Opium.
Opium.
The milky exudate, air dried, obtained by incising unripe capsules of the growing plant Papaver somniferum, Linné; and its variety, album, De Candolle (Nat. Ord. Papaveraceae). Asia Minor chiefly; also some other parts of Asia, Europe, and Africa. Cultivated.
Description.—Rounded, flattened, grayish-brown masses, showing a dark-brown, lighter-streaked interior, and having a somewhat nauseous bitter taste, and a peculiar narcotic odor. When fresh it is more or less plastic; when kept it becomes hard and brittle. Opium masses are of variable sizes and usually coated with adherent poppy leaves, and often with the fruits of a species of Rumex used in packing for transportation. The U. S. P. requires that normal, moist opium should contain not less than 9.5 per cent of anhydrous morphine. Dose, ¼ to 2 grains. (Average dose, 1 grain.)
Principal Constituents.—Opium contains nineteen or twenty alkaloids, some of which are combined with meconic acid, forming meconates, some with sulphuric acid, some free, as narcotine, a weak base. Those of medicinal interest are: (1) Morphine (C17H19NO3.H2O), anodyne and narcotic; (2) Codeine (C18H21NO3.H2O); (3) Narcotine (Anarcotine) (C22H23NO7); (4) Narceine (C23H29NO9); Thebaine (C19H21N3O) Papaverine (C20H21NO4); and Pseudo-morphine (C34H36N2O6).
Other alkaloids are: rhoeadine, cryptopine, codamine, laudanine, lanthopine, meconidine, protopine, hydrocotarnine, laudanosine, oxynarcotine, gnoscopine, tritopine, and xantholine. Besides these are the non-alkaloidal constituents: meconic acid, meconin, meconoisin, opionin; volatile oil and other common plant constituents and inorganic salts.
Preparations.—1. Opii Pulvis, Powdered Opium. A fine light-brown powder. Should contain ½ per cent more, but not more than 1 per cent more, of anhydrous morphine than opium. The U. S. P. permits the reduction of morphine content higher than indicated by the use of any inert diluent. Dose, ¼ to 2 grains (average, 1 grain).
2. Opium Deodoratum, Deodorized Opium. Should be of same morphine strength as Opii Pulvis (see above). Dose, ¼ to 2 grains (average, 1 grain).
3. Opium Granulatum, Granulated Opium. Same morphine content as Opii Pulvis (see above). Used in the preparation of tincture of opium and deodorized tincture of opium. Dose, ¼ to 2 grains (average, 1 grain).
4. Pulvis Ipecacuanhae et Opii, Powder of Ipecac and Opium (Compound Powder of Ipecac, Dover's Powder). A grayish-white or pale-brown powder containing 10 per cent each of opium and ipecac. (Ten (10) grains represent 1 grain of opium or about ⅛ grain of morphine.) Dose, 1 to 20 grains.
5. Pulvis Ipecacuanhae et Opii Compositus, Compound Powder of Ipecacuanha and Opium (Diaphoretic Powder, Beach's Diaphoretic Powder). (Contains Opium (10), Camphor (40), Ipecac (20), Bitartrate of Potassium (160). (Each ounce of this powder contains 19 grains of Opium. Each ten (10) grains, therefore, represents nearly ½ grain of opium (accurately, 11 ½ grains contain ½ grain of opium), 2 grains of camphor, 1 grain of ipecac.) Dose, 2 to 10 grains.
6. Tinctura Opii, Tincture of Opium (Laudanum). Contains 10 per cent of opium, almost the equivalent of 1 per cent of morphine. (Therefore 10 minims equal about 1 grain of opium, or approximately ⅛ grain of morphine.) Dose, 1 to 30 minims. (The large amounts should never be used as initial doses.)
7. Tinctura Opii Deodorati, Deodorized Tincture of Opium. Same strength as Tincture of Opium. Dose, 1 to 30 minims. (The large doses should never be used as an initial dose.)
8. Tinctura Opii Camphorata, Camphorated Tincture of Opium (Paregoric). About 4/100 per cent opium. Paregoric is about 20 times weaker than Laudanum (Tincture of Opium) as it contains about ¼ grain of opium in each fluidrachm. This is practically equivalent to 1/40 grain of morphine. Dose: For infants, 5, 10, to 20 minims; for adults, 1 to 4 fluidrachms.
