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9. Clinical study of postoperative value of barbituric acid hypnotics
ARtERICAN
BYNE(!OLOGICAL
9. C1inica.l Study of Postoperative
Value of Barbituric
by Dr. Alice F. Maxwell, San Francisco, (See page 579, October issue.)
9x3
SOCIETY
Calif.
Acid Hypnotics, (By
invitation.‘)
DISCIJSSIOS DR. WILLIAM C. DANFORTH, EVAP;STON, ILL.-It is agreed that the preoperative use of barbiturates has a distinct value. Dr. Maxwell now shows us how this may be very greatly extended into the postoperative field. I wonder in speaking of the paralyzing effect of morphine upon the bowel whether or not Dr. Maxwell considers that really is the physiologic effect of that drug? A statement has been made by Dr. Ivy, Professor of Physiology at Northwestern University, that opium derivatives in general were not to such a great extent as supposed, the producers of a paralyzing effect upon the bowel as they were producers cjf sphincter spasm. Possibly this spasm of the sphincter muscle might have more to do with the distention than the actual paralyzing effect upon the bowel muscle. The trauma to which the patient is subjected upon the table, length of time of operation, and intraabdominal manipulation, may have a very distinct effect upon postoperative distention. In a clinic such as that which Dr. Maxwell represents these factors would be reduced to a minimum. She brings out very interestingly too, the fact that we should use the drugs in a careful way, that the standard dose should not be set up, that WC should use them according to the varying rate of excretion. It is interesting, too, to set that the simplest and from an economic point of view, the cheapest drugs seem to work as well as the others. DR.. WILLIAM E. CALDWELL, NEW YORK, N. Y.-The careful preparation of a patient and the excellent technic during operation which Dr. Maxwell describes account in a large part for the few postoperative complications which she reports. In spite of the disagrceabie and sometimes deleterious symptoms which follow the use of opium and its derivatives in the preoperative and postoperative care of patients, I am sure the majority of us have felt until now that we would be greatly handicapped were we deprived of their use. Though I have used small doses of alIona1 before operation, I have persisted in the use of morphine both before the After the anesthetic and for the first twenty-four hours after the operation. first da!r, luminal with codeine and allonal in much smaller doses than Dr. Maxwell advocates, have been used. Our results at the Sloane have been reasonably good but not so satisfactory as those Dr. Maxwell reports. The restlessness and delirium which, as Dr. Maxwell points out, follow in some cases, as well as the swallowing of the tongue with resulting asphyxia, require eonstant and careful nursing as long as the effect of the drug lasts. Unfortunately, it is difficult in some clinics to give sufficient nursing care to watch these cases. For the past ten months we have used pernocton in labor cases at Sloane. We have found it a very useful drug since it gives the patients sleep and amnesia without interference with uterine contractions. In fact, these are frequently much stronger and better after the use of the drug. We have found that small doses are very likely to be followed by restlessness, and that larger doses give better results. But, occasionally, serious delirium lasting for a few hours follows even when an adequate dose has been given. This occurred in six cases out of three hundred. We also had one patient die with bronchopneumonia a few hours after delivery where pernocton in very small doses had been used. Many of our cases had small doses of morphine preceding the pernoeton by two to four hours before the barbituric preparation was given. DR. .FRANK W. LYNCH, SAN FRAP;CISCO, CALIF.-Dr. be of interest to every surgeon because it represents work
Maxwell’s subject which is designed
should to save
934
AMERICAN
JOURNAL
OF
OBSTETRICS
AND
GYNECOLOGY
nerve strain following surgery. I do not feel that surgeons, as a rule, have ever given proper attention to the mental distress which attends surgical procedures. There is nothing more distressing than to operate upon a patient for some anatomical lesion and see the patient become neurotic. If this paper accomplishes nothing more than to stimulate work along these linos, it will be well worth while. While these 500 laparotomies were developing, we used barbiturates in more than 900 cases. There were three deaths in the series and in none of them did the barbiturates play any part, This would suggest that the method is safe since three deaths in 500 major cases, more than half of which were hysterectomies, constitutes a very small mortality. I question whether delirium is the right term with reference to some cases, since the picture is one of disordered sleep and does not occur in all. Our recent observations suggest this represents an overdose of the drug. Nearly all patients wake up twenty-four to thirty-six hours after a period of complete amnesia. The protection from nerve shock is the part of this postoperative treatment that appeals most strongly to me. There is no doubt, however, that the treatment lessens abdominal distention and diminishes the need for catheterization. These, in themOne should remember, however, that morphine selves, are more than worth while. even if given only once increases the chance for abdominal distention. DR. MAXWELL (closing).-This investigation was begun four years ago and while the body of the paper is concerned particularly with postoperative medication with’barbiturie acid hypnotics, within the last six months we have been using barbiturates as a preoperative adjunct to the anesthetic and have eliminated preoperative morphine. The results have been most satisfactory, the patient is tranquil and often asleep on entering the operating room, the induction of the anesthetic is facilitated and following the recovery from the postoperative hypnotics there is often complete oblivion of the entire operative procedure. The dosage has been controlled by body weight as I was unable to determine any relation between preoperative metabolic rate, blood-pressure readings, hemoglobin or other laboratory data and the postoperative reaction to the drug. The dosage, which is expressed in total dosage, was’ given over a 72 hour period so that at no time was an excessively large amount of the medication administered. Our recent experience with the most simple barbiturate, namely Barbitol (“VeronaI”) indicates that it compares most favorably with the most complex malynol-urea derivatives.
