Twilight Sleep: the Horrifying Way Early 20th Century Women Gave Birth

The business of giving birth has long been a dangerous one. For most of human history, an estimated 4% of all women died in pregnancy or childbirth due to infections, haemorrhages, and other complications. Starting in the mid-19th century, improvements in sanitation and new medical techniques steadily began to improve these odds, such that today in the United States approximately 15 women die per 100,000 live births. But even as childbirth became increasingly safer, for many decades it remained just as painful as it had always been. Then, at the dawn of the 20th Century, a miraculous new method for giving birth emerged in Germany which promised to change everything. Known as twilight sleep, the technique promised to banish forever the the pain of childbirth which had plagued womankind seemingly since there have been womankind, and was enthusiastically championed by early feminists as a cornerstone of women’s liberation. But like so many ‘miracle cures,’ twilight sleep proved too good to be true, and its use – and abuse – would lead to one of the most horrifying periods in the history of obstetrics.

The widespread use of general anaesthesia in medicine originated in the mid-19th Century when pioneering doctors such as Horace Wells, William Morton, and James Simpson successfully demonstrated the use of substances like nitrous oxide, ether, and chloroform for pain management. But while anaesthesia rapidly took off for use in surgery, doctors were initially reluctant to use it to ease the pain of childbirth. Much of this resistance was religious in nature, as Christian doctrine saw the pain of childbirth as a divinely ordained punishment for the original sin of Eve. As Genesis 3:16 declared:

I will make your pains in childbearing very severe;

    with painful labor you will give birth to children.

Your desire will be for your husband,

    and he will rule over you.

However, this taboo was shattered in 1853 when Queen Victoria gave birth to her eighth child, Prince Leopold, while under the influence of chloroform. Now bearing the royal seal of approval, the use of anaesthesia in childbirth soon caught on among the upper classes and eventually the rest of society. But while a definite improvement, the use of chloroform was far from a perfect solution, for women in labour could not be completely knocked out lest they become unable to actively push out the baby. Then, in 1902, an Austrian physician named Richard von Steinbüchel developed a unique solution. Von Steinbüchel experimented with a drug called scopolamine or hyoscine, derived from the deadly nightshade plant. Used in small doses to alleviate motion sickness, in higher doses scopolamine is a powerful hypnotic, inducing a dissociative state and amnesia such that a patient remembers little or nothing of what happens while under the influence of the drug. By administering a carefully balanced combination of scopolamine and morphine, von Steinbüchel sought to alleviate the pain of childbirth without the need to render a woman completely unconscious. Properly administered, this drug combination would cause a woman to wake up from childbirth with no memory whatsoever of the ordeal.

In 1906, Bernhardt Kronig and Karl Gauss, obstetricians working in Freiburg, Germany, refined von Steinbüchel’s methods into a technique they called Dämmerschlaf or “twilight sleep.” When a pregnant woman first began experiencing contractions, she was be given a dose of 1/150th of a grain of scopolamine and 1/2 a grain of morphine. 45 minutes later another dose of scopolamine was given, along with a memory test to determine the extent of the amnesiac effect. This procedure was repeated every half hour until the optimal dose of scopolamine was determined, with no further morphine being given for the remainder of the birthing process. As scopolamine had a tendency to induce violent delirium, the original “Freiburg Method” for twilight sleep placed great emphasis on sensory deprivation. Women gave birth in darkened rooms, often blindfolded and with oiled cotton pushed into their ears, while nurses wore uniforms designed to minimize noise – all to limit distractions and promote peaceful sleep.

Later that year, Konig and Gauss presented their technique at the National Obstetrics Conference in Berlin, where they revealed that the use of twilight sleep resulted in fewer post-delivery complications and faster recovery times. Despite initial hostility from the obstetric community, the pair continued to refine the technique. By 1907 Karl Gauss was using twilight sleep on all his pregnant patients, and within a few years the State University Women’s Clinic in Baden where he worked boasted the lowest rate of childbirth deaths and complications in the city. As the popularity of twilight sleep grew, patients from around the world began travelling to Germany to experience the miracle of painless childbirth. In 1912, an American woman named Cecil Stewart visited Freiburg to give birth to her second child. Stewart later described the experience as being like a fairy tale and enjoyed the clinic and its attentive staff so much that she stayed for a full month after giving birth.

But the popularity of twilight sleep truly exploded in May 1914 when American journalists Marguerite Tracy and Constance Leupp published an article titled Painless Childbirth in McClure’s Magazine, which praised the technique and the work of the Freiburg clinic. The article triggered a flood of letters from readers inquiring where they could find doctors willing to perform the procedure. Later that year, the National Twilight Sleep Association or NTSA was formed to promote the technique in the United States.

Lead by C. Temple Emmet, a member of the wealthy Astor family and the first American to give birth at the Freiburg clinic, the Association launched a massive campaign to inform the American public of the benefits of twilight sleep and pressure doctors and hospitals to adopt the technique. The NTSA produced pamphlets, books, lectures, and even a film – one of the first medical documentaries ever made. These materials were filled with glowing testimonials, including from one woman who declared:

“I was so happy. The night of my confinement will always be a night dropped out of my life.”