CHIEF OPIUM ALKALOIDS AND THEIR SALTS.
Morphina, Morphine. Permanent colorless or white fine needles or crystalline powder, without odor and very sparingly soluble in most ordinary solvents. Dose, 1/12 to ¼ grain (average, ⅛ grain).
Morphine Hydrochloridum, Morphine Hydrochloride (Morphine Chloride). Permanent and odorless silky needles, or cubical masses or crystalline white powder, readily soluble in hot or cold water; soluble also in glycerin. Not soluble in chloroform or ether. Dose, 1/12 to ¼ grain (average dose, ⅛ grain).
Morphine Sulphas, Morphine Sulphate. Permanent and odorless, white, silky and feathery needle crystals, freely soluble in hot or cold water; not soluble in chloroform or ether Dose, 1/12 to ¼ grain (average dose, ⅛ grain).
Codeina.
Specific Indications.—Opium and Morphine Salts. Pulse soft and open, or when waves are short, and it gives a sensation of fullness and always lacking hardness, skin soft, tongue moist, face pale, eyes dull and expressionless and immobile or dilated; permanent glycosuria with prostration of powers; pain in incurable diseases.
Morphine Salts. (In addition to above.) Unbearable pain; pulmonary hemorrhage; gall-stone and renal colics; pain, with spasm; pain and shock from accidents or acute poisoning; angina pectoris; to prevent shock from surgical operations; in obstetrics to relax and quiet nervous apprehension (use with discrimination).
Action.—The dominant action of opium is due chiefly to its contained morphine and is spent upon the cerebro-spinal tract, quieting the functions of the cerebrum and exciting those of the spinal cord. In man the most profound effect is upon the cerebrum; in animals upon the cord. Upon the brain, if the dose be small, the first effect is a temporary excitation followed by depression resulting in sleep; if the dose be large the stage of excitation may be absent. When absorbed the drug is a depressant to the sensory filaments, benumbing them against pain, and finally the motor nerves come under its depressing power. While the exact cause of its pain-relieving properties is not definitely known, it is believed to be due to its depressive effect upon the cerebral perceptive centers and upon the conducting paths of the cord.
Through whatever channel opium or its alkaloid, morphine, is introduced into the body-by stomach, subcutaneously, or intravenously, by rectum, or a wound or abrasion, its chief and dominant effect is upon the higher cerebral centers finally producing depression. Upon the unbroken skin it probably has no action; but when applied to mucous surfaces it is readily absorbed. Children and old persons are profoundly affected by the drug, and women, as a rule, are more susceptible than men. Nursing children may become narcotized by the milk of a mother who takes opium, and infants have been known to die within a day or two after birth when deprived of the effects of the drug as acquired in intra-uterine life.
In small doses opium does not appreciably affect the circulation. Full doses, however, stimulate the vagi, both centrally and peripherally, causing a slow action of the heart, the force of which is also increased by direct stimulation of the heart-muscle and the intracardiac ganglia. To the increased heart action is due the rise in blood pressure. Toxic doses paralyze both the pneumogastrics and the heart, the pulse then becoming excessively rapid and weak.
The effect of morphine upon the respiration is very important, and therein lies its danger as a lethal agent. In very small doses it is said to stimulate respiration, but large doses powerfully depress breathing, and in fatal opium poisoning death is usually due to asphyxia through centric respiratory paralysis.
Morphine causes profound myosis when given in full doses. This is due to stimulation of the oculo-motor centers. Usually just preceding death paralysis of these centers results in dilation of the pupils.
Opium diminishes all the secretions except that of the sweat. That normal diaphoresis remains unabated or is increased is probably due to dilation of the blood vessels of the skin. Opium causes retention, rather than suppression, of the urine, though the secretion of the urine is thought to be somewhat inhibited by the drug. Opium very pronouncedly checks the secretions of the intestines and arrests peristalsis, chiefly by stimulation of the splanchnic inhibitory nervous apparatus. The result is constipation. On the other hand toxic doses may paralyze the inhibition and thus stimulate peristalsis.
Opium moderately elevates temperature unless the dose be toxic. In that event the body-heat is reduced. Opium limits tissue-waste by decreasing the output of urea and other nitrogenous detritus.
