European "twilight sleep" or American, which?
O. C. BAIRD, M.D., CHANUTE, KANSAS.
"Twilight sleep," painless childbirth, scopolamine-narcophine amnesia, or the "I'd rather have a baby than a bad cold" method of childbirth, has been looked upon by we Americans with a large degree of awkwardness, to say the least. Any method or measure foisted upon, or introduced to the medical profession by the laity, and the Ladies' Home Journal, we are very loath to favor, much less to adopt. Conditions in the twenty-five years last past, as well as the demands and customs, have made great strides. Conventionalism in times past held men to the fast conventional dress for occasions, while now comfort first is the demand. Tight shoes with extreme heels, a tight corset with no limit, has been replaced by the "comfort first" slogan. Dentistry has caught it. If you ever sat, in your boyhood days, on the floor, with your head between the knees of that august personage, the family physician, posing as dentist for the purpose of the painful extraction of one or all of your dental excrescences, as I have, you will appreciate the "comfort first" method which dentistry has adopted in this age.
This slogan, of comfort first, and painless childbirth has grasped the women of the gestating group with a strong hand, and what are you going to do about it? It has come to stay. After a careful study it will be perfected in the hands of careful American investigators, until I doubt not, it will be universally adopted. If there is any class of physicians or obstetricians that is capable of handling such methods, it is surely the Eclectic physician and obstetrician, who has a thorough individual, as well as synthetic knowledge of drugs.
It is a foregone conclusion that we have always used some form of analgesia or partial anesthesia in parturition. Chloroform, ether, morphine or H. M. C. (Hyoscine, Morphine and Cactin Compound, an analgesic-anesthetic made by the Abbott Alkaloid Co., widely used by Eclectic physicians and some "regulars".) You have taken great satisfaction in the fact that, while the whole duty of our physician fathers was to sit, on such occasions, demurely in the parlor, nursing the wet end of a cigar, while he let the woman do the work. You have gone them one better by giving, in a special case, a sixth of a grain of morphine, resulting in restfulness, less consciousness to pain, a greater ability to work, a sweeter disposition. As the pains grew stronger, and the effect of the pains became more manifest upon her nervous system, the chloroform or ether you gradually increased, as the case demanded, until with the index finger upon the now tense perineum for the purpose of dilation and support, but primarily to note the degree of advancement of the fetal head, in the process of engagement, then gradually pushing your anesthetic to unconsciousness in the last half dozen pains, when the most vital period in motherhood is consummated. The mother arouses in thirty or forty-five minutes to say, "Is that my baby crying?" or "Is it all over?" and "Doctor, I did not know when it all happened." But, behold! take notice! There comes a report from Germany that they have been doing the same thing; only that and nothing more? Well, yes; I may say a little more, but they are doing it in the best, but not always safest German way.
Steinbuchel, in 1902, began the use of scopolamine and morphine for analgesia in labor, then reported a series of cases. Gauss, at Freiburg, conceived the idea of strengthening the dose to the stage of amnesia, or loss of memory, and, in company with his associate, Kronig, of the University of Freiburg, evolved the so-called "Twilight Sleep." This method has been more or less studied by the American physicians, with a diversity of opinion as to its rationality, safety and practicability to the American physicians.
Freiburg medical authorities in 1909, at a meeting of the American Association of Obstetricians and Gynecologists, in Washington, D. C., read a report of three thousand cases, with the special technique evolved by them. Many who heard it were impressed—going home to try the new method, of which a report was given at the next annual meeting. This report was in the main favorable. Yet the undisputable fact remained, whoever else could not do it, Gauss and Kronig were delivering women painlessly and with no damage to the mother or child, they shortening the lying-in period, reducing morbidity and appealing to that weakness, of not only women, but men, the desire to evade pain.
In reading these reports one can only arrive at this conclusion: First, that those who had tried it out thoroughly were favorable, and those who had not done so were opposed to it; second, the reports showed that the technique was not carefully observed in the trying out process. It was this human weakness, a desire to evade pain, that caused one woman, after trying out the method, to tell the other, and another, imparting the information finally to American motherhood, until it came out in the lay press commanding the attention of the profession. To-day, a majority of the obstetric institutions in this country are using it in an investigative spirit. Some of these, as the Lying-in-hospital of New York, undertook to show that it was not good. So far after two years, in a hundred cases, the evidence certainly does not make a case against it. Recently, the New York Public Health Department desired an expression of opinion from good authority on this matter.
Harrar and McPherson, of the Lying-in, and Druskin from the Sloane Maternity, reported 60 to 90 per cent. amnesia, 10 per cent. analgesia, and, in some, no effect. It was the experience of all that in proportion as skill and experience in the use of the method increased, it was more satisfactory. In a report of a hundred cases there were two stillbirths, both due to obstetric conditions, which would have more than likely have happened without scopolamine. Dr. Wakefield, of San Francisco, in the March American Journal of Obstetrics, reports its use in forty cases in this spirit, that he would as soon try to operate without anesthesia as to deliver obstetric cases without scopolamine. This drug is obtained from the Scopola plant, while it is similar to hyoscine, it is not the same; in its effect, it is very different.
