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Use of dilaudid in gynecology
USE OF DILAUDID
IN GYNECOLOGY
A PRELIMINARY
REPORT
G. L. MOENCH, M.D., Associate Professor of GynecoIogy,
N. Y. Post-Graduate NEW
0
P.A.C.S. Medical School of Columbia University
YORK CITY
NE of the most important, if not the After aI1, there are addicts to caffeine, most important, drug avaiIabIe to aspirin, etc., drugs which in the true sense the physician is opium with its are non-habit forming. FinaIly true addicderivatives, especiahy morphine. The adtion can onIy be measured by the deveIopvantages which particuIarIy morphine ment of toIerance and the severity of the possesses are, however, tempered by some withdrawal symptoms. very undesirabIe side actions inherentIy Because of the favorabIe resuIts reported possessed by this otherwise so vaIuabIe in the Iiterature we decided to try out drug. More important perhaps than a11 diIaudid on the gynecological servive of the other disadvantages is the great tendency New York Post Graduate HospitaI and to habit formation based to a Iarge extent MedicaI SchooI (CoIumbia University). on the euphoria which foIIows its adminisOur first trials were faiIures. We used the tration. Preoperativeiy and postoperativeIy recommended dose of >$g g r. diIaudid again the paraIyzing action on intestinal (equivaIent to about 36 gr. morphine) and peristaIsis is a most disagreeabIe secondary aIthough this dose preoperativeIy and posteffect. In many cases aIso the cIose associaoperativeIy is reported as being sufficient, tion of the anaIgesic and soporific actions found it entireIy insufficient for our are to be decried. AIthough in some patients. Perhaps this was due to our type instances this quaIity may be desirabIe, it is of patients, mainIy excitabIe Jewish women, certainIy not so under other conditions. who are used to “getting a needIe” and Because of these facts substitutes for being put to sIeep. For such patients anymarphine, especiaIIy derivatives of opium thing short of this wiI1 be and indeed often or morphine, have been searched for which is, unsatisfactory. wouId be as free as possibIe from undesirAfter this most inauspicious beginning, abIe secondary actions. I tried a second series of about 24 cases One of the most promising of such derivawhen I had charge of the service, and in tives seems to be diIaudid (dihydromorjudging the resuIts obtained in this smal1 phinone hydrochloride) which has a greater series, I wouId say that diIaudid merits a anaIgesic than soporific effect and which, tria1 with a Iarger number of carefuhy according to reports in the Iiterature which checked-up patients. I can corroborate, is not foIIowed by I at first used hypodermic injections of the euphoria resuhing from the use of 31s gr. diIaudid, combined in the same morphine. Th us whiIe diIaudid is unway as the morphine had been, with doubtedIy habit forming to a certain >{se gr. atropine one-haIf hour before degree, it must be Iess so than morphine on operation. The narcotizing effect of this this account aIone. The question of habit dose was ample, but we did have some formation of course must be carefuIIy respiratory disturbances, especiaIIy at the investigated. In so new a drug as diIaudid beginning of anesthesia. I purposeIy quote it is scarceIy possibIe to give a definite no figures as the series is too smaI1 to answer because the simpIe addiction to a caIcuIate percentages. In evaIuating the drug does not mean true habit formation. respiratory depressive effect of the diIaudid 310
NEW SERIESVOL. XXX,
No. z
Moench- _ -Dilaudid
in these cases, one must take into consideration that I found the diIaudid to exert its fuII effect decidedIy sooner than the morphine. Since now some of the patients are cahed for operation sooner than expected, an injection of morphine might not yet have taken hoId as much as the faster acting dilaudid, thus giving more respiratory depression than wouId occur, other things being equal However I feIt despite a11this that dilaudid was to be given in as smaI1 a dose as possibIe. I therefore for the rest of my cases used ii0 gr. diIaudid, and this seemed to be about the Iowest effective and best dose. As far as the patients were concerned, I could notice no difference during operation between those who had received morphine and those who had had diIaudid. PostoperativeIy, however, a