The Real Story of Twilight Sleep and How it Shaped Obstetrics and Hospital Birth
What a Blessing She Had Chloroform: The Medical and Social Response to the Pain of Childbirth from 1800 to the Present - Donald Caton, M.D.
Birth Day: A Pediatrician Explores the Science, the History, and the Wonder of Childbirth - Mark Sloan, M.D.
Deliver Me From Pain: Anesthesia & Birth in America - Jacqueline Wolf
How It Began
In 1913 two female reporters from McClures Magazine in New York, Marguerite Tracy & Constance Leupp, went to the Frauenklink in Freiburg Germany to witness and write about “Dammerschlaf,” the apparent miracle of Painless Childbirth. The Frauenklink was the Women’s Clinic of the State University of Baden, directed by Dr. Bernhardt Kronig and Dr. Karl Gauss.
Dr. Kronig had both a scientific and humanitarian interest in the pain of childbirth and had been obsessed for a decade with the development of Twilight Sleep. He believed labor pain was destructive - causing uterine complications, postpartum trauma and terror of future births. He especially deemed this true for “modern” (weak, vulnerable) vs. “peasant” women (strong-willed, hardened).
Twilight Sleep was based on the earlier research of Dr. Richard Steinbuchel. Scopolamine, though derived from a highly toxic plant (henbane), was gaining acceptance in general surgery, but many obstetric experiments with it ended badly or in overdose. Reports, including those by Kronig & Gauss, recorded the desirable sedated state but also the problems and side effects: slowed pulse, decreased respiration, delirium. Experimentation continued, with repeated small injections of varied doses of scopolamine and morphine.
Kronig & Gauss presented a series of papers on Twilight Sleep that included the drug’s ability to erase the memory of the birth at a national obstetrics conference in Berlin in 1906. They were met with indifference, hostility and rejection. City doctors balked at the small town “country” doctors experiments, and cited the dangers of scopolamine.
For the next several years, as Kronig & Gauss kept publishing their successes, wealthy German women started traveling to Freiburg for “painless babies.” Finally a team of city doctors went to investigate [and hopefully bring an end to] the treatment. They did poor research trials, and ultimately concluded in their final reports that Twilight Sleep was “a poison . ..incalculable in its effects.”
Twilight Sleep disappeared as a topic of consideration in the German medical world, but Kronig & Gauss quietly continued their work in Freiburg.
In these first years of experimentation, a few U.S. doctors also went to Freiburg, returning with mixed reactions. Dr. Joseph De Lee, Professor of Obstetrics and Founder of the Chicago Lying-In Hospital, was unimpressed, citing long labors, hemorrhage, delirium, and fetal death. Another Chicago doctor warned that Twilight Sleep in the hands of untrained doctors could be dangerous.
Kronig and Gauss eventually found that given carefully with a single small dose of morphine, scopolamine produced a “clouded consciousness with complete forgetfulness.” Women woke up with no memory of the birth. The doctors attributed their improved outcomes (fewer complications, quicker recovery) to the eradication of pain and fear. Soon the clinic had the lowest maternal and neonatal deaths in the state of Baden.
American Women Revolt
In 1912 an American woman named Mrs. Stewart gave birth to her second child in Freiburg and described her experience as “a fairy tale:” luxury room, compassionate doctor, sleeping through the birth, wonderful food, mountain view, “like a beautiful hotel.” She stayed for a month.
When journalists Marguerite Tracy & Constance Leupp arrived at the Frauenklink in 1913, they were turned away. Neither doctors nor staff were interested in or willing to speak to them. Not to be thwarted, they talked to local women, who spoke glowingly of their birth experiences at the clinic: comfortable suites, wonderful staff, and awakening from labor to find their babies born.
In order to gain access, the two reporters sent a pregnant Mary Sumner Boyd to give birth at the clinic in the summer of 1913. She was attended by Dr. Gauss, who was unaware of the undercover ploy that would soon thrust Kronig and himself into the international limelight. Sumner Boyd received the state-of-the-art care bestowed on the wealthiest, most privileged women of Germany.
The McClures article, published in May/June 1914, ignited an already volatile Feminist Movement in the U.S. Describing the 1912 birth of Mrs. Stewart, along with Mary Sumner Boyd’s experience, the article presented Twilight Sleep as a new miracle discovery, rather than the return of a 12 year old medical controversy rejected by most American doctors and hospitals. The article criticized the medical world for withholding the miracle and urged women to rise up and fight against the oppression of medical men.
