric department of Queen Charlotte’s Maternity Hospital, London. The
staff of the Wellcome Library and Archive, University College London Library, the University
of London Library, the London School of Economics Library, Cambridge University Library,
Addenbrooke's Hospital Library, The National Archive and the Royal College of Obstetricians
and Gynaecologists Library and Archive all provided a characteristically high standard of
service and support. Dr Jean Horton, archivist of the Neurosurgical Anaesthetists’ Travelling
Club, generously provided copies of minutes and membership lists. Trisha Hawkins, secretary
and honorary archivist of the OAA, kindly gave over her kitchen table for several afternoons of
research in the OAA archive.
Finally, Dr Michael Neve has been in every sense the best man, not least in introducing me
to Dr Caroline Essex. When I began this project, Caroline was a new friend. She is, as I write
these words, my wife. Over three years Caroline and Michael have dealt gracefully with an
entire menagerie, from archive rats to bears with sore heads. The dedication of this thesis is poor
compensation, but it comes with my love and gratitude. No news.
ABBREVIATIONS IN MAIN TEXT
AAGBI Association of Anaesthetists of Great Britain and Ireland
AIMS Association for Improvements in the Maternity Services
BBC' British Broadcasting Corporation
BJA British Journal of Anaesthesia
BMA British Medical Association
BMJ British Medical Journal
BOC British Oxygen Company
BCOG British College of Obstetricians and Gynaecologists
BRCS British Red Cross Society
BPMS British Postgraduate Medical School
BSI British Standards Institute
CAM Committee on analgesia in midwifery
CCHE Central Council for Health Education
CHSC C'entral Health Services Council
CMB Central Midwives Board
CMO Chief Medical Officer
CNOOA Committee on nitrous oxide / oxygen analgesia
CSNSS Committee on senior nursing staff structure
DA Diploma in Anaesthetics
DCMMM Departmental committee on maternal mortality and morbidity
DCTEM Departmental committee on the training and employment of midwives
DHSS Department of Health and Social Security
DObst Diploma in Obstetrics
EAA European Anaesthesiological Association
EMS Emergency Medical Service
FARC'S Faculty of Anaesthetists of the Royal College of Surgeons
FF ARC'S Fellowship of the Faculty of Anaesthetists of the Royal College of Surgeon
FRC'A Fellowship of the Royal College of Anaesthetists
GMC' Cieneral Medical Council
CiNC General Nursing C ouncil
GP General practitioner
GRO General Register Office
HMC Hospital management committee
HMSO His / Her Majesty’s Stationery Office
ICI Imperial Chemical Industries
IJOA International Journal of Obstetric Anesthesia