CHILDBIRTH IN TWILIGHT SLEEP
A method of effecting painless childbirth through the use of
scopolamine and morphine was first used in 1902 by Steinbuechel,
and in 1906 Gauss, of the University of Freiburg in Baden, reported
a series of five hundred obstetrical cases in which scopolamine
and morphine had been used. The woman's condition was called
in Freiburg a _Dämmerschlaf_, a Twilight Sleep, because she is
somnolent and forgetful of pain. In 1903 the chief obstetricians
in several of the leading American and German universities tried
the drugs, but they quickly abandoned the method because they found
it dangerous and unscientific. The process was exploited here by
_McClure's Magazine_,[203] _The Ladies' Home Journal_, and other
lay periodicals. The articles in these magazines were written by
persons who are not physicians, and their erroneous statements are
misleading. _The Ladies' Home Journal_, however, while favoring
the method, published letters from several leading obstetricians
in the United States, all of whom are opposed to the use of these
drugs during parturition because they had tried them and found them
unscientific. The method is illicit morally, and it is unscientific.
[203] June, 1911.
Obstetricians divide a parturition into three stages. In most
primiparae and many multiparae there is a prodromal stage, in which
false labor pains (_dolores praesagientes_) are the most evident
symptom. When the real labor sets in there are rhythmic uterine
contractions about every fifteen minutes, which cause pain to the
woman by the pressure of the fetus on the uterine nerves--_dolores
praeparantes_. From the time the pains become rhythmic, and are
effective in dilating the neck and mouth of the womb, until the
mouth of the womb is completely stretched and flush with the vaginal
wall, thus completing the continuous parturient canal, is the first
stage of labor. The fetal enveloping membranes (the "bag of waters")
usually rupture at the end of this stage, but sometimes the bag
bursts before the end, or as late as the second stage of labor. The
first period is the stage of dilatation.
The second stage extends from the end of the dilatation until the
expulsion of the child is completed. This is the stage of expulsion.
The third stage lasts from the delivery of the child until after the
expulsion of the placenta and membranes and the retraction of the
uterus has ended--the period of the afterbirth.
Normal parturition is always painful to the woman. As the labor
progresses the pains gradually grow more intense, and the interval
between them shorter. After a few hours the pain is strong enough
to cause the woman to cry out, but there is a great variety in the
endurance of these pains, as the women's characters differ. Neurotic
women begin to scream and act hysterically even in the early part of
the first stage. When the pains are fully developed each lasts about
half a minute.
In most cases the infant comes out head first, but almost any part of
its body may present. Before the advancing child part of the _liquor
amnii_ within the fetal enveloping membranes is forced down into the
neck of the womb, and causes dilatation. In primiparae especially the
bag of waters may rupture prematurely and thus cause what is called
a dry labor, which is commonly tedious and painful. Often operative
interference is required in dry labors.
In the second stage the pains are stronger, recur every two or three
minutes, and are expulsive. The woman then strives to expel the
child. She strains violently with the abdominal muscles--literally
labors; her pulse is high, the veins of her neck stand out, her face
is turgid, and her body is covered with sweat. When at last the head
of the child is driven out the woman feels as if she were being torn
asunder in the _dolores conquassantes_. The pain is so great that the
woman may faint from it, but that is not the rule. After a pause the
shoulders are forced out, and then the trunk in one long convulsive
effort. The umbilical cord is tied and cut, and the child is born.
After from five to twenty minutes the womb begins to contract again,
but the pains (_dolores ad secundum partum_) are not nearly so
intense as they were during labor. Then in from fifteen minutes to
about three hours the placenta is expelled.
The pains of labor are so evident that the expulsive contractions of
the uterus, of which the pains are symptoms, are themselves called
"the pains." These pains in all scientific exactness of statement
are, as has been said, agonizing. "In dolore paries filios" is a
very literal text. The scopolamine-morphine method was devised with
the intention of mitigating them, or mercifully rendering the woman
unconscious of them during at least a part of the labor. If she is
unconscious of pain she is thus saved also from shock and depression,
which render her susceptible to infection. Such results certainly are
immeasurably valuable if attainable without taint of moral evil, but
as the method stands just now, they are not free from that taint.
