Part 9 (1/2)
The remedies recommended must be perseveringly used, remembering that as long as life lasts hope of recovery is not to be banished. In the great majority of cases the treatment is successful.
_Tests._-There are no direct means by which opium may be detected. We endeavor therefore to obtain evidence of the presence of morphia and meconic acid. The two substances may be separated from organic admixture by the following process: The suspected matters should be well boiled with distilled water, and spirit acidulated with acetic acid, and strained. To the fluid which has pa.s.sed through, acetate of lead is to be added until precipitation ceases, and the whole, after standing, is to be thrown on a filter. The insoluble meconate of lead remains on the filter, the morphia pa.s.sing through as acetate. To separate the meconic acid the substance on the filter is to be diffused through water, and sulphuretted hydrogen pa.s.sed for a time. Sulphide of lead is thus thrown down and may be separated by filtration, the meconic acid remaining in solution. On concentration this should give the requisite reactions.
In the search for morphia the filtered fluid above referred to is also to be treated with sulphuretted hydrogen, to secure the precipitation of all acetate of lead, &c., which is next to be carefully separated from it by further filtration. The fluid now pa.s.sing through, containing the acetate of morphia, is next to be concentrated by evaporation over a water bath, and carefully neutralized by bicarbonate of pota.s.s, if it be desired to obtain the pure alkaloid; but this is not necessary, as the acetate responds to all reagents. The acetate may be dissolved out of the ma.s.s in dilute alcohol (it is not soluble in ether), again filtered, the filtrate being finally evaporated to dryness and tested.
MORPHIA.-The best tests for this alkaloid, in substance or in solution (substance is preferable) are:
1. Nitric acid, which strikes an orange red color, varying in intensity with the strength of the acid and the concentration of the morphia solution. Ruddy fumes are also developed.
2. Neutral perchloride of iron, strikes a rich blue color with morphia when added in small quant.i.ty; if added in excess, the yellow of the test, combining with the blue, may produce a green. This blue is destroyed by acids and by heat. Nitric acid not only destroys the blue produced by this test, but replaces it with the orange-red color; so that the nitric acid test may be applied to the same portion of morphia after the iron test, but not _vice versa_.
3. Iodic acid. This acid becomes decomposed, owing to the reducing action of morphia, setting free the iodine. The latter is detected by its brown color, and the blue which it strikes with starch. The iodic acid should be previously tested to ascertain its purity, as it occasionally contains free iodine.
4. b.i.+.c.hromate of pota.s.sium gives a green with morphia, pa.s.sing to a dingy brown.
MECONIC ACID.-This is obtained from solutions of opium, in the form of little scaly crystals of a reddish tint, which are decomposed by heat and partly sublimed. In solution it may be detected by its acquiring a blood-red color on the addition of the perchloride of iron. A similar color is produced by sulphocyanide of pota.s.sium, as found in the saliva; but the color of the meconate is not discharged by chloride of gold; the sulphocyanide is.
NARCOTINE dissolves in sulphuric acid with a yellow color, converted into a carmine red by the addition of a trace of nitric acid.
CHAPTER XXIII.
ANaeSTHETICS.
NEUROTICS ACTING ON THE BRAIN AND PRODUCING INSENSIBILITY.
CHLOROFORM-CHLORAL-b.i.+.c.hLORIDE OF METHYLENE-ETHER-AMYLENE-NITROUS OXIDE.
The anaesthetics which have hitherto been employed in the practice of medicine are chloroform, sulphuric ether (or a mixture of these), b.i.+.c.hloride of methylene and nitrous oxide, and amylene. Any of these agents may cause death when introduced into the system by inhalation.
CHLOROFORM is a colorless, heavy, volatile liquid; having a fruity ethereal odor and a sweet pungent taste. It is formed by the union of chlorine and marsh gas, but more commonly by the action of bleaching powder on ethylic or methylic alcohol. It is readily soluble in alcohol, but very sparingly so in water. Chloroform is a good solvent of caoutchouc, gutta-percha, camphor, wax, resin, some of the alkaloids, &c.
The _symptoms_ produced by the vapor of chloroform may be divided into three groups of varying intensity; briefly they are these: First, a degree of relief from pain, the senses being but slightly affected; second, a stage of excitement and incoherence, wherein the patient is p.r.o.ne to struggle; and thirdly, a stage of which the most marked features are complete insensibility and narcotism, with relaxation of the muscular system. At first the patient is conscious of all that is pa.s.sing around him, but there is dizziness and singing in the ears. Then the mental functions are impaired, there is often excitement, the saliva is increased, the patient pushes away the inhaler, rigidity and spasms of the muscles may occur, and there is incoherent talk. In the next stage there is insensibility to pain, and the conjunctiva may be touched without causing flinching. If the use of this anaesthetic be pushed further the breathing becomes stertorous, the muscles quite relaxed, and the pupils dilated; while a still further increase of the chloroform embarra.s.ses and then stops the breathing and arrests the heart's action.
