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OPIUM                                                621

Even in poisoning by the hypodermic injection of morphine the stomach f
should always be washed out as, after absorption in the blood, morphine is
excreted into the stomach from which it is again liable to be reabsorbed.

The bowels should be cleared by the administration of half-an-ounce of
magnesium_sulplxate in water, and the bladder should be emptied by cathe-
terizalion7if necessary.

If a patient is seen in the earlier stages before coma has supervened an
attempt should be made to keep him awake by flicking a wet towel on the
face, or slapping, pinching, etc. He should not be made to .walk,

Administration of oxyjjen at high tension is necessary if cyanosis is
present. If respirations are markedly depressed artificial respiration should
be given. Patient may be put in an iron lung if available.

The body heat should be maintained by hot water bottles and warm
blankets. The heart should be stimulated by hypodermic injections of
caffeine, strychnine and sulphuric ether. Hot coffee or tea may be adminis-
tered either by the mouth or by rectum.

A 25 per cent solution of nikethamide (coramine) in doses of 5 to 15 cc.
may be administered intravenously or intramuscularly as a stimulant to the
respiratory and circulatory systems, and repeated as necessary.

If there is no doubt that coma is due to opiate poisoning then 5 mg. of
N-allylnormorphine (Nalline, Merck) should be given intravenously. In a
couple of minutes the respiratory rate usually increases and the pupils
dilate. If not, 10 mg. more may be given intravenously. As its antigonistic
action subsides, 10 to 15 mg, may be given subcutaneously at 15 to 30
minutes interval until the patient is aroused. This drug should be used with
care in opiate addicts, as its use precipitates the maniacal dysphoria of the
abstinence syndrome,13 Shock is treated by giving 1,QOO cc. of .5 per cent7
glucose saline intravenously by drip method.                                                  *

Charles R. Bex14 reports a case in which a lady who had swallowed
some 6 ounces of laud&ftum half-an-hour earlier was saved , by free vene-
section when she had got coma, stertorous breathing, deep cyanosis and com-
mencing oedema of the lungs, Sen ir> also advises venesection, specially
when the patient is cyanosed and has a feeble pulse. Fifteen ounces of blood
should be drawn out at once to relieve the congested heart, when blood
pressure is not very low, and the loss should be replenished by normal saline
or 25 'per cent glucose solution given intravenously. Adrenaline chloride'
solution should be given to guard against the fall of blood pressure, or 25 to
30 mg, of ephedrine may be injected subcutaneously.

Post-mortem Appe»0BC©&.-— The post-mortem appearances are not very
characteristic, t>ut the sigAs ©f asphyxia are prominent. The face and the
finger-nails ar& livid. Froth is seen at the mouth and nostrils. The blood is

When the stomadbi is opened, small, soft, brownish lumps of opium may
be f ound in its contmte* ^rfcich may also look brown and viscid, and may
give the smell of o$ium.

The smell of opium is often noticed, as soon as the chest is opened, but
it disappears with the setting in of putrefaction. The trachea is rosy
coloured, congested and covered with froth, if seen after' death. The lungs
are often engogjg:^^                       and exude frothy fluid blood on section

The bronchM tubes are also congested and contain froth.   The fight side of

13.   Pharmacology in Medicine by Victor A. Drill, 1954, p. &817,                   :>

14.   Lancet, April 23, 1927, p, 899, „          «.,...               -                         -— ......

15.   Jnd Med, Gazette, Dec. 1934, p. 693.                                .                      r,  ; ;   , v