Before long the crusade for twilight birth had taken on an almost evangelical fervour, as first-wave feminists and suffragists began championing the technique as a new weapon in the fight for gender equality. According to these activists, twilight sleep freed women of the pain and danger traditionally forced upon them by the obligations of motherhood and allowed them to regain agency over their own bodies. NTSA member Mary Boyd, whose lectures on twilight sleep regularly drew crowds of over 300 women, framed the fight for twilight sleep as a battle against the patriarchal medical establishment, declaring:

“[Twilight sleep] is the dawning of a new era for woman and through her for the whole human race. [But] you women will have to fight for it, for the mass of doctors are opposed to it. For the first time… the whole body of patients have risen to dictate to the doctors.”

Meanwhile, many American obstetricians remained skeptical of twilight sleep, not only because of scopolamine’s unpredictable side effects but also the German origins of the technique. With the First World War raging overseas, many saw women who used twilight sleep as being disloyal to the United States. Yet many doctors caved to public pressure and travelled to Freiburg to learn the trendy new method. But unfortunately for an entire generation of women, the technique did not transplant well to America. Thanks to the efforts of the NTSA, the demand for twilight sleep far outstripped the supply of doctors and nurses capable of performing the procedure. Thus, while the original Freiburg method was a highly personalized and attentive affair, its practitioners taking years to learn and perfect the technique, few American hospitals were able to lavish such care and attention on any given patient. In America the technique was largely administered by overworked, poorly-trained nurses, and while German doctors took the time to customize the scopolamine dose for each patient, American patients all received the same standardized dose. The results were horrifying. Under the influence of the drug cocktail women often became delirious or even psychotic, forcing them to be confined in special padded delivery beds and tried down with leather straps or straitjackets to prevent them from thrashing about and injuring themselves. They would be left in this state for days until they gave birth, often wallowing in their own vomit and excrement. And while twilight sleep was billed as being painless, the small amount of morphine administered meant that most patients were still very much in pain, with one doctor explaining to The New York Times:

“There is as much [pain] as in the ordinary childbirth. The only difference is that the patient does not remember having the sensation of pain.”

There were other problems as well. While the mothers were technically conscious throughout the ordeal, the confusion and delirium induced by the scopolamine prevented them from assisting in the birth process, resulting in most twilight sleep babies being delivered mechanically through the use of forceps. This, in turn, increased the risk of injury and other complications for both mother and child. The morphine could also cross the placental barrier, resulting in babies born with depressed breathing as described in this 1915 account by one Dr. Stella Lehr:

“The baby was pinkish lavender in color and did not breathe for about ten minutes. During that time various means of resuscitation were used: the baby was suspended by the feet, and body vigorously slapped, then laid on a table, and chest rhythmically pounded; then body immersed alternately in hot and cold water, and finally intratracheal catheterization used. After witnessing this I naturally concluded that the twilight sleep was to be used very conservatively or better still not at all.”

But perhaps the most alarming side effect was the very amnesia the entire technique was billed on. As Dr. Henry Smith Williams wrote in 1914:

“She may seem to be conscious of the birth of her child, and may give evidence of apparent suffering, yet when a few moments later the child is brought in by the nurse from the neighboring room where it has been cared for, and placed in the mother’s arms, the patient does not recognize the child as her own, or realize that she has yet been delivered.”

This effect could be bewildering and even traumatizing for the mother, as one Mrs. Sargent described in 1915:

“The next thing I knew I was awake […] and then I thought to myself ‘I wonder how long before I shall begin to have the baby,’ and while I was still wondering a nurse came in with a pillow, and on the pillow was a baby, and they said I had had it—perhaps I had—but I certainly can never prove it in a courtroom.”

This sense of disconnection and alienation from the baby and the birthing process itself resulted in elevated rates of what is now termed postpartum depression amongst twilight sleep mothers. Yet despite these myriad disturbing side effects, the popularity of twilight sleep would persist until August 1915 when Frances Carmody, a prominent advocate for the technique, died while giving birth to her third child. While Carmody’s husband and doctor maintained that the death was due to a haemorrhage and unrelated to twilight sleep, this event was enough to turn a large part of the public and the medical establishment against the technique, and its popularity quickly faded.

Yet twilight sleep did not completely go away. Well into the 1960s, it was rare for a woman to give birth without being placed under some kind of sedation. It was not until the 1970s and 80s that movements emerged promoting more natural births, and new techniques like epidurals – injecting painkillers directly into the spine – allowed for more localized pain control without the need for general anaesthesia. But while twilight sleep is no longer used, its legacy is still with us. As late as the 1940s only one-third of births took place in hospitals, with the vast majority of women still giving birth at home in the traditional manner. Twilight sleep, however, could only be administered in a controlled clinical environment, and its brief popularity was instrumental in triggering the mass shift towards hospital births. This was the final step in a nearly century-long process wherein childbirth was increasingly pathologized, stripped from the hands of midwives and pregnant women themselves, and placed under the control of largely male obstetricians. But while much work remains before women can fully reclaim the birthing process, we can at least be thankful that the experience no longer involves the terrifying combination of hypnotic drugs, straitjackets, and memories wiped clean.

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