In recent years much has appeared in both the popular magazines and the medical press concerning the so-called "twilight sleep" and other methods of producing "painless childbirth." Many of these popular articles in the lay press cannot be regarded in any other light than as being in bad taste and wholly unfortunate in their method and manner of presenting the subject; nevertheless, these writings have served to arouse such a general public interest in the subject of obstetric anesthetics, that we deem it advisable to devote two chapters to the brief and concise consideration of the subjects of pain and anesthetics in relation to the day of labor.

THE PAIN OF LABOR

First, let us briefly consider the question of pain in connection with childbirth. Many women—normal, natural, and healthy women—suffer but comparatively little in giving birth to an average-sized baby during an average and uncomplicated labor. Like the Indian squaw, they suffer a minimum of pain at childbirth—at least this is largely true after the birth of the first baby; and so there is little need of discussing any sort of anesthesia for this group of fortunate women; for at most, all that would ever be employed in the nature of an anesthetic in such cases, would be a trifle of chloroform to take the edge off the suffering at the height or conclusion of labor.

But the vast majority of American mothers do not belong to this fortunate and normal class of women who suffer so little during childbirth; they rather belong to that large and growing class of women who have dressed wrong; who have lived unhealthful and sometimes indolent lives; who are more or less physically and temperamentally unfitted to pass through the experiences of pregnancy and the trials of labor.

The average American woman shrinks from the thought and prospect of suffering pain; she is quite intolerant with the idea of undergoing even the few brief moments of physical suffering attendant upon childbirth. She refuses to contemplate the day of labor in any other light than that which insures her against all possible pain and other physical suffering.

And it is just this unnatural and abnormal fear of labor-pains—this unwomanly dread of the slightest degree of physical suffering—that has indirectly led up to so much discussion regarding the employment of "twilight sleep" and other forms of obstetric anesthesia.

While the authors recognize the great blessing of anesthesia to the woman in labor—and almost unfailingly make use of it in some form—nevertheless, we also recognize that it would be a fine form of mental discipline and mighty good moral gymnastics, if a great many self-centered and pampered women would "spunk right up" and face the ordeal of labor with natural courage and normal fortitude. It would be "the making of them," it would make new women out of them, it would start them out on the road to real living. At the same time we do not mean to advocate that women should suffer unnecessary pain in childbirth any more than we allow them to suffer in connection with surgery.

PREPARATION FOR LABOR

While so much is being written about "twilight sleep" and "painless labor," it might be well to remind the American mother that much can be done to lessen the sufferings of the day of labor by one's method of living prior to the confinement.

We believe that child-bearing is a perfectly normal physical function for a healthy and normal woman—that it is even essential to her complete physical health, mental happiness, and moral well-being. Theoretically, child-bearing ought to be but little more painful than the functionating of numerous other vital organs—stomach, heart, bladder, bowels, etc.—and, indeed, it is not in the case of certain savage tribes and other aboriginal people, such as our own North American Indian.

But we must face the facts. The average American woman does suffer at childbirth; and she suffers more than we are disposed to allow her, or more than she, as a general rule, is willing to suffer. So, while we discuss appropriate methods of lessening the pain of labor and the pangs of childbirth by the scientific use of anesthetics, let us also call attention to certain things which may aid in decreasing the amount of pain which may reasonably be expected to attend child bearing.

To assist in bringing about this preparation for decreased pain at childbirth, mothers should teach their daughters how to develop, strengthen, and preserve their physical, mental, and moral resistance. The young mother should be taught by both her mother and her physician how to dress, how to work, and how to eat. Every care should be given to the hygiene of pregnancy and labor.

The expectant mother should have plenty of fruits and fruit juices, and if not physically well endowed to give birth to a large babe, she should have her diet restricted in meat, bread and milk, as well as the cereals. Overeating during pregnancy should be carefully guarded against, as emphasized in an earlier chapter. Deformities of the pelvis, etc., should rule out a consideration of pregnancy.