Probably most of the morphine ingested is oxidized in the body; that which is eliminated, partly as morphine, is voided by way of the stomach and kidneys. Morphine is rapidly eliminated into the stomach when a poisonous dose is taken, so that it is well to bear this fact in mind and prevent its reabsorption by frequently washing out that organ.
Very small doses of morphine, or its equivalent of opium, induce a primary stimulation or excitation which may or may not be followed by a sedative effect. Medium doses augment the size and slow the velocity of the pulse, increase cutaneous heat, render the mind active, and produce a general sedative effect upon the whole body. The higher brain centers are profoundly impressed, the intellectual faculties becoming sharper, ideas more brilliant, precise, and under control, the power of application more intense, and the conversational propensities stimulated. The imaginative and creative faculties are, if anything, exaggerated, while judgment, steadiness and coordinate thought and reasoning seem to be more in abeyance than usual. If the dose be small this stage is never passed. Under large or full doses, however, this state of excitation and well-being abates, leaving a calm, careless, indifferent, and pleasurable sensation, with a series of fleeting ideas, succeeded, after a longer or shorter interval, by a dream-filled sleep which may last for several hours. Upon awakening the patient may complain of dizziness and nausea, trembling, headache, and loss of appetite. Most of the secretions will have become more or less suspended and constipation induced, though the sweat glands will retain their activity. From this state the patient awakens when the drug has spent its force, and if the drug be not repeatedly resorted to no harm will have been done. If there is pain the patient will have lost all sensibility to it while under the influence of the drug, for morphine is the most perfect analgesic known. If the dose be large the sleep from morphine may be dreamless.
Toxicology.—When a toxic dose of morphine or opium has been taken there occur symptoms which may be grouped under three stages:
The first, or stage of excitation, may be absent; or if present, be of very short duration.
In the second stage, depression speedily comes on with a full and slow pulse, suspension of the cerebral functions, overpowering drowsiness followed by a deep sleep with slow and stertorous breathing, suffused, flushed or cyanotic countenance, strongly contracted pupils, warm dry skin, and muscular prostration. The patient may be aroused by shaking, flagellation, or loud shouting, but as soon as undisturbed sinks again into a deep slumber. If he is not kept awake and breathing stimulated, he passes almost imperceptibly into the final or lethal stage.
In the third or lethal stage coma is absolutely complete. The face, at first turgid or livid, becomes pale and the lips livid, the extremities are cold, the pupils minutely contracted (pin-point myosis), the dry skin gives way to the sweat of death, the breathing becomes progressively slower and slower, shallow and labored, until it finally ends in a soft or almost imperceptible respiration. Death then takes place from respiratory paralysis or asphyxia, though the heart stops almost immediately after breathing ceases.
The treatment of acute opium poisoning must be prompt and unremitting. Owing to the fact that the vomiting centers and the peripheral nerves of the stomach are depressed by toxic doses of opium, emetics do not act well. They should be tried, however, as well as other means of inducing vomiting, as tickling the throat, etc., but should not be relied upon. Washing out the stomach by lavage is to be preferred, and should be repeated at short intervals because morphine is readily eliminated from the blood-current into the stomach, and continuation of the poisoning may be maintained through its reabsorption. In the meantime a solution of potassium permanganate (3 to 5 grains in a half pint of water) should be given to destroy the morphine, and strong black coffee administered freely by mouth and by rectum. Tannic acid only imperfectly precipitates the morphine, and some of its salts not at all. The all-important necessity is to keep the patient breathing, as depression of respiration is the most dangerous feature of opium poisoning. For this purpose strychnine sulphate (1/30 to 1/10 grain) preferably, or atropine or cocaine is to be used. Ammonia or alcohol may be needed to support both the heart and respiration. While death probably does not take place because of the deep sleep or narcosis, it is absolutely necessary to keep the patient awake in order to have his co-operation and voluntary effort to keep up breathing, and thus fight the depression of the respiratory centers. The patient should be walked between two attendants constantly, and flagellated with hot and cold wet towels, or switches, artificial respiration performed or the faradic current applied to the skin. In all of these efforts, however, human limitations must be considered, and there is no necessity for bruising or lacerating the flesh, or pushing annoyance to exhaustion of the patient. The latter only favors deeper narcosis, and if the patient goes to sleep his voluntary efforts to breathe by sheer will power are lost and death is the penalty. To prevent reabsorption of the drug from the urine, catherization should be resorted to several times.
