If a poisonous dose of opium has been taken only a few minutes before the patient is seen, an ordinary emetic may act, but if the patient is under the influence of the narcotic, the emetic will not act, therefore the stomach must be washed out by means of the stomach tube. Tannic acid solutions are sometimes used, or permanganate of potassium solutions, tannic acid forming more or less insoluble tannates, and the potassium permanganate decomposing the alkaloid, causing it to be more or less inert. Whatever is used, the stomach should be washed out until apparently clean.

To meet the second indication, half a pint of strong coffee may be passed into the stomach and left there. Give atropine sulphate hypodermatically in a dose of 100 of a grain. Caffeine may also be given hypodermatically.

To meet the third indication every means possible in the way of arousing the patient should be tried, but it is not advisable to walk him around to the point of exhaustion, or to uncover a patient too much for different skin stimulations or irritations, as in opium poisoning heat is lost rapidly, and many of the methods previously used to keep a patient awake have caused serious heart depression. Sometimes faradic electricity applications to different parts of the body act as one of the best stimulants.

If the patient breathes very slowly, artificial respiration must be done. This may be kept up for hours. The pulmotor may be used, if it is deemed advisable. Artifical respiration should not be done too rapidly, twelve to fourteen respirations a minute being sufficient.

Large doses of atropine should not be given, as the secondary effect of atropine is also to paralyze the respiratory center, therefore the single dose of 1/100 of a grain is generally sufficient, whatever the amount of the opium or morphine that was taken. If the respiration of the patient has not greatly improved in two or three hours, a second dose of 1100 of a grain might be given.

To meet the fourth indication, the patient should be kept warm. A hypodermatic injection of 130 of a grain of the sulphate of strychnine may be administered, which may be repeated in an hour. It is generally well to wash out the stomach again

in two or three hours, and also to catheterize the bladder, as the morphine is excreted in the stomach and also by the urine, and could be again re-absorbed, if it was not removed. Artificial respirations may be continued for hours, if necessary, and patients have been saved by such prolonged treatment

Chronic Poisoning.-Chronic poisoning due to smoking opium is of rare occurrence in this country, but the habit of taking opium, morphine or heroin in some form, most frequently perhaps hypodermatically, is still of frequent occurrence, although under the action of the National law these drug addiction cases will gradually be eliminated.

The symptoms caused by suddenly stopping morphine are always serious; the nervous irritability and excitement is sometimes terrible. There may be vomiting; coughing; diarrhea; various forms of skin disturbances, itching of the skin; absolute inability to sleep; and there may even be dangerous weakening of the heart. Hence, whatever the method used for overcoming the morphine habit, the patient must be under the constant supervision of a competent physician. The gradual method of stopping morphine is at times selected by the physician, and often is satisfactory where the patient has been receiving the drug for some acute illness and has acquired a partial habit. The drug in such cases may be gradually stopped without causing the patient to suffer. But a patient who really has acquired a habit cannot be cured at home in this manner, and if he is cured at home by the absolute stoppage of the drug, the surroundings must be unusually good. As a working rule a chronic morphine habitué must be treated at an institution. The method of curing these patients is described on page 716.

Uses. The two most important indications for the use of opium or morphine are pain and spasm. Acute pain, whether neuralgic, inflammatory, or due to distention of a canal by a calculus, or due to some spastic condition as an intestinal colic, must ordinarily be stopped by morphine or some other form of opium, or by one of its synthetic salts; or if the condition is excessively acute, inhalations of chloroform may be required. If the dose of morphine must be large for this purpose, it is well combined with atropine so that the action on the respiratory

center may not be quite so intense, ordinary doses of atropine stimulating the respiratory center. Also, sometimes peripheral spasm is modified by the action of the atropine.

Conditions calling for morphine for pain are renal and hepatic colic, intestinal colic, lead colic, and very acute inflammatory or neuralgic pain. The dose for any of these colic conditions. should be large, from 14 to 1% of a grain, to be followed by a smaller dose in an hour, if the pain has not been relieved. Associated with this treatment should be a hot bath or hot fomentations to the abdomen, to aid in the production of relaxation. It may be found that benzyl benzoate will be more valuable for these conditions without causing such narcosis as does morphine. It should be remembered that as soon as the colic ceases. or the stone has passed, the opposition to the morphine is gone, and the patient may immediately become stupid, while immediately before he was alert. Therefore, such a patient should not be allowed to sleep, but should be kept awake until the profound effects of the morphine have passed, and if advisable he may be given large doses of coffee or caffeine.

