The cesarean section of Mary Hodges, Part 1

In which we learn of Dr Fifer’s humble beginnings, San Franciscan medical politics, and the anesthetic choices available to physicians in the 1850s. Dir Fifer’s choices are made somewhat more limited by the surgeon’s insistence on smoking during the operation.

It was the season when the SS Sierra Nevada, out of San Francisco, built to accommodate 900, arrived in Victoria with 1900 on board, the season when the price of a meal of beans and dampers reached 65 cents, with an extra dime for a glass of water, just as dear as Hudson’s Bay rum; the season of the portentous appearance of Donati’s comet with its prominent dust tail, curved like a scimitar. The year was 1858, the stage was New Caledonia in the British Northwest Territories, the country that is now part of the province of British Columbia. As to locality, the small town of Yale, situated at the entrance to the Fraser River Canyon, had become the destination of thousands of gold seekers. Among the arriving Argonauts was a solitary traveler, quite uninspired by the fervor for treasure; he was a fugitive from the mortal retaliation of California’s anti-vigilance gangs. Dr M.W. Fifer, previously of San Francisco, had found safe haven in Yale, anon in peaceful pursuit of his occupation, the practice of medicine. During the night of October 21, some urgent knocking got him out of bed. The caller, a scantily dressed woman, out of breath, entreated him, “Please…doctor…come to Mrs Yorke’s ’ouse; she’s ’avin’ a bad time; it’s the baby, it won’t deliver!” He followed her, finding the patient, a primagravida, in the final stage of pregnancy, and progressing poorly. Adroitly, he ruptured the woman’s amniotic membranes; shortly the head of the child engaged in the inferior strait, and she delivered a healthy male infant. After the night of intent care, he made his way home along the riverbank, half-asleep. The fresh morning fog cleared his dreaminess and made him aware of the startling change by which nature gives notice of the coming of winter; overnight, the surrounding riparian vegetation had turned golden yellow, red, and russet. The phenomenon brought recollections of a place where the leafy boughs were not of the hyperborean species of maple, birch, alder, and cottonwood, but of grapevines, fig trees, meridional sycamore, and eucalyptus. Across a thousand miles of ocean, rivers, mountains, and frontiers, the memories of a year ago were haunting his conscience. How could he forget that ill-fated day, when a botched cesarean operation cost the life of an infant, permanent injury to the mother, and the unleashing of a crushing malpractice suit, filed in the Fourth District Court of San Francisco? Humble beginnings The past unfolded with a whim of nostalgia: his arriving as an immigrant in New York, walking the streets penniless, and very hungry. All he had the day before were three glasses of water to fill his stomach. How faint he felt, nearly insane with hunger, fearing he might die from starvation. How, at that desperate moment, he met a man, happy as a king, who told him he had a bad tooth drawn under most miraculous circumstances. The dentist had him inhale a strong gas; he had no pain now, he said. He felt queasy and could not eat his lunch, a large ham sandwich, and offered it to Fifer who devoured it on the spot, like a man possessed. He could not remember the name of the Good Samaritan, yet, how could he forget the wondrous substance, of which the adverse aftereffect brought forth the cheerful giver’s generosity, providing the sustenance that saved his sanity, perhaps his life. The stuff was called letheon, after Lethe, the mythological river of oblivion. By a further run of luck Fifer enlisted and embarked for California where he chased the golden butterfly until his pockets bulged with nuggets. He spent a good portion of the fortune on becoming a medical doctor and, as a pinnacle to the endeavor, put up his MD shingle on Washington Street in San Francisco. The practice flourished; many patients were ex-miners like Elkanah Hodges, who had worked a claim next to his. When Elkanah married, it was Fifer’s privilege to look after his wife’s pregnancy. She became ill; the doctor tasted sugar in her urine and diagnosed diabetes during her gestation. The throng of immigrants snowballed across the Isthmus of Panama; among them medical men and specialists proclaiming their skills and cures. How times had changed! Patients could take their pick of physicians and treatments: from the Thomsonians, some advertising publicly the cure of private diseases; the hydropathists, offering electrochemical baths and colonic irrigations; the thalassotherapists, promoting kelp therapy; the homoeopathists, claiming efficacy of infinitesimally diluted concentrations of medicines; to the