Ferdinand Raimund - "Die gefesselte Phantasie"

Ruth McEnery Stuart - "Moriah's Mourning and Other Half Hour Sketches"

Charles Morris - "Historical Tales, Vol. 6 (of 15)"

Robert de Boron - "Li Romanz de l'estoire dou Graal"

Annual Bibliography of Commonwealth Literature 2007
This paper argues that discourses of love in Ghanaian market literature for youth offer a view into complex negotiations of agency and empowerment. Drawing on Deborah Durham's notion of youth as "social `shifters'" and Francis Nyamnjoh's conception of the "interconnectedness" of agency, I take Ghanaian market literature as one specific case of how African literature for youth foregrounds questions of continuity and change as African societies enter into increasingly complex global relations. In this literature for youth, received notions of love, often constructed out of impressions from American pop and hip hop music, carry new notions of agency that compete with existing "domesticated" forms. Authors like Ike Tandoh and Evelyn Tay employ discourses of love to offer youth alternative avenues for empowerment in a context of socio-economic disenfranchizement. In a creative process of "straddling", this writing both reveals and reproduces the contradictions that obtain in youth configurations of agency.

The Mother and Her Child

W >> William S. Sadler >> The Mother and Her Child




5. The patient must be in a quiet and partially darkened room. She
must not be disturbed; while the physician, or a competent trained
nurse, must be in constant attendance.

6. While this method of treatment is best carried out in the
well-appointed hospital, there is no real reason why it cannot be
fairly well carried out in a well-regulated private home, provided the
necessary preparations have been made, a trained nurse is present, and
provided, further, that the physician is willing to remain in the home
with the patient the length of time required properly to supervise the
treatment.

7. Even when the treatment is not instituted early in labor, it can,
in certain selected and appropriate cases, be utilized even in the
second stage of labor--thus saving these special cases much
unnecessary pain; in fact, some authorities regard it as a valuable
adjunct in the management of "borderland contractions" as it allows
the patient a full test of labor.

8. In our opinion, this method has little effect on the first stage of
labor if properly administered; but it does undoubtedly prolong and
tend to complicate the second stage; in fact, we are coming to look
upon "twilight sleep" as being more distinctly a first stage
procedure; that it bears the same relation to the first stage of labor
that chloroform bears to the second stage--relieving the pain but not
stopping the progress of labor.

9. That when safe amounts of the drug are used the pain is greatly
lessened in all cases--the subsequent memory of pain is absent in the
majority of the patients--but the labor is not always entirely
painless as is popularly supposed.

10. We do not believe that this method when properly administered
increases the number of forceps deliveries--at least not in the case
of high forceps operations. It undoubtedly does cover up the symptoms
of a threatened rupture of the uterus, and thus increases danger from
that source; nevertheless it may be safely stated that this method
does not in any way greatly interfere with any other measures which
might be found necessary to institute in order to bring about a
successful termination of the labor.

11. The baby's heart beat must be carefully and constantly watched;
sudden slowing means that the treatment must be discontinued and the
child delivered as soon as possible; even then, difficulty may be
experienced in getting the baby's breathing started after it is born.
In the vast majority of cases where the baby does not cry or breathe
at birth, the usual methods employed in such cases serve quickly to
establish normal respiration, and the baby seems to be but little the
worse for the experience.

12. While altogether too much has been claimed for "twilight sleep" at
the same time many false fears have also been suggested, among which
may be mentioned the fear of the mother losing her mind after the
treatment; the undue fear of asphyxiation on the part of the baby; the
fear of post-partum hemorrhage; and the fear that it will lessen the
milk supply. We cannot deny that the child's dangers are often
increased; but in other respects, this method (in properly selected
cases) presents little more to worry us than the older methods of
anesthesia.

13. We are inclined to the belief that this method has but little
influence on the course of convalescence following labor. Certain
nervous and highly excitable women certainly seem to do better, as a
result of experiencing less pain and nervous shock; while other cases
do not turn out so well. It certainly does not retard repair and
recovery during the puerperium.

14. This method seems to have its greatest field of usefulness in
those cases of highly intelligent but excessively neurotic women who
have an abnormal dread of pain and child bearing; or women who have
suffered unusually at the time of a previous confinement--perhaps in
the case of the first baby--or from other complications; women such as
these, and other special cases, are the ones to benefit most from the
employment of "twilight sleep."

