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SULPHATE OF ATROPINE IN THE TREATMENT OF POISONING BY OPIUM.
CLINICAL NOTES.
548
hwe to b3 suported in their last days and finally buried by the inhabitants of up-country health resorts six thousand miles f] om home. Honor Oak, S.E.
in the case of a piece of needle it would not only show it if present, but also indicate the direction in which it lay. Mr. Rowland kindly took a photograph of the hand, and discovered the piece of needle lying across the metacarpo-phalangeal joint, but would not say whether on the anterior or posterior aspect of the joint. This was, however, A NEEDLE EXTRACTED FROM THE HAND decided by the condition of the part. On Feb. 21st I made an incision in the long axis of the thumb in a BY THE ASSISTANCE OF THE line corresponding to the interval between the abductor ROENTGEN RAYS. pollicis and the opponens pollicis, almost down to the joint, BY W. H. BATTLE, F.R.C.S. ENG., and exposed the end of the needle at once, which ASSISTANT SURGEON TO ST. THOMAS’S HOSPITAL AND TO THE ROYAL appeared as a little black spot in granulation tissue. It was FREE HOSPITAL. readily extracted with dissecting forceps, and was about half an inch long and the eye-end of a fine needle. A CASE which has recently been under treatment at the Mansfield-street, W. Royal Free Hospital gives proof of the occasional usefulness of the new method of photography. A woman aged thirty years had been sent to me on account of pain in the region of the metacarpo-phalangeal joint of the right thumb, which she said was due to the presence of part of a needle which AND she ran into this part of her hand nine months before. A THERAPEUTICAL. medical man had failed in an attempt to find the needle three months previously. There was an appearance of slight SULPHATE OF ATROPINE IN THE TREATMENT OF POISONING BY OPIUM. ________________
Clinical Notes:
MEDICAL, SURGICAL, OBSTETRICAL,
I
BY B. LEWIS
PATON, M.B., C.M. EDIN.
sulphate of atropine in the treatment of poisoning by opium seems to be shown by the following THE value of
case.
On Oct. 12th, 1895, a Chinese woman, married, aged twenty-nine, living in Amoy, tried to poison herself by taking, according to her own statement, two ounces of prepared opium in a cold infusion of some sort which she bad made overnight. She drank the mixture at about daylight, but it
was not found out till some hours afterwards. Native methods were used to produce vomiting, so that by the time I was asked to see her she had already vomited frequently, the vomited matter, according to the statements of those who saw it, giving unmistakable evidence that opium had been taken. I was not at first allowed to see the patient, but her hand was thrust through the bed-curtain to enable me to feel the pulse, and by asking her questions I gathered that she was already
drowsy. A mixture containing atropine sulphate prescribed to be taken at frequent intervals. In the afternoon I was again sent for, and was now allowed to see the patient, whom I found in bed and deeply comatose, it being difficult to rouse her. She was unable to swallow, so that the medicine could not now be taken by the mouth. The friends were indignant when I suggested that she should somewhat was
The
positio1. photograph
of the needle
having
hv -Mi,. Rowland, was for Mr.Battle’s better information.
been detected upon the him in white
painted by
swelling in the neighbourhood of the joint, considerable tenderness, with some thickening, but no foreign body could
be felt. She had difficulty in flexing the thumb and was unable to use the hand properly. The only way in which it could be proved that there was a piece of metal in the hand was either by a special electrical apparatus or by means of the new photography; the latter possessed special advantages; as
be got out of bed, moved about, and any and every means used to keep her awake. How could they treat a lady in I then suggested the use of the hypodermic that way ?‘! needle and the injection of a drug which was believed to be antagonistic to opium. Strange to say, the husband gave his consent, for the Chinese are not yet sufficiently acquainted with this method of introducing a drug into the system. The patient was now lifted out of bed and put in a chair, and the hypodermic injection was begun at 3 P.M., a solution of atropine sulphate of 2 grains to the ounce of distilled water being employed, 20 minims of which were injected. This wasdone four times-viz., at 3 P.M., 3.15 P. 3.30 P.1L, and 3 45 P.M. ; 80 minims, or about one-third of a grain of the sulphate, being injected in all. There was very little change in the condition, and as the husband was unwilling to have the injections continued I then left, asking that word might be sent in an hour or two. ’When next sent for I found the coma somewhat deeper, the head was thrown back, and the neck rigid. It was impossible now to make her walk about, even had the friends been willing, as there was rigidity of all the joints. If she was made to stand it was with the greatest ditficulty that the hip- and knee-joints could be bent toenable her to be seated again. The injections were now recommenced, but of double the strength, 4 grains to the ounce being now used. I should mention that the respirations were now only 4 or 5 per minute and were of the Clheyne-Stokes’ character, the face becoming somewhat cyanosed in the long intervals. Twenty minims wereinjected five times as follows: at 5.45 P.M., 6.15 P )1., 7.45 P.M., 8.30 P.M., and 9.30 P.M. By this time there waan improvement in the number of respirations. They laa6
CLINICAL NOTES.-HOSPITAL MEDICINE AND SURGERY.