allopathists, with their medicines strong as Beelzebub to drive out the devil. It soon followed that those distinguished by university education or a diploma to that effect were looking down on the local, often inadequately trained colleagues, and the disparity caused contrariety and discontent in the small medical community they had established as the San Francisco County Medico-Chirurgical Association. One case in point was Dr Elias S. Cooper from Philadelphia. Flamboyant, arrogant, dominating at medical meetings, half eccentric, and half genius, Cooper possessed surgical knowledge, boldness, and skill. He was ambitious and planned to elevate the city to the Athens of the Pacific by establishing a university. Many woman patients flocked to this medical man whose ostentatious comportment made him a celebrity, and in no time had Mary Hodges switched from the run-of-the-mill Dr Fifer to the more fashionable specialist who accepted her into his care, even though his métier was neither obstetrics nor the treatment of diabetes. As soon as Dr Cooper joined the local medical society the meetings became acrimonious; there were bitter words when Dr Fifer, who was a charter member, questioned the use of association funds for the publication of a private paper called “Removal of a foreign body from beneath the heart.” The members had generously approved the cost of printing 500 copies, when the author, none other than Dr E.S. Cooper, had ordered 4000. Dr Fifer’s petty-minded query was too much for the great man; he became abusive, and told them to go to hell. As a result, the association expelled the heretic, the secretary struck his name from the members’ list and confirmed the deletion by adding the word “expelled.” Dr Fifer’s assistance requested Since the stormy diatribe, the two antagonists had comported themselves reasonably well; at least no pistols were drawn. Although that counted as a good beginning of reconciliation, the prima donna was riding for a fall, and it was not long in coming when he descended on his lowly colleague. “Look here, Fifer, I’m having a problem with that Hodges woman. She is at term to deliver; uterine contractions commenced spontaneously, but there seems to be an impasse: absolutely no progress for a total of 60 hours. During contraction the cervix will efface to no more than a dollar size.” “Why are you consulting me?” Dr Fifer asked. “She has left me as a patient.” Dr Cooper knew of Dr Fifer’s experience in administering anesthetics for resection of shattered legs, arms, or of compound fractures bound to become gangrenous. “I diagnosed Mary’s condition as a twin pregnancy and made the husband aware of the need for a cesarean operation. He requested that I consult with you, and if it comes to surgery, the couple would want you to be the one to put her to sleep.” Dr Fifer felt sheepish having missed the putative twin pregnancy. Although conceding Dr Cooper’s superior diagnostic skills, the idea of a cesarean operation seemed preposterous and circumstantial. In deferential obeisance he suggested, “That kind of surgery has never been done here, Dr Cooper. How about a dram of ergot to enhance uterine tonus?” “No,” Dr Cooper rejected arrogantly. “Ergot spasms can tear the uterus.” Trying to spare Mary the dreadful risk of surgery, Dr Fifer suggested, “Why not rupture the membranes? Draining the amniotic fluid promotes stronger rhythmic contractions and effaces the cervix.” “Absolutely none of that,” Dr Cooper remonstrated. “Ripping the membranes intentionally will cause the umbilical cord to prolapse, kill the babies in utero, and invite endometritis.” He insisted on proceeding with surgery, and seemed to care when he said peremptorily, “We must save the lives of the mother and her offspring.” Dr Fifer could not refute the arguments; his compunction was that an anesthetic for abdominal surgery would take much longer than for an amputation. Vomitus could obstruct the airway and choke the unconscious patient. At the end of their dispute, Dr Fifer accepted the complex task for the sake of the life of the mother and her presumed unborn children. In the mid-1800s, the method to obtund the senses and obtain adequate muscle relaxation was inhalation anesthesia. Anesthetic choices Recently a dentist, himself suffering from toothache, had requested a traveling lecturer on “laughing gas” to exhibit the gas to him while another dentist extracted the troublesome tooth. The extraction was painless, and nitrous oxide became an effective agent of pain suppression until, like a bolt from the sky, the Evening Bulletin reported a death in the dentist’s chair during a wisdom tooth drawing under nitrous oxide. Consequently, Mary Hodges would have none of that laughing gas for her surgery. Though letheon acted similarly to laughing gas, it suppressed pain more effectively in