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 "s.p.u.n.k right up" and face the ordeal of labor with natural courage and normal fort.i.tude. 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 a.s.sist 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 a.s.sociated 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 cla.s.ses 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 cla.s.ses," 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 att.i.tude; 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 pract.i.tioners 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 fort.i.tude 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 cla.s.ses 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 pract.i.tioner 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.