Therapy.—External. Notwithstanding the fact that opium and its alkaloids in watery solutions are probably not absorbed by the skin, and therefore do not impress the peripheral cutaneous nerves, lead and opium wash (Tinctura Opii and Liquor Plumbi Subacetatis each 2 fluidounces; water to make 16 fluidounce) is a common application intended to subdue pain and act as a local sedative in contusions, sprains, bruises, articular inflammations, and in erysipelas and other local inflammations. For this purpose it has never attained popularity among Eclectic practitioners. This practice has been well expressed by Wilcox as "simply a concession to popular sentiment".
Upon mucous structures, however, the anodyne effects of opium are more perfect. In suppository or ointment opium is often included to relieve pain in hemorrhoids and anal fissures and to check reflex vomiting. Sometimes solutions of morphine are used in painful ophthalmias and as an injection for gonorrhea. It has nothing to commend it for either purpose, and its use in this manner is not wholly unattended by danger.
Internal. The therapeutic virtues of opium are due chiefly to morphine and but little to the associated alkaloids, excepting codeine. To the narcotine is due the occasional tetanic action of the drug. The uses given below, therefore, will apply to both morphine (chiefly) and opium (where a slower effect is desired), and to the latter when specifically stated.
The therapeutic uses may be conveniently grouped under the following necessities: (1) To relieve pain and distress; (2) to allay peripheral irritation and inflammation; (3) to restrain excessive or hyper-secretion; (4) to control spasm and convulsions; (5) to stop hemorrhage; (6) to produce sleep; (7) to cause diaphoresis; (8) to maintain strength under systemic strain and to favor metabolic functioning.
While both opium and morphine may be used arbitrarily for the relief of severe pain, they should for most other purposes, and even for pain, when possible, be employed with due regard for their specific indications. To prescribe them intelligently it should be remembered that "the patient with the hard, small pulse, the dry tongue, dry contracted skin, the flushed face, bright eye, and contracted pupil, is always injured, temporarily at least, by the administration of opium. On the contrary, the patient will be benefited when the pulse is soft and open, or when small the waves are short, and it gives a sensation of fullness and always lacking hardness, the skin is soft, the tongue moist, the face pale, and the eyes dull, expressionless, immobile, and dilated." Under these conditions pain and spasm are much more readily controlled and the so-called effects of idiosyncrasy are minimized. While nearly always pain yields to morphine and its use may be absolutely imperative, it yields much better and kindlier and to smaller doses when the indications as given are present, and with less general harm to the patient. For other uses than for the relief of pain, as far as possible one should be governed by the established specific indications. As the chief therapeutic value of opium resides in morphine, the alkaloid will be preferred except where opium or one of its combinations is designated.
Morphine (usually administered in the form of the sulphate) is the best and most certain remedy for pain. As such, however, it should be reserved for emergency uses and not be prescribed for slight and ill-defined conditions, for persistent, protracted, or oft-recurring neuralgias, for ordinary menstrual distress, or for long-continued pain from any cause or of any character, except in incurable diseases. In most painful states, except excruciating paroxysmal pain, other agents should be used if possible, and morphine only as last resort. In neuralgias, with the possible exception of sciatic neuralgia and tic douloureux, other drugs, such as aconite, gelsemium, rhus, arsenic, acetanilid or phenacetin are far preferable, not because they are equally as analgesic, but because they do not engender a pernicious habit—a condition sure to be established when morphine is given for more than a very brief time for a temporary purpose.
For pain with spasm morphine is the most certain and most effectual remedy known. It is absolutely imperative for the relief of severe gall stone or renal colics. Not only does it relieve the excruciating suffering, but it relaxes the gall duct and the ureters, so that the concretions, if at all voidable, may be more readily passed. As a rule, such concretions as give rise to spasmodic pain are voidable, else they would not be small enough to engage in the passages, and the paroxysmal pain, shifting in position, is a fair indication that they are passing. During these ordeals the patient should be kept under the full influence of the drug, one-fourth to one-half grain of morphine sulphate being given hypodermatically, and repeated as needed, until the distress has abated. Patients suffering from severe pain stand opiates in doses that would prove disastrous under other conditions; still the doses should not be so closely plied that an overdose is duplicated near the termination of the passage of such concretions; the latter usually passing in from thirty-six to forty-eight hours.