decided difference was noticed in the dilaudid cases. Except in difficuIt operations a11the women who had received diIaudid had Iess vomiting and distention and compIained less of “gas” and had a softer and flatter abdomen than those patients who had received morphine. This was a great comfort to the patients. Postoperatively I aIso used diIaudid mainIy by injection, and again tic, gr., since smaIIer doses and aIso the suppositories of $54 gr. were not sufficient to comfort our type of case unIess combined with some other hypnotic, a procedure I did not adopt, because I did not want to cIoud the picture I was attempting to appraise. I have the impression, and with so smaI1 a series it can be but an impression, that especiaIIy in the perinea1 pIastic cases
American
Journ,ri
of Surgerv
3”
the patients were abIe to voIuntariIy empty their bIadder sooner after dilaudid than after morphine. This is a most vaIuabIe point, if it can be corroborated. In order to evaIuate more specifically the question of postoperative distention, I ran a second series of about an equa1 number of cases when on service again. Instead of using diIaudid, however, I used morphine, but empIoyed no lap pads at a11 in the abdomen and reduced a11 intraabdomina1 manipulations to the absoIute minimum. As a result, these patients showed aImost the same Iack of distention as those treated preoperativeIy with dilaudid. The ConcIusion, of course, is obvious. hlinimum intra-abdominal manipulation and dilaudid preoperativeIy wiI1 best avoid postoperative abdomina1 distention. I also tried dilaudid in patients with peb-ic inflammation. Here I couId see no advantage of diIaudid over morphine. SUMMARY
Summarizing, I wouId say that dilaudid in proper dosage is an adequate substitute for morphine. It is about three to four times as strong as morphine in its narcotizing effect, and perhaps five times as strong in analgesic action. With some types of patients this Iack of soporific effect may be a detriment. DiIaudid, to judge from my smaII series, inhibits intestina1 peristalsis much Iess than morphine and appears to affect the bIadder similarly. In conclusion, the we11 known vaIue of minimum intraabdomina1 manipuIation may again be stressed.
IN GYNECOLOGY
A PRELIMINARY
REPORT
G. L. MOENCH, M.D., Associate Professor of GynecoIogy,
N. Y. Post-Graduate NEW
0
P.A.C.S. Medical School of Columbia University
YORK CITY
NE of the most important, if not the After aI1, there are addicts to caffeine, most important, drug avaiIabIe to aspirin, etc., drugs which in the true sense the physician is opium with its are non-habit forming. FinaIly true addicderivatives, especiahy morphine. The adtion can onIy be measured by the deveIopvantages which particuIarIy morphine ment of toIerance and the severity of the possesses are, however, tempered by some withdrawal symptoms. very undesirabIe side actions inherentIy Because of the favorabIe resuIts reported possessed by this otherwise so vaIuabIe in the Iiterature we decided to try out drug. More important perhaps than a11 diIaudid on the gynecological servive of the other disadvantages is the great tendency New York Post Graduate HospitaI and to habit formation based to a Iarge extent MedicaI SchooI (CoIumbia University). on the euphoria which foIIows its adminisOur first trials were faiIures. We used the tration. Preoperativeiy and postoperativeIy recommended dose of >$g g r. diIaudid again the paraIyzing action on intestinal (equivaIent to about 36 gr. morphine) and peristaIsis is a most disagreeabIe secondary aIthough this dose preoperativeIy and posteffect. In many cases aIso the cIose associaoperativeIy is reported as being sufficient, tion of the anaIgesic and soporific actions found it entireIy insufficient for our are to be decried. AIthough in some patients. Perhaps this was due to our type instances this quaIity may be desirabIe, it is of patients, mainIy excitabIe Jewish women, certainIy not so under other conditions. who are used to “getting a needIe” and Because of these facts substitutes for being put to sIeep. For such patients anymarphine, especiaIIy derivatives of opium thing short of this wiI1 be and indeed often or morphine, have been searched for which is, unsatisfactory. wouId be as free as possibIe from undesirAfter this most inauspicious beginning, abIe secondary actions. I tried a second