9. That the prospects of pa.s.sing through labor which may be rendered painless by artificial methods, tends to produce an att.i.tude 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 a.s.sistance 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 att.i.tude 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 pract.i.tioners, 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.

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 inst.i.tuted 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 inst.i.tute 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 r.e.t.a.r.d 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 repet.i.tion 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 pa.s.ses 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.

This chapter has been devoted to "twilight sleep;" the following chapter will consider "nitrous oxid" and other methods of anesthesia in connection with labor, and should be read along with the foregoing discussion in order to obtain an intelligent view of the whole subject of "painless labor."

CHAPTER X

SUNRISE SLUMBER AND NITROUS OXID

Since the public has already been told so much about obstetric anesthesia, we deem it best to go into the whole subject thoroughly, so that the expectant mothers who read this book will be able to form an intelligent opinion regarding the question, and thus be in a position to give hearty cooperation to the decision of their physician to employ, or not to employ, any special form of anesthesia or a.n.a.lgesia in their particular case. In order to give the reader a complete understanding of "painless labor," it will be necessary to give attention to that newer and more safe method of obstetric anesthesia called "sunrise slumber." This method of anesthesia consists in the employment of nitrous oxid or "laughing gas," and will be fully considered in this chapter.

OBSTETRIC FEAR

In this connection we desire to reiterate and further emphasize some statements made in the preceding chapter concerning the unnatural fear and abnormal dread of childbirth.

We feel that it is very important in connection with this new movement in obstetrics to reduce the woman's pain and suffering to the lowest possible minimum, that the trials of labor should not be overdrawn and the pangs of confinement overestimated. We must not educate the normal woman to look upon labor as a terrible ordeal--something like a major surgical operation--which, since it cannot be escaped, must be endured with the aid of a deep anesthesia.

The facts are that a very small per cent of healthy women suffer any considerable degree of severe pain--at least not after the first child. We often observe that judicious mental suggestion on the part of the physician or nurse in the form of encouraging words and supporting a.s.surances tends to exert a marked influence in controlling nervousness and subduing the sufferings of the earlier labor pains.

We must not allow the efforts of medical science to lessen the sufferings of child-bearing, to rob womankind of their natural and commendable courage, endurance, and self-reliance.

We do not mean to perpetuate the old superst.i.tion that pain and suffering are the necessary and inevitable accompaniments of child-bearing--that the pangs of labor are a divine sentence p.r.o.nounced upon womankind--and that, therefore, nothing should be done to lessen the sufferings of confinement. Severe and unnatural pain is not at all necessary to childbirth, and there exists no reason under the sun why women should suffer and endure it, any more than they should suffer the horrors of a very painful surgical operation without an anesthetic. In this connection, it should be recalled that a.n.a.lgesic drugs have been introduced into obstetric practice only during the last fifty years, while such methods of relieving pain have been used in general surgery for a much longer period. It is now only sixty-nine years since Simpson first employed anesthetic in obstetrics, while six years afterwards Queen Victoria gave her seal of approval to the use of chloroform in labor cases.

Thirty years ago, in speaking of the expectant mothers, Lusk warned us:

As the nervous organization loses in the power of resistance as the result of higher civilization and of artificial refinement, it becomes imperatively necessary for the physician to guard her from the dangers of excessive and too prolonged suffering.

NITROUS OXID--"LAUGHING GAS"

Nitrous oxid, or "laughing gas," was first used in labor cases in 1880 by a Russian physician. During the last twenty-five years it has been used off and on by numerous pract.i.tioners in connection with confinement, but not until the last few years has this method of relieving labor pain come into prominent notice.

While the "laughing gas" method of obstetric anesthesia did not gain notoriety and publicity from being exploited in magazines and other lay publications, it did get its initial boost in a very unique and unusual manner. A gentleman who manufactured and sold a "laughing gas"

and oxygen mixing machine for the use of dentists, insisted that this method of anesthesia should be used in the case of his daughter, who was about to be confined. This patient was kept under this nitrous oxid anesthetic for six hours--came out fine--no accidents or other undesirable complications affecting either mother or child, and thus another and safe method of reducing the sufferings of childbirth has been fully demonstrated and confirmed, although it had previously been known and used in labor cases to some extent.

Starting from this particular case in 1913, many obstetricians began experimental work with "gas" in labor cases; and, at the time of this writing, it has come to occupy a permanent place in the management of labor, alongside of chloroform, ether, and "twilight sleep."

a.n.a.lGESIA VS. ANESTHESIA