Morphine may be used to relieve the pain and quiet nervous agitation and relax muscular contraction in fractures, lead colic, and the crises of locomotor ataxia. In angina pectoris it is probably the most useful remedy. While contraindicated in ordinary congestion and inflammation of the brain and meninges, it may prove the only agent that will give relief from the intense pain of acute simple meningitis (early stage before effusion) and in cerebro-spinal meningitis or "spotted fever". It is sometimes necessary in acute peritonitis, especially when traumatic, where the pain is intolerable and bowel movements aggravate, and in acute appendicitis, when nothing else will relieve. After an undoubted diagnosis has been made and a case is to be operated upon, morphine is permissible to quiet the pain, relax rigidity, prevent shock, and allay the agitation and apprehensiveness of the patient. It should not, however, be used too early or, if possible, in the first attack of acute catarrhal appendicitis to the extent that the symptoms may be so obscured as to mislead the patient and the physician as to the true condition of the disease. If other expedients can be employed morphine should be withheld, as far as possible, in appendiceal inflammations.
In very severe gastralgia morphine with bismuth gives prompt relief, but should not be repeatedly used in oft-recurring attacks. It is sometimes demanded in ulcer of the stomach, especially if hemorrhage occurs. In cancer of the stomach, or any other organ of the body, it is a most merciful drug, and there should be no compunction concerning its use after an unquestioned diagnosis has been made by every means of precision possible, including radiography.
Morphine is to be employed as necessity dictates, to alleviate the pain from irritant poisons, and of severe burns and scalds, both external and internal.
Morphine is frequently employed preceding the use of anesthetics, especially chloroform, to increase their efficiency, allow lesser dosage, and to prevent shock. More recently the tendency has been to discourage this use of the drug on account of the shallow breathing induced by it, thus retarding the prompt induction of proper anesthesia. After operations small doses may be given to produce rest, quiet pain and agitation, and to prevent shock and irritative febrile reaction. Frequently codeine serves the purpose better than morphine and is less restraining to the secretions. It is the custom with many obstetricians to inject one-eighth grain of morphine during the severer periods of the ordeal of parturition. It gives rest, relaxes a rigid os, and stimulates normal contractions; besides it gives comfort and assurance to the woman, and many contend that it in no way harms either the mother or the child. Personally, however, we believe that it often narcotizes the child and results in a deeply cyanosed state and stupor from which it is difficult to resuscitate the child. Many of these cases are attributed to imperfect anatomic evolution of the circulatory tract (blue babies), when in fact they are morphinized babies.
Opium and morphine induce sleep in insomnia from almost any cause; but they should not be so employed except where sleeplessness is due to pain. Other forms of insomnia yield to safer hypnotics. It may, however, be needed in the insomnia of acute melancholia, and in that accompanying distressing incurable heart-disease, with pain and dyspnea, and in the sleeplessness of phthisis and cancer. If excitement is great in maniacal conditions with insomnia, morphine alone may aggravate, and chloral will act better. Sometimes a small dose of the former may be combined with a less than usual dose of the latter and become effective in producing sleep, the combination acting better than either drug given alone.
Both opium and morphine may be used to relieve peripheral irritation, such as gives rise to cough and asthmatic seizures, and in chronic bronchitis and phthisis. Sometimes codeine is preferable to either. For cardiac asthma and bronchial asthma, without pulmonary edema, morphine is the promptest remedy that can be used. The state of the kidneys, however, should be determined, and if the renal functions are bad the drug must be cautiously employed, if at all. Morphine and deodorized tincture of opium are sometimes of value, in small doses, to relieve acute attacks of vomiting, but they should not be employed where nausea is of daily or frequent occurrence, as in that of pregnancy. In fact, opiates have little or no control over the latter condition. Morphine is a remedy for spasmodic and paroxysmal dyspnea, especially that experienced upon assuming the reclining position. It is of no value for continuous and persistent shortness of breath, and examination in such instances will usually reveal a chronic kidney disorder which makes the use of the drug inadmissible.
