External

Hot fomentations or poultices sprinkled with laudanum are often applied to painful parts; but probably it is the heat and not the opium which relieves the pain. Linimentum Opii B. P., tincture of opium and soap liniment, equal parts, rubbed into the skin diminishes the pain of chronic rheumatism and myalgia; probably in this case the friction is more efficacious than the opium. Locally applied to sores and ulcers, it may soothe the pain due to them. The ointment of nutgall and opium B. P., powdered opium, 2; gall ointment, 27; will often relieve the pain of piles and anal fissures, especially if a mild laxative is given by the mouth. The warm decoction of the white poppy is used in England as an anodyne fomentation. Poppy capsules (Papaveris Capsulae, B. P.) are obtained from the Papaver somniferum (nat. ord. Papaveraceae) which is cultivated in England. A ten per cent. decoction made from these contains but a small and uncertain amount of opium, and its beneficial effects, if any, are doubtless due to its warmth.

Internal

Stomach. - Morphine is of great service for the pain of gastric ulcer, cancer, or even for simple painful dyspepsia. A solution of morphine in water, 1 in 480; dose, 1 fl. dr.; 4. c.c. is preferable to opium, as that may aggravate the indigestion. Morphine is frequently combined with preparations of bismuth, and taken immediately before or after meals. Many forms of vomiting are relieved by morphine, because it decreases pain, peristalsis, and excessive secretion.

Intestines. - Opium is invaluable for stopping many varieties of diarrhoea. If they will yield to any treatment, opium is most likely to be successful. Intestinal colic, being due to irregular, excessive peristaltic action, is generally relieved by opium, - and, indeed, so is abdominal pain of all sorts. In all inflammatory conditions of the peritoneum full doses of opium must be given, the object being so to paralyze the intestinal movements as to prevent the peritoneal surfaces rubbing against each other. This method is quite likely to result in extensive peritoneal adhesions. It is the great mainstay in perityphlitis, acute peritonitis, and after operations or wounds in the abdomen. Opium is far preferable to morphine for abdominal cases; if they are severe, it must be boldly pushed, the patient being kept just drowsy, with slightly contracted pupils; and it often does not matter if the bowels are not open for a week, or even more. The more recent and better practice, however, is to keep the bowels slightly open by the use of the salines. Morphine should be given sparingly, if an abdominal operation is impending, for it masks the symptoms.

Heart. - Much skill is required to give opium properly in heart disease. The hypodermatic injection of morphine is, on the whole, to be preferred to opium. The great indication for it is when cardiac pain and distress keep the patient awake. Often it acts like a charm, a quiet refreshing sleep being the result of a single injection. No doubt it is a cardiac depressant, but we have to set against this the exhaustion of pain and insomnia. Still, if the patient is very ill, these two factors must be carefully balanced. It is quite probable that in small doses administered hypodermatically morphine is a cardiac stimulant. It likewise often relieves the pain of aneurism and intra-thoracic growths. Its depressant effect may be to some extent counterbalanced by combining belladonna with it.

Vessels. - Opium is an excellent haemostatic. It is probably efficient after absorption, but its great value is in gastric and intestinal haemorrhage, when it acts partly by stopping peristaltic movements. An excellent form in which to give it is the Pilula Plumbi cum Opio, B. P., powdered opium, 1; lead acetate, 6; dose, 2 to 4 gr.; .12 to .25 gm. It is also very useful in haemoptysis, for it acts as a haemostatic, and relieves cough.

Respiration. - It will be remembered that opium depresses the respiratory centre; therefore, by diminishing the activity of the centre for the reflex act of coughing, it will often alleviate the distressing symptoms, but it is only justifiable to give it when the irritation which reflexly sets up a cough is irremovable, as in intra-thoracic growth or aneurism, or when there is little or no lividity and yet the cough is violent, as is often the case in pleurisy. The liability to lividity and asphyxia in many diseases attended with cough must never be forgotten. Thus opium is quite inadmissible in the last stages of bronchitis and pneumonia, and, as a rule, in even the earlier stages of these diseases other means of relieving the cough should be tried first; and if opium is given, it must be administered with great caution and judgment. But in pneumonia without lividity it is very useful, lessening cough and pain, and promoting sleep. A " linctus opiatus," a favorite remedy, is often given at night when a cough keeps the patient awake. It may consist of tincture of opium, 1; diluted sulphuric acid, 1; treacle, 15; water to 30 parts. The object of the treacle is to soothe the pharynx locally. Opium must also be given cautiously for the relief of the symptom asthma, as there is in this disease a great liability to the growth of a permanent opium habit. Codeine is preferable to all other preparations and alkaloids of opium for relief of cough in pulmonary diseases. An insufflation of one-half grain .03 gm. of morphine acetate with 5 gr. .30 gm. of starch is of great use when blown on to a larynx painful from organic disease. A grain .06 gm. of boric acid or of iodoform is often added to each insufflation.