15. This method as has already been intimated, is most useful in the
case of the first baby, or in the case of women who have established a
record of tedious and painful labors. It has no place in normal and
short labors; although it may be used to great advantage in certain
cases during the first stage of labor--being carefully and lightly
administered--while chloroform or gas is utilized at the end of the
second stage just as has been our custom for a generation.

16. As noted under the special claims made for this method, it is (as
also is nitrous oxid) the ideal procedure in cases of heart,
respiratory, kidney, and other organic difficulties, the details of
which have already been noted, and their repetition here is not
necessary.

17. It must be remembered that scopolamin and morphin are more or less
uncertain in their action; scopolamin is variable in its results,
often producing such marked nervous excitement in the patient as
greatly to interfere with the carrying out of an aseptic technic;
while morphin has been shunned by obstetricians for a whole
generation, because of its well-known bad effects on the unborn child
as well as its interference with muscular activity on the part of the
mother.

In Germany, it is said, that a great many damage suits against
prominent physicians have resulted because of the alleged ill effects
which have followed the use of "twilight sleep."

18. In presenting these facts and opinions regarding "twilight sleep,"
the reader should bear in mind that we are not only endeavoring to
state our own views and experience, but also to give the reader just
as clear and fair an idea of what other and experienced physicians
think of the method, both favorably and unfavorably; and we will draw
these conclusions to a close by citing the opinion of one or two who
have had considerable experience with the method and who, in summing
up their observations, say:

The disadvantages of the method are entirely with the accoucheur
and not to the mother or child. _It requires his presence at the
bedside from the time the treatment is undertaken until the
completion of labor_, not so much because of any danger, but to
keep the patient evenly under anesthesia on a line midway between
consciousness and unconsciousness, for if she is allowed to go
above that line in several instances she will have several
so-called "isles of memory," and will be able to draw a picture
of her labor in her mind and thus lose the benefit of the
treatment.

These methods of anesthesia are very important and have merit.
They should be used when properly indicated. No one should limit
himself to a routine method. Each case should be individualized
and the form of anesthesia best suited to the case in hand should
be employed. For instance, in dealing with a primipara--one who
is full of fear, who cannot stand pain, who is of an hysterical
nature--morphin-scopolamin anesthesia is best suited in that
particular case, because these drugs have a selective action when
it comes to allay fear and produce amnesia. On the other hand, in
a multipara who has had three or four children, whose soft parts
are relaxed and who has short labors, the anesthetic of choice
would be a few whiffs of chloroform as the head passes over the
perineum. It is ridiculous to try to give such women the
"twilight sleep." Furthermore, take the cases you see for the
first time at the end of the first stage of labor, or during the
second stage; these cases are best treated with the nitrous oxid
and oxygen method. You have to individualize your cases. The
prospective mother now consults the obstetrician early to find
out if her particular case is suitable for the "twilight sleep."
She has been informed that certain examinations--urine, blood
pressure, etc.--are necessary. She knows that these examinations
have to be made at regular intervals. In other words, we get the
patients early and we can give them good prenatal care.

This chapter has been devoted to "twilight sleep;" the following
chapter will consider "nitrous oxid" and other methods of anesthesia
in connection with labor, and should be read along with the foregoing
discussion in order to obtain an intelligent view of the whole subject
of "painless labor."




CHAPTER X

SUNRISE SLUMBER AND NITROUS OXID


Since the public has already been told so much about obstetric
anesthesia, we deem it best to go into the whole subject thoroughly,
so that the expectant mothers who read this book will be able to form
an intelligent opinion regarding the question, and thus be in a
position to give hearty cooperation to the decision of their physician
to employ, or not to employ, any special form of anesthesia or
analgesia in their particular case. In order to give the reader a
complete understanding of "painless labor," it will be necessary to
give attention to that newer and more safe method of obstetric
anesthesia called "sunrise slumber." This method of anesthesia
consists in the employment of nitrous oxid or "laughing gas," and will
be fully considered in this chapter.


OBSTETRIC FEAR

In this connection we desire to reiterate and further emphasize some
statements made in the preceding chapter concerning the unnatural fear
and abnormal dread of childbirth.