Scopolamine hydrobromide, one of the drugs used in this method, is
an alkaloid obtained from the roots of _Scopolia_ (or _Scopola_)
_carniolica_, and it cannot be differentiated chemically from
hyoscine hydrobromide, which is made from henbane and other plants of
the _Solanaceae_ group. Rusby was of the opinion that scopolamine is
really a mixture of hyoscine, hyoscyamine, and atropine: one-tenth
hyoscine and nine-tenths hyoscyamine and atropine. Cushny and others
find different proportions of these alkaloids. As the leaves of
_Scopolia_ are used to adulterate the belladonna leaves from which
atropine is derived, hyoscine and scopolamine are substituted for
each other--if, indeed, there is an any real difference between
them. Some of the largest drug-houses in Germany before the war
supplied hyoscine and scopolamine from the same stock bottle--the
name depended on the asker. Even in a pure state hyoscine and
scopolamine have the same chemical formula (C{17}H{21}NO{4}),
and their physiological action is the same. Each can exist in three
isomeric forms, and in one of these forms they turn polarized light
to the left, in another to the right, while in a third form they do
not affect the light at all. The higher the rotatory power of the
drugs, the more active they are physiologically. The levorotatory
scopolamine has, according to Cushny, Peebles, and Hug, double
the action of the inactive scopolamine on the cardiac inhibitory
fibres of the vagus, but the levoactive and the inactive scopolamine
produce the same effect on the central nervous system. The drug on
the market is usually composed of a mixture of the levoactive and
the inactive forms, and as one or the other predominates the results
differ: the rotatory power of a given specimen should be known. Old
solutions of scopolamine decompose and give rise to toxic substances.
Gauss attributed post-partum hemorrhages in the women and asphyxia
in infants to these decomposition products, but he avoided these
untoward effects somewhat by cutting down the morphine dose. He had
five infant deaths before he cut down the morphine, and 25 per cent.
of the children were intoxicated. The chief action of scopolamine
or hyoscine is upon the cerebral cortex, producing sleep, which is
accompanied often by a low delirium. They depress the centre of
respiration, and have a depressant effect also on that part of the
spinal cord which governs the motions of the body. They intensify the
action of morphine and other narcotics.
Morphine, which is used to prevent pain, is the chief drug in the
twilight sleep method, and it is greatly intensified in action by the
presence of scopolamine. When, however, morphine and scopolamine are
given to a pregnant woman hypodermically, these drugs are at once
carried by the blood to the fetus. Children for years after birth all
withstand the action of morphine badly, and a fetus _in utero_ may be
overwhelmed by it. Just in this fact lies the chief moral crux in the
use of the twilight sleep method of obstetrical delivery. The woman
may go on to the end more or less safely in competent hands, but if
constant watch is not kept at the bedside by a skilled observer the
infant is liable to be killed, and the danger comes to it not solely
from the drug directly--it may be drowned in the amniotic fluid, its
condition may be masked by the restlessness of the mother, which
prevents proper observation: when a woman is plunging all over the
bed, as is extremely common in twilight sleep, the pulse-rate of the
baby cannot be properly watched.
If the mother happens to be particularly susceptible to scopolamine
or morphine, the first will cause delirium and the second coma; or
the respirations may become arhythmic and be reduced to only five or
six a minute. The kidneys may be affected by the morphine so as to
bring on total suppression of urine. Labor is prolonged, and it may
be very much prolonged. In some women uterine atony is induced by
the morphine, with very dangerous consequent post-partum hemorrhage.
Morphine relaxes all musculature, and it relaxes the muscle of the
arterial walls and so disposes to hemorrhage. There is little or no
premonitory symptom of these idiosyncrasies (except in the case of
an injured kidney) to inform the physician that he should avoid the
scopolamine-morphine treatment.
