546. There is little doubt that poisoning with opium may cause

extravasation, by developing a disposition to apoplexy; but considering the very great rarity of this appearance in persons killed by opium, it may reasonably be questioned whether extravasation can be produced without some predisposition co-operating. The lungs are sometimes found gorged with blood, as in many cases of apoplexy. They were so in the soldier mentioned in the Journal Universel, who died in convulsions. They were in the same state in a patient of Dr. Home, a man who died in the Infirmary here in 1825, four hours after taking two ounces of laudanum in six ounces of whisky; and likewise in the case quoted from Pyl, in which sixty grains of solid opium were taken. But this appearance is not more constant than congestion in the brain. Orfila never found it in dogs, and in three cases I have examined the lungs were perfectly natural. Perhaps they are more usually turgid when death is preceded by convulsions. They were particularly so in the case of the soldier above mentioned, and likewise in another case of the same nature recorded in Rust’s Magazin.[1780] The stomach, as in Knape’s case, is occasionally red, and in the woman mentioned by Lassus, who died after swallowing thirty-six grains, it is said to have been inflamed. But even redness is rare, and decided inflammation probably never occurs. In four cases I have examined, the villous coat was quite healthy; and it was equally so in another related in Knape and Hecker’s Register.[1781] Lividity of the skin is almost always present more or less, and sometimes it is excessive. In one of the cases I examined it was universal over the depending surface of the body. It has been said that the blood is always fluid. This certainly appears to be very generally the case. For example, the blood was fluid in the case of the soldier who died in convulsions, in Dr. Home’s patient, in four adults I have examined, in Dr. Traill’s case of death from morphia, and likewise in Pyl’s case. But at the same time this condition of the blood is not invariable: In the case related in Knape and Hecker’s Register, it was coagulated in the left cavities of the heart; in another related by Petit in Corvisart’s Journal, there were clots in both ventricles;[1782] and in the case of the first infant mentioned in page 549, clots were also found in both ventricles. In Alibert’s case a large fibrinous concretion was found in the heart, clearly showing that the blood had coagulated after death as usual. It appears that the body is often apt to pass rapidly into putrefaction. In one of the cases I examined, although the body had been kept only thirty hours in a cool place in the month of December, the cuticle was easily peeled off, the joints were flaccid, and an acid smell was exhaled. In Réaumur’s case, that of a young man who died in fifteen hours, in consequence of his companions in a drunken frolic having mixed a drachm of opium in his wine, the body soon became covered with large blue stains, and gave out an insupportable odour. A French physician has related in the Journal de Médecine a still more pointed case of a lady who died seven hours after taking a large quantity of laudanum by mistake, and whose body was so far gone in putrefaction fourteen hours after death, that the dissection could not be delayed any longer. The hair and cuticle separated on the slightest friction, and the stomach, intestines, and large vessels were distended with air.[1783] It is doubtful whether this is a constant appearance or not. In one case I examined, the body was free from putrefaction forty-eight hours after death. Although opium is generally believed to suspend all the secretions and excretions but the sweat, instances have been met with where a great collection of urine was found in the bladder after death. In a paper on the signs of death by opium, in Augustin’s Repertorium, it is stated that Welper of Berlin always found the bladder full of urine, and the kidneys gorged with blood, both in man and animals.[1784] I am not prepared to say how far this is a common condition, as the state of the urinary organs is seldom noticed in published cases. In the examination of the dead body unequivocal evidence will sometimes be procured by the discovery of a portion of the poison in the stomach. But it must not always be concluded that opium has not been swallowed, because the sense of smell, chemical analysis, and experiments on animals fail to detect it. For, as previously remarked, the opium may not remain in the stomach after death, though a large quantity was swallowed, and not vomited. This may arise from two causes. It may be all absorbed, as will often happen when it has been taken in the liquid form: or it may be partly absorbed and partly decomposed by the process of digestion. But in one or other of these ways it may certainly disappear, and that in a very few hours only. Several instances to this effect have been already mentioned (pp. 57, 537). These remarks are important, because the fact is generally believed to be the reverse. Dr. Paris, in his work on Medical Jurisprudence, has tended to propagate the misconception, by asserting that in all fatal cases opium may be detected in the stomach;[1785] and in the last edition of his Toxicology, Orfila has overrated the facility and frequency with which an analysis may be conducted successfully. [See p. 538.] At the same time there is no doubt that the poison may sometimes be found in the stomach. In Knape and Hecker’s Register there is the case of a girl who died about eight hours after taking half an ounce of laudanum; and the reporters found that an extract prepared from the contents of the stomach caused deep sleep in frogs, chickens, and dogs, and threw some of them into a comatose state, which proved fatal.[1786] Wildberg has related a very interesting case of a young lady of Berlin, who had been seduced, and finding herself pregnant, swallowed about half an ounce of laudanum in the evening, and died during the night. In this instance the contents of the stomach had a narcotic odour, and their extract when given to a young dog caused excessive sleep, reeling, palsy of the legs, convulsions, and death.[1787] M. Petit has related another case fatal in about ten hours, where the contents of the stomach had the smell of opium; and their alcoholic extract had a bitter taste, and killed guinea-pigs, with symptoms of narcotism.[1788] In a case related by Mayer in Rust’s Magazin, which also proved fatal after an interval of ten hours, the poison, which in this instance was the saffron-tincture, was distinctly detected in the stomach by a strong odour of opium and saffron.