We feel that it is very important in connection with this new movement
in obstetrics to reduce the woman's pain and suffering to the lowest
possible minimum, that the trials of labor should not be overdrawn and
the pangs of confinement overestimated. We must not educate the normal
woman to look upon labor as a terrible ordeal--something like a major
surgical operation--which, since it cannot be escaped, must be endured
with the aid of a deep anesthesia.

The facts are that a very small per cent of healthy women suffer any
considerable degree of severe pain--at least not after the first
child. We often observe that judicious mental suggestion on the part
of the physician or nurse in the form of encouraging words and
supporting assurances tends to exert a marked influence in controlling
nervousness and subduing the sufferings of the earlier labor pains.

We must not allow the efforts of medical science to lessen the
sufferings of child-bearing, to rob womankind of their natural and
commendable courage, endurance, and self-reliance.

We do not mean to perpetuate the old superstition that pain and
suffering are the necessary and inevitable accompaniments of
child-bearing--that the pangs of labor are a divine sentence
pronounced upon womankind--and that, therefore, nothing should be done
to lessen the sufferings of confinement. Severe and unnatural pain is
not at all necessary to childbirth, and there exists no reason under
the sun why women should suffer and endure it, any more than they
should suffer the horrors of a very painful surgical operation without
an anesthetic. In this connection, it should be recalled that
analgesic drugs have been introduced into obstetric practice only
during the last fifty years, while such methods of relieving pain have
been used in general surgery for a much longer period. It is now only
sixty-nine years since Simpson first employed anesthetic in
obstetrics, while six years afterwards Queen Victoria gave her seal of
approval to the use of chloroform in labor cases.

Thirty years ago, in speaking of the expectant mothers, Lusk warned
us:

As the nervous organization loses in the power of resistance as
the result of higher civilization and of artificial refinement,
it becomes imperatively necessary for the physician to guard her
from the dangers of excessive and too prolonged suffering.


NITROUS OXID--"LAUGHING GAS"

Nitrous oxid, or "laughing gas," was first used in labor cases in 1880
by a Russian physician. During the last twenty-five years it has been
used off and on by numerous practitioners in connection with
confinement, but not until the last few years has this method of
relieving labor pain come into prominent notice.

While the "laughing gas" method of obstetric anesthesia did not gain
notoriety and publicity from being exploited in magazines and other
lay publications, it did get its initial boost in a very unique and
unusual manner. A gentleman who manufactured and sold a "laughing gas"
and oxygen mixing machine for the use of dentists, insisted that this
method of anesthesia should be used in the case of his daughter, who
was about to be confined. This patient was kept under this nitrous
oxid anesthetic for six hours--came out fine--no accidents or other
undesirable complications affecting either mother or child, and thus
another and safe method of reducing the sufferings of childbirth has
been fully demonstrated and confirmed, although it had previously been
known and used in labor cases to some extent.

Starting from this particular case in 1913, many obstetricians began
experimental work with "gas" in labor cases; and, at the time of this
writing, it has come to occupy a permanent place in the management of
labor, alongside of chloroform, ether, and "twilight sleep."


ANALGESIA VS. ANESTHESIA

The reader should understand the difference between analgesia and
anesthesia. Anesthesia refers to the condition in which the patient is
more or less unconscious--wholly or partially oblivious to what is
going on, and, of course, entirely insensible to all pain. Analgesia
is a term applied to the loss of pain sensation. The patient may not
be wholly or even partially unconscious--merely under the influence of
some agent which dulls, deadens, or otherwise destroys the realization
of pain. This is the condition aimed at by the proper administration
of any form of "twilight sleep," whether by the scopolamin-morphin
method, or by the nitrous oxid ("sunrise slumber") method.

Any method of treatment which can more or less destroy the pain of
labor without in any way interfering with its progress, and which in
no way complicates its course or leaves behind any bad effects on
either mother or child, must certainly be hailed with joy by both the
patient and the physician. While chloroform has served these purposes
fairly well, there have been numerous drawbacks and certain dangers;
and it was the knowledge of these limitations in the use of both
chloroform and ether, that has led to further experimentation and the
development of these newer methods of producing satisfactory
analgesia--freedom from pain--without bringing about such a state of
profound anesthesia as accompanies the administration of the older
methods.

It should be borne in mind that in using "sunrise slumber" (nitrous
oxid) for labor pains, the gas is so administered that the patient is
just kept on the "borderline"--in a typical "twilight" state--and not
in the condition of deep anesthesia which is developed when nitrous
oxid is employed by physicians and dentists as an anesthetic for major
and minor surgical operations.