Dr. Polak, professor of obstetrics at the Long Island College
Hospital, reported[204] on 155 cases of the twilight sleep method,
and he is in favor of it under several restrictions. He uses the
drugs from ampules which contain one two-hundredth of a grain of
scopolamine and half a grain of narcophin, which is a proprietary
drug said to be composed of the meconate of morphine with the
meconate of narcotin in molecular proportion. Morphine itself is a
tribasic meconate, and narcotin, of course, another opium derivative.
The American Council on Pharmacy and Chemistry was unable to accept
the claims made for narcophin.[205] Polak says he finds no difference
between morphine and narcophin.
[204] _Long Island Medical Journal_, December, 1914, and
_American Journal of Obstetrics_, May, 1915.
[205] _Jour. Amer. Med. Assoc._, November 21, 1914.
In the twilight sleep treatment the patient, especially if she is
a primipara, should be definitely in labor before any injection
is given. She should have pains occurring at regular intervals,
preferably every four or five minutes, before the first injection of
scopolamine and morphine is administered; that is, the first stage of
labor should be well advanced. Gauss gives one-sixth of a grain of
morphine at the first injection, and Polak nearly three-fourths of a
grain of narcophin, with one two-hundredth of a grain of scopolamine.
If the woman is a multipara, Polak begins the treatment at the very
beginning of the pains. The patient is kept in bed, in a darkened
room, removed from all noise and excitement. Some stop the ears and
blindfold the patient, and, according to Baer of Chicago, the women
are put into restraining sheets as a routine practice in certain
clinics to keep them from infecting themselves. The ordinary practice
is to give a half dose of scopolamine an hour after the first dose
and about every two hours thereafter, according to the indications.
The morphine may be discontinued, or used approximately every six
hours in a long labor. Smaller doses are required if the first is
given early in the labor, and larger if the pains have been well
developed. In these latter cases the danger to the child is, of
course, greater.
The condition of the patient's pulse, respiration, pupillary
reaction, and the frequency and character of the uterine contractions
are constantly watched, to guard against poisoning. Fonyo[206]
reported two fatal poisonings by the scopolamine-morphine method
as used in surgery. Both were operations for the delivery of
women by laparotomy, and in each case the centre of respiration
was overwhelmed. In each of these operations only one-hundredth
of a grain of scopolamine and one-third of a grain of morphine
had been used, but chloroform was administered later. Robinson
recently reported the fatal poisoning of a negress by scopolamine,
and Chandler of Philadelphia two more where one thirty-third of a
grain of scopolamine had been used. One-ninetieth of a grain given
hypodermically has caused severe toxic disturbance which lasted
for twenty-eight hours, and Root[207] reported a case where one
three-hundredth of a grain given by mouth poisoned violently.
[206] _Zentralblatt f. Gynäkologie_, September 19, 1914. Leipsic.
[207] _Therapeutic Gazette_, vol. ii.
In Freiburg, Gauss tests the consciousness of the women about every
half hour by showing them some object, and if they remember having
seen this object he gives an additional dose of scopolamine. Polak
says this memory test is not necessary: even if the patient gives
outward evidence of pain by cries and motion, she is apparently but
very dimly conscious in his opinion.
The progress of the delivery must be constantly watched by repeated
extraäbdominal or rectal examinations, following the fetal shoulder
as it rotates--and not by vaginal examinations--to avoid sepsis. The
fetal heart must be auscultated every half hour at most, between
and during the pains. If the child's pulse grows arhythmic or slow
between pains, these are bad prognostic signs. All use of the drugs
is to be discontinued, and the child is to be delivered at once to
save its life, by the most suitable method and route.
Polak holds that the solutions of the drugs must be absolutely pure,
and that hyoscine cannot be substituted for scopolamine, but that
narcophin is no better than morphine: the American preparations
have produced delirium. As I have shown, no one can possibly tell
the difference between hyoscine and scopolamine, even by chemical
analysis. All we can do is to take the druggist's word that the drug
at hand was made from _Scopolia_ and not from _Hyoscyamus niger_. It
does not make any difference which is the source of the supply.