While artificial painless childbirth by means of "twilight sleep" and other similar methods all have their place; nevertheless, these procedures should not lead to the neglect of those natural methods and preventive practices which aid in preparing the normal expectant mother for nature's relatively painless labor. When so much anesthesia has to be used in a normal labor, it cannot but strongly suggest that both patient and physician have neglected those common but efficient methods which contribute indirectly to lessening the pangs of child bearing.

WHAT IS TWILIGHT SLEEP?

"Twilight sleep" is a recent term which has become associated in the public mind with "painless labor." The reader should understand that "twilight sleep" is not a new method of obstetric anesthesia. While this method of inducing "painless labor" has been brought prominently before the public mind in recent years by much discussion and by numerous magazine articles—being often presented in such a way as sometimes to lead the uninstructed layman to infer that a new method of obstetric anesthesia had just been discovered—it has, nevertheless, been known and more or less used since 1903. Later known as the "Freiburg Method," and as the "Dammerschlaf" of Gauss, and still later popularized as "twilight sleep," this "scopolamin-morphin" method of obstetric anesthesia, has gained wide attention and acquired many zealous advocates.

"Twilight sleep" is, therefore, nothing new—it is simply a revival of the old combination of scopolamin and morphin anesthesia. While many different methods of administering "twilight sleep" have been devised, the following general plan will serve to inform the reader sufficiently regarding the technic of this much-talked-of procedure.

The scopolamin must always be fresh, although different forms of the drug are used. It tends quickly to decompose—forming a toxic by-product—and, according to some authorities, this decomposed scopolamin is responsible for many undesirable results which have attended some cases of "twilight sleep." Various forms of morphin are also used, as also is narcophin.

TECHNIC OF "TWILIGHT SLEEP"

The "twilight-sleep" injections are not started until the patient is in the stage of active labor. The initial injection consists of the proper dose of scopolamin and morphin (or some of their derivatives), while the patient's pupils, pulse, and respiration are carefully noted, as also are the character of the uterine contractions and the character of the fetal heart action.

Usually within an hour, a second dose of scopolamin is given, while the application of so-called "memory tests" serves to indicate whether it is advisable to administer additional injections. Some leading advocates of this method claim that the majority of the unfavorable results attendant upon "twilight sleep" are the direct result of failure to control the dosage of the drug by these "memory tests;" and they call attention to the large percentage of "painlessness" as proof of probable overdosing. If the patient's memory is clear and she is not yet under the influence of the drug, a third dose is soon given. If, however, the patient is in a state of amnesia (lack of memory), this third injection is not commonly given until about one hour after the second injection. The amount of amnesia present is used as a guide for repeated injections at intervals of one to one and a half hours. As a rule, the morphin is not repeated.

It must be evident that the success of such a method of anesthesia must depend entirely upon thoroughgoing personal supervision of the individual patient by a properly trained and experienced physician; and it is for just these reasons that "twilight sleep" is destined to remain largely a hospital procedure for a long time to come.

Experience has shown that those cases of "twilight sleep" that are not under the influence of scopolamin over five or six hours do vastly better than those under a longer time. When employed too long before labor this method seems to favor inertia and thus tends to increase the number of forceps deliveries.

The number of injections may run from one to a dozen or more, and patients have come through without accident with fifteen or more doses, running over a period of twenty-four hours.

THE CLAIMS OF "TWILIGHT SLEEP"

While "twilight sleep" as a method of anesthesia is not altogether new, many of the claims made for it by recent advocates are more or less new; and, to enable the reader clearly to comprehend both the advantages and disadvantages of this method, both the favorable and unfavorable facts and contentions will be summarized in this connection. The favorable claims made for "twilight sleep" are:

1. That eighty to ninety per cent of all women who use this method can be carried through a practically painless labor.

2. That there is practically no danger to the mother (some degree of danger to the child is admitted by most of its champions) other than those commonly attendant on the older and better known methods in general use.

3. That "twilight sleep," being almost exclusively a hospital procedure, would result in more women going to the hospital for their confinement—if it were used more; and would, therefore, tend to bring about more careful supervision and individual care on the part of the attending obstetrician.

