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Twilight Sleep

labor, method, patient, women, morphine, effect, operation and scopolamine

TWILIGHT SLEEP. This term is used as the equivalent of the German term Dimmer schlaf, a fanciful term applied by Kronig and Gauss for the method used by them in the de livery of parturient women at their private hospital for women in Freiburg, Germany. It was claimed by them in 1914 that they had been using it for 15 years with great success and they certainly have been fortunate in spreading abroad the knowledge of it and draw ing patrons from many parts of the world. It consists in the hypodermatic use of a combina tion of scopolamine and morphine in solution from the beginning of labor pains and con tinued at sufficient intervals to keep the patient semi-narcotized and in a state of amnesia so that she is oblivious of the fact that she is in labor or that she has labor pains, or even that she has a baby when it is born. The dosage is graded according to the tolerance of the patient and repeated as often as she appears to be com ing out from its influence. Kronig and Gauss assert that it is uniformly or nearly uniformly satisfactory in depriving labor of its suffering, that it has few fatalities, that occasionally, rarely, an infant is apparently narcotized, but that suitable effort will always, or nearly al ways, relieve this. They insist that it is a great boon for women to proceed to labor with the assurance that the much dreaded pain of that ordeal will be eliminated, that the mental effect will prove very stimulating and offer to the woman a much more desirable prognosis than she could have by other methods of treatment at present in vogue.

An account of the method of treatment at the Freiburg institution was published by two laymen (women), who had been there and familiarized themselves with the method, in McClure's Magazine for June 1914. The treat ment requires the constant attendance and watchful care of the physician from the mo ment the first hypodermic of the mixture is given. It is quite possible that it may result in morphine poisoning if given unadvisedly and there is a very real danger that the infant may be still-born. It seems a little strange if the method has all the merits which are claimed for it that it should have been used so long in Germany and not have found favor at the great maternities at Berlin, Munich, Vienna, Prague and elsewhere, but none of these great institu tions seems to have been sufficiently impressed with its importance to take it up and use it as a matter of routine in its obstetric service.

After the appearance of the article above mentioned the method was tried in several hos pitals in New York and Brooklyn and under skilful obstetric management. In the two years which have passed since then it has been used in some hundreds of cases with very good suc cess, as reported in various contributions by those who have tried it and advocate it. But it has failed to meet general approval with obstet ricians just as it seems to have failed to excite enthusiasm in Europe.

The combination of these drugs has been used in this country a number of years as a preliminary to general anaesthesia before the performance of a major surgical operation. Its effect in the experience of the writer in such use has been good; it calms the patient's fear, slows the pulse and keeps it slow during the operation, and relieves the patient of the post operating tendency to vomiting. Also the patient may sleep uninterruptedly for many hours after the operation, which frequently is a great advantage.

It is not receiving the attention or discussion which it had a year ago, and it seems likely that the slight wave of popularity with which it was ushered in has passed along, like anaesthesia by injection of certain fluids into the spinal canal which a few years ago was used by numerous obstetricians but now has been practically aban doned because of its danger. For many years • _ obstetricians have made use of ether and chlo roform during labor and it would be hard to imagine anything more effective than one or the other of these in relieving the severe pain of parturition when it is properly given. Its effect passes off more quickly than the scopolamine morphine combination and when chloroform is used it is rarely followed by vomiting or other unpleasantness. There is a mortality to ether and chloroform, and also a certain morbidity, but the percentage is so small it would be unwise to discard such beneficent helps. If it were possible for the use of scopolamine and mor phine to be applied to 100,000 unselected cases and compared with an equal number of cases in which chloroform was used it is probable there would not be a very great difference in the mor tality and morbidity of the two methods. It is quite improbable that there will be any revolu tion in obstetrics from the twilight sleep in fluence and from present appearances it will very soon be one of the curiosities in obstetric practice.