Nervous system - Brain. - It is in its action on this organ that the marvellous value of opium is seen, its great function being to relieve pain and to produce sleep when that is prevented by pain. For these purposes it is best given hypodermatically as morphine, for that acts more quickly, more certainly, and is less liable to produce indigestion and excitement than opium. Many prefer to inject a solution containing 1/50 gr. .0013 gm. of atropine sulphate to each 1/2 gr. .03 gm. of morphine salt, for by so doing the liability of morphine to upset the stomach and bowels is diminished and its efficacy as an anodyne is not sensibly lessened. It would be a long list to give all the diseases the pain of which can be relieved by morphine; cancer and fractures are typical instances. Morphine is very valuable for the insomnia of acute diseases; but it should never be prescribed for habitual sleeplessness, for fear the patient should contract the habit of opium taking - unless the disease causing the insomnia is incurable, when the use of opium is quite justifiable. It should not be given in gout, for that is often accompanied by granular kidneys; nor for hysteria, for often it does not relieve hysterical pains, and an opium habit may be formed. It is especially useful in renal and biliary colic, and for the after-pains of a confinement. In these cases it relieves the pain partly from its power as an anodyne, and also because by its paralyzing effect on unstriped muscle it relaxes the muscular contraction. This property also makes it valuable in some cases of spasmodic stricture of the urethra. It may be given as a sedative in delirium tremens and some forms of mania, but often such large doses are required that its use is not justifiable. Patients suffering great pain can take enormous doses without any symptoms of poisoning.

Spinal cord. - It has been used for pains of locomotor ataxia and occasionally in convulsive diseases, but without much success.

Kidneys. - It should always be remembered that morphine is excreted with difficulty, if the kidneys are diseased. There are several cases recorded in which persons suffering from Bright's disease have been killed by quite small doses of opium. But it often so markedly relieves uraemic dyspnoea, uraemic insomnia, the cardiac dyspnoea which may complicate Bright's disease, and even uraemic convulsions, that it may be justifiable to inject 1/6 of a grain .01 gm. of a morphine salt subcutaneously into a patient suffering from one of these conditions and run the slight risk there is of poisoning him. But it is clear that this treatment must be adopted very cautiously.

Skin. - Combined with ipecacuanha as in Dover's powder, opium is commonly given as a mild diaphoretic, in cases of slight inflammatory disorder, such as a common cold.

Metabolism. - Opium is administered to persons suffering from diabetes, and the amount of sugar in the urine certainly diminishes and the patient's general health improves but, however, codeine is preferable. Opium can, in the opinion of many, control all varieties of inflammation, therefore it is given for a cold in the head, for cystitis, pleurisy, etc. Occasionally persons taking morphine suffer from retention of urine. We have indicated the occasions on which opium and morphine are respectively preferable.

Heroine (not official) is morphine diacetic ester, which as a hydrochlorate is freely soluble in water and alcohol. It generally produces no disagreeable symptoms, beyond headache, and is said not to give rise to habituation. It occasionally produces violent and uncontrollable vomiting. Since it diminishes the sensitiveness of the respiratory centres to an excess of carbon dioxide in the blood (Wood) it is useful in some forms of dyspnoea. It is of great value in quieting cough. The dose is 1/20 to 1/5 gr.; .003 to .012 gm.

Dionine (not official) is morphine mono-ethyl ester hydro-chlorate, which is readily soluble in water. It is somewhat hypnotic, and like heroine is useful to allay cough. It is said to check night sweats. The dose is 1/6 to 1/4 gr.; .01 to .015 gm.

Peronine (not official) is morphine benzylic ester hydro-chlorate, soluble in water. This is hypnotic, producing sound sleep without previous excitement, and is useful in allaying the cough of pulmonary tuberculosis, chronic bronchitis and pertussis. Dose, 1/150 gr.; .0004 gm. in pill.

Toxicology

Acute poisoning. - There may be slight preliminary excitability; but soon drowsiness sets in. This is followed by incapacity for exertion, sleep, and finally deep coma. The pupils are minutely contracted. At first the patient can be roused; but soon no stimulation will do this. Reflex action is abolished. The skin is cold, the face and lips are livid, and toward the end bathed in sweat. The pulse is weak and slow. The respiration becomes slower and more irregular; and last it is stertorous, and the patient dies from asphyxia.