Polak says the morphine shortens the first stage of labor by
softening the cervix, but that the treatment lengthens the second
stage. Other observers have not found that it shortens the first
period. He tells us that if this second stage--that is, the time from
the full dilatation of the os until the delivery of the child--lasts
over an hour in multiparae, or over two hours in primiparae, delivery
must be effected by the Kristeller expression or by low forceps. In
the Kristeller expression the child is pushed out of the canal by
the hands of the physician applied to the fundus uteri. It should be
a method of last resort, because there is danger of rupturing the
uterus, of tearing the placenta loose, or of crushing an ovary.
In his report Polak says he has had no failures; the patients had
no recollection of the labor; in the first series of fifty-one the
children showed no sign of asphyxiation or even cyanosis except
in two cases. In this first series one patient had a long second
stage and the child had to be resuscitated. There were, he said,
no post-partum hemorrhages; no low forceps; the placentas were
delivered without difficulty; none of the women showed signs of
tire or exhaustion the next day; in fact, they were better off
than the women who have normal labor. This report is different from
that made by other men just as competent, and in exactly the same
circumstances; even Gauss confesses many failures. The lay journals
say Gauss had no failures, but he himself should know. In April,
1915, I was told in New York City that there had been no failures
there, yet in May, Dr. Broadhead, professor of obstetrics at the
Postgraduate School of Medicine in that city, after observing
seventy-two cases confessed[208] several failures where the child was
concerned. One Catholic woman, a member of the executive committee in
a Twilight Sleep League of married and unmarried women, was killed in
Brooklyn by the method in the summer of 1915.
[208] _The Postgraduate_, May, 1915.
Dr. Charles M. Green, professor of obstetrics in Harvard University,
tells us:[209] "My own observations, published in 1903, led me at
the time to favor this therapeutic means of producing the 'Twilight
Sleep,' and removing the consciousness of pain, or at least
preventing all remembrance of it. I have long since abandoned this
agent, however, for two reasons: First, because it has apparently
been the cause, occasionally, of fetal asphyxia. Second, because the
effect of the drug on the mother is often uncertain, and unless used
with great care may cause unfavorable or dangerous results. Moreover,
we have other and safer measures for the relief of pain in labor. So
I have given up teaching the use of scopolamine in my lectures."
[209] _Ladies' Home Journal._
Dr. Williams, professor of obstetrics in Johns Hopkins University,
and the author of a book on obstetrics which is very valuable,
says:[210] "We have used the scopolamine treatment of childbirth in
two separate series of cases at the Johns Hopkins Hospital, but in
neither series were the results satisfactory, nor did they in any way
approach the claims made for the treatment. We expect to do more with
it next year." In the fourth edition of his _Obstetrics_, published
in 1917, he thinks that the twilight sleep method will fall into
disuse, or at least that its use will be restricted to a small group
of neurotic patients. From his experience, he says, the method is
not adapted for private practice.
[210] _Ibid._
Dr. Hirst, professor of obstetrics in the University of Pennsylvania,
tried the scopolamine treatment in the maternity hospital of the
university in about 300 cases at three different times. He tried it
first in 1903, but he found that if sufficient morphine is given
to abolish pain there is danger of hemorrhage in the mother and
of asphyxia in the child. At a meeting of the Obstetrical Society
of Philadelphia[211] Hirst, commenting on a paper by Polak, said:
"I am sorry to say I cannot agree with my friend Dr. Polak in his
conclusions ... I had to discontinue morphia and scopolamine because
there were too many cases of post-partum hemorrhage, too many cases
in which forceps had to be used, too many asphyxiated babies. So I am
not an enthusiast for 'twilight sleep.'"
[211] Proceedings printed in _American Journal of Obstetrics_,
May, 1915.
