The complications following the use of pantopon-scopolamin were few. In one case, high forceps had to be used, as the patient had a contracted pelvis. The patients all bore down well during the second stage. The third stage was undisturbed. A few patients complained of thirst after the labor was over, but almost all fell into a deep sleep, lasting many hours after delivery.

In conclusion, Kolde says that pantopon is an excellent drug to lessen the sensitiveness of labor pains. In combination with scopolamin, one can obtain a "twilight sleep" with complete amnesia. Pantopon alone, or in combination with scopolamin, is indicated in every case of childbirth where a normal pelvis and a proper position exist. Abnormal positions and contracted pelves contraindicate its use. Lastly, the method is entirely harmless to the child.

A few more obstetricians have used pantopon in their maternity cases, but perhaps those already reviewed will give a fair understanding of the various methods employed and the different results attained.

In order to work out the efficacy of this new opium preparation, as a means of making the process of childbirth easier for both mother and child, some observations were made at the Woman's Hospital in Detroit. The method of administration was as follows: A two per cent solution of pantopon was first made up in the following manner:

Pantopon
Aqua distill

Spir. vini optimi

Glycerin. pur. neutr.

Misce. Signa. For hypodermic use, 1.0 cubic centimeter.

2.0

.78.0

5.0

.15.0

This solution was placed in glass ampules under sterile conditions, each ampule containing 1.0 cubic centimeter (equals one-third gram pantopon) of the above solution. When dilatation was complete, or, rather, when the second stage had commenced, 1.0 cubic centimeter pantopon was injected. From twenty minutes to onehalf hour afterwards the action was felt and the patient stated that the contractions were much more easily borne. The action of the abdominal muscles and the force of the expulsive pains remained undisturbed. The patients bore down with vigor. The third stage showed no change. The general results were observed in thirty-four cases, a more complete analysis of which may be had by consulting the appended table, from which the following résumé of these thirtyfour cases is taken.

The patients were all primiparæ and the average duration of the labor was

In the average above are included Case VII and Case XIV, whose first stages were forty-seven and one-half and forty-seven hours, respectively. This would tend to make the average length of the first stage longer. The second stage was undisturbed. In Case XIV the third. stage was five hours and twenty minutes long, due to a retained placenta for which the injection was not at fault. This case is not included in the above average of the third stage.

The injection of 1.0 cubic centimeter of a two per cent solution of pantopon was made during the second stage in each case. This was done because other investigators, in the opinion of the writer, made their injections too early in the course of the labor, especially where they used pantopon alone. Whether it would be better to inject 0.5 cubic centimeter during the first stage and follow this up with a full dose (1.0 cubic centimeter) at the commencement of or during the second stage, must be left for another series of observations. In only two cases (Case XIII and Case XXX) were two injections made. In the first of these the first injection was given three hours before the second, during the second stage. The contractions stopped for one hour after the first injection. Six hours after the second injection, low forceps were applied, as the head made no progress, although the pains were of good frequency and duration. In the other case, the first injection was, through error, made soon after the first stage began and the second injection, three hours later, also during the first stage. The sensitiveness of the contractions was less, but the labor progressed slowly, the cervix took a long time (eighteen and one-half hours) to dilate, but the patient did not seem to suffer at any time during the labor. The second and third stages were uneventful.

COMPLICATIONS.

Complications, that could be traced to the action of pantopon, did not exist. In Case V, the contractions ceased for several hours, but no change in their character was noted when they started again. In Cases VI and XIII, owing to lack of progress of the presenting part, low forceps were applied, although the pains were strong and of good duration. A severe hemorrhage occurred in Case VII onehalf hour after the injection. Internal podalic version was performed. In this case the effect of the pantopon was lost one hour after the injection. The patient withstood the pain of contraction. better while the effect lasted. After that, the sensitiveness was as severe as ever. The criticism here is that the dose should have been repeated from two to three hours after the first one. In Case XIV an adherent placenta complicated an otherwise normal delivery. No blame, however, can be placed on the pantopon. In Case XXXII, breech presentation was encountered. Pantopon (1.0 cubic centimeter) was injected ten minutes before delivery, which took place

a

without any untoward results. The effect of the pantopon upon the labor was doubtful, although the third stage was not influenced. It was unfortunate that an earlier injection was not made.

RESULTS.

Observations, that are more or less dependent upon the statement of the patient, must be considered with extreme care. There can be no question but that the element of suggestion exists, as far as the patient is concerned, to a wonderful degree. Doubtless, in some of the cases reported above, an injection of sterile water might have eased the labor pains, according to a later statement of the patient. Patients are often too eager to answer in the affirmative when questioned as to whether a certain form of medication was successful or With this fact in mind, the following results are tabulated: No results

Doubtful results

Fair results

Good results

2 cases.

3 cases..

8 cases.

.21 cases..

or ca. 6%

or ca. 8%

or ca. 24%

or ca. 62%

As further observations will be made of the effect of pantopon in controlling the sensitiveness of the uterine contractions in childbirth, this paper is offered simply as a preliminary report. It is hoped that several series of investigations along this same line may be carried out; first, the action of pantopon when injected during the first stage; second, when used in divided doses; and third, the effects and results of pantopon given with scopolamin. The results of these various methods may then be studied and compared, and more accurate conclusions deduced.

CONCLUSIONS.

From the investigations already made, from the cases reported, and from the original observations given above, the following tentative conclusions seem justifiable:

(1) In general, pantopon seems destined to replace morphin and the various tinctures and extracts of opium.

(2) It can be administered wherever opium and morphin are indicated.

(3) Pantopon has all the therapeutic action of these two drugs, without any of their unpleasant, dangerous after-effects.

(4) The observations, regarding the use of pantopon in internal medicine, in psychiatry, and as a substitute for morphin in surgical anesthesia, recommend its further use in medicine and surgery.

(5) In obstetrics, pantopon tends to lessen the sensitiveness of the uterine contractions, without changing the force and duration of the pains.

(6) It is also harmless for the child.

(7) Later investigations will doubtless determine and clear up many hazy points and establish, not so much a fixed dosage, as the proper time at which to make the injection.

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