As to my personal observation at the Freiburg clinic, I will say it consisted of only four cases, one which had been progressing for two hours, another for four hours before our arrival, and our entire observation being between 6 P.M. and 6 A.M., our conclusion can not be trustworthy. In these cases the technique by the assistant was adhered to very rigidly. Preparing the patient in the ordinary way, bath, enema, vaginal irrigation, etc. Then pains being five minutes apart, lasting one-half minute, a one-hundred-and-fiftieth grain of scopolamine, and a one-sixth of a grain of morphine was administered. In one hour, if much memory remained, a two-hundredth of a grain of scopolamine was given. In one hour, if loss of memory was not complete, a two-hundredth of a grain of scopolamine was repeated. When the case advanced, head bearing low down, engaging, a very small quantity of chloroform was administered. In one of the four cases forceps was used. The case being one with short pelvic diameters. One baby of the four (and that one was the forceps delivery) needed some resuscitation efforts, which is very often necessary in instrumental delivery, as you know. These cases were conducted in small individual, well ventilated, darkened, quiet rooms. The condition of the patient about as follows: The faces of all were flushed, quickened pulse. Two did considerable incoherent talking during pains. Three strained with the pains very perceptibly, and two had about five minutes' chloroform inhalation at the least. Except the one, the babies cried, at least, in a minute after birth. Mothers sleeping from one to three hours after delivery. The most profoundly amnesic were longest sleeping. All through the process co-ordination was tested occasionally, and the memory was tested every thirty to sixty minutes. It is true that a close watch of the patient is necessary, as you can not always judge of the degree of advancement from appearance or symptoms of pains, except with the index finger, and the child may be born before you expect.
It is not desired that every symptom of pain should disappear. The patient is awake during pains. Gauss laid much stress upon the fact that if all evidence of pain is banished, it would mean that the patient was being overdosed. If there was any noise, the ears were muffled. If light, artificial or natural, the eyes were muffled. In the after treatment—Gauss allowed passive motion on the first day after labor, and the patient gets up on the second day, he told us. Involution surely progresses more rapidly, and the patients are in a much better condition to sit up early than with the usual method.
In the last year I have used the above on six women, four primipara. No stillbirths. Two of the six having a slight recollection of the occurrence. Kept all in bed eight or nine days. All did well and seemed to recover from the shock quickly, it being too slight to be so termed. In this one phase it is much preferable to the old method. As to asphyxiation of the infant, I believe there is a limit and a danger line in the administration of all drugs in these cases. What is there about this that you and I can not do? Nothing. What is there in "twilight sleep" that can not be done in a well regulated home? Nothing. If you have nothing better, try it. As you can not get the Hoffman form of scopolamine, use P. D., made from Merks' preparation, and you will find it reliable. If you are timid use less dose of scopolamine, or farther apart. The one-sixth grain of morphine will be a benefit to most any case you could mention when pains are strong and five minutes apart.
The success of the method in your hands or mine, depends on your close adherence to the technique, which is about as follows: When pains are five minutes apart, lasting one-half minute, give one one-hundred-and-fiftieth grain scopolamine, one-sixth grain of morphine, or one-half grain of narcophine hypodermically, in hip or buttocks, using separate syringes for the two solutions, or cleanse thoroughly with hot water after using each. After one hour, repeat scopolamine, 1/200 grain. Never repeat the morphine unless there is extreme restlessness. Test the memory and co-ordination every forty minutes or hour to see if the patient remembers some object which has been shown her before the first injection. If memory is good in one hour after second injection, give scopolamine 1/200 grain. Test memory frequently and give just sufficient scopolamine to keep patient under its influence. Pulse should be registered every two hours, and fetal heart occasionally.
Evidence of pain should always be manifest during pain, by the ordinary expression of pain. Room quiet absolutely, fairly dark. In final pains small quantities of chloroform inhalation can be used to good advantage. Amount of medicine necessary in ordinary primipara, ⅙ grain morphine. Three injections of scopolamine one 1/150, two 1/200 grain. Give slight amount of chloroform if needed. The great argument against this method is that it prolongs labor, but, on observing one hundred cases where scopolamine was used, the average duration of labor was two hours shorter than that in one hundred cases of the same type without scopolamine. After waking, if amnesia has been satisfactory, she will have no recollection whatever of what has happened after the second injection, and thinks her pains stopped. Only her change of shape, and your explanation can convince her.
