The next object in conducting the treatment of poisoning with opium is to keep the patient constantly roused. This alone is sufficient when the dose is not large, and the poison has been discharged by vomiting; and in every case it forms, next to the evacuation of the stomach, the most important of the treatment.
The best method of keeping the patient roused is to drag him up and down between two men, who must be cautioned against yielding to his importunate entreaties and occasional struggles to get free and rest himself. For the sopor returns so rapidly, that I have known a patient answer two or three short questions quite correctly on being allowed to stand still, and suddenly drop the head in a state of insensibility while standing. The duration of the exercise should vary according to circumstances from three, to six, or twelve hours. When he is allowed at length to take out his sleep, the attendants must ascertain that it is safe to do so by rousing him from time to time; and if this should become difficult, he must be turned out of bed again and exercised as before.
It appears from some cases published not long ago by Mr. Wray[[1797]] and Dr. Copland,[[1798]] and more lately also by Dr. Bright,[[1799]] that the most insensible may be roused to a state of almost complete consciousness for a short time, by dashing cold water over the head and breast. This treatment can never supersede the use of emetics: and as its effect is but temporary, it ought not to supersede the plan of forced exercise. But it appears to be an excellent way to insure the operation of emetics. If the emetic is about to fail in its effect, cold water dashed over the head restores the patient for a few moments to sensibility, during the continuance of which the emetic operates. Dashing cold water over the head may perhaps be dangerous in the advanced stage, when the body is cold and the breathing imperceptible; but the most desperate remedies may be then tried, as the patient is generally in almost a hopeless state. In one of the cases mentioned by Dr. Bright from the experience of Mr. Walne, complete recovery was accomplished, mainly by cold affusion of the head, where there appeared reason to believe that more than an ounce and a half of laudanum had disappeared from the stomach before evacuating remedies were used.—This treatment seems to have been first proposed in 1767 by a German physician, Dr. Gräter.[[1800]] A suggestion, which is probably an improvement, has been recently made by Dr. Boisragon of Cheltenham, to alternate the use of cold with that of warm water, applied to children in the shape of warm bath, and to adults in the form of warm-sponging and the foot-bath. The alternating impression of heat and cold may act better as a stimulant than either agent singly; and the occasional employment of heat prevents the risk of collapse from too continuous exposure to cold. Dr. Boisragon saved in this way two cases in very unpromising circumstances.[[1801]]
In some cases internal stimulants have been given with advantage, such as assafœtida, ammonia, camphor, musk, &c. It is always useful to stimulate the nostrils from time to time, by tickling them or holding ammonia under the nose; but the application should be neither frequent nor long continued, as the ammonia may cause deleterious effects when too freely inhaled. Pulling the hair and injecting water into the ears are also powerful modes of rousing the patient.
Venesection has been recommended and successfully used by some physicians. If the stomach be emptied, and the patient kept roused, as may almost always be done when means are resorted to in time, venesection will be unnecessary. Sometimes, however, when the pulse is full and strong, it may be prudent to withdraw blood; and it certainly appears that in most cases where this remedy has been employed the sensibility began to return almost immediately after. This is very well shown in a case of poisoning with opium related by Mr. Ross[[1802]] in the Edinburgh Medical Journal, in another described in the same journal by Mr. Richardson,[[1803]] and also in two cases of poisoning with acetate of morphia mentioned in a former page. Sometimes, on the contrary, it has seemed injurious, probably because it was not had recourse to till the patient was moribund. It is a sound general rule that blood-letting ought not to be resorted to until the poison is thoroughly removed from the stomach; for it favours absorption. And yet facts are not wanting to show that this rule, now generally admitted since the researches of Magendie on absorption, is not infallible. Dr. Young of the United States has given the particulars of a case where imperturbable coma was formed, together with puffing stertorous respiration, in consequence of an ounce of laudanum having been swallowed,—and where recovery took place, without the poison having been removed at all, simply under the employment of three blood-lettings to the amount of twenty-eight ounces altogether, of cold to the head, and of sinapisms to the legs.[[1804]]
Galvanism has been sometimes resorted to, but seldom with decided advantage. I saw it tried, with dubious utility, a few years ago in an urgent case which was treated in the Edinburgh Infirmary. Six ounces of laudanum had been swallowed, but most of it was removed in three-quarters of an hour by the stomach-pump. A stage of deep sopor followed, after which sensibility was restored, and maintained for four hours by forced exercise. A state of pure and extreme coma then ensued, during which galvanism was for some time of great service, in rousing the patient. Gradually, however, it ceased to have any effect of the kind. Recovery took place eventually under the use of external and internal stimuli. Mr. Erichsen of the University-College Hospital, London, has related a case, in which electro-magnetism was of undoubted service. The usual symptoms had been occasioned by an ounce of laudanum. The poison had been withdrawn by the stomach-pump, when unavailing attempts were made to restore sensibility by means of various stimulants. At length several electro-magnetic shocks were passed from the forehead to the upper part of the spine, with the effect of speedily eliciting signs of consciousness; in twenty minutes the patient could answer questions and walk a little; and eventually complete recovery took place.[[1805]]