When constipation is due to a spasmodic contraction of the unstriped musculature of the intestines, morphine is distinctly useful. This is particularly evident in the results obtained from it in lead constipation. Sometimes a similar condition of cystic spasm is responsible for retention of urine; then morphine also relieves.
Morphine is a drug of preeminent importance in convulsions. It is by far the most generally useful remedy in puerperal eclampsia. Here it is not contraindicated by the usual restrictions for its employment. In traumatic tetanus the patient should be kept fully under the influence of morphine.
Morphine must be avoided if possible in uremic convulsions due to chronic nephritis, with uremic or cardiac dyspnea, or in uremic insomnia. When uremic eclampsia occurs in acute nephritis it may be cautiously used if other agents prove ineffective.
Opium is of value in delirium tremens, but has been recklessly used. As one looks back over the history of therapy it appears that many deaths from this complaint can be attributed to this drug alone. This is largely owing to the enormous doses that were used and the utter disregard of specific conditions. If the dipsomaniac cannot take food or cannot sleep he will die; if there is kidney disease, opium will probably kill; if there is a flushed countenance, blood-shot eyes, wild and furious delirium, pain in the head, red, dry and turgid tongue, and full bounding pulse, opium is likely to kill the patient. If, on the contrary, the skin is relaxed and moist, the circulation feeble, the face pale and the tongue moist and dirty, opium is a safe drug. The dose should not exceed one-eighth grain of morphine, or onefourth grain at the most, every four or six hours, until sleep is induced.
Opium and morphine are much less commonly used than formerly in acute inflammations. Sometimes they are demanded in acute pleurisy and in pericarditis, and no drug so effectually helps as a single small dose of morphine in the excruciating pain of acute articular rheumatism that does not readily yield to the salicylates, macrotys, or bryonia. Both the diaphoretic and Dover's powder are useful here, and the former is the less likely of the two to provoke nausea. Formerly opium and its alkaloid were much employed to allay inflammation and quiet peristalsis, as well as to annul pain, in acute peritonitis, but of late years it has fallen into disuse.
Opium, preferably to morphine, is used in one form or another in excessive diarrheal and other exhaustive discharges. When a persistent summer diarrhea, with much undigested food, or an intractable mucous diarrhoea is first treated by thorough catharsis, then opium may be given, by mouth, to restrain further abnormal secretion. It has, however, proved a pernicious drug in the hands of those who unwisely use it under all conditions when safer specific means would have been far more effectual. It is a good drug, however, in persistent serous diarrhoea. An injection of morphine is the promptest drug for the relief of cholera morbus. Together with the compound tincture of cajuput this forms our best treatment. While minute doses have been advised in cholera infantum, the drug should under no circumstance or in any dose be administered to infants. In Asiatic or true cholera an injection of morphine (one-eighth grain) often checks the cramps, vomiting, and rice-water discharges. In choleraic diarrhoea, rendering one very prone to attacks of true cholera during epidemics of the latter, Locke advised: Rx Tincture of Opium, Spirit of Camphor, Spirit of Peppermint, Tincture of Kino, 1 fluidounce each Tincture of Capsicum, ½ fluidounce; Neutralizing Cordial, 3 ½ fluidounces. Mix. Sig.: One teaspoonful every half hour in severe cases; three times a day in mild attacks.
Opium is a useful drug in polyuria, especially that of true diabetes, in which the drug restrains both the quantity of urine and the output of sugar. For this purpose its continuous use is permissible only in confirmed glycosuria, and it should not be employed in cases in which sugar temporarily appears in the urine. Only in incurable conditions, in which every consideration for consequences has been invoked, should opium be used in sugar diabetes. Then it is perfectly permissible, provided it gives comfort and rest to the patient. By many it is considered the best drug in diabetes, the disease establishing a tolerance for the opium, and it is given in ascending doses as long as it does good and meets urgent conditions. Singularly it is far less effectual in simple polyuria or so-called diabetes insipidus. Probably its effect in giving rest to the nervous system accounts for its value in diabetes mellitus.
