[204] _Long Island Medical Journal_, December, 1914, and _American Journal of Obstetrics_, May, 1915.
[205] _Jour. Amer. Med. Assoc._, November 21, 1914.
In the twilight sleep treatment the patient, especially if she is a primipara, should be definitely in labor before any injection is given. She should have pains occurring at regular intervals, preferably every four or five minutes, before the first injection of scopolamine and morphine is administered; that is, the first stage of labor should be well advanced. Gauss gives one-sixth of a grain of morphine at the first injection, and Polak nearly three-fourths of a grain of narcophin, with one two-hundredth of a grain of scopolamine. If the woman is a multipara, Polak begins the treatment at the very beginning of the pains. The patient is kept in bed, in a darkened room, removed from all noise and excitement. Some stop the ears and blindfold the patient, and, according to Baer of Chicago, the women are put into restraining sheets as a routine practice in certain clinics to keep them from infecting themselves. The ordinary practice is to give a half dose of scopolamine an hour after the first dose and about every two hours thereafter, according to the indications. The morphine may be discontinued, or used approximately every six hours in a long labor. Smaller doses are required if the first is given early in the labor, and larger if the pains have been well developed. In these latter cases the danger to the child is, of course, greater.
The condition of the patient's pulse, respiration, pupillary reaction, and the frequency and character of the uterine contractions are constantly watched, to guard against poisoning. Fonyo[206] reported two fatal poisonings by the scopolamine-morphine method as used in surgery. Both were operations for the delivery of women by laparotomy, and in each case the centre of respiration was overwhelmed. In each of these operations only one-hundredth of a grain of scopolamine and one-third of a grain of morphine had been used, but chloroform was administered later. Robinson recently reported the fatal poisoning of a negress by scopolamine, and Chandler of Philadelphia two more where one thirty-third of a grain of scopolamine had been used. One-ninetieth of a grain given hypodermically has caused severe toxic disturbance which lasted for twenty-eight hours, and Root[207] reported a case where one three-hundredth of a grain given by mouth poisoned violently.