4. That by lessening the dread of labor and the fear of painful childbirth, there will probably occur an increase in the birth rate of the so-called "higher classes of society"—the social circles which now show the lowest birth rates.

5. That it is of special value in the cases of certain neurotic women and those of low vital resistance; especially those patients suffering from certain forms of heart, respiratory, kidney, and other organic diseases.

6. Some authorities maintain that "twilight sleep" is of value even in threatened eclampsia, although they admit it tends to produce a rise in blood-pressure.

7. It is supposed to shorten the first stage of labor—by facilitating the dilation of the cervix—owing to the painless stretching; although the majority of its special advocates admit that it lengthens the second stage of labor, during which the patient must be very closely watched.

8. That even in those cases where the sense of pain is not entirely destroyed, the patient seems to possess little or no subsequent memory of any physical suffering or other disagreeable sensations.

9. That the method is of special value in sensitive, high-strung, nervous women of the "higher classes," who so habitually shun the rigors of child bearing—especially in the instance of their first child.

10. That the action of scopolamin is chiefly upon the central nervous system—the cerebrum—that it diminishes the perception of pain without apparently decreasing the contractile power of the uterus; labor may, therefore, proceed with little or no interruption, while the patient is quite oblivious to the accompanying pains.

11. That the physical and nervous exhaustion is quite entirely eliminated—especially in the case of the first labor—that patients who have had this method of anesthesia appear refreshed and quite themselves even the first day after labor.

12. That there is decidedly less "trauma" (appreciable injury) to the nervous system and therefore less "shock;" and that all this saving of nervous strain tends greatly to hasten convalescence.

13. And, finally, that "twilight sleep" does not interfere with the carrying out of any other therapeutic measures which may be deemed necessary for a successful termination of the labor.

DANGERS OF TWILIGHT SLEEP

While we are recounting the real and supposed advantages of "twilight sleep"—especially in certain selected cases—it will be wise to pause long enough to give the same careful consideration to the known and reputed dangers and drawbacks which are thought to attend this method of anesthesia in connection with labor cases.

We desire to state that these expressions, both for and against "twilight sleep," are not merely representative of our own experience and attitude; but that they also represent, as far as we are able to judge at the time of this writing, the consensus of opinion on the part of the most reliable and experienced observers and practitioners who have used and studied this method in both this country and Europe. The dangers and difficulties of "twilight sleep" may be summarized as follows:

1. That this method tends to weaken the mental resistance of many women; to lessen their natural courage and to decrease that commendable fortitude which is such a valuable feature of the character endowment of the normal woman.

2. That "twilight sleep" is essentially a hospital method and is, therefore, inaccessible to the vast majority of women belonging to the middle and lower classes of society, as well as to those women who live in rural communities.

3. That in fifteen or twenty per cent, the method fails to produce the desired results—at least, when administered in amounts which are deemed safe.

4. That this method does decrease the baby's chances of living; that the second stage of labor is definitely prolonged; that from ten to fifteen per cent of the babies are sufficiently under the influence of the anesthesia when born as to be unable to breathe or cry without artificial stimulus.

5. That it is a method requiring special training and experience; that it will be many years before the average practitioner will become proficient in its use; and that the older methods are probably far safer for the average physician.

6. That the method requires more care in its administration than can be expected outside of the hospital in order to avoid the dangers of fetal asphyxiation—which danger has led not a few obstetricians to abandon it.

7. That a satisfactory technic is almost impossible of development; that every patient must be individualized; that the chief dangers are connected with the over dosage of morphin; that the method is not adaptable to the general practice of the average doctor.

8. That by prolonging the second stage of labor and by sometimes giving too much morphin, the number of forceps deliveries is greatly increased, with their attendant and increased dangers to both mother and child.

9. That the prospects of passing through labor which may be rendered painless by artificial methods, tends to produce an attitude of carelessness and indifference towards those natural methods of living and other hygienic practices which so greatly contribute to naturally painless confinements.