Diaphoretic Powder.—We unreservedly assert our preference for this opiate, when an anodyne of this class is to be used. It will not take the place of morphine when pain is intense and must be quickly relieved; but it may be employed (whenever opium is indicated by the open pulse and moist tongue) to relieve the milder degrees of pain. It acts without the deleterious effects derived from morphine and other opium preparations. Though this product has been modified from time to time, it contains to-day, as in the original formula by Dr. Beach, powdered camphor, opium, ipecac and potassium bitartrate—in such nicely balanced proportions that the system is gradually prepared for the action of its chief ingredient—opium. Being a decided sedative, both of temperature and nervous excitation, it may be used even where there is a high degree of fever. It is unquestionably the best pain-reliever for continuous use in pleurisy and pneumonia. The ipecac allays irritation, and if the doses be not too large or too often administered it will not usually cause nausea or emesis. Diaphoretic powder, as the name indicates, promotes activity of the skin. Diaphoretic powder not only relieves pain, but quiets nervous irritability, allays cough, facilitates expectoration, and thus proves an ideal sedative. It is the best remedy of its class for children. Diaphoretic powder, with an equal bulk of bismuth subnitrate, is the best remedy we have found for profuse irritative diarrhea and for the watery diarrhea of intestinal la grippe. When the patient cannot rest and there are no contraindications, it may be employed to restrain excessive diarrhea in typhoid fever and to relieve nervous unrest and promote sleep. Taken early and in rather free doses it will check a cold. It strongly assists macrotys in the relief of myalgic and rheumatic pains, being the safest anodyne with which to relieve the pain in acute inflammatory rheumatism. There are few cases of inflammatory and painful conditions in which it will not give relief, and that without the danger attendant upon the use of many of the anodynes. It is an ideal anodyne and relaxant in various forms of colic and in severely painful menstruation. It should not, however, be used every month, or for the milder attacks of pain, lest a habit be induced. In that form of menstrual pain or ovarian irritation attended with great nervous excitability simulating hysteria, the powder infused in hot water and given hot in quite liberal doses will bring about relief quicker than any agent we know of. Singularly, when administered very hot its tendency to provoke nausea is slight, but when given lukewarm or when warm drinks follow its administration, emesis is very apt to be induced. It is of especial value in after-pains. Its effectiveness as a preparator for the administration of quinine is one of its many virtues. The ordinary dosage is from two to ten grains in cold water, repeated as the necessity of the case demands. Diaphoretic powder, known in Eclectic pharmacy as the Pulvis Ipecacuanhae et Opii Compositus of the American Dispensatory, was introduced by Dr. Wooster Beach, and was undoubtedly a modification of the celebrated Dover's powder.
Dover's Powder.—"Dover's powder, according to the dose administered, is an excellent stimulant, sedative, anodyne, and narcotic. It has a better action than either of its chief ingredients administered separately. It is a very good agent to improve the quality of the skin, the necessary moisture being induced by the ipecac to insure the favorable action of opium, for the specific indication for the latter is a moist skin and tongue, and soft, open pulse. As a pain-relieving agent and to promote sleep, it may be used where opium alone would not be tolerated. Though profuse perspiration may be produced by it, it is also capable of checking that secretion as shown by the favorable action of five-grain doses of the powder given to control the colliquative sweats of phthisis. It should be given a half hour before the sweating begins. Dover's powder sometimes causes sickness at the stomach, and should never be followed immediately after its administration with warm drinks, but they may be used later, if desired. As a pain-reliever, or stimulant to the internal organs, or as a hypnotic, it is admissible when there is no nausea, inflammation of the brain, or high temperature. It is an efficient drug in rheumatism, the incipient stage of inflammations, and to control cough. Hot applications to the abdomen and five-grain doses of Dover's powder with one grain of camphor, every one half or one hour, give marked relief in dysmenorrhea. Without camphor, it is very efficient in amenorrhea from cold, being used together with external heat. It allays nervous excitation in cases of abortion, and assists in controlling uterine and pulmonary hemorrhages; two or three grains of the powder, with a like quantity of quinine, forms an efficient treatment in neuralgia, with hot, dry skin. In dysentery, it assists the action of other remedies, as well as controlling peristaltic movements, while in irritative diarrhea, after a mild laxative, it controls any spasmodic bowel complications that may supervene. It may be used in enteritis, both to control the inflammation and the movements of the bowels. It is useful in the early stage of renal catarrhal inflammations and in granular degeneration of the kidneys, chiefly for the purpose of maintaining a good circulation and a moist condition of the skin. Dose, two to ten grains, preferably in capsules." (From a previous article by the author in the American Dispensatory.)
