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and Veit opposed it. It was also used for a time by many men in this country; condemned by some, faintly praised by others, but eventually abandoned by all. Newell' of Boston reported favorably on 112 cases in 1907. He later gave it up on account of the asphyxiated babies. Scopolamine-morphine narcosis in labor was tried by McPherson in 1908 at the Lying-In Hospital in New York, but proved exceedingly dangerous to the babies and also failed to produce results as far as the mother was concerned.
A few months ago in the columns of a magazine with wide circulation among American women, four professors of obstetrics in four of the most prominent medical schools in this country publish statements over their names denouncing scopolamine-morphin in child-birth. They claim respectively that its use is uncertain, dangerous and unsatisfactory; that it does not abolish pain in the small amounts used; and that the impressions received and opinions formed by them are decidedly unfavorable to the treatment.
There is nothing new in the use of scopolamine in obstetrics. Von Steinbuchel in 1902 first suggested that it would be of value. The technic was further elaborated by Gauss in Krönig's clinic at Freiburg, and in 1906 he published his first 600 cases. In 1907 and 1908 the literature contains several articles by Gauss, Krönigs and Mansfeld', describing the administration of the method in all the details mentioned by Krönig10 in 1913. Notwithstanding the good results claimed, Steffens and Hocheisen wrote strongly opposing its use after trial in 300 cases, and Leopold and Veit soon gave it up as dangerous. Frequent asphyxia and death of infants, with atonic postpartum hemorrhage and prolongation of labor, were the bad results reported. The final verdict was; first, the method did not accomplish the desired results, second, it could not be regarded as harmless for mother and child, and third, it was not to be recommended in private practice, as the by-effects liable to develop made it necessary that medical aid could be summoned at any moment.
Thus the subject had been dropped during the last six years by most obstetricians until last fall, Krönig10 again called the attention of the profession to its value. It is scarcely possible that the distinguished head of a reputable German clinic would presume to publish successful results of a method in over 3000 cases unless there was some virtue in it.
We are aware that an important factor in the increasingly difficult labors among more highly civilized and cultivated modern women is that they have not the strength to resist the nervous exhaustion caused by the appreciation of continued labor pains. To be sure it is possible by the administration of small amounts of ether, chloroform, or nitrous oxide, to make the actual delivery of the child practically painless. But the difficulty with such narcotics is that they cannot be given over
a sufficient length of time to relieve the nervous exhaustion of labor without largely inhibiting its efficiency. Hence it seems justifiable to make another trial of the method in a series of cases, following more closely the technic of Krönig11 and Gauss, provided there is no repetition of our previous bad results. We desired to see if we can secure anything like the results claimed by Krönig in Chicago last November. The question arises, can scopolamine when given in nonpoisonous doses have an action adequate to produce appreciable relief in labor pains. It was entirely with an open mind that we approached the experiment, wishing to ascertain to our own satisfaction to just what extent we could condemn or extol the merits of the treatment. A phenomenon as interesting as the twilight sleep itself is that detailed descriptions of the technic such as have been followed closely in this study have lain idle in the literature for six years with no one taking advantage of them. Those who did make a trial of the procedure wandered far afield both in method and in the object to be obtained.
The crux of the proposition seemed to lie in three errors. First, most men in this country at least used a combination of the two drugs, scopolamine and morphine, not only for the initial dose, but for the succeeding doses as well; second, the bad results were due also to excessive dosage, and to the use of unstable and deteriorated preparations of the scopolamine; and third, the erroneous notion prevailed that the method was to abolish the sufferings of labor, whereas it is intended only to prevent memory of the event.
The technic recommended by Krönig 10 and Gauss, and followed by us in the present series of cases is as follows. The treatment is not started until the pains are occurring regularly, every four to five minutes, and lasting at least thirty to forty-five seconds, as determined by laying the hand on the fundus and noting its contractions. The outcry of the patient is no guide to the strength of her pains. Waiting for labor to be well established thus at once eliminates cases of so-called primary inertia from treatment. The first injection consists of 0.00045 (1/150 gr.) of scopolamine hydrobromide combined with 0.03 (1⁄2 gr.) of narcophin. Narcophin is a proprietary preparation of narcotine-morphine meconate, and according to Krönig gives better results than morphine and is less toxic. We have used both and find no marked difference in the result, but in order to follow the technic in detail we are using the narcophin. It is sold in this country in ampoules, ready for hypodermic use, and also in bulk. In the latter form it must be made up into tablets for use. Scopolamine doubtless varies greatly in its purity and therapeutic action. We used several preparations, and were finally fortunate to secure a supply of the "Scopolamine, haltbar" prepared in sterile ampoules after the formula of Straub of the Freiburg clinic. Its advantage lies in the fact that it is a stable solution and carefully standardized. Threequarters of an hour after the first injection a second injection is given
consisting of 0.00045 (1/150 gr.) scopolamine alone. Thus far the dosage is empirical and standard. The further dosage varies for each patient and depends entirely upon repeated tests of memory.
