Who Has Permission

I

On 7 April 1853, at Buckingham Palace, a doctor called John Snow dripped chloroform onto a handkerchief and brought it gradually to the face of a thirty-three-year-old woman who was in labour with her eighth child.

The woman was Queen Victoria. The child was Leopold, the eighth of nine. Snow did not put her to sleep. He gave her small quantities during the contractions [fifteen drops each time, on a folded handkerchief], for almost an hour, so that she was conscious and collaborating the whole while with the pain reduced.

The queen wrote afterwards in her diary that the effect had been “soothing and delightful” —two words that were going to be worth more than fifty medical papers—.

It was not the first obstetric anaesthesia [not by a long way]. James Simpson had been using chloroform in births in Edinburgh since 1847, and hundreds of women had already received it.

What happened in 1853 was not medical. It was a permission.

II

Until that day, relieving the pain of childbirth had against it an argument that sounds today like a joke and then was not one: that the pain had been put there on purpose, that it appeared named in Genesis as a sentence, and that removing it was disobedience.

The debate was serious and took up pages of medical journals. There were obstetricians who held that the suffering formed part of the physiological process and that suppressing it would spoil it. There were clergymen who said it in other terms [with another bibliography]. There was, underneath all of it, a very old idea about who ought to bear what.

That the most visible woman of the empire used it and said so ended the argument within a few years. Not with an argument, but with an authorisation.

This is the first thing the piece teaches and it has nothing of biology about it: the availability of a relief and the social permission to use it are two different things, and they can be decades apart.

III

I arrived at casualty on a Thursday at twenty past ten at night with renal colic, which is the pain with the best press of all pains and has earned it.

It is a pain that does not let you keep still. In the manuals they call it colicky pain, and that word describes nothing. You cannot lie down, you cannot sit, you cannot wait standing; you go round and round a corridor bent to one side, sweating, nauseous, counting floor tiles.

They saw to me quickly and believed me first time [not one checking question]. At ten to eleven I had a line in and a painkiller inside me, and at a quarter past eleven the pain had gone from being everything to being a weight in my side.

Fifty-five minutes from the door.

In that while I did three things I now recognise as a script: I mentioned my profession when it had nothing to do with anything, I used the word colic instead of saying my back hurt, and I described the pain to the nurse on a scale of one to ten before she asked for it. None of that was calculated. All of it works.

The next day, telling it, I realised that at no point did I have to convince anybody. Not once. I said what was wrong, described where, and the process started up without anyone asking me whether I was sure, whether it was really that bad or whether I had taken anything beforehand.

I do not know what would have happened had I been somebody else. I do know there is abundant medical literature, in several countries, on the differences in time and in dose of analgesia according to who comes through that door [by sex, by age, by language, by origin], and that it has been saying the same thing for thirty years.

The bill, in a public hospital, I did not see. The scan afterwards, privately, cost a hundred and ninety euros.

From that night I also remember unimportant things that stuck to the pain. A broken coffee machine with a handwritten sign. An older man asleep in a chair with his coat on. The buzz of the fluorescent tube in the corridor, which was the same buzz a fluorescent tube makes anywhere and which that night seemed to me unbearable. When the painkiller went in, all of that went back to being what it was.

IV

Chloroform is a minuscule molecule: one carbon with three chlorines and a hydrogen, so small it fits into almost any gap.

It is given through the lung and within a few breaths it is in the brain, because it dissolves in fat better than in water and the brain is above all fat. There it does something like what ether does, though with more finesse: it gets in among the components of the membranes and puts out of true the gates that let electrical charges through, favouring the ones that brake and hindering the ones that excite.

The nervous system switches off in layers, and the order matters. First anxiety goes, then awareness of what is happening around, then memory, then pain and lastly the control of breathing and of the heart.

Snow was working in that first band on purpose. He was not trying to put the queen to sleep; he was trying to keep her in the layer where the pain is attenuated and the person is still there.

What makes chloroform dangerous is how narrow that stretch is. The distance between the dose that relieves and the one that stops the heart is small, and besides this molecule has an obsession of its own: it sensitises the heart to adrenaline, so that a fright at the wrong moment can set off a rhythm that does not recover.

It was called sudden death by chloroform and it went on killing healthy people for decades, almost always in minor operations [the first documented, a girl of fifteen being operated on for an ingrown nail].

The body, for its part, does the usual and with a late bill: the liver dismantles the molecule, and in that dismantling produces fragments that damage the liver itself. That is why chloroform was abandoned, and why today it is used neither for this nor for almost anything.

V

What was decided that day at Buckingham goes on being decided on every casualty shift in any hospital.

Not the technique, which is settled and is cheap. The permission.

Who has the right to be believed when they say it hurts; how quickly; at what dose; and how many questions have to be answered first. That is not fixed by pharmacology. It is fixed by custom, by the standing of whoever complains and by the time available to whoever listens.

It is a matter of money only in part. The painkiller they gave me costs little more than the packaging; what is expensive is the minute of the person who decides to give it, and that minute is shared out by criteria written into no protocol.

In 1853 it took a queen to unblock it [not a trial, not a journal, a queen]. That is a fairly exact way of measuring how far the matter was from being a medical question.

VI

There are two things against me and both are uncomfortable.

The first is that I am the example of the good side of the statistic, and writing about analgesic inequality from a trolley on which I was believed within twenty minutes has something indecent about it.

The second is subtler. It is very easy to tell the queen's episode as a joke about priests and the Bible, and it is not one: the argument that the pain of childbirth has a function and should not be touched stayed alive long afterwards, in secular versions, and still turns up today with another vocabulary every time somebody argues over whether a woman really needs the epidural she is asking for.

The justification changed. The question did not change so much.

When the permission arrives late, moreover, it leaves no trace. Nobody writes into a clinical record the four hours somebody spent waiting to be believed, because the box that exists is the one for the time the drug was given. The delay disappears from the file just as the sexual effects disappeared from the scales of the seventies.

VII

Snow died five years later, at forty-five, of a stroke, while writing a book on anaesthesia [he left it half done, on the page he was on]. He is the same doctor who had taken the handle off a water pump in Soho to stop an outbreak of cholera, five years before that birth —the same man, two different foundings, and in both it was necessary to convince somebody of something that was already evident—.

The queen used chloroform again at her next birth, in 1857, and recommended it to anyone who would listen; by then it was already called, in the journals, anaesthesia à la reine.

7 April 1853, fifteen drops every contraction for almost an hour.

Six years from the first obstetric anaesthesia until it stopped being argued about.

Renal colic, Thursday, twenty-two twenty at night.

Fifty-five minutes until the painkiller.

Scan afterwards, privately: a hundred and ninety euros.