10. That this method as sometimes practiced greatly increases the dangers of a general anesthetic, if such should be found necessary later on during the labor.

11. That "twilight sleep" is contra-indicated (should not be used) in the following conditions: primary inertia (abnormally delayed and slow labor); expected short labor—especially in women who have already borne children; when the fetal head is known to be large and the mother's pelvis small; placenta praevia (abnormal placental attachment); accidental hemorrhage; absent or doubtful fetal heart beat; when labor is already far advanced; and in threatened convulsions and eclampsia.

CONCLUSIONS REGARDING TWILIGHT SLEEP

Having presented the evidence both for and against "twilight sleep," it may be of assistance to the lay reader to have placed before her the personal conclusions and working opinions of the authors. We, therefore, undertake to summarize our present attitude and outline our practice as follows:

1. "Twilight sleep" as a method of obstetric anesthesia in certain selected cases and in well-equipped hospitals, and in the hands of careful and experienced practitioners, has demonstrated that it is a scientific reality—and has probably come to stay—at least until better and safer methods of affecting a relatively painless confinement are discovered; although we are compelled to state that it is not the panacea the lay press has led many of our patients to believe. (That we believe a much better and safer method has been devised, the next chapter will fully disclose.)

2. We do not expect this method ever to become general in its use; we do not look for a chain of special "twilight hospitals" to stretch across the continent and then to overrun the country. We expect much of the recent forced enthusiasm to die down, while scopolamin-morphin anesthesia takes it proper place among other scientific methods of alleviating the pangs of labor.

3. We know that standard and fresh solutions—as already noted—are absolutely essential for the success of this method.

4. We are certain that no routine method or technic can be developed. Each patient must be individualized. The method does not consist in injecting scopolamin every so often. The patient's mental and physical condition—as also that of the unborn child—must control the administration of "twilight sleep."

5. The patient must be in a quiet and partially darkened room. She must not be disturbed; while the physician, or a competent trained nurse, must be in constant attendance. well-appointed hospital, there is no real reason why it cannot be fairly well carried out in a well-regulated private home, provided the necessary preparations have been made, a trained nurse is present, and provided, further, that the physician is willing to remain in the home with the patient the length of time required properly to supervise the treatment.

6. While this method of treatment is best carried out in the well-appointed hospital, there is no real reason why it cannot be fairly well carried out in a well-regulated private home, provided the necessary preparations have been made, a trained nurse is present, and provided, further, that the physician is willing to remain in the home with the patient the length of time required properly to supervise the treatment.

7. Even when the treatment is not instituted early in labor, it can, in certain selected and appropriate cases, be utilized even in the second stage of labor—thus saving these special cases much unnecessary pain; in fact, some authorities regard it as a valuable adjunct in the management of "borderland contractions" as it allows the patient a full test of labor.

8. In our opinion, this method has little effect on the first stage of labor if properly administered; but it does undoubtedly prolong and tend to complicate the second stage; in fact, we are coming to look upon "twilight sleep" as being more distinctly a first stage procedure; that it bears the same relation to the first stage of labor that chloroform bears to the second stage—relieving the pain but not stopping the progress of labor.

9. That when safe amounts of the drug are used the pain is greatly lessened in all cases—the subsequent memory of pain is absent in the majority of the patients—but the labor is not always entirely painless as is popularly supposed.

10. We do not believe that this method when properly administered increases the number of forceps deliveries—at least not in the case of high forceps operations. It undoubtedly does cover up the symptoms of a threatened rupture of the uterus, and thus increases danger from that source; nevertheless it may be safely stated that this method does not in any way greatly interfere with any other measures which might be found necessary to institute in order to bring about a successful termination of the labor.

11. The baby's heart beat must be carefully and constantly watched; sudden slowing means that the treatment must be discontinued and the child delivered as soon as possible; even then, difficulty may be experienced in getting the baby's breathing started after it is born. In the vast majority of cases where the baby does not cry or breathe at birth, the usual methods employed in such cases serve quickly to establish normal respiration, and the baby seems to be but little the worse for the experience.