Besides its slight analgesic action in combination with small doses of narcophin, scopolamine has the peculiar quality of producing prolonged interruptions in the mental associations. Based upon this action the psycological test of the patient's memory is the most accurate guide to the dosage required in a particular case. Some women require much less than others. It is quite simple to keep repeating very small doses of scopolamine and get results as to complete amnesia. But herein lie the dangers of the method, asphyxia of the child, prolonged labor, and atonic relaxation of the uterus. It is most important to secure amnesia with the minimal dose for each case. At Freiburg they have proved to their satisfaction that the quantity given must be regulated by the memory test, and Gauss insists that the success of the treatment stands or falls by the observations of this one test. Half an hour after the second dose the woman is asked whether she has had an injection, how many, and where; or if she remembers a watch, or some simple object that was shown her at that time. A note is made of her answer. Even if the memory is retained no new dose is given, but twice more at intervals of half an hour her memory is tested again. If the memory is still retained, a third injection of scopolamine, 0.0003 or less, is given. The third dose thus usually comes an hour and a half after the second. Further injections are given depending upon whether the memory is retained, dubious or lost. Abolition of memory is the result desired. It requires the nicest judgment to suit the test to the standard of the intelligence of a given case, especially in patients of the lower grades of mentality.
Frequent observations of the uterine contractions, the subjective and objective symptoms of the woman, the condition of the memory, the fetal and maternal heart rate, are noted and recorded on a suitable chart.
The patient is drowsy and sleeps lightly between her pains. When a pain occurs she manifests her suffering to a greater or less degree and again dozes. But consciousness is not entirely lost. She responds somewhat tardily to questions, and usually obeys commands as to change in posture or to an increase in her bearing-down efforts. The progress of labor must be more closely watched than usual, for the presenting part frequently is bulging the perineum without any increase in the apparent effort of the patient. This might be considered a disadvantage by those who are accustomed to judge of the advance by listening to the outcry of the patient from an adjoining room. The straining efforts as the head distends the vulva are not nervously augmented as in an entirely conscious patient. We have noted especially a more perfect mechanism and more regularly gradual escape of the head over the perineum, as attested by a distinct diminution of perineal lacerations.
Whether this is the result of more perfect relaxation of the levator ani, or due to less tendency to reflex spasm thereof, remains to be proved.
Krönig lays great stress upon maintaining a condition of semiunconsciousness, wherein the pains though apparently perceived are nevertheless immediately forgotten. The patient perceives a pain but does not apperceive it, in other words she does not appreciate it. At any rate on awakening she has no recollection of anything that has occurred. The patient may complain that the treatment is not working and roundly abuse those in charge, yet half an hour after the birth have absolutely no recollection of her pains or of the coming of her baby even in cases in which no anesthetic is given. We find it a distinct advantage, however, to administer a few whiffs of chloroform or ether as the head escapes over the perineum. It is possible that this last pain may be so acute as to remain fixed in the patient's attention, and the whole treatment fail. One patient saw the accoucheur's hand covered with blood as he examined the placenta, and this was the only feature of her entire labor that remained fixed in her mind. It is important to reduce the sensory impressions as much as possible, hence isolation of the patient is necessary, the room is darkened and loud noises of any kind are avoided. Under disquieting conditions scopolamine induces excitement in the patient. At the time of actual birth the woman's face is kept covered, and the assistant occludes the patient's ears, or the cries of the child are muffled by the sound of running water. Thirty minutes after the birth of the child the woman is asked whether she has been delivered, and in the majority of cases she has actually no remembrance of the birth process and hesitates to believe that the child is actually hers.
The entire service of the Hospital is being utilized at present, and we are trying the method chiefly in primiparae. Very early we found it necessary to select our cases, and it is perhaps in less than a quarter of all confinements at the Hospital that we are able to use it. Gauss was able to use the method in 70 per cent. of all cases, but a majority of our admissions come in so far advanced in labor that it is too late to start the treatment. We have found it impossible to get the patient under control of the drug after the onset of bearing down pains, and at present are only using it in cases in which we anticipate a normal labor. We have to report our results in the first 100 cases, and for purposes of general comparison present brief statistics of the labors of an additional consecutive 100 primiparae in which the scopolamine was not used. Krönig claims complete amnesia covering the duration of labor in 80 per cent. of cases. In our very limited experience in 100 cases we have secured complete amnesia in sixty-six women; and partial amnesia, hazy recollection with distinct alleviation of the patient's suffering in ten. Of the remaining twenty-four, twenty did not respond to the drug at all, and four were too far advanced in labor to derive any benefit. It is noteworthy that practically all of the successful cases were those