obstetric cases and surgical operations. Admittedly, coughing during induction would interfere with proper inhalation of the vapor, and post-anesthetic nausea and vomiting were common. Dr Fifer had not forgotten Lethe, haunting reminder of the mythological river where the souls, on their way to the beyond, drank from the waters to forget their past lives. Letheon, by its post-anesthetic effect, had saved him from starvation when the anorexic dental patient could not eat his lunch. Notwithstanding the side effects, the drug was considered safe, and Dr Fifer would have chosen letheonization of Mary Hodges, were it not for Dr Cooper’s uncompromising vice that he would pursue even in the course of his operations. During surgery, so as not to bloody the cigar, he would use the tweezers to pick up a lighted Cuban Monte Christo for a puff or two, a besetting foible that precluded the administration of the inflammable letheon. There was amylene, a powerful drug; Dr John Snow, the doyen of anesthesia, claimed that by using amylene, he could achieve the fourth degree of narcotism, the complete state of insensibility, with a fraction of the amount necessary for ether. Shortly, however, Dr Snow published the report of two deaths under amylene anesthesia, attributing its fatal action to paralysis of the nerves of the heart. Dr Fifer learned that the substance was as combustible as ether, therefore out of the question for any surgery performed by the stogie-addicted Dr Cooper. The best choice seemed to be chloroform, said to be non-flammable and possessing excellent anesthetic properties. According to the Lancet, it had been successfully administered to Queen Victoria when she delivered her eighth child, Leopold, and her ninth, Beatrice, with the famous chloroformist Dr Snow in attendance. While Dr Snow had raised the popularity of chloroform, too little was made of his utilizing the anesthetic phase, an episode of painlessness briefly preceding the state of unconsciousness. Meticulous timing, stopping the administration just short of the patient’s reaching total insensibility, was the clue to the absence of fatal complications in more than 4000 of his chloroform anesthetics. In spite of Dr Snow’s caveat about cardiac abstruseness under chloroform, the general press, in a sweepingly inappropriate and irresponsible statement, hailed chloroform anesthesia as safe. “The drug will do good without doing evil, the heart will take care of itself without the need to check the pulse, the simple rule is to observe the respirations.” In their quest for oblivion of surgical pain, the newspapers gave glowing reports of medical students in hospitals as far away as the colonial city of Hyderabad administering chloroform daily with perfect ease and in absolute safety, creating excellent conditions for surgery from a small bottle and simple mask, without difficulty. The need to maintain adequate circulation during anesthesia received very little attention. Other than observing the pulse rate and quality, there was no practical instrument to monitor the cardiac output; the value of the precordial stethoscope was not recognized. Contemporary ambrotypes depicting anesthesia show the anesthetist holding the mask over the patient’s face with one hand, taking the radial pulse with the other, while observing the chest movement as the means to monitor circulation and respiration. Direct measurement of arterial blood pressure would pose an invasive challenge, risking blood loss, hematoma formation, infection, gangrene, and embolism. The observation and control of the human cardiovascular system remained a no-man’s-land about which little was known and nothing could be done except for palpation of the peripheral pulse. The chloroformist would focus his attention on the obvious vital sign at hand, the quality of respiration. Based on reports that patients tolerated chloroform even better in the warmer, humid California air than in the clime of England, Dr Fifer, irreverent of royalty, made up his mind. “What suits the English Queen at Osborne House on the Isle of Wight will be good enough for Mary Hodges by the Golden Gate of San Francisco.” Part two, including the hair-raising operation and the allegations of malpractice and professional misconduct, will appear in the April 2006 issue of the BCMJ.

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Gerd A. Asche, MD

Dr Asche is a retired family physician who has lived, along with his wife Dr Ursula Asche-Quint, in Hope for the past 50 years. He is also an air pilot and performs medical examinations for fitness of air pilots and air traffic controllers. His special interest is medical history of the Victorian era; he is currently writing a biography of Dr Maximilian William Fifer, his predecessor in the area during the Fraser River Gold Rush, 150 years ago.