acting drug, because of the many curious conditions of consciousness. The majcrity go to sleep, some are nervous, while others are extremely excitable. They can all be made excitable by needless interference, by noise, or by talking, so, for that reason, it is best to allow no one to talk to your patient but yourself. A few will talk at random but others will talk so reasonably, that you will decide. they know what they desire to impress upon you, they will try to convince you that they need more medicine, as the following case illustrates: Mrs. C., age twenty-nine, strong physically and with an exceptionally developed mind, was given 1/80th grain of scopolamin. In forty minutes after the last dose, she sat up in bed, and most politely said "Dr. House, I believe if you will give me just a little more of the medicine, I will get easy, but so far, I cannot feel any influence of the drug at all. I am sure the drug will ease me, for all the women I have talked with said it eased them, and I am anxious for you to be successful in my case." I believed she was rational and brought the dose down to grain one-sixtieth. The next day she laughed and said, "She remembered nothing of the conversation, nor of my giving her more medicine." I could cite several similar cases, and for this reason I strongly advise great care in noting conversations, that you may not use more scopolamin than you have first judged sufficient, after having measured the mental capacity of the patient.

The memory test is made by showing the patient some article every five min utes after you know the scopolamin has had time to be absorbed. Before you show a new article, have them first recall in order the other articles shown. If they do not show they have forgotten after four articles are shown, then I would lightly anaesthetize again with

chloroform. This is my way, although there are various ways, all of which are similiar in principle. A characteristic phenomena is that the patient will awaken of herself for brief intervals, and retain what they observe. What they remember is described by Dr. Gauss as "Memory Islands." Presumably his description meant they were in a sea of unconsciousness. Since it is the earliest symptom of effect, the first question I ask a patient is in regard to dry mouth. Quite often one calls for water, but say when it is brought, "I don't want it now." Sometime they will drink a few swallows, but strange to say, drink very little.

Zoe Beckley who furnished to me the following statistics, obtained recently at Freiberg, says, "Doctors are remiss when it comes to admitting mercy in obstetrics to a place ahead of "laissez faire," and its cruel analogue "Nature will take care of itself."

In Germany, Dammerschlaff is now receiving more respect than ever before. Today, throughout England and Scotland, the Freiberg technic is being quietly followed. It is estimated that ten percent of the doctors now follow that technic. The placidity of the child is the result of the mothers perfect shockless condition. The drug is strange in that it prevents stimulus from being recorded in the brain, but does not interfere with the normal function of the rest of the body economy. The mind knows at the time what is happening, but does rot register the event for future use. This action is similiar to absent mindedness. Oligopoca is a benefit. it checks premature respiration and the danger of drawing Loebial scretion into the bronchial tubes. Asphyxia the most serious breathing difficulty in natural births, never occurs in Twilight Sleep" Statisties in Ceray show the death

case

rate under twilight, in both mothers and babies, to be less than one half the number registered as not using twilight. The Freierg Clinic claims from an average of one hundred babies a month the death rate has decreased from three and four tenths to one and three tenths percent, and that they have a lower death rate of mothers and babies than any other clinic in Europe can show. The objection, that the Gauss Method is injurious to the mother is also answered by statistics from the same clinic, in these words "There has never been known among the more than twelve thousand, the Frauenklinik has cared for to date, of any such harm. In a period of two years (twenty-five hundred cases) eighty-three percent of twilight mothers nursed their babies while of those who delivered them in full consciousness, only sixty-seven percent were able to nurse their babies. These statistics also coincide with my personal experience. What deceives the inexperienced observer is the manifestation of pain, but the truth is, they do not suffer in proportion to appearances. I have observed this statement is always corroborated by the patient when her consciousness returns. shall in fairness reproduce Dr. Gauss' own words "A physician must be experienced, not only as a physician but as a "Twilight Sleep Specialist" if results are to be perfect. I believe that two years of observation and study of this treatment are necessary before anyone should use it. That in Twilight what has happened is not dammerschlaff but to the mistakes that were committed in its name. The longer experience physicians have with it, the surer it is that it should not and cannot die. These statistics should make the physician who fears the "Blue Baby" stop and think. personally, I feel if a physician can deliver to the parents a live healthy

I

baby, the color should not be a matter of requirement."

All

manifestations of nervousness show the beginning of a pain. When the pain is over, the nervousness stops. The pain, not having been registered in the brain as memory, is therefore forgotten. They do appreciate pain, but do not retain the recollection-hence the excuse for saying they do not remember when the baby is born. If a patient goes under scopolamin showing symptoms of nervousness, she will be nervous with every pain,that is not a danger sign at all, but it means that you had best not give this woman any pituitrin. She will cry or scream out with each pain in proportion to the medicine given, and this condition will last during the period of unconsciousness, an indication that you will obtain the results you seek.