Dr. Joseph B. De Lee, professor of obstetrics in the Northwestern
University Medical School, Chicago, and the author of a book on
obstetrics which is now one of the best we have in English, tells
us[212] that the impressions he received from studying ten cases of
childbirth in Professor Krönig's clinic at Freiburg were "decidedly
unfavorable to the method of 'Twilight Sleep.'" In all the ten cases,
he testifies, the birth pains were weakened, and labor prolonged--in
two instances for forty-eight hours. In three cases pituitrin, which
is in itself a dangerous drug to use before the uterus has been
almost emptied, had to be given to save the child from imminent
asphyxia. In five of the cases forceps had to be used owing to the
paralyzing effects of the drug, and all these forceps cases were
extensively lacerated. Several of the women became so delirious and
violent that ether had to be used to quiet them, with the result that
the infants were born "narcotized and asphyxiated to a degree." One
child had convulsions for several days.
[212] _Ladies' Home Journal._
The complete failure in these ten cases is so obvious as to be a
scandal, although De Lee does not say so. He abandoned the use of
the method twelve years ago, and in 1913 he visited the maternities
at Berlin, Vienna, Munich, and Heidelberg, and found that all had
tried the method and had rejected it.
Several so-called detoxicated substitutes for morphine, like
"tocanalgine" and "analgine," have been tried; but these turned
out to be morphine, and to be equal in strength to morphine as
we ordinarily have it. These were the drugs that were advocated
in the _Cosmopolitan Magazine_ as "having nothing to do with the
morphine-scopolamine treatment originating some years ago in
Freiburg." They are morphine treacherously disguised, and the
assertions in the _Cosmopolitan_ were never retracted when attention
was called to the untruth by the _Journal of the American Medical
Association_. In the _American Journal of Obstetrics_ for May, 1915,
is a full description of these drugs (page 772).
Dr. Joseph Baer reported[213] sixty cases of the morphine-scopolamine
treatment at the Michael Reese Maternity Hospital in Chicago, and
his results were diametrically opposed to those Dr. Polak himself
obtains. The rooms used were large, and had cork-lined sound-proof
walls and doors; obstetricians and specially trained nurses were
present day and night. The circumstances, then, were the best that
could be had.
[213] _Jour. Amer. Med. Assoc._, May 22, 1915, lxiv, 21, p. 1723.
He used Merck's scopolamine at first, and later a solution made up
after the formula of Straub of Freiburg, which is more stable. His
doses of morphine were from one-eighth to one-fourth of a grain;
Gauss uses one-eighth to one-sixth of a grain; Polak, as much as
three-fourths of a grain of narcophin for his first dose.
Baer's series ended on February 5, 1915, and of his sixty cases
only five were successful. Three of the successful cases received
one-fiftieth of a grain of scopolamine in all, and some of the
unsuccessful cases got as high as one-sixteenth of a grain, with only
wild delirium as a result.
The labor was lengthened by about seven hours over untreated cases.
As to the amnesia, in twenty-six cases the memory was not dulled at
all, although they received more scopolamine than thirty-nine cases
in which the memory was cloudy.
Thirty-two women had unbearable thirst throughout the labor, and
nothing would slake this thirst. Their incessant cries for water
were very distressing to the attendants. Headache was present in
twenty-seven cases and vertigo in thirty-one, and the headache,
which was very intense in some women, lasted for several days after
delivery.
Pain was diminished in thirty-nine cases, absent in one, as severe
as in the average untreated woman in nineteen, and increased in one.
That is, only one woman in sixty did not suffer the pain for which
the treatment was devised. The reason evidently is that his dose of
morphine was too small, yet if he went above this dose he ran the
risk of post-partum hemorrhage and of narcotizing the baby. As it
was, he had seven post-partum hemorrhages, but in a series of sixty
unselected normal delivery cases he had only one hemorrhage.
Restlessness was present in eighteen cases, and delirium in nine; six
of these women had to be wrapped in restraining sheets, and one had
to be shackled for four days after she had overpowered a nurse in an
effort to jump out of a window. It took three attendants to get her
into the strait-jacket. Chandler of Philadelphia saw a woman in a
like delirium who was shackled only after six attendants together had
tackled her. Two physicians in the Chicago maternity were severely
beaten by women in a twilight sleep delirium.