Analgesia is the first stage of anesthesia--the "twilight zone" of
approaching unconsciousness--in which the sense of pain is greatly
dulled or entirely lost, while even that which is experienced is not
remembered. It seems to the authors that "gas" is the ideal drug for
producing this condition whenever it is necessary, as nitrous oxid is
the most volatile of anaesthetics, acts most quickly, and its effects
pass away most rapidly, while its administration is under the most
perfect control--it may be administered with any desired proportion of
oxygen--and may be discontinued on a moment's notice. It is
practically free from danger even when continued as an analgesic for
several hours. Nitrous oxid never causes any serious disturbance in
the unborn child, as chloroform sometimes does when used too
liberally.


EFFECTS OF NITROUS OXID

It will not be necessary to compare the favorable and unfavorable
claims for nitrous oxid as we did the contentions for and against
"twilight sleep." Whatever service "laughing gas" or "sunrise slumber"
can render the cause of obstetrics we can accept, knowing full well
that, in competent hands, it can do little or no harm; and this we
know from the facts herewith recited and from the further fact that we
have gained a wide experience with this agent in the practice of both
dentistry and surgery. In a general way, the influence of "sunrise
slumber" on mother and child may be summarized as follows:

1. It can accomplish its purpose--can quite satisfactorily relieve the
mother of severe pain--when employed as an analgesic. It is not
necessary to administer the gas to the point of anesthesia except at
the height of suffering at the end of the second stage of labor, when
the head of the child is passing through the birth canal.

2. This method can be stopped at any moment--the patient ran be
brought out from under its influence entirely and almost
instantaneously. It is not like a hypodermic injection of a drug which
may exert a varying and unknown influence upon the patient, and which,
when once given, cannot be recalled.

3. It is a method which may be used in the patient's home just as
safely as in a hospital; the only drawback being the inconvenience of
transporting the gas-containing cylinders back and forth. This is even
now partially overcome by the improved combination gas and oxygen form
of apparatus which has been devised.

4. The administration of nitrous oxid analgesia or anesthesia does not
interfere with or lessen the uterine contractions or expulsive efforts
on the part of the mother--at least not to any appreciable extent.

5. Just as soon as a severe uterine contraction--attended by its
severe pain--begins to subside, the gas inhaler is immediately
removed, and in a few seconds the patient is again conscious. It is
not necessary to keep the patient continuously under the influence of
the drug, as in the case of the scopolamin-morphin method of "twilight
sleep."

6. This method ("sunrise slumber") is certainly far more safe in
ordinary and unskilled hands than the "twilight sleep" procedure. The
patient is more safe with this method in the hands of the average
doctor or trained nurse.

7. It has been our experience that nitrous oxid in the smaller,
interrupted and analgesic doses, actually tends to stimulate the
uterine pains and contractions, while at the same time rendering the
patient quite oblivious to their presence. When properly administered,
the freedom from pain is perfect.

8. Under the influence of "gas," patients often appear to "bear down"
with increased energy. It certainly does not lessen their cooperation
in this respect.

9. We have not observed, nor have we learned of, any cases of inertia
(weak and delayed contractions), post partum hemorrhage, or shock, as
a result of "laughing gas" or "sunrise slumber" analgesia.

10. This method lends itself to perfect control--it may be decreased,
increased, or discontinued, at will; it may be given light now and
heavy at another time; while, at the height of labor, it may be pushed
to the point of complete anesthesia, if desired.

11. We have found "sunrise slumber" (nitrous oxid) analgesia to be the
ideal obstetric anaesthetic, and have adopted it quite to the
exclusion of both chloroform and "twilight sleep." We find that this
form of analgesia has all the advantages of "twilight sleep" without
any of its dangers or disadvantages.

12. A possible objection to the nitrous-oxid method is the cost,
especially in the private home. The average cost in the hospitals
where we are using this method runs about $2.00 for the first hour and
$1.50 for each hour thereafter. This is the cost when using large
tanks of gas, and is, of course, somewhat increased when the smaller
tanks are used in the patient's home.