Finally, my brethren, let us consider if this method be worth while. Safety of mother being first; second, the life and welfare of the child; third, the last, but not least, your satisfaction in knowing and doing the best that any man in any country can for his client, and the ever-present tendency for you, the medical leader in your vicinity, to supply the demand of the people, which has been proven to be the greatest key to success in any line. First, in this final summary, we will have this understanding that until we have thoroughly tried out a thing, we have absolutely no right to condemn it. This method is not dependent alone upon German authority, but better in thousands of cases in the hands of Americans in this country. We first conclude that there was less than 2 per cent. mortality in mothers one hundred years ago. From natural causes and other causes, a total of ½ of 1 per cent. less in recent time, does not look bad for modern methods. Try it by first asking the mother if you may use "twilight sleep" methods, and explain it to her. She will consent. She will be pleased and tell it.
In considering the second proposition the gap is too broad, for I believe the day is here, when any physician who condemns these measures, one and all, which are for the relief of suffering parturient women, when not contraindicated (which is only one in a thousand), should be barred from practice. Anyone with a heart must know how a mother suffers, too much at the very best, and shrinking from the same has played no small part in reducing our birth rate. Vitality and force in the woman becomes exhausted in prolonged labor. The mechanism of labor is disturbed by pain, and pain produces shock.
As to the third proposition—child life and welfare—two blue babies in a hundred cases. Is this not a little less than the ordinary? Have you not had some very unpleasant experiences when the ordinary methods were employed?
Fourth: May it be said of the Eclectic physician, whose pride is in his knowledge of drugs and in his rational methods, that he is in the forefront of advancement on any line that will reduce pain, reduce mortality, reduce the pain of motherhood to a dream, and supply the demands of the age. But first let us prove all things, choosing that which is good, and come back here in one year with some reports on the above method.
DR. A. J. ATKINS: In this connection, there is a question that ought to come before not only this convention, but before every doctor in the United States, and we would like to have it threshed out here in this convention and get your opinion. We want you to state absolutely what your experience has been with European Twilight Sleep. Is it European or American? It was introduced in Freiburg, Germany, by Kronig and Gauss. McClure's Magazine had quite an extensive article about it recently, calling attention to this wonderful German discovery. Dr. Wheeler, down at Healdsburg, just a plain Eclectic practitioner, was giving H. M. C. years ago, a very similar formula. Abbott's man happened to visit Dr. Wheeler, but he said it would kill any man who tried to introduce it. Dr. Wheeler is a graduate of the California Eclectic Medical College, and, as I knew him, I became interested and used H. M. C. in my practice. The product was prepared by the Alkaloidal Company, of Chicago. Dr. Wheeler wanted the Abbott people to make it, but they refused; he insisted and they did make a few tablets. One of Abbott's men tried it, and now they claim H. M. C. as an absolutely original discovery. Now hyoscin and scopolamine are near neighbors, and now we have this wonderful discovery from Germany. Whenever a magazine like McClure's gets hold of a thing of this kind and exploits it, the public wakes up and takes notice. What we want to know is what is your attitude towards twilight sleep; we want to know your experience with hyoscin, morphine and cactin.
DR. T. L. SHARPE: I thought 80 per cent. of the Eclectic physicians had been using H. M. C. I have been using it for ten years and I think it is great; hardly ever a case but what I use some of it. I think it is due a woman to relieve her suffering all we can, and if any of our Eclectic physicians are not using it they ought to commence to use it. I suppose it can do harm, but I have used it for ten years without any harm.
DR. COATES: The feature of this subject that we want brought out is the technique of using it. I have used it a few times and I did not use it at the beginning of labor. I understand this "Twilight Sleep" treatment is at the beginning of labor. We want the technique. Can we use it at the beginning of labor and relieve the pain all the way through labor? We hear a great deal about "blue" babies in the use of this treatment. What is your experience in that respect? In my experience, when I use it late in labor, the babies are blue.
DR. W. N MUNDY: Three minutes is too short a time to discuss the subject of twilight sleep. It is used in the early stages of labor. Blue babies are caused by the use of too much morphine. In the Freiburg method they use narcophene in addition to scopolamine, and after that the morphine is dropped and scopolamine is used, according to the patient's mental condition. Remember, the twilight sleep does not produce a painless birth. It is not analgesic, it is amnesic, and the repetition is guided by the patient's mental condition and not her insensibility to pain. Formerly, we used twilight sleep in the last stages and accomplished it with chloroform. Twilight sleep is not very practical in general practice. You need a hospital, you need trained assistants, for, in the use of twilight sleep the fetal heart sounds must be constantly listened to. It needs the constant attention of the physician, and you will find with twilight sleep the length of labor is from eighteen to twenty hours. In my practice my labors only very rarely run to eighteen or twenty hours. I am a firm believer in painless childbirth, but not with twilight sleep. Every patient does not bear scopolamine well, and even those who advocate it say that it produces a condition of irritation in the patient so that at times it is necessary to have two or three attendants to hold the patient in bed.