549
The rigidity, too, was A woman aged twenty-nine years came to me on Christmas or 10 per minute. passing off, and freshly pounded carbonate of ammonium Day, 1895, complaining of inability to completely extend applied to the nostrils began to have some effect in rousing the terminal phalanx of the middle finger of the left hand. her. Just before midnight I visited the patient again and She alleged that a few hours previously, while pulling up her injected 15 minims, which brought the total amount injected stocking, in some way she caught the finger and heard a to 115 minims, or about 1 grain of the sulphate. Next snap, although she felt no pain. On her attempting extenmorning I was not allowed to do more than feel the pulse, sion the terminal phalanx formed an angle of 135° with the the hand being thrust through the bed-curtain as at the rest of the finger. There were tenderness and swelling over first visit. She was then quite conscious; the pulse was 128 the back of the joint and some pain over the middle of the and she had some fever. As the bowels had not been moved dorsum of the middle phalanx. It was put up in a splint, and the bladder emptied since the day before taking the with the terminal phalanx as far as possible in a, state of opium an aperient with some quinine was prescribed. I hyper-extension. Though the patient removed the splint heard no more of the case for a week or two, when I was several times, it was reapplied each time and kept on" for told that by the afternoon of the day of my last visit the about ten days, after which a splint with a spring which patient was perfectly well. The total amount of sulphate pressed back the terminal phalanx was worn for a fortnight.
ircreased to 9
Some improvement has resulted, attempted extension producing an angle of 160°. Some tenderness over dorsum of the middle phalanx still remains.
of atropine injected was about 1,3’ grain. The patient had at one time smoked opium, but according to the statement of her friends had given up the habit about a year ago. Amoy, China.
now
the
Earl’s-court-road, W.
NOTE ON THE PREVENTION OF LARGE MAMMARY ABSCESSES BY EXPRESSION OF THE MILK. BY WALTER G. SPENCER, F.R.C.S. ENG.,
A Mirror OF
SURGEON TO THE OUT-PATIENTS AND TO THE THROAT DEPARTMENT, WESTMINSTER HOSPITAL, ETC.
HOSPITAL PRACTICE, BRITISH AND FOREIGN.
UNFORTUNATELY cases of large mammary abscesses are too often in the wards of a general hospital. A woman has been exhausted by the previous pregnancy and lactation Nulla autem est alia pro certo noscendi via, nisi qnamplurtmas et m orhistorias, tum aliorum tum proprias collectas and is usually more or less worried about her family. Gene- borum etetdissectionum inter se oomparare.—MoBGAeNi De Sed. et Cau8. Jforb., habere, rally more than one incision has to be made, the sinuses are lib. iv. Prooemium. long in healing, sometimes the removal of the whole breast UNIVERSITY COLLEGE HOSPITAL. has been required, and even after healing the scars which EPILEPTIC HEMIPLEGIA ; VERY NUMEROUS FITS OF JACKDoubtless remain may become later the site of cancer. SONIAN TYPE; RECOVERY. with proper care the breast need never become so overwhen it is the distended, but beyond powers of suction to (Under the care of Dr. CHARLTON BASTIAN, F.R.S.) empty it the application of hot fomenta.tions, poultices, or SOME of our readers may recollect a lecture by Dr. Bastian1 belladonna plaster is surely a mistake, for all the secondary ducts must quickly become converted into abscess cavities which was published in THE LANCET on the subject of In that lecture he included two unless the milk be first removed. Professor Tarnier Epileptic Hemiplegia. some years ago devoted a clinical lecture to the subject. distinct classes of cases under this head. There are. first, have had some half a dozen cases during the last the cases referred to in a previous lecture, in which a very two years among the out-patients at the Westminster brief and is apt to follow certain severe temporary hemiplegia Hospital. In all instances the breasts were extremely attacks of unilateral convulsions, the hemiplegic condition disteaded, lactation having been recently interrupted ; the in these cases being presumably due merely to vascular skin over the breast was, however, still free from induration, spasms plus certain molecular changes in definite parts so that the full ducts could all be felt. By the forcible expres- of the brain. Secondly, there is the much more forsion of half to a pint of milk suppuration was prevented. In midable group of cases in which we have to do with distinct two of the cases nitrous oxide gas was given ; the other and obvious organic lesions in the brain, giving rise both to patients bore the pressure without an anavsthetic. Taking the epileptiform mode of onset and to the more persistent the breast in the hollow of the hands and increasing the hemiplegic condition. Dr. Todd wrote on this subject. Our pressure very gradually and as uniformly as possible there readers will also find interesting contributions by Dr. Hughfirst oozed from the nipple a few drops of whey, