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A hundred years ago: On the use of opium

By I. Burney Yeo, M.D., F.R.C.P

Emeritus Professor of Medicine in King's College, and Consulting Physician in King's College Hospital

By I. Burney Yeo, M.D., F.R.C.P

Emeritus Professor of Medicine in King's College, and Consulting Physician in King's College Hospital

Extracted from the May 1907 issue of The Practitioner

If I were asked to name the best single test of the judgement and clinical capacity of a medical practitioner, I should reply that, in my humble opinion, it would be his skill in the use of opium – to know when and how to give it, and when to withhold it.

When examining candidates for diplomas at the Conjoint Board, I own I often felt alarmed at the possible consequences that might follow, if all those hypodermic injections of morphia, which were prescribed on paper, were actually introduced into the connective tissue of real patients, and I have noticed, not without consternation, what a large place in the resources of some practitioners is occupied by the hypodermic syringe. I feel convinced that a veritable history of all the doings of that small but potent instrument would make very sensational reading!

The first thing, then, to be kept in view, with regard to opium, is the necessity of great caution in its use and dosage, and especially in the hypodermic use of morphia. An overdose given by the stomach can be vomited, or, in part, washed out, but, once introduced into the connective tissue under the skin, it can never be withdrawn.

It should be remembered that, when administered in this way, it enters the circulation very rapidly – this, indeed, is one of the advantages of the method, as it enables the practitioner to relieve suffering with great rapidity – but it has its drawbacks; one of these is the temptation it offers the patient to self-administration and the establishment of the morphia habit, another is the risk, with certain hyper-sensitive patients with feeble hearts, that morphia given hypodermically may cause cardiac failure. The feeble, degenerated cardiac muscle is readily paralysed by morphia, save in quite small doses, which should be guarded, and combined with a cardiac stimulant.

Where opium stands unrivalled as a therapeutic agent is in the relief of pain accompanied by spasm; no known drug approaches it in efficiency for this purpose. And these are the most severe and terrible form of pains which we are called upon to treat.

Take, for instance, the various forms of colic – intestinal, biliary, and renal – attacks of spasmodic asthma – the pain of angina! What could adequately replace opium in the treatment of these affections? I have seen – and who has not? – the most severe paroxysm of asthma yield, in a few minutes, to hypodermic injection of a quarter of a grain of morphine combined with a sixtieth of a grain of atropine. In some cases it is preferable to give morphine by the mouth, combined with some spirit of chloroform and aromatic spirit of ammonia. There is thus less risk of depressing the cardiac action in debilitated patients. With regard also to attacks of biliary colic, I prefer to give opium by the stomach, because I have found that it gives more complete relief when administered in this way. Indeed I have often had reason to think that the nearer to the seat of pain the opium is absorbed, the better and more lasting is the effect. Opium liniment rubbed into a painful joint, opium suppositories, a small opium enema in painful conditions of the rectum and bladder, friction of the abdomen with opium in lead colic, an opium lotion in painful conjunctivitis; these are a few instances of the local applications of opium usually attended with satisfactory results.

In recent correspondence in a medical journal on the treatment of a "common cold," it was remarkable that there was no reference to the value, for this purpose, of a suitable opiate preparation. I say "suitable" because much depends on the preparation, or rather the combination, employed. Whoever has suffered from what is known as an acute streaming cold, and has felt the almost immediate relief brought about by a dose of morphine, is not likely to forget it. But this drug must be given with care, in order to avoid any unpleasant after effects. The best combination, in my experience, consists of one-quarter to one-third of a grain of morphine with a dram of spirits of nitrous ether and three drams of solution of acetate of ammonia, and one ounce and a half of camphor water. This should be taken at bedtime, after a very light dinner, at the very onset of the attack.

I have repeatedly taken this dose myself, and prescribed it for others, and it is remarkable how, in perhaps a quarter of an hour, the secretions from the nose will cease, the respirations become free, soreness and aching of the eyes disappear, and a comfortable night's rest be enjoyed, instead of a sleepless night with constant secretion from the nose causing respiratory obstruction. But, although it relieves the initial stage of an acute coryza in this remarkable way,

it does not usually "cure" the attack unless taken at the immediate onset, and, if you treat a cold in this way, the patient should be confined to his room for a day or two, otherwise, on exposure to chill, his symptoms will return.

Some of the symptoms associated with respiratory diseases, as I have already pointed out, call for the cautious administration of opium for their relief. Heroin is, I think, better suited than other opium derivatives for this purpose in many cases. In acute laryngeal catarrh, especially that form so often connected with influenza, with scanty tenacious secretion difficult of expulsion, morphine sometimes seems to aggravate the scantiness and tenacity of the mucus, unless it is combined with minute doses of tartarised antimony, or apomorphia, but the latter drug has seemed to me to exert a depressing effect on the heart, and therefore to be unsuitable in influenza cases. Heroin, however, appears to be quite as efficacious in quieting the cough as morphine, and to have the advantage of loosening the mucus.

The foregoing observations on the use of opium are the results of long clinical experience, and may, perhaps, prove of use to younger practitioner in applying, to the relief of sufferers, the drug that has been fitly named "God's gift to man."

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