Diagnosis of poisoning by Opium. - I. From Alcoholic poisoning. - Often very difficult, especially if, as commonly happens, the man poisoned with opium has taken alcohol or had it given to him. The pupils are more contracted in opium poisoning. The patient is more easily roused in alcohol poisoning. Examine the urine for morphine and alcohol. Get a careful history. 2. From cerebral hemorrhage. - If this is in the pons Varolii, the pupils may be very contracted and the diagnosis difficult, but look carefully for local paralysis. Usually cerebral haemorrhage takes place into the internal capsule, and then the face and the limbs on the opposite side are paralyzed. If the haemorrhage is a small one, and especially if it is in the pons, the temperature may be raised; if it is a very large one, the temperature falls for the first few hours, but may rise subsequently. If the pupils are unequal, the case is one of cerebral haemorrhage. 3. From Carbolic Acid poisoning, in which there may be coma and contracted pupils. The acid produces white patches in the mouth, and the odor is characteristic. 4. From Chloroform and Ether poisoning, by the odor of the breath and of the vomited matters. 5. From uraemia, by the signs of Bright's disease, especially albuminuria. 6. From diabetic coma, by the smell of the breath and the glycosuria. 7. From the comatose stage of an epileptic fit, by the history, the dilatation of the pupils, and the fact that the lividity does not deepen. 8. From the same stage of a fit in general paralysis of the insane and other nervous diseases, by the same symptoms.

Post-mortem

The appearances after death from Opium poisoning are those always found after fatal asphyxia.

Treatment

Wash out the stomach. This should be repeated at frequent intervals, because the morphine, which has been absorbed, is excreted into the stomach. Give prompt emetics (see p. 139), as apomorphine hydro-chlorate subcutaneously. Always arouse the patient by walking him about, flapping him with a towel, pinching him, applying the faradic current, and putting ammonia to the nose; a pint 500. c.c. of strong coffee should be injected into the rectum, 1/20 gr. .003 gm. of atropine sulphate given subcutaneously, or 30 minims, 2. c.c. of tincture of belladonna by the mouth, repeated every quarter of an hour. Instances of recovery from opium poisoning followed by death from the belladonna or atropine, used as an antidote, have been observed. Great caution must be exercised if this antidote be used,- if indeed it should be employed at all. If the breathing is very difficult, artificial respiration should be employed. Oxygen or amyl nitrite inhalations may be used. The treatment must be kept up for several hours if necessary. Potassium permanganate, well diluted, has been successfully used in an amount equal to that of the alkaloid ingested; it almost immediately destroys the latter, through its chemical action. It is claimed that it can act upon the poison when in the blood so that a hypodermatic injection of it even for some hours after its ingestion may afford relief. Wood, however, has found that its hypodermatic injection does no good in morphine poisoning. The reports have been so generally favorable that potassium permanganate should be used immediately.

Chronic Morphine poisoning. - As many persons administer this drug sub-cutaneously to themselves, chronic poisoning is very common. The symptoms are that the patient loses all sense of right and wrong, he will lie and thieve in the most degrading way, especially if his desire is to obtain the drug, and absolutely no statement that he makes can be trusted. He neglects his work, and lets his business go to ruin. He wastes and becomes anaemic, he suffers from loss of appetite, indigestion, dry mouth, sluggish bowels, and a foul tongue. The nails are brittle, the skin is dry, the hair turns gray early, and falls out. There is sexual impotence, no erections take place, no semen is secreted, there is amenorrhoea, and the flow of milk is stopped, but there is polyuria. The pupils are small, there is loss of muscular power, slight ataxia and tremor in severe cases. The arm, leg, or portions of the body are scarred with marks of the needle. Even 20 gr. 1.20 gm. of morphine may be taken each day.

Treatment

The patient must be isolated and carefully watched so that he gets no morphine (he often eludes or bribes his nurse); it should be diminished gradually, so that at the end of a fortnight he is taking none. If it is stopped suddenly there may be serious collapse and wild delirium. Relapses are very common, and a complete cure after a relapse is very rare. No reliance can be placed upon any of the advertised cures for the morphine habit; most contain morphine and the remainder are useless. The patient on entering an institution for his cure must be most thoroughly and carefully searched so that he shall not be possessed of a supply sufficient to keep him comfortable during his treatment.

Antagonism

Atropine. - Atropine see p. 373 is a valuable antidote to morphine, because it powerfully stimulates the respiratory centre. It also stimulates the cerebral convolutions and intestinal peristalsis, both depressed by morphine. It appears to be antagonistic to opium in other particulars, but is not really so. Thus, although it prevents perspiration and dilates the pupil, these effects are due to action on the peripheral nerve terminations, while morphine produces contrary results by acting on the central nervous system. Still it has been found that some of the undesirable effects that may follow the subcutaneous injection of morphine, such as indigestion, constipation and cardiac depression, may be avoided if 1/150 to 1/100 gr.; .0004 to .0006 gm. of atropine sulphate is injected at the same time.