10. The Induction of Labor. When Is It Indicated? Its Dangers and a Suggestion of a New Method of Procedure, by Dr. Edmund B. Piper, Philadelphia,
Pa.
(This paper was read by title.)
11. The Clinical Importance Dodds, London, England. ber issue.)
of Sex Hormones,
11-a. The Use of an Anterior
Pituitary Uterine
Treatment
of Functional
(By invitation.)
by Professor. E. C. (See page 520, Octo-
Luteinizing Substance in the Bleeding, by Drs. Emil Novak
and Gerald B. Hurd (by invitation), Baltimore, Md. by Dr. Novak.) (See page 501, October issue.)
(Paper
read
DISCUSSION DR. Zondek women,
OTTO SCHWARZ, ST. LOUIS, Mo.-With of the presence of anterior pituitary the relationship of the anterior portion
the discovery hormones in the of the pituitary
by Aschheim and urine of pregnant body to the ovary
BYNE(!OLOGICAL
9. C1inica.l Study of Postoperative
Value of Barbituric
by Dr. Alice F. Maxwell, San Francisco, (See page 579, October issue.)
9x3
SOCIETY
Calif.
Acid Hypnotics, (By
invitation.‘)
DISCIJSSIOS DR. WILLIAM C. DANFORTH, EVAP;STON, ILL.-It is agreed that the preoperative use of barbiturates has a distinct value. Dr. Maxwell now shows us how this may be very greatly extended into the postoperative field. I wonder in speaking of the paralyzing effect of morphine upon the bowel whether or not Dr. Maxwell considers that really is the physiologic effect of that drug? A statement has been made by Dr. Ivy, Professor of Physiology at Northwestern University, that opium derivatives in general were not to such a great extent as supposed, the producers of a paralyzing effect upon the bowel as they were producers cjf sphincter spasm. Possibly this spasm of the sphincter muscle might have more to do with the distention than the actual paralyzing effect upon the bowel muscle. The trauma to which the patient is subjected upon the table, length of time of operation, and intraabdominal manipulation, may have a very distinct effect upon postoperative distention. In a clinic such as that which Dr. Maxwell represents these factors would be reduced to a minimum. She brings out very interestingly too, the fact that we should use the drugs in a careful way, that the standard dose should not be set up, that WC should use them according to the varying rate of excretion. It is interesting, too, to set that the simplest and from an economic point of view, the cheapest drugs seem to work as well as the others. DR.. WILLIAM E. CALDWELL, NEW YORK, N. Y.-The careful preparation of a patient and the excellent technic during operation which Dr. Maxwell describes account in a large part for the few postoperative complications which she reports. In spite of the disagrceabie and sometimes deleterious symptoms which follow the use of opium and its derivatives in the preoperative and postoperative care of patients, I am sure the majority of us have felt until now that we would be greatly handicapped were we deprived of their use. Though I have used small doses of alIona1 before operation, I have persisted in the use of morphine both before the After the anesthetic and for the first twenty-four hours after the operation. first da!r, luminal with codeine and allonal in much smaller doses than Dr. Maxwell advocates, have been used. Our results at the Sloane have been reasonably good but not so satisfactory as those Dr. Maxwell reports. The restlessness and delirium which, as Dr. Maxwell points out, follow in some cases, as well as the swallowing of the tongue with resulting asphyxia, require eonstant and careful nursing as long as the effect of the drug lasts. Unfortunately, it is difficult in some clinics to give sufficient nursing care to watch these cases. For the past ten months we have used pernocton in labor cases at Sloane. We have found it a very useful drug since it gives the patients sleep and amnesia without interference with uterine contractions. In fact, these are frequently much stronger and better after the use of the drug. We have found that small doses are very likely to be followed by restlessness, and that larger doses give better results. But, occasionally, serious delirium lasting for a few hours follows even when an adequate dose has been given. This occurred in six cases out of three hundred. We also had one patient die with bronchopneumonia a few hours after delivery where pernocton in very small doses had been used. Many of our cases had small doses of morphine preceding the pernoeton by two to four hours before the barbituric preparation was given. DR. .FRANK W. LYNCH, SAN FRAP;CISCO, CALIF.-Dr. be of interest to every surgeon because it represents work