Many cases of death from the vapor of chloroform have occurred, the fatal effect sometimes happening very rapidly from shock, syncope, or convulsions. The vapor of only thirty drops has destroyed life in one minute. Death under the influence of chloroform must not be confounded with death from its effects. The smallest fatal dose when the drug has been swallowed is one drachm in a boy aged four.
The effects of chloroform taken by the mouth are of the same description as those which follow the inhalation of this agent; with this exception, that the fatal result seems to be longer deferred. A case reported in the _Medical Times and Gazette_, 10th May, 1862, ill.u.s.trates the symptoms, &c., in a clear way. Mr. M., thirty-four years of age, a highly-gifted restless man, was in the habit of inhaling chloroform on account of sleeplessness. He was very sensitive to its action. At about 12.30 A.M. on the 7th October, 1861, he drank some chloroform; the quant.i.ty being uncertain, though it may be inferred that it was about one ounce. At 7.15 he was in such a profound sleep that his wife felt uneasy, and she sent for Dr. Axel Lamm. This gentleman found his patient in a tranquil sleep, the respiration being somewhat hurried and audible, the pulse full but slow, the body warm, and the pupils dilated and insensible. There was a perceptible smell of chloroform in the breath and in the air of the room. The window was opened, ice was applied to the head, cold affusions were used along the spine, and an enema was administered. At 9.30 A.M., the patient was paler, breathing less audibly, and with a weaker pulse. Artificial respiration was employed by means of electricity, an ammonia lavement was given, and aspersions of iced water to the chest and pit of the stomach were used alternately with warm coverings. The stupor continued, the respired air smelt distinctly of chloroform, the abdomen was tympanitic, and the pupils began to contract. About 9 P.M. the eyes began to move, the pupils seemed sensible to light, the pulse was 160, there was abundant perspiration, and the patient sat up for a few moments and looked surprised. Exhaustion, however, set in, and death occurred just before midnight, nearly twenty-four hours after swallowing the poison.
A second interesting case (_Medical Times and Gazette_, 31st May, 1862) also deserves attention. A gentleman, fifty years of age, swallowed two ounces of pure chloroform at 8 A.M. He was not seen until 3 P.M., when he was found in a state of deep coma. His breath smelt strongly of chloroform, the pupils were widely dilated and insensible, the pulse slow and feeble, the surface colder than natural, the movements of the thorax scarcely perceptible, and sensation generally abolished. Ammonia, sinapisms, bottles of hot water, and cold affusion did no good; but on using a stomach-pump a quant.i.ty of chloroform mixed with watery mucus was withdrawn, and in less than an hour the patient was able to answer questions. For three or four days he complained of a burning sensation in the throat and epigastrium, and then got well. A consideration of the treatment employed in this instance cannot but suggest the idea that the first patient might have had a better chance of recovery had the stomach-pump been used when Dr. Lamm was first called in; though it is difficult to conceive how any quant.i.ty of chloroform could remain in the stomach for seven hours, without all of it being absorbed.
Various plans have been suggested for the administration of chloroform with safety, but this must be remembered: the use of anaesthetics is at all times attended with risk, and we can only at best diminish the danger. Apparatus may be used so as to reduce the risk to a minimum; but this is plain, any contrivance which in itself requires much attention, and thereby diverts it from the patient, is bad. More lives have been lost by bungling in its administration than from the noxious character of the drug.
In the _treatment_ of poisoning by the vapor of any of the anaesthetics mentioned in this chapter, we must expose the patient to a current of pure air, use cold affusion, and employ artificial respiration until the poison is eliminated. Galvanism may be employed to keep up the action of the diaphragm, either directly or through the phrenics. As these agents are got rid of through the lungs, the purity of the expired air is one test of the elimination being complete; though of course inferior to the evidence afforded by the subsidence of the symptoms. In poisoning by liquid chloroform or ether the stomach-pump ought to be promptly used.
CHLORAL HYDRATE, which with an alkali is converted into chloroform, has of late been much used as a narcotic and for easing pain. No details of any case of poisoning by its agency have yet been published.
b.i.+.c.hLORIDE OF METHYLENE has been used for anaesthetic purposes. It is supposed to be safer than chloroform. Practically they act much alike, and death happens with the one as with the other.