Twilight Sleep

A Simple Account of New Discoveries
in Painless Childbirth

By Henry Smith Williams, B. Sc, MD, LLD ~ 1914

Written in collaboration with Dr. J. Whitridge Williams, author of “Williams Obstetrics”

CHAPTER V 

THE TWILIGHT SLEEP AND ANESTHESIA

            In the last chapter or two, it will be observed, we have dealt with the question of the suffering of the parturient woman as a general problem rather than with any particular means of assuaging that suffering.

Of course, the reader has had in mind, at least as a mental background, the Twilight Sleep of Freiburg as the implied remedy for what we have agreed to consider the evils of painful childbirth.  Just what the twilight sleep is, and what it is alleged to have accomplished, were matters considered in some detail in the earlier chapters.  It remains now to consider the Freiburg method from a somewhat different standpoint; to give audience to the criticisms that have been passed upon it, and to inquire whether it probably represents a final method, or whether it only calls vivid attention to the problem, and points the way to its solution.

We must inquire, also, whether there are alternative methods, or methods that may be used in combination with that devised at Freiburg.

In a word, I would make it clear that my object is not primarily to sanction or exploit the method of making childbirth painless that is employed at Freiburg, but to emphasize the desirability of investigating that method, searching diligently for a better method, if such can be found, and in general taking up on a comprehensive scale the vitally important project of lessening the sum total of human suffering by systematically and habitually assuaging the pain needlessly suffered by the mothers of the race is carrying out their essential function of motherhood.

In the pursuance of this general object, let us first consider a little more critically than we have done heretofore the Freiburg method.  We have told what it accomplishes in the hands of Dr. Krönig and his associates at Freiburg, let us inquire what it has accomplished in other hands, and, incidentally, what it has failed to accomplish.

DEFECTS OF THE METHOD

It must appear, from what has already been said, that the administration of scopolamine and morphine, as practised at Freiburg, is a rather delicate operation.  That is to say, it is not something that can be done as a mere routine dosage, to be practised by nurses, or even by physicians untrained in the particularities of the method.

As a general thing with the use of other drugs, the physician gives a dose of recognized standard size, and repeats it presently if certain rather clearly defined symptoms do not manifest themselves.

But with the scopolamin treatment, the tests of full dosage are not physical; they are mental.  The patient who is narcotized to the full extent desired does not seemingly have her suffering alleviated in the least during the period of vigorous uterine contraction, which is commonly described as a “pain.”  So even the skilled observer could not determine from direct observation of the patient whether or not the dosage had been sufficient.  But immediately after the pain the patient falls into a deep sleep, and if awakened and questioned about the pains she has had, she has no recollection of having had any pains at all.

It is this forgetting that constitutes the test, and, according to the authorities at Freiburg, the sole dependable test, of the sufficiency of the scopolamin medication.

“As technically described by Gauss, ‘Twilight Sleep’ is accomplished successfully when there is an adequate abolition of the apperception of pain.  It is to be looked upon as a kind of subconsciousness in which the cortex of the cerebrum is completely cut off from the reflex columns of the spinal cord.”

Professor Gauss is said to have illustrated the matter colloquially to an American thus: “In the spine are telephone girls. I am asleep and a fly bites my foot; I brush it off.  If I am awake, a telephone girl calls my brain also. If I am asleep, she does not. But the action is the same either way.”

The entire condition is well described by Dr. H. Fuchs, of Danzig, in a recent analysis of different methods of narcosis in childbirth, as follows: “When the pains come, the women usually cry out just as loud as any other lying-in women, answer the question whether they have pains in the affirmative, but during the intervals between the pains fall into a deep sleep.  If awakened from this sleep, and questioned about the pains they have suffered, there is a complete loss of memory, that is, if the semi-sleep is complete.  Psychologically the facts of the case are that the pains are perceived at the moment, but they make no impression.  They leave behind in the higher cerebral centers no memory picture.  It results that if the semi-sleep is properly produced the whole of the processes of labor are banished from remembrance.”

It remains to be said, however, that the morphine-scopolamin treatment, even in the hands of the skilful exponents of Freiburg, is by no means certain in its beneficent action.

Dr. Gauss himself has given an analysis of the 3,000 cases treated at the Frauenklinik up to 1911, from which it appears that there is a great difference in susceptibility to successful treatment by the Freiburg method, according to the temperament of individual women.  In general, it appears that the women of the upper classes are more amenable to the treatment, and that successful results are gained with them in a much higher percentage of cases than with women of the peasant class.