METHOD OF ADMINISTRATION

Since it was thought best to give the reader some idea of the technic
for the administration of "twilight sleep," it may not be amiss to
explain how "sunrise slumber" is usually employed in labor cases. The
technic is very simple. The administration of the gas is generally
begun about the time the patient begins seriously to complain of the
severity of the second stage pains; although, of course, the gas can
be given during the first stage pains if desired. In the vast majority
of cases, however, we think it is best to encourage the patient to
endure these earlier and lighter pains without resorting to analgesic
procedures.

The form of apparatus used is the same as that employed by dentists
and contains both nitrous oxid and oxygen cylinders. A small nasal
inhaler is best, although the ordinary mouthpiece will do very well.
The gasbag attached to the tank should be kept under low pressure and,
as a pain begins, the patient is told to breathe quietly, keeping the
mouth closed. As a rule this sort of light inhalation serves to
produce the desired analgesic effect. It is not necessary to put the
patient deeply under in order to relieve the pain.

It is our custom to begin "sunrise slumber" as soon as the uterine
contractions become painful. The earlier the gas is started, the more
oxygen should be used. Two or three inhalations will suffice to take
the "edge" off the earlier and lighter pains. When the pains grow
heavier we use less oxygen and permit three or four deep inhalations
just before a bearing-down pain. At the first suggestion of a
contraction, the patient must begin to inhale the gas; while after the
patient has pulled hard on the traction strops--just as the
contraction pain is passing--she is given an inhalation containing a
larger percentage of oxygen.

At the beginning of a pain, pure nitrous oxid is administered, and the
patient is instructed to breathe deeply and rapidly through the nose.
The gasbags should be about half filled. The mixture of gas and oxygen
must be determined by the severity of the pains and individual
behavior of the patient.

Four to six inhalations of the gas are sufficient to produce the
required analgesia in the average case. Following the first few deep
inspirations through the nose, the patient can be instructed to
breathe through the mouth, while the gas is well diluted with oxygen
and continued until the end of the pain. In this way a satisfactory
analgesia is maintained throughout the "pain" with a minimum of "gas."
The proportion of oxygen used will run from nothing up to ten per
cent. This procedure is repeated with the occurrence of each pain.

The use of the "mask" is just as effective as a nasal inhaler, but
wastes more gas and so is more costly.

When the head is passing the perineum the gas should be pushed to the
point of anesthesia, while the patient's color will suggest the amount
of oxygen to be used as well as serve to control the administration of
the nitrous oxid.


CHLOROFORM AND ETHER

For many years chloroform and ether have been used to alleviate the
pains of women in labor. Valuable as these agents are when deep
anesthesia is required for the carrying out of operative procedures,
they have not proved satisfactory as analgesic agents. If administered
in small quantities at the commencement of a strong uterine
contraction, the patient does not usually inhale sufficient to abolish
pain. She is then apt to be irritated and is certain to insist on
being given a larger quantity. If a sufficient amount be administered
to satisfy the woman, the continued repetition gradually inhibits the
power both of the uterus and of the accessory muscles, so that labor
is unnecessarily prolonged, and, possibly, the life of the fetus
endangered. Physicians have, therefore, been accustomed to employ
these drugs very sparingly, restricting their use to the very end of
the second stage, during the painful passage of the head through the
vulva. The results of the administration at this time are also
uncertain. If delivery be rapid the woman may not be able to inhale
sufficient to abolish her consciousness of pain. If it be slow she may
take too much and weaken the muscular powers, thereby prolonging labor
and, often, necessitating forceps delivery. It is not surprising,
therefore, that the medical profession has long been hoping that a
more satisfactory method of relieving the pain of labor would be
found.


CONCLUSIONS

In summing up our conclusions regarding analgesia and anesthesia in
labor cases, the authors would state their present position as
follows:

1. That anesthetics or analgesics are a necessary accompaniment of
confinement in this day and age; that the average labor case demands
some sort of pain-relieving agent at some time during its progress;
but that intelligent efforts should be put forth to limit and
otherwise control their use. While we recognize the necessity for
avoiding needless suffering, at the same time we must also avoid
turning our women into spineless weaklings and timid babies.

2. That we should seek to develop, strengthen, and train our girls for
a normal and natural maternity; that we should study to attain
something of the naturalness and the painlessness of the labors of
Indian tribes; and, even if we partially fail in this effort, we shall
at least leave our women with ennobled characters and strengthened
wills.

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