Maxwell’s subject which is designed
should to save
934
AMERICAN
JOURNAL
OF
OBSTETRICS
AND
GYNECOLOGY
nerve strain following surgery. I do not feel that surgeons, as a rule, have ever given proper attention to the mental distress which attends surgical procedures. There is nothing more distressing than to operate upon a patient for some anatomical lesion and see the patient become neurotic. If this paper accomplishes nothing more than to stimulate work along these linos, it will be well worth while. While these 500 laparotomies were developing, we used barbiturates in more than 900 cases. There were three deaths in the series and in none of them did the barbiturates play any part, This would suggest that the method is safe since three deaths in 500 major cases, more than half of which were hysterectomies, constitutes a very small mortality. I question whether delirium is the right term with reference to some cases, since the picture is one of disordered sleep and does not occur in all. Our recent observations suggest this represents an overdose of the drug. Nearly all patients wake up twenty-four to thirty-six hours after a period of complete amnesia. The protection from nerve shock is the part of this postoperative treatment that appeals most strongly to me. There is no doubt, however, that the treatment lessens abdominal distention and diminishes the need for catheterization. These, in themOne should remember, however, that morphine selves, are more than worth while. even if given only once increases the chance for abdominal distention. DR. MAXWELL (closing).-This investigation was begun four years ago and while the body of the paper is concerned particularly with postoperative medication with’barbiturie acid hypnotics, within the last six months we have been using barbiturates as a preoperative adjunct to the anesthetic and have eliminated preoperative morphine. The results have been most satisfactory, the patient is tranquil and often asleep on entering the operating room, the induction of the anesthetic is facilitated and following the recovery from the postoperative hypnotics there is often complete oblivion of the entire operative procedure. The dosage has been controlled by body weight as I was unable to determine any relation between preoperative metabolic rate, blood-pressure readings, hemoglobin or other laboratory data and the postoperative reaction to the drug. The dosage, which is expressed in total dosage, was’ given over a 72 hour period so that at no time was an excessively large amount of the medication administered. Our recent experience with the most simple barbiturate, namely Barbitol (“VeronaI”) indicates that it compares most favorably with the most complex malynol-urea derivatives.
10. The Induction of Labor. When Is It Indicated? Its Dangers and a Suggestion of a New Method of Procedure, by Dr. Edmund B. Piper, Philadelphia,
Pa.
(This paper was read by title.)
11. The Clinical Importance Dodds, London, England. ber issue.)
of Sex Hormones,
11-a. The Use of an Anterior
Pituitary Uterine
Treatment
of Functional
(By invitation.)
by Professor. E. C. (See page 520, Octo-
Luteinizing Substance in the Bleeding, by Drs. Emil Novak
and Gerald B. Hurd (by invitation), Baltimore, Md. by Dr. Novak.) (See page 501, October issue.)
(Paper
read
DISCUSSION DR. Zondek women,
OTTO SCHWARZ, ST. LOUIS, Mo.-With of the presence of anterior pituitary the relationship of the anterior portion
the discovery hormones in the of the pituitary
by Aschheim and urine of pregnant body to the ovary