The Feminist Backstory
The 1914 article was received as a call to action. All hell broke loose. Wealthy women went to Freiberg and returned with glowing reports. American media and women’s magazines demanded that obstetricians follow their enlightened German colleagues and adopt Twilight Sleep. The battle for Twilight Sleep symbolized the battle for Women’s Rights.
This was the period when the early Feminists were demanding the right to vote, serve in the army, receive equal pay for equal work, use birth control, form women’s colleges, and end male domination.
At the same time, the Anti-Feminists were the wealthy, well-connected women, who called Feminist demands such as equal pay, voting, and especially birth control “unnatural.” They were likely afraid of their privileged lives being derailed; they also held an upper class racism that sought to out-reproduce the immigrants and working-class. Removing the “torture” of childbirth meant that upper-class, better educated women would have more babies.
The cause of Twilight Sleep united them both. The prospect of painless childbirth cut across battle lines, uniting feminists and anti-feminists in a shaky coalition.
Feminists saw Twilight Sleep as a liberation from male oppression, while the Anti-Feminists saw it as good for childbearing women - an encouraging step toward fulfilling a woman’s “god-given” duty to reproduce. In 1915, Mary Sumner Boyd (of the wealthy, traditionalist camp) and Marguerite Tracy (single reporter of the feminist camp) wrote a book together, Painless Childbirth. The overwhelming response resulted in the formation of the National Twilight Sleep Association. High-profile women like Madeleine Astor, well-known suffragettes, and a prominent Chicago obstetrician, Dr. Bertha Van Hoosen, took on the crusade.
One of the few American doctors to embrace Twilight Sleep, Van Hoosen became it’s most prominent medical advocate. She espoused that less awareness meant less birth injury - that scopolamine relaxed the uterus, leading to fewer forceps deliveries. Interestingly, Van Hoosen and other painless childbirth advocates incorporated a very anti-sex mentality with their pro-Twilight Sleep beliefs: “Painless childbirth will eradicate prostitution, abortion, divorce, childlessness, venereal disease, sexual excess in marriage.” Van Hoosen was a firm advocate of using anesthesia to break the link between the brain and the sexual organs. She began used it in her practice. Some women slept through labor; others became hysterical. Van Hoosen developed a canvas crib-like bed, to cage them in.
Ladies World, Readers Digest, Ladies Home Journal and other such magazines presented only the blissful outcomes; movies such as “Science’ Greatest Triumph” were shown throughout the U.S.. Twilight Sleep was the biggest topic in the nation alongside World War I. Kronig and Gauss were dismayed by the publicity.
While the 1914 lay press raved about Twilight Sleep, the medical literature continued to report the problems - asphyxia, agitation, inhuman suffering of women, morphine-slowed contractions, headaches, thirst, uncontrollable delirium requiring restraints or straitjackets. Some hospitals tried it after its introduction and abandoned it within months. Women kept insisting on it. Champions of Twilight Sleep insisted that the side effects stemmed from incompetence. The popular press excluded details of violent kicking, thrashing, screaming, restraints, caged animal behavior, depressed newborns. Their information came from the accounts of patients like Mary Boyd, who had no memory of the birth, thanks to the highly skilled, one-on-one care of the Freiburg doctors. Articles implied that women drifted to sleep after one shot, and awakened refreshed, 12-24 hours later, with a healthy child. Some disclaimers, such as a long article in the NY Times, sounded notes of caution.
Most U.S. doctors were anti-Twilight Sleep, angry at the avalanche of demand from “ladies’ magazines.” The 1914 New York Medical Journal warned that doctors were being rushed into “indiscriminate administration” of a procedure “tested and found wanting.” But the speed of demand was unstoppable, as the popular media simultaneously presented huge local successes. With enormous public pressure and potential loss of clients who were switching to doctors offering the “Freiburg Miracle,” hospitals from New York to San Francisco began scrambling together Twilight Sleep units.
Francis Carmody was the first American woman after the McClures article to give birth in Freiburg, taking her OB with her. Her first birth experience and lengthy recovery had been traumatic. The delivery in Freiburg of her second child in July 1914 was flawless. Carmody became a tireless advocate of Twilight Sleep, staging huge rallies in stores, squares, churches: “If you women want Twilight Sleep you will have to fight for it, for the mass of doctors are opposed to it.” She and her wealthy attorney husband opened a Twilight Sleep hospital in Brooklyn. Carmody became the face of Twilight Sleep.