[1789] In a case where the patient lived between thirteen and fourteen hours, that of the individual for whose murder Stewart and his wife were executed at Edinburgh, Dr. Ure succeeded in detecting meconic acid in the contents of the stomach, which had been removed by the pump about three hours after the opium was swallowed.[1790] In another case published by Mr. Skae of this city, where death was caused by half an ounce in thirteen hours, without any attempt having been made to evacuate the stomach, the contents of that organ, treated according to the process at p. 534, yielded evident indications of morphia, and obscure evidence of meconic acid.[1791] Lastly, it may be added that in Dr. Traill’s case of poisoning with ten grains of muriate of morphia, when the contents of the stomach were decomposed by magnesia, a solution was obtained from the precipitate by rectified spirit, which, when concentrated, had the strong bitter taste of morphia, and became yellow with nitric acid; and yet the individual survived no less than twelve hours. An important fact, ascertained by MM. Orfila and Lesueur, is that neither opium nor the salts of morphia undergo decomposition by being long in contact with decaying animal matter. Even after many months they may be discovered; at least the putrefaction of the matter with which they are mingled does not add any impediment in the way of their discovery. It is only necessary to observe that the alkaloid may be rendered insoluble by the evolution of ammonia, which separates it from its state of combination.[1792] SECTION IV.—_Of the Treatment of Poisoning with Opium._ The treatment of poisoning with opium, owing partly to the numerous cases that have been published, and partly to the experiments of Orfila on the supposed antidotes,—is now well understood. The primary object is to remove the poison from the stomach. This is proper even in the rare cases in which vomiting occurs spontaneously. It is by no means easy to remove all the opium by vomiting, especially if it was taken in the solid state; for it becomes so intimately mixed with the lining mucus of the villous coat, that it is never thoroughly removed till the mucus is also removed, which is always effected with difficulty. The removal of the poison is to be accomplished in one of three ways, by emetics administered in the usual manner, by the stomach-pump, or by the injection of emetics into the veins. By far the best emetic is the _sulphate of zinc_ in the dose of half a drachm or two scruples, which may be repeated after a short interval, if the first dose fails to act. In order to insure its action it is of great use to keep the patient roused as much as possible,—a point which is often forgotten.—The _sulphate of copper_ has been used by some as an emetic; but it is not so certain as the sulphate of zinc. Besides, as it is a much more virulent poison, it may prove injurious, if retained long in the stomach. In Dr. Marcet’s case the patient, after recovering from the lethargic symptoms, suffered much from pain in the throat and stomach, occasioned probably by the sulphate of copper which he took remaining some time undischarged. _Tartar emetic_, from the uncertainty of its action when given in considerable doses, is even worse adapted for such cases. This is illustrated by a case in the seventh volume of the Medical and Surgical Journal, the same which has already been referred to as exemplifying the occasional occurrence of convulsions and delirium in poisoning with opium. A scruple of tartar emetic was administered to cause vomiting, but to no purpose. When it had remained fifteen minutes, sulphate of zinc was also given, and with immediate effect. But the patient, after recovering from the sopor, was attacked with pains in the stomach and bowels, and with tenesmus, which lasted several days. Emetics should be preferred for evacuating the stomach, provided the case be not urgent. Even then, however, they sometimes fail altogether. The best practice in that case is to endeavour to remove the poison with the stomach-pump; and this in urgent cases should be the first remedy employed. The treatment by the stomach-pump has now become so generally known, that it is unnecessary to describe it particularly. It was recommended in this country by the late Dr. Monro in his lectures; but does not appear to have been tried by him. In 1803 it was first published by Renault in his treatise on the counter-poisons of arsenic; and he had tried it on animals.[1793] But the first person who used it in an actual case of poisoning with opium was Dr. Physick of Philadelphia. He saved the life of a child with it in 1812; and not long afterwards his countryman, Dr. Dorsey, cured two other individuals.[1794] More lately it was again proposed in London by Mr. Jukes, who does not appear to have been acquainted with these prior trials and experiments. Although he cannot be considered in the light of a discoverer, the profession is much indebted to him for having recalled their attention to this treatment, and for having by his success and activity fairly established its reputation. An account will be seen of his apparatus and of several cases in the Medical and Physical Journal for September and November, 1822. In using the stomach-pump care must be taken not to injure the stomach by too forcible suction.—When it is not at hand, Mr. Bryce of this city recommended the substitution of a long tube with a bladder attached. After the stomach has been filled with warm water from the bladder, the tube is to be turned down so as to act upon the contents of the stomach as a syphon. Dr. Alison cured a patient in this way.[1795] Another method of removing opium from the stomach, which has been practised successfully where the patient could not be made to submit to the common treatment, is the injection of tartar-emetic into the rectum. A case is related by Dr. Roe of New York where this treatment proved successful. Fifteen grains in half a gallon of water excited free vomiting, and ten grains more renewed it. Care was taken to insure the discharge of the whole tartar-emetic by a subsequent purgative injection.[1796] The last method for removing opium from the stomach is a desperate one, which can only be recommended when emetics by the mouth have utterly failed, and when a stomach-pump or Mr. Bryce’s substitute, cannot be procured. It is the injection of an emetic into the veins. Tartar-emetic answers best for this purpose, and its effect is almost certain. A grain is the dose. While injecting it, care must be taken by the operator not to introduce air into the vein. 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.