My personal experience with scopolamin began in Dallas, Texas, during the years 1897 and 1898. Dr. J. H. Florence was then City Health Officer, and Dr. C. M. Rosser was chief of the Hospital Staff. At the Hospital all the City's pauper cocain and morphin addiets were treated. Both of the physicians, in their official capacity prescribed the hyoscin method. Like the hod carrier, all I had to do was to give the medicine and watch the patient.

That splendid opportunity enabled me to witness the various phases of hyoscin, which is synthetically the same as scopolamin.

When the Freiberg method was first advocated, I had sufficient confidence in its merits to believe it would live up to all the claims made for it, but adverse criticism following quickly made me skeptical. I conluded it would be best for me to make a personal investigation. With that idea in view, I went to New York for further study. While there, I visited every hospital in Manhattan and

Brooklyn where scopolamin was being tried out. My observation forced me to accept the conclusion that the method being followed was susceptible to improvement. I further noticed that some of the men who were using the Freiberg method were not as familiar as they should be with some of the physiological functions of scopolamin, viz; that with some women the more scopolamin, the more exaggerated the nervous symptoms, and instead of putting them to sleep, made them more nervous, their endeavor to force a condition of sleep only was an evidence of inexperience and unsafe dosage.

My New York visit invited a comparison of all the different cases I had seen. The result of my reflection led me to believe that, in the scheme of creation, the law of environment, which governs every thing in nature, must necessarily apply its rules to scopolamin. Consequently, if scopolamin would produce blue babies when administered to mothers in confinement, there must be some drug provided to combat this condition, and prevent the appearance of blue babies. Futhermore, if scopolamin would not even injure the mother, then it certainly must. have some friend so to speak (the law of control) which would not permit scopolamin to kill the baby.

Then the idea came forcibly to me, that if I would test out the FlorenceRosser method for morphin addicts, the strychnin would eliminate the impediment found in the incomplete Freiberg method. The suggestion would not leave me, so while working in the Biological Laboratories of a northern pharmaceutical house, I investigated all the drugs which recommended themselves to me, and by the time I returned home, my confidence in the possible value of the Florence-Rosser method was so firmly established that I investigated, and the

end results far exceeded my expectations.

I have never lost a woman where I used scopolamin. I count among my patrons many mothers who have used scopolamin three times, while quite a number have taken Twilight twice.

I have never lost a baby where the loss could be attributed to scopolamin. My whole record shows that I have lost but three babies in six hundred and eight confinements. One was an instrument delivery. The baby was alive when the head was delivered, but my assistant had placed the patient under the anaesthetic sufficiently to stop pains, and before I could deliver the shoulders by hand, the baby choked to death. The neighbors blamed scopolamin, but the mother and family did not. I confined this woman two years later and again used scopolamin.

The second case was a hand presentation, which I had failed to diagnose correctly before dilatation commenced. I made version without any trouble, but lost the baby-through having to resort to instrument delivery of the head. I might add for consideration, that I did all this work without any other anaesthetic. This woman was very small, the mother of four children, all being lost at delivery.

The last case was an odd one. The coccyx cut a groove down the middle of the frontal bone. The baby lived thirty six hours, but I was never able to control the hemorrhage from the nose, as a result of the fracture.

I have experimented with scopolamin in every size dose that appealed to me as reasonable, and I have been convinced that grain one eightieth of scopolamin in broken doses will protect any physician, while in eighty percent of cases, it will produce the results desired and sought for by the expectant mother.

The concensus of opinion in New York was that morphin caused, or helped to cause the "BLUE BABY." It never appealed to me that morphin was safe to give an unborn baby, when it was contra-indicated immediately after birth. Consequently, I omitted any consideration of morphin in all of my research work.

The Florence-Rosser method advised strychnin grain one sixtieth with each dose of hyoscin. That was the way I began my earlier cases. I noticed howI noticed how ever, there was more nervousness in the babies than was desirable. I perceived that I could obtain proper effects with smaller doses of strychnin than I was using, also that I must find some drug to use with scopolamin, that would assist me to give smaller doses of scopolamin, yet receive the same results.

I then conducted an investigation with cannabis-indica. In each instance, the drugs counteracted one another, producing no loss of memory, so thereby losing the attractive attribute of scopo lamin.

I next tried a gas machine. When set up, that instrument always inspires confidence by its attractiveness and apparent possibilities, but the nitrous oxide also counteracted the effects of the scopolamin.