In desperate circumstances artificial respiration may be used with propriety. After the breathing has been almost or entirely suspended the heart continues to beat for some time; and so long as its contractions continue, there is some hope that life may be preserved. But it is essential for the continuance of the heart’s action, that the breathing be speedily restored to a state of much greater perfection than that which attends the close of poisoning with opium. It is not improbable that the only ultimate cause of death from opium is suspension of the respiration, and that if it could be maintained artificially so as to resemble exactly natural breathing, the poison in the blood would be at length decomposed and consciousness gradually restored. The following is an interesting example by Mr. Whately, in which artificial respiration proved successful. A middle-aged man swallowed half an ounce of crude opium and soon became lethargic. He was roused from this state by appropriate remedies, and his surgeon left him. But the poison not having been sufficiently discharged, he fell again into a state of stupor; and when the surgeon returned, he found the face pale, cold and deadly, the lips black, the eyelids motionless, so as to remain in any position in which they were placed, the pulse very small and irregular, and the respiration quite extinct. The chest was immediately inflated by artificial means, and when this had been persevered in for seven minutes, expiration became accompanied with a croak, which gradually increased in strength till natural breathing was established. Emetics were then given, and the patient eventually recovered.[[1806]]—Dr. Ware of Boston (U. S.) has more lately described another case, where artificial respiration was employed with marked advantage, and would probably have saved the patient’s life in very unfavourable circumstances, but for the disease on account of which the opium was given.[[1807]]—Another has been lately described by Mr. C. J. Smith of Madras. The patient was not seen for four hours, and received no benefit from the ordinary remedies during the next hour and a half. Artificial respiration was then resorted to and maintained for nearly five hours with an hour of interval; and this measure certainly seems to have brought the case to a favourable termination under most unpromising circumstances.[[1808]]—Dr. Watson of Glasgow has mentioned to me the particulars of an instructive base in the person of an infant three weeks old, in whom, after the breathing had stopped and the heart had nearly ceased to beat, the occasional inflation of the chest with the breath at intervals of two or three minutes restored for a time the action both of the heart and lungs, and eventually accomplished recovery. On physiological principles it appears probable, that this simple mode of procedure may prove more frequently successful than might at first be thought.
It would be a fruitless task to examine into the merits of the numerous antidotes which have from time to time been proposed for poisoning with opium. Professor Orfila has examined many of them with great care, such as vinegar, tartaric acid, lemonade, infusion of coffee, decoction of galls, solution of chlorine, camphor, diluents; and he has found them all useless before the poison is expelled from the stomach, with the single exception of decoction of galls. As he remarked that this fluid throws down the active principles of an infusion of opium, and subsequently found that such a mixture acts more feebly on the animal system than the opiate infusion itself, he thinks the decoction of galls may with propriety be used as an imperfect antidote, till the poison can be evacuated from the stomach.[[1809]] His experiments, however, do not assign to it very material activity as a remedy; and certainly the whole efforts of the physician ought in the first instance to be directed to the removal of the opium, and to keeping the patient roused. When the opium has been completely removed, the vegetable acids and infusion of coffee have been found useful in reviving the patient, and subsequently in subduing sickness, vomiting, and headache; but till the poison is completely removed the administration of acids is worse than useless, provided the opium was given in the solid state, because its solution in the juices of the stomach is accelerated. It has been maintained that iodine, chlorine, and bromine are all antidotes for poisoning with the vegetable alkaloids.[[1810]] Some notice will be taken of this statement in the chapter on Nux Vomica. It has also been lately alleged in the United States that opium has no effect when given with acetate of lead; and an hospital case is reported as having occurred at New York, where the poison was swallowed in this way to the extent of thirty grains, without any injurious effect.[[1811]] There must have been some mistake here, however. When given with acetate of lead in medicinal doses, opium exerts its usual sedative and anodyne action; and indeed there is no chemical or physiological reason why it should not do so.
CHAPTER XXVIII.
OF POISONING WITH HYOSCYAMUS, LACTUCA, AND SOLANUM.
Of Poisoning with Hyoscyamus.—Of the narcotic poisons none bears so close a resemblance to opium in its properties as the hyoscyamus or henbane. Several species are poisonous; but the only one that has been examined with care is the H. niger, from which the extract of the apothecary is prepared.