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Of the Patients with Secondary Depression, However, Into the Fold of Medicine

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Of the Patients with Secondary Depression, However, Into the Fold of Medicine 1088 ROBERTS AND KUCK: ALPHAPRODINE AND LEVALLORPHAN NOV. 19, 1960, o.83 better ones with imipramine (Tofranil). Only two are those which help to place the specialty back of the patients with secondary depression, however, into the fold of medicine. To this end, the newer required E.C.T., the rest being successfully treated drugs are undoubtedly playing their part. "Putting by imipramine. psychiatry back into medicine" is a phrase that E.C.T. still remains a most valuable form of we owe to Ayd. However, I consider that it will treatment, but our standard practice is to give a be a long time before we reach an integrated prac- two- to three-week trial of an antidepressant drug tice of both medicine and psychiatry. Perhaps this first. Only if there is no improvement or in the will be achieved both by the general hospitals presence of severe agitated or retarded depression advancing towards psychiatry and the mental with a risk of suicide would we proceed with E.C.T. hospital advancing towards the general hospital. The ultimate period of sickness is probably not In this way a proper community of service will be prolonged by this regimen, which may in fact yield set up without perhaps the series of parallel, and a more stable recovery. Certainly the retarded at times overlapping, facilities that exist at present. patient has no wish to indulge in explorative and Until continuity of treatment is achieved, I think interpretative psychotherapy, and his very inability that our best efforts will always be to some extent to do so may be construed by him as yet another vitiated. culpable failure. Thus the armamentarium of the general physician is here surely extended bv such REFERENCES antidepressant drugs, aided by his knowledge of 1. REES, T. P.: J. ment. Sc., 103: 303, 1957. the natural history of the illness. Perhaps just as 2. TROUTON, D. S. AND EYSENCK, H. J.: In: A handbook of the physician of old abnormal psychology, H. J. Eysenck, ed., Sir Isaac recognized syphilis as the great Pitman & Sons, Ltd., London, 1960 (in press). diagnostic deceiver, so we in the twentieth centurv 3. RAYMOND, M. J. et ai.: Brit. M1. J., 2: 63, 1957. must recognize the multiform nature of depression, 4. CURRAN, D.: Ibid., 2: 515, 1955. 5. HINKLE, L. E., JR. et al.: Psychlosom. Med., 20: 278, 1958. fortified by the better weapons at our disposal. 6. MENNINGER, K.: Theory of psychoanalytic technique In conclusion, I would say that the trends in (Menninger Clinic monograph series, No. 12), Basic Books, Inc., New York, 1958. psychiatry which to me are the most optimistic 7. SHEPHERD, M. et al.: Proc. Roy. Soc. .MIed., 52: 269, 1959. USE OF ALPHAPRODINE AND Adequate relief from pain during labour entails LEVALLORPHAN DURING LABOUR* the use of the more powerful narcotics, the effects of which produce varying degrees of respiratory de- HILDA ROBERTS, F.F.A.R.C.S.t and pression. Alphaprodine (Nisentil) is no exception to MARJORIE A. C. KUCK, M.B., B.S., M.R.C.O.G., this rule, and in doses of 1 mg./kg. it has been Toronto found to reduce both the respiratory rate and the minute volume in adults.3 The value of alphaprodine THE EFFICIENCY and safety of pain-relieving drugs as an obstetrical analgesic has been investigated by administered during labour must be assessed in many workers, as the sole agent, or in combina- the light of extreme sensitivity of fetal respira- tion with scopolamine, or with the barbiturates. tion to narcosis. Barcroft's1 investigations on sheep The general opinion has been that it is a satisfac- revealed the pattern of development of the respira- tory analgesic if given at frequent intervals, since tory control mechanism in the medulla, and its its effect is comparatively short-lived, approximately response to the new environment after birth. an hour in duration.4 Snyder2 and many other workers have contributed further knowledge concerning the reactions of The introduction of narcotic antagonists has led fetal respiration to many extraneous factors. It is inevitably to administration of larger doses of generally accepted that analgesic and anesthetic narcotics and to a tendency to rely on the good agents can depress the respiratory system of the offices of the antagonist drug in the event of fetus and newborn infant, but it is essential to untoward reaction to the narcotic. Levallorphan remember that the respiratory system practically tartrate (Lorfan), the allyl derivative of levodro- always bears the brunt of any injury, direct or moran, is one of the more recently synthesized indirect, incurred during labour and delivery. narcotic antagonists. Studying the mode of action Therefore, in attempting to establish the value of of this narcotic antagonist, Landmesser, Cobb and any analgesic or anesthetic agent, the whole