It appears that the lying-in department of the hospital is divided into four classes, according to accommodations, which grade all the way from well-furnished private rooms to open wards.  Dr. Gauss’ report shows that among patients of the first class 82 per cent. of the cases were successful, in the sense that they experienced “perfect Twilight Sleep” (with attendant loss of memory) under the treatment.  But among patients of the second class only 66 per cent. of the cases were successful; with the third class only 59 per cent.; and with the fourth class only 56 per cent., or slightly more than half of the cases treated.  So even if the number of patients in each class were the same, success would be attained, on the average, in only 66 per cent. of cases.

In other words, even under the conditions that obtain at the Freiburg Frauenklinik, only two women in three who receive the morphine-scopolamine treatment are blessed with the painless delivery that they sought.

But who will deny that to give surcease of sorrow to two women out of three that are brought to childbed, is a very notable achievement?

IS THERE INJURY TO THE CHILD?

There remains one other important point to be considered.  This is the question of the effect of the treatment on the child.

It is well known that the nervous system of the infant is peculiarly susceptible to the effects of drugs.  Opiates in the smallest quantity sometimes have an alarming effect when administered to young children.  It is not surprising, then, to learn that the critics of the method have declared that the morphine-scopolamine treatment not infrequently has a more or less alarming effect on the child.  According to the analysis of Dr. Fuchs:  “The excitability of the respiratory center is lowered, with the result that one-fourth of the children are born in a state of oligopnea or apnea” – that is to say, in a state of partial asphyxiation.

The authorities at Freiburg contend, however, that the tendency to retard respiration on the part of the child may sometimes be beneficial, preventing the infant from inhaling too early, and thus minimizing the danger of strangulation from inhalation of fluids.  It appears, further, that statistics of the Frauenklinik show that the percentage of infant mortality is low.  Let me quote:

“As against an infant mortality of 16 per cent. for the State of Baden in the same year, a report on 421 ‘Twilight Sleep’ babies showed a death-rate of 11.6 per cent.

“For this strikingly low mortality of the children during and after birth under semi-narcosis, explanation was sought of Professor Ludwig Aschoff, the great German authority on morbid anatomy.  He offered the theoretic explanation that slight narcotization of the respiratory organs during birth by extremely minute quantities of scopolamine is advantageous to the child, as it tends to prevent permanent obstruction of the air-passages of children by premature respiration during birth.”

Whatever may be thought of this explanation, at least it would appear from Dr. Gauss’ figures that the morphine-scopolamine treatment, as practised under skilled direction at Freiburg, does not very greatly endanger the life of a child.  The partially asphyxiated condition in which some of the children are born is one from which they recover under the skilled and vigorous treatment given them.

But, on the other hand, it must appear that a drug which produces such effects, even when given in just the right quantity, might readily produce effects not so remediable if given in slightly larger quantity.  So the necessity for exceedingly careful dosage is emphasized, and the possible dangers of the morphin-scopolamine treatment in careless or unskilful hands are very apparent.

WHY THE METHOD HAS NOT BEEN WIDELY ADOPTED

            Even the most partisan advocates of the treatment admit that it cannot be applied successfully in large hospitals.  At the Freiburg clinic only about three patients are confined daily, on the average, and yet it has been necessary entirely to remodel the Obstetrical Department.  Just why this is necessary, and why the method cannot be applied in large hospitals, is well stated by Dr. Krönig himself:

“The proper carrying out of the method,” he says, “demands concentrated attention on the part of the obstetric staff, for the purposes of perfecting our method and for giving it the widest possible application to all classes of the population.  We were able, thanks to the Grand Duke of Baden, to triple the obstetric staff in the delivery room.  I mention this intentionally, because I am of the opinion that, especially in hospitals with a very large number of cases, our procedure can be employed with any prospect of success only when a complete administrative reorganization has been affected in the assignment of duty in the delivery ward.  If, as is the case in large hospitals, the medical man on observation duty is relieved every twelve hours, the colleague who comes on duty will not be sufficiently well-informed as to the condition of the various patients in labor.  In such a case failure is certain beforehand.

“I consequently do not consider it the result of chance that it is precisely in hospitals with a smaller number of cases that our method has been adopted.  In large hospitals, with many thousands of births a year, as in the cases of the large hospitals of Berlin and Dresden, our procedure has proved a total failure.

“This is easier to understand when we remember that the surroundings of the patient have an importance which we should not underestimate for the success of the method.  Sense impressions, loud noises, bright light, etc., considerably disturb the half-consciousness.  When six or seven parturient patients lie side by side in one ward, it is obviously impossible to obtain an even fairly effective semi-consciousness.  This makes itself felt even with the small number of patients that we have (a yearly average of three births a day).