Baer says the serious risk of self-infection during labor through the
uncontrollable motion of these women is a source of constant anxiety.
They sit cross-legged, and the heel infects them with coli communis
from the expressed feces. The dazed women constantly try to get at
the vague pain with their hands, and on this account, according to
Baer, some clinics that practise the twilight sleep method keep all
the women in strait-jackets, but they omit to publish this fact.
One of Baer's patients died from a ruptured uterus, and her dead
baby was taken from her belly-cavity. The drug will mask symptoms in
a case like this. Sudden cessation of puerperal pain as a symptom
of rupture, and the peculiar pain of a premature loosening of
the placenta, are both covered from observation by the drugs, the
darkening of the room, and the tossing of the patient, which prevent
proper examinations.
One patient had a mitral insufficiency and myocarditis. This should
be an ideal case for the treatment, according to the twilight sleep
men. The woman, however, after three doses of the scopolamine
developed pulmonary edema. Her child was delivered in asphyxia
pallida and resuscitated with difficulty.
Thirteen of the children did not breathe at delivery, six were
asphyctic, and two cases relapsed into asphyxia. One child was
killed, as we said, when the mother's uterus ruptured. Avarffy[214]
had one fatal case in fifty, and Chrobak one in one hundred and seven.
[214] _Gynäkol. Rundschau_, 1909, iii.
Eight of the women had blurred vision after delivery, which lasted
for over twenty-four hours; two had marked delirium for from two
to four days after childbirth. As to exhaustion after labor, Baer
says he found no difference between the twilight sleep women and the
normal cases.
Some advocates of the twilight sleep method say that there is less
use of the forceps in this method than in normal delivery. At
Freiburg, for example, operative delivery has been "reduced" to six
or seven per cent. Six per cent., as a matter of truth, is two per
cent. above the normal average for forceps delivery in eighteen
German maternities. In 95,025 deliveries in these hospitals the
average forceps delivery was 4.5 per cent., and some were small
teaching hospitals where the forceps were used on any provocation
for class demonstration. The twilight sleep method has a much higher
operative delivery, and this varies, of course, according to the
skill and judgment of the operators.
Holmes, one of the first in Chicago to try the newly revived
method, says[215] that in July, 1914, before the great war broke
out, there were twenty-five malpractice suits pending in one German
city as a result of the morphine-scopolamine fad. He quotes a noted
obstetrician on this subject: "If you will use the method, have the
patient in the best hospital possible, with all the appurtenances
requisite for the revival of the child; if you do not know, learn
at once the differences between asphyxia, oligoapneia, and narcotic
poisoning, and the methods of treating them; get the best and the
most reliable product called scopolamine; and then be sure you
are in a position to be adequately defended by a lawyer versed in
malpractice suits."
[215] _American Journal of Obstetrics_, May, 1915.
This is the state of the question. Two or three men in the best
circumstances say they get one hundred perfect results; other men,
equally or far more skilled and in equally favorable circumstances,
get one hundred results which are anything but successful, often
a disgrace to science, and undoubtedly immoral. They are immoral
because they risk human life in an attempt to ease a physiological
pain, and this is not a sufficient reason; moreover, these attempts
fail oftener than they succeed. The second group of practitioners
have no motive except honesty to induce them to make their
unfavorable reports of failure. The reports of the two groups are
directly contradictory, and the judgment is thus a matter of motives.
Testimony from women who have gone through the process is not to be
taken into account. They were dazed, and in any case they are not
competent to judge a matter which is wholly technical.
We know the limitation of morphine and scopolamine and we cannot
improve their use. If enough is given to still pain, we take a
criminal risk; if we do not give enough to remove the sense of pain,
why not use the safer nitrous oxide, ether, and chloroform? If
enough morphine and scopolamine are administered early in labor to
a multipara, the labor is commonly stopped; if this dosage is given
after the pains are developed, the baby is born, as a rule, before
they take effect.