pro- Converse5 offer the hypothesis that narcotic anal- cess of labour must be reviewed with great care. gesics and At times it is extremely difficult to dissociate the antagonists compete for cell sites in the effect of drugs from complications arising from sensory and respiratory centres. They suggest that labour itself, and thus carelessly conceived opinions administration of a narcotic antagonist results in can create unnecessary bias. displacement of the analgesic drug from most of the respiratory and some of the sensory receptor *From the Department of Obstetrics and Gynecology, cells. This results in elimination of the respiratory Women's College Hospital, Toronto. tAssociate Chief of Anesthesia. depression produced by the narcotic. Canad. M. A. J. 1089 Nov. 19,1960, vol. 83 ROBERTS AND KUCK: ALPHAPRODINE AND LEVALLORPHAN The use of alphaprodine and levallorphan in ob- TABLE II.-DISTRIBUTION ACCORDING TO PARITY IN TIHE stetrics has been described by Backner, Foldes and Two GROUPS Gordon,6 and their observations on 200 patients Treated group Control group indicate the effectiveness of this mixture in reduc- Parity (No. of patients) (No. of patients) ing the time of onset of breathing and crying in the Primigravida ............. 74 72 Multipara ................ 125 120 by one of newborn infant. Previous observations X2 = .01 1 d.f. P = .90 us (H.R.7) on the effect of levallorphan on respiratory depression at birth due to meperidine The statistical analysis of data in Table II gives (Demerol) analgesia indicated that the antagonist the probability value of .90, indicating no signifi- was particularly effective when the dose of cant difference in the make-up of the groups in meperidine had been high. this respect. CASE MATERIAL AND METHOD TABLE III.-MATURITY DISTRIBUTION Control group The survey presented here was carried out on Treated group ADuration of pregnancy (No. of patients) (No. of patients) 391 patients. Two groups were established by one of the methods of random selection; the patients in 28- 35 weeks............ 3 9 36 - 38 " ............. 27 27 a the treated group numbered 199 and received 39 - 42 " ............. 143 134 mixture of alphaprodine and levallorphan while Over 42 " ............. 26 22 X2 = 4.244 3 d.f. P = .20 those in the control group totalled 192 and were given alphaprodine only. The drugs were The patients have been grouped according to administered in accordance with the following maturity, and the distribution in the treated and instructions: control groups has been examined. The result is not When labour was well established, the uterine significant, P = .20. Thus without subdividing contractions regular and causing definite discom- the treated and control groups according to parity fort, and the cervix at least two fingers dilated or maturity it seems reasonable to compare them 1. The patients in the treated group received as a whole, and the results produced by the aid- alphaprodine 60 mg., levallorphan 1 mg. admini- ministration of alphaprodine and levallorphan can stered intramuscularly and repeated at 2-hourly be validly assessed. intervals until the 2nd stage of labour was reached. The second and subsequent injections were delayed RESULTS if the patient did not require further medication after the 2-hourly interval. The primary aim of this survey was to estimate with 2. Patients in the control group received alpha- the value of combining levallorphan alpha- reduce or anoxia in the prodine 60 mg. given intramuscularly and repeated prodine in order to prevent other points have as in the treated patients. newborn. However, important been recorded, such as relief of pain, length of labour, and any complications arising during the TABLE I.-ANESTHETIC TECHNIQUE USED FOR DELIVERY third stage. A specially designed proformata re- Treated group Control group corded the necessary data concerning the patient's Anesthetic technique (No. of patients) (No. of patients) progress throughout labour, and the condition of Local infiltration of perineum 42 34 the mnother and infant after delivery. The observa- Pudendal nerve block ....... 21 13 tions of the labour floor staff and those of the Epidural block ............. 25 29 Subarachnoid block 1 0 mother herself were taken into consideration. Care- Nitrous oxide and oxygen .. 84 73 ful note was made of the condition of the infant Nitrous oxide, oxygen and trichlorethylene 33 29 at birth and of his condition in the nursery the Cyclopropane 36 38 next day. Cyclopropane and ether. 0 1 Halothane 2 3 X2 = 2.684 8 d.f. P = .90 Relief of Pain There were three classifications: (i) Good-indi- It will be noticed that the total number of cating an unqualified success. (ii) Fair-when the anesthetics listed in Table I is greater than the relief was partial at some time during labour but number of patients in the survey. This is because the general impression was quite good. (iii) a large proportion of mothers delivered under Poor-poor or no relief at all.
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