12. While altogether too much has been claimed for "twilight sleep" at the same time many false fears have also been suggested, among which may be mentioned the fear of the mother losing her mind after the treatment; the undue fear of asphyxiation on the part of the baby; the fear of post-partum hemorrhage; and the fear that it will lessen the milk supply. We cannot deny that the child's dangers are often increased; but in other respects, this method (in properly selected cases) presents little more to worry us than the older methods of anesthesia.

13. We are inclined to the belief that this method has but little influence on the course of convalescence following labor. Certain nervous and highly excitable women certainly seem to do better, as a result of experiencing less pain and nervous shock; while other cases do not turn out so well. It certainly does not retard repair and recovery during the puerperium.

14. This method seems to have its greatest field of usefulness in those cases of highly intelligent but excessively neurotic women who have an abnormal dread of pain and child bearing; or women who have suffered unusually at the time of a previous confinement—perhaps in the case of the first baby—or from other complications; women such as these, and other special cases, are the ones to benefit most from the employment of "twilight sleep."

15. This method as has already been intimated, is most useful in the case of the first baby, or in the case of women who have established a record of tedious and painful labors. It has no place in normal and short labors; although it may be used to great advantage in certain cases during the first stage of labor—being carefully and lightly administered—while chloroform or gas is utilized at the end of the second stage just as has been our custom for a generation.

16. As noted under the special claims made for this method, it is (as also is nitrous oxid) the ideal procedure in cases of heart, respiratory, kidney, and other organic difficulties, the details of which have already been noted, and their repetition here is not necessary.

17. It must be remembered that scopolamin and morphin are more or less uncertain in their action; scopolamin is variable in its results, often producing such marked nervous excitement in the patient as greatly to interfere with the carrying out of an aseptic technic; while morphin has been shunned by obstetricians for a whole generation, because of its well-known bad effects on the unborn child as well as its interference with muscular activity on the part of the mother.

In Germany, it is said, that a great many damage suits against prominent physicians have resulted because of the alleged ill effects which have followed the use of "twilight sleep."

18. In presenting these facts and opinions regarding "twilight sleep," the reader should bear in mind that we are not only endeavoring to state our own views and experience, but also to give the reader just as clear and fair an idea of what other and experienced physicians think of the method, both favorably and unfavorably; and we will draw these conclusions to a close by citing the opinion of one or two who have had considerable experience with the method and who, in summing up their observations, say:

The disadvantages of the method are entirely with the accoucheur and not to the mother or child. It requires his presence at the bedside from the time the treatment is undertaken until the completion of labor, not so much because of any danger, but to keep the patient evenly under anesthesia on a line midway between consciousness and unconsciousness, for if she is allowed to go above that line in several instances she will have several so-called "isles of memory," and will be able to draw a picture of her labor in her mind and thus lose the benefit of the treatment.

These methods of anesthesia are very important and have merit. They should be used when properly indicated. No one should limit himself to a routine method. Each case should be individualized and the form of anesthesia best suited to the case in hand should be employed. For instance, in dealing with a primipara—one who is full of fear, who cannot stand pain, who is of an hysterical nature—morphin-scopolamin anesthesia is best suited in that particular case, because these drugs have a selective action when it comes to allay fear and produce amnesia. On the other hand, in a multipara who has had three or four children, whose soft parts are relaxed and who has short labors, the anesthetic of choice would be a few whiffs of chloroform as the head passes over the perineum. It is ridiculous to try to give such women the "twilight sleep." Furthermore, take the cases you see for the first time at the end of the first stage of labor, or during the second stage; these cases are best treated with the nitrous oxid and oxygen method. You have to individualize your cases. The prospective mother now consults the obstetrician early to find out if her particular case is suitable for the "twilight sleep." She has been informed that certain examinations—urine, blood pressure, etc.—are necessary. She knows that these examinations have to be made at regular intervals. In other words, we get the patients early and we can give them good prenatal care.