I next tried ether, because it was a heart stimulant, but the patients became so nervous and irritable from its effects, I felt obliged to pass that combination.

I then tried chloroform, and found the results I had sought. I did not feel satisfied however, with my first trials with chloroform, so I devised many ways of administering it. After much experimenting, I finally selected the technic which I now follow. Let me strongly advise the purchase of fresh scopolamin tablets from the manufacturer, as old

tablets will give you all the symptoms of atropine, with no loss of memory.

It would be superfluous to enumerate all my experimental cases, so I will invite you to go with me to the bedside of a patient in her home; my object being to reach that class of women who cannot go to a hospital, or who prefer to stay at home.

First, I make an inventory of my surroundings, relative to hot water and a fire. Next, I make an examination to ascertain the position of the baby, the amount of dilation, how many children she has had, and the time required to deliver the others. Then the next step is to decide upon the size dose probably required, so I engage her in conversation to measure her mental strength, and whether or not she is of a nervous temperament. The most important thing of all is to correctly measure the mind, for the stronger the mind, the larger the dose. Educated women, therefore, require larger doses than uneducated people, provided their brain capacity is about the same. A negress rarely requires over grain, one one hundredth of scopolamin. Nervous women require larger doses than women who are not excitable and super-sensative to pain. To sum up the whole: a physician must learn to be a student of temperament, and apply his experience in the selection of dosage, both as regards size or dose, and speed of administration, enabling him to judge whether his patient should be put under scopolamin quickly or slowly. All data must be considered to reach a correct conclusion, because one cannot get away from the axiom "Scopolamin is a Paralyzant to the Peripheral ends of the autonomic nerves." Consequently, the dose must be measured by the acceleration of the heart. Especially does one have to watch respiration. It is by the effect shown in the respirarion that he

has his one and only guide to the true condition of the baby. Whatever is the condition of the mother, that exactly represents the condition of the baby. Do not allow the baby to nurse for six hours after delivery as this gives the mother time to destroy the medicine in her system.

After the environment and the patient have been studied, and the size of the dose has been decided upon, we are ready to proceed. Suppose for this illustration we take a woman of average intelligence, and where everything is normal. I never start twilight sleep until I am assured the woman is in labor, and I always request an enema, and have the bladder emptied. I have decided in favor of giving one eighteenth grain of scopolamin, and I will show you how to get results equeal to one fiftieth grain by using chloroform. First, I will inject scopolamin grain one, one hundred thirtieth, then wait twenty minutes, or if pains are slow, wait thirty minutes. I then inject scopolamin grain one two hundredth, and wait twenty or thirty minutes, unless the pains are too fast or labor too near termination. I then place the patient completely under chloroform to light unconsciousness; few can count to one hundred. By depressing the cerebrum with chloroform, I do what that size dose of scopolamin cannot do, yet it is a large enough dose to hold the cerebrum depressed, by keeping the synapses of the dentrites of cortical cells contracted sufficiently to prevent pain stimulus from reaching the cerebrum, to be registered there as memory, because chloroform also contracts the synapses.

When she comes out from the effects of the chloroform, an average woman will show whether the scopolamin is effective or not by the manner in which she replies to questions. If she quiets down

between pains, that is a favorable sign, but, as I said before, their conversation is often misleading. In the event that I am convinced the cerebrum is not depressed sufficiently, I again anaesthetize with chloroform. The second depression rarely fails to permit the scopolamin to manifest its effects. However, if it happens that the capacity of the patient's brain was misjudged, then I administer grain one four hundredth of scopolamin, wait twenty minutes, and again administer chloroform. If the grain one sixtieth does not produce the results anticipated, then I have made a bad guess, and I abide by the consequences, for that is as large a dose of scopolamin as I feel any physician should attempt to give a parturient

woman.

Under scopolamin, a physician can use instruments without an anaesthetic. The patient herself will take any position she is requested to assume. It matters little how much a woman may have suffered in previous confinements, the attending physician can assure her she will suffer very little, with the same assurance and degree of confidence that he could persuade a patient with a case of colic, that morphine would alleviate his suffering, The longest that I have kept any woman in labor under the infiuence of scopolamin was nine hours, althoug I have kept morphine addicts under its infiuence for two weeks.

I have employed my method so often, that I can now produce any condition requested by the patient. I favor holding them on the border line betwen consciousness and unconsciousness. Then they obey me, while otherwise they are so intoxicated, they comprehend nothing. Scopolamin softens the involuntary muscles, and I do not recall a single tear during its use, that required a stitch.

The baby experiences the same effects