If morphine is required for such a condition as sciatic pain, or for neuritis, the dose need not be so large, but must be more or less frequently repeated; but it should be remembered that all other methods to ease this local pain must be tried before morphine is used. However, it is not justifiable to allow any patient to suffer, whether an adult or a child. Codeine may be the better drug to give, as it is less likely to cause constipation and loss of appetite, but it is not as much of an analgesic.

In recurrent conditions, as asthma and dysmenorrhea, morphine should be considered the last resort, as a large number of morphine addicts have become such through using morphine in asthma, and a dysmenorrhea pain is very rarely so intense as to require or justify morphine. A hot sitz bath, bromides, and alcohol in some form, or benzyl benzoate are efficient in ordinary pelvic pain.

Angina pectoris is generally relieved by nitroglycerin, but if the heart ache persists, morphine should be given, but sharp cardiac pain is only temporary, if the patient lives at all, and chronic heart pain is better relieved by some other method.

Profound nausea and vomiting from any cause may require a hypodermic of a small dose of morphine, ordinarily 10 of a grain, or at most % of a grain. Such treatment may be justifiable while other methods of treatment are being tried.

To cause sleep in great restlessness, other drugs should generally be used, but if a patient is very weak, or his condition is serious, or he is in the midst of an acute illness, a small dose of morphine, perhaps by the mouth, may be all that is required, rarely more than 110 of a grain.

Occasionally an acute diarrhea is so serious as to require morphine to stop it while other more rational treatments are being used. A small dose of morphine, 110 of a grain, is all that is necessary to stop the active peristalsis; or two teaspoonfuls, or more, of paregoric may be the preparation of choice. The pain of an acute gastrointestinal disturbance often requires a hypodermic dose of morphine, 1% of a grain or more.

If a patient who has had an hemoptysis is very nervous a small dose of morphine may be advisable, given hypodermatically, to quiet his nervous system, slow his heart, and relieve him from fear.

For the severe pains of cerebrospinal meningitis, morphine at times must be given in a sufficient dose to quiet the patient. It is very regrettable that in locomotor ataxic pains at times morphine must be given, as these pains are bound to recur, and a morphine habit is easily established. Therefore, before resorting to morphine all physical and other medicinal methods should be tried.

Occasionally, in uremic conditions, there may be sufficient pain, in the form of neuralgias, to necessitate an injection of a small dose of morphine, although it is known to act more intensely in such conditions, but if required for this purpose its use is justified.

In the last stages of pulmonary tuberculosis, when there is great distress from air starvation, small doses of morphine are justifiable in preventing this terrible air hunger, even if such a dose must be for some little time repeated.

In patients who are suffering from incurable cancer and who have pain, morphine or codeine, or perhaps benzyl benzoate,

should be given without hesitation. The matter of developing a habit is secondary; the patient should not be allowed to suffer. For frequent, troublesome coughing, due to nervous irritation and without much expectoration, as occurs so frequently in acute colds and bronchitis, a small dose of codeine may be combined with ammonium chloride in a cough mixture, with great benefit to the patient. There is no possibility of causing a habit. The prescription cannot be repeated without the knowledge of the physician, and unless the patient has been a morphine habitué, he will not know that he is taking it. To repeat what has been said previously, there is no excuse for heroin, we do not need it, and it is not necessary in cough mixtures. Codeine answers every purpose, and the dose need not be large.

For acute pain in the beginning of pneumonia, pleurisy, and pericarditis, and for acute abdominal pain in peritonitis, morphine is justifiable, and the dose should be sufficient to stop the pain. In peritonitis it may be necessary to repeat the drug for several days, provided the surgical condition that is under treatment, does not contraindicate it.

Although opium and morphine will inhibit the activities of the glands of internal secretion, it is generally inexcusable treatment for such conditions. It causes more harm than it can possibly do good. Large doses of opium or morphine inhibit the activities of the suprarenals, and also inhibit nutrition and normal metabolism. Therefore in glandular disturbances there is rarely an excuse for using these drugs.

When there is cerebral inflammation and excitement, morphine is rarely the drug that should be used, as small doses tend to increase the irritability, and large doses are inadvisable. Therefore other brain and nerve sedatives should be used.

DRUGS USED TO CAUSE SLEEP
Hypnotics

We all recognize the various conditions that prevent sleep, from pain to intestinal indigestion and to disturbances of the ductless glands, but we do not consider the causes of sleep. Various physiologic theories of the cause of sleep have been presented, and, probably, they all play some part in its produc