This section is from the book "A Treatise On Therapeutics, And Pharmacology Or Materia Medica Vol1", by George B. Wood. Also available from Amazon: Part 1 and Part 2.
There is no antidote to opium which can be relied on. The important indications are to evacuate the stomach, and to support the system in the state of prostration which follows the direct influence of the poison. The first indication is to be met either by emetics, or the stomach-pump, or by the two combined. If called at any period before prostration has taken place, one of these measures should be resorted to. For various reasons, I prefer first the trial of emetics. They are, in general, more immediately at command, and time is an object of much importance. Besides, if solid opium has been swallowed, it must remain in the stomach, when the pump is used, if in masses too large to pass through the tube. I was once cognizant of a case of this kind. A young man was brought to my house, with the statement that he had taken solid opium. He was sent immediately to the hospital, where, as I afterwards learned, the stomach-pump was promptly applied, and everything apparently evacuated. The patient, however, died. I was convinced that a portion of opium had remained in the stomach, because too large to enter the tube; and from that time I determined never to depend on the stomach-pump, in any case where opium had been swallowed in mass, however small the fragment. Besides, there may be an hour-glass contraction, which might yield to an emetic, but not to the stomach-pump. I once attended a case in which, after the contents of the stomach seemed to have been completely discharged under the influence of emetics, a sudden gush of liquid was thrown up. smelling strongly of laudanum. Had the stomach-pump been relied on in this case, it might have ended fatally. When emetics cannot be made to act. this instrument should be resorted to; and it may often also be advantageously used in conjunction with emetics, especially when the patient refuses to swallow, as it then affords the means of introducing the medicine into the stomach.
The emetics I prefer are sulphate of zinc and ipecacuanha. The former is very prompt and energetic, safer in large doses than sulphate of copper, because less corrosive, and than tartar emetic, because less sedative or prostrating in its influence. The ipecacuanha is also a quick and active emetic, at the same time that it is safe in almost any quantity.
Thirty grains of sulphate of zinc, and a drachm of ipecacuanha may be given at once, and repeated every twenty minutes until they operate. Indeed, the ipecacuanha may be thrown in ab libitum. I should fear an indefinite repetition of the sulphate; for, though it may produce no perceptible irritation at the time of exhibition, in consequence of the want of susceptibility in the stomach, it may yet leave an impression behind, which, upon the occurrence of reaction, may end in inflammation. In a case of opiate poisoning in a woman, which occurred to me many years since, the patient, after the evacuation of the poison, was reduced to the lowest state of prostration, from which she was saved with difficulty. Among the measures employed to excite her, was a pair of sinapisms applied to the legs. As, in the existing insensible state of the skin, they produced neither pain nor redness, they were allowed to remain on for three hours. When they were taken off, no rubefaction was visible. But when the system reacted, violent inflammation took place in the surface with which they had been in contact, followed by vesication and obstinate superficial ulceration, which was long in healing. Applying this observation to the influence of irritants on the stomach, I felt convinced that, by giving largely of substances of this kind, though they might not act at the time, we might upon the occurrence of reaction have violent and perhaps fatal gastritis. It is probably not going too far to say, that some of the deaths in narcotic poisoning, which have occurred notwithstanding the complete evacuation of the poison, may have resulted from this cause. I have never, therefore, proceeded further with the sulphate of zinc than to give three doses; and have not ventured on sulphate of copper at all. Yet I have never failed in evacuating the stomach by emetics, when I have employed them in these cases.
The emetic, however, should be aided by various accessory measures. Among the most important of these is the use of large quantities of warm water, or warm chamomile tea, of which the patient should be made to swallow tumblerful after tumblerful, until the stomach will receive no more. The throat also may be tickled by a feather, in order to rouse the stomach by its sympathies. The great difficulty, however, is not so much in the direct insusceptibility of the stomach as in that of the cerebral centres, through an impression upon which it is that emetics are enabled to act. It is, therefore, important to rouse these centres, and render them more sensible to the nauseating impression. For this purpose, cold water may be dashed on the face, head, or neck of the patient.*
* The case of a woman is recorded by Dr. A. Le B. Monroe, of Medway, Massachusetts, in which life seems to have been saved, after the swallowing of two ounces of laudanum, by placing the patient on her back, and pouring on the naked epigastrium, from a height of nine feet, a small stream of water from a pitcher. Before the second pailful was exhausted, there were signs of improvement; and after the third, she was restored to consciousness. She was then kept walking about the apartment for some time, and ultimately recovered. (Boston Med. and Surg. Journ., May 81, 1866, p. 354.) Yet the direct influence of cold, except for the shock, would seem to be injurious. Brown-Sequard recommends that the patient should be kept warm; asserting that, if of two animals, poisoned with opium, one be placed near a fire and warmly covered, and the other in some cold place, the former, caeleris part-but, will live, while the latter will perish. (Dublin Quart Journ., May, 1865, p. 434.) - Note to the third edition.