1. The successes in Freiburg came from the meticulous procedure refined by Gauss & Kronig. The doctor stayed with the woman from the first dose, even up to 24 hours, doing memory tests every 1/2 hour, increasing or decreasing the amount of scopolamine based on her level of awareness of her surroundings. To shield from overstimulation, women were put in tentlike beds, soothed with dark glasses and ear plugs. Some restraints were used for those who became disoriented. (One in 10 ended with general anesthesia, a fact not recorded by the advocates). Women were required to come to Freiburg a month before their due date so the staff could determine the precise amount of scopolamine that would suit her “individual psychology.”
2. The Freiburg clinic was funded by the State University. Doctors received the same government income, no matter how many babies were delivered. The U.S. doctors were in private practice, with no time to stay with a woman during an entire labor, and with much incentive to increase their patient load. The “real” Twilight Sleep was too time-consuming and impractical.
3. The Freiburg clinic was class-oriented. Wards were divided by “nervous temperament” (upper class) and “women of no great intelligence” (lower class). The wealthy received the lengthy prenatal and postpartum stays, private suites, absolute quiet, constant monitoring, and personalized dosages of medication. Visiting doctors did not always see the “best” but rather the experimental models. What transferred to the U.S. hospitals were the protocols of the “low-class” wards. If doctors did witness the refined treatment, they later adjusted to standardized protocols in order to deal with many more patients.
At the peak of the frenzy, the number of women seeking Twilight Sleep outstripped the number of doctors trained to provide it, and drowned out the medical arguments against it. Gauss had recommended a three-year course of study to master the technique and was appalled by physicians who visited the clinic, observed a few deliveries, and went home declaring themselves Twilight Sleep-trained. American doctors sought shortcuts for busy practices. They gave fixed doses of morphine and scopolamine and turned the labor over to untrained nurses until delivery. Reports from this time period from nurses (and hospital neighbors) documented the "inhuman" use of knee, wrist and elbow shackles to restrain the agitation and terror of screaming, delirious Twilight Sleep women. Some hospitals abandoned the technique despite the demand, citing babies turning blue after birth. A meeting of the Twilight Sleep Association was held in New York in April 1915 to map out a strategy for the continued use of Twilight Sleep, including better training, but still blaming any negative outcomes solely on individual incompetence.
Medicine and Obstetrics
Before the Twilight Sleep phenomenon, Obstetrics received little to no respect as a medical specialty. Birth was considered a normal physiologic process; the belief was that women did not need a doctor with special skills in order to give birth. OBs were laughed at by other doctors for doing “nothing.” Training was minimal, lectures considered “worthless.” Many OBs had seen few births before becoming a “Professor of Obstetrics.” Delivering babies was viewed as the work of ignorant midwives, yet the training for dealing with complications was known to be inadequate. With the advent of Twilight Sleep, obstetrics suddenly became complex.
Despite doctors antipathy toward Twilight Sleep and their outrage at women’s demands, Twilight Sleep was an avenue for attention and respect. Every woman desiring Twilight Sleep had to be hospitalized, enhancing the scientific aura surrounding the obstetrician. In 1915 these doctors finally felt they were receiving the “proper appreciation of scientific obstetrics.” Kronig & Gauss had long touted their technique as one requiring virtuoso talent to master and valuable time to administer.
In August 1915 Francis Carmody died giving birth to her third baby and Twilight Sleep crashed. After 15 months, the demand for the “Freiburg Miracle” virtually disappeared.
The organized crusade for Twilight Sleep was short but the change in obstetric practice was dramatic. It changed how OBs were perceived, how they treated birth, and how American women experienced it. It accelerated the trend to hospital birth, where, with newly elevated status, doctors gained control of the birth room. By the 1920s, fewer and fewer women gave birth at home, attended by friends and family.
The Twilight Sleep movement revealed the power of consumers to shape medical practice. Patient demand outstripped supply. Patient demand forced inadequately trained clinicians to supply inadequately researched procedures. Patient demand forced shortcuts.
The Aftermath and Legacy
Twilight Sleep morphed into different forms and other drugs. The desire for painless childbirth (and belief in its feasibility) led to assembly line, hospital-based programs of heavy sedation. Well into the 1970s most women were anesthetized or asleep, their babies pulled out with forceps. [Especially during the 1950s baby boom, there were simply too many births and not enough doctors. ]
Birth became a mainstay of hospitals, originally triggered by the promise of Twilight Sleep. Forgotten were the early controversies, feminist demands, negative clinical data. The next public campaign began in 1960, out of concern for the potentially harmful effects of drugs on the infant.