series of about 24 cases One of the most promising of such derivawhen I had charge of the service, and in tives seems to be diIaudid (dihydromorjudging the resuIts obtained in this smal1 phinone hydrochloride) which has a greater series, I wouId say that diIaudid merits a anaIgesic than soporific effect and which, tria1 with a Iarger number of carefuhy according to reports in the Iiterature which checked-up patients. I can corroborate, is not foIIowed by I at first used hypodermic injections of the euphoria resuhing from the use of 31s gr. diIaudid, combined in the same morphine. Th us whiIe diIaudid is unway as the morphine had been, with doubtedIy habit forming to a certain >{se gr. atropine one-haIf hour before degree, it must be Iess so than morphine on operation. The narcotizing effect of this this account aIone. The question of habit dose was ample, but we did have some formation of course must be carefuIIy respiratory disturbances, especiaIIy at the investigated. In so new a drug as diIaudid beginning of anesthesia. I purposeIy quote it is scarceIy possibIe to give a definite no figures as the series is too smaI1 to answer because the simpIe addiction to a caIcuIate percentages. In evaIuating the drug does not mean true habit formation. respiratory depressive effect of the diIaudid 310
NEW SERIESVOL. XXX,
No. z
Moench- _ -Dilaudid
in these cases, one must take into consideration that I found the diIaudid to exert its fuII effect decidedIy sooner than the morphine. Since now some of the patients are cahed for operation sooner than expected, an injection of morphine might not yet have taken hoId as much as the faster acting dilaudid, thus giving more respiratory depression than wouId occur, other things being equal However I feIt despite a11this that dilaudid was to be given in as smaI1 a dose as possibIe. I therefore for the rest of my cases used ii0 gr. diIaudid, and this seemed to be about the Iowest effective and best dose. As far as the patients were concerned, I could notice no difference during operation between those who had received morphine and those who had had diIaudid. PostoperativeIy, however, a decided difference was noticed in the dilaudid cases. Except in difficuIt operations a11the women who had received diIaudid had Iess vomiting and distention and compIained less of “gas” and had a softer and flatter abdomen than those patients who had received morphine. This was a great comfort to the patients. Postoperatively I aIso used diIaudid mainIy by injection, and again tic, gr., since smaIIer doses and aIso the suppositories of $54 gr. were not sufficient to comfort our type of case unIess combined with some other hypnotic, a procedure I did not adopt, because I did not want to cIoud the picture I was attempting to appraise. I have the impression, and with so smaI1 a series it can be but an impression, that especiaIIy in the perinea1 pIastic cases
American
Journ,ri
of Surgerv
3”
the patients were abIe to voIuntariIy empty their bIadder sooner after dilaudid than after morphine. This is a most vaIuabIe point, if it can be corroborated. In order to evaIuate more specifically the question of postoperative distention, I ran a second series of about an equa1 number of cases when on service again. Instead of using diIaudid, however, I used morphine, but empIoyed no lap pads at a11 in the abdomen and reduced a11 intraabdomina1 manipulations to the absoIute minimum. As a result, these patients showed aImost the same Iack of distention as those treated preoperativeIy with dilaudid. The ConcIusion, of course, is obvious. hlinimum intra-abdominal manipulation and dilaudid preoperativeIy wiI1 best avoid postoperative abdomina1 distention. I also tried dilaudid in patients with peb-ic inflammation. Here I couId see no advantage of diIaudid over morphine. SUMMARY
Summarizing, I wouId say that dilaudid in proper dosage is an adequate substitute for morphine. It is about three to four times as strong as morphine in its narcotizing effect, and perhaps five times as strong in analgesic action. With some types of patients this Iack of soporific effect may be a detriment. DiIaudid, to judge from my smaII series, inhibits intestina1 peristalsis much Iess than morphine and appears to affect the bIadder similarly. In conclusion, the we11 known vaIue of minimum intraabdomina1 manipuIation may again be stressed.