“The number of cases in which we obtain loss of memory or amnesia is in Freiburg far smaller in those deliveries which occur in the general ward than in the case of patients treated in our private wards, where they lie in a separate room protected as far as possible from all impressions of sight or hearing.”

IS THERE AN ELEMENT OF MENTAL SUGGESTION?

            It may be added, as further illustrating the difficulties of the method, that a patient in a private room, where the best results are attained, as we have seen, is kept in semi-darkness until just the moment of delivery, when the electric lights are suddenly turned on with a dazzling glare; which seems strongly to argue that there is a pronounced element of suggestion or hypnosis in the Freiburg method.

I do not wish to imply that the drugs employed do not have a large share in producing the observed results; nor would I imply that the use of suggestion is in any sense illegitimate.  But the analysis serves to emphasize the rather large share of the personal element in the success of Dr. Krönig’s method.

All in all, then, it appears on critical analysis that the Freiburg method, whatever its merits, cannot be pronounced ideal.  Nevertheless, it has profound interest, because this method, whatever its limitations, has been so energetically and systematically carried out through a term of years as to command the attention of obstetricians all over the world; because it calls persistent attention to the idea of making childbirth painless; and because finally, it seems more than probable that there is a measure of permanent value in the morphine-scopolamin treatment.  It is hard to question this in the face of the testimony of thousands of women who have shared its benefactions.

And even if the Freiburg method now lacks something of perfection, it may very well serve as a forerunner of methods that will accomplish what it fails to accomplish.

It is at least possible that the morphine-scopolamine treatment may be used advantageously in connection with ether or chloroform, and that the combination may produce a really ideal result.

And even if the morphine-scopolamine treatment itself should ultimately be altogether abandoned for some better method, it still will have served a useful purpose in calling attention to a great need, and in stimulating experiment through which that need will ultimately be met.

THE METHOD TO BE TESTED AT JOHNS HOPKINS

            As to the latter point, there can perhaps be no better evidence than the fact that the Freiburg method is to be put to a careful test in the near future at the Johns Hopkins Hospital in Baltimore, under the skilled direction of the Dean of the Medical Faculty of the Johns Hopkins University, who is also the Professor of Obstetrics and the Obstetrician-in-Chief to the Johns Hopkins Hospital, Dr. J. Whitredge Williams.

I talked with Dr. Williams about the matter not long ago.  He told me that he had made tentative tests of the morphine-scopolamine method at the Johns Hopkins Hospital in the past, and had not been favorably impressed with it.

Moreover, he personally visited the Freiburg Frauenklinik two years ago and there witnessed the delivery of two women under the conditions of the Twilight Sleep.  The fact that the women appeared to suffer and were even more vigorous in their outcries than women usually are who receive no medication, made an unfavorable impression on his mind, despite the fact that the women may afterward have had no recollection of what had occurred.

“In Johns Hopkins Hospital,” said Dr. Williams, “no patient is conscious when she is delivered of a child.  She is oblivious, under the influence of chloroform or ether.  I could not see wherein the patients at Freiburg have a great advantage over those under chloroform narcosis; I certainly think the condition of the latter is a more pleasant one for the attendants and surrounding patients.  But the obstetricians of Europe do not use chloroform and ether to assuage the pains of labor habitually as we do here in America, and this perhaps accounts in part for the interest that has been shown in the morphine-scopolamine method.”

Dr. Williams further stated that, to his mind, there seemed a strong probability that there is an element of suggestion associated with the Freiburg method, accounting in part for its success, quite aside from the direct influence of the drugs employed.

Nevertheless this leader among American obstetricians went on to say that his preconceptions would not be allowed in any way to influence his final judgment on the Freiburg method, which as yet he held in abeyance.

“A physician who has spent an entire year in the Frauenklinik at Freiburg studying the method at first hand is coming to Johns Hopkins as an assistant next fall,” he said, “and he will be given every opportunity here to apply the method and test it fully.  When these facts have been carried out for a sufficient period, we shall be in a better position than we are at present to pronounce judgment on the morphine-scopolamin method.”

Such, then, is the attitude of mind of one of the foremost obstetricians and teachers of obstetrics in America.

It is perhaps not too much to say that every prospective mother in the land should feel a vital and personal interest in the outcome of the unprejudiced and scientific investigation of the Twilight Sleep that is thus about to be carried out at the Johns Hopkins Hospital.

Continue: Chapter 6