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.
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 (C17H21NO4), 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.
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.
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.
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."
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.
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.'"
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.
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.
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.
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."
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.