DR. F. M. ANDRUS: As I understand it, it is the narcophene which puts the patient into the condition of irritability. I am afraid, with some of your Jewish patients, it would take more than two attendants to take care of them. It looks to me like the rich man's way of getting through. I do not believe I have very many people who could afford to pay me to stay, even if I knew how to use it.
DR. A. S. TUCHLER: The great trouble is that this combination of drugs which produces a somnolent effect upon the patient has really been found by an Eclectic practitioner, Dr. Wheeler, but we are too prone to be backward; we do not make our findings public. It is the other people who get the publicity in the lay press and they get the cream. We ought to be more pugnacious, and, if we have a good thing, bring it to the public notice. It is not too late yet to bring that matter before the public as it should be, because this is a very important discovery. But this twilight sleep proposition must be very carefully handled. In my experience, I find that blondes can stand very little scopolamine. My habit is to use half strength at the beginning of labor, but you can not use it in every case. You had better fight shy of blondes and those who use liquors of any kind, or you will have to have two or three attendants to hold them down. Temperament must be taken into account. I find those of bilious temperament take it better than those of a nervous temperament.
DR. W. E. DANIELS: There seems to be confusion between twilight sleep and H. M. C. As I understand it, they are different. I do not believe it is safe to use these in a country practice unless you have a trained nurse. I care not what drug it is, anything that will reduce your circula-from 65 to 40, and your respiration from 20 to 12, is not a very safe remedy to use, and I do not believe that in ordinary practice it can be used with safety.
DR. C. M. CHANDLER: I have had some experience with H. M. C. tablets, and I have three indications for it. In the first place, strong pains, then rigidity and nervousness, and in almost all these cases a No. 2 tablet will relax the nervousness and take the edge off the pain so they can bear it. Seldom do I have to repeat it. I agree that it should be used early. The only time I ever saw any effect on the child was when it was used late.
DR. H. C. SMITH: The influence of twilight sleep, H. M. C., narcophene, or any of these things is depressing. Hyoscin and scopolamine are the same, only hyoscin is obtained from hyoscyamus, and scopolamine from scopola, so the effects are identical, whether you use it as morphine or narcophene or hyoscin or scopolamine. Scopolamine and hyoscin have another effect on the respiratory centers, and as soon as it gets into the blood stream it affects the respiration of the child as well as the mother. If there is anything about this but a dangerous experiment, I can not see it. I used it about eight years ago first, and I had the same experience in both cases.
DR. JOHNSON (Nebraska): I have used H. M. C. for eight or ten years. I believe that the twilight sleep may be produced from H. M. C., and while I believe scopolamine is dangerous and should be used only in hospital practice, I believe H. M. C. may be used in the country to great advantage. In my practice I have never experienced any trouble. However, I select my cases; I give it only to the nervous, fretful women who are inclined to shrink from the pains.
DR. LEE STROUSE: Just before leaving home I saw a piece in the paper, a report from the Cook County Hospital on twilight sleep, where they had lost nine cases. I do not know whether this was the babies or mothers or both, but it seems to me it would be entirely unsafe to use such a remedy.
DR. WM. P. BEST: I do not know just what has been said relative to the use of these drugs. I have had considerable experience with them, but there is one thing we should not lose sight of, and that is if you allow your patient to be annoyed, either by noise or light, you will have the condition of extreme nervousness mentioned. These drugs produce a hyper-esthetic condition of the nerves of hearing, and every sound is exaggerated, which makes the patient nervous. Our method is to stuff their ears with cotton, darken the room, keep people away so they can be quiet. In the administration of this remedy I have witnessed two cases in which the child was born in a condition where he thought death would follow. In cases of confinement it requires great discrimination and you must watch your patient. I do not believe it is safe to give a woman a large dose and go away and leave her unless you have someone who understands the remedy to leave in your place.
DR. E. H. STEVENSON: In this treatment, it is like everything else, it is used empirically and we get bad results. As Dr. Best has just said, it is a good remedy if used properly, but it must be used carefully. I have been using it ever since it was called to the attention of the profession by the Abbotts, and I have had good results. But I have made no attempt at complete anesthesia, and there is where you should put down a pin. With a nervous, irritable woman with a rigid os, no dilatation, where she is trying to bear down and there is no living in the room with her, a small dose will be helpful, and then later, you can give another small dose if necessary, and otherwise terminate your labor under the use of our long-tried remedy—chloroform—and you will get your patient through in very good shape.
DR. T. D. ADLERMAN: In the New York hospitals, in Bellevue and some others, they have proven that some cases have been followed by insanity when the Freiburg system is used. There were four cases that I knew of, consequently, those who are using this particular remedy would better look out a little and go slow. I also know of a few cases where the children were rather backward in mentality.