If the pulse is exceedingly full or strong. some blood may be taken from the arm, in order to lessen, in some measure, the pressure on the brain. But this measure must be used with great caution. The prostration following the direct action of the poison is generally the greatest danger of the case. Anything which may increase that prostration may be hazardous. My preceptor, the late Dr. Joseph Parrish, used to relate the case of a young woman to whom he was called in the country, and who had swallowed a poisonous dose of laudanum. The physician in attendance, influenced by the state of her pulse, had bled her largely, and I believe more than once. The consequence was, that, after the evacuation of the poison, though she recovered her consciousness perfectly, she fell into a prostrate condition from which it was found impossible to raise her. Another and, perhaps, the most important adjuvant of the emetic, is to keep the patient in constant motion until vomiting is induced. For this purpose, assistants should aid him in walking steadily about the room, and, when there is resistance, should use compulsory measures to this end if necessary. It is surprising, sometimes, to witness the efficiency of this measure in relieving the cerebral congestion. While moving, the patient remains at least partially awake, the colour of the face brightens, and more or less expression comes into his features; but the instant that he is allowed to lie down, he falls again into a deep, perhaps stertorous sleep; and the dark suffusion of face, and utter want of expression return. Bouchardat recommends that the patient be kept awake for twelve hours, so as to prevent the paralyzing influence of the absorbed narcotic on the nervous centre of respiration, until the poison shall have been discharged by the kidneys. (Ann. de Therap., 1862, p. 3).
It is not sufficient to obtain a single evacuation of the stomach. After vomiting has begun, it should be kept up by free draughts of warm water, until the liquor returns colourless and odourless.
If the stomach-pump is employed, the same thorough evacuation should be effected. The water injected should return without smell. and the last liquid contents should be drawn out by means of the syringe.
But the subsequent treatment is all-important. It has not fallen to my lot, out of numerous cases of this kind which I have seen, to witness death in a single instance, except in that of the infant before referred to, and that occurred at a period when all the resources, now at our command, had not been made known. But I am quite confident that, in more than one instance, if nothing had been done after the evacuation of the poison, the consequences would have been fatal. The prostration is sometimes very great, and comes on sooner than it otherwise might do, in consequence of the evacuation of the poison. It must be encountered by stimulant measures proportioned to the exigencies of the case. External stimulation by means of heated Cayenne pepper and brandy or oil of turpentine, and the internal use of the aromatic spirit of ammonia, wine-whey, wine beat up with the yolk of egg, brandy with milk, etc., are means, of which one or all may be employed, as the degree of prostration may require. Rich soup, or essence of beef or mutton, may also be given as nourishment. Should the stomach be irritable, a blister should be applied to the epigastrium, and nutritious and stimulating enemata be employed, if the same materials should be rejected when swallowed. In relation to the use of sinapisms, caution should be observed not to leave them on longer than half an hour, or at furthest one hour, in any one place, for fear of subsequent inflammation.
When the patient is first seen in the prostrate condition, with a cold skin, and scarcely perceptible pulse, no time should be lost in attempts to evacuate the stomach; but the stimulating and supporting plan should be at once resorted to. It is not the direct action of the poison that is now the source of danger; it is the depression following that action. Even though respiration may have ceased, and the pulse no longer be perceptible at the wrist, efforts to save the patient should not be abandoned. While stimulants are employed externally and internally, recourse should be had to artificial respiration; for the heart continues to act feebly after the occurrence of these phenomena, and. if the office of respiration can be performed, and arterialized blood sent to the heart, the function of circulation may be resumed, and life saved. Several instances of this kind are on record; and a medical friend of mine is confident that he saved the life of an infant about to parish, by breathing into its lungs. It is important, however, not too speedily to relinquish the process, after the restoration of the function; for the respiratory centres may not yet have recovered from the blow, sufficiently to carry on their office without aid. The patient should be carefully watched for several hours, and the remedy reapplied if found to be required. The case of a woman is recorded in the London Medico-chirurgical Transactions for 1836, in which, after the restoration of animation through the influence of artificial respiration, the patient was left for an hour, and upon the return of the medical attendant, at the end of that time, was found relapsing into her former pulseless condition. A repetition, however, of the remedy was followed by the same success, and life was saved.
Another remedy which may be had recourse to, under similar circumstances, is galvanism, or the powerful action of the alternating currents of the electro-magnetic machine. At least three cases of recovery under this agent are on record. For the method of applying this remedy, the reader is referred to the article on Electricity, page 538.
Coffee is another remedy which may be employed to qualify the effects of opium. It acts, probably, more nearly in the capacity of an antidote than any other agent. Its use was suggested by its well-known tendency to produce wakefulness. It should be taken freely, and as strong as possible; never, however, to the exclusion of other means. Caffein has been substituted for coffee in several cases, with encouraging results Belladonna has recently acquired no little reputation from its supposed antagonistic powers to those of opium. That there is, in some respects, an antagonism between these two narcotics, I have no doubt; but I do not believe that it extends to those points in their action which entitle them both to the name of cerebral stimulants; and it would be extremely hazardous to trust the poisonous action of opium to the antidotal powers of belladonna. But in the advanced stage of the poisoning, when the immediate effects of the opium are passed, and the chief danger consists in the prostration of the nervous power, belladonna may be used with great propriety; and I can readily conceive that, under these circumstances, it may sometimes save the life of the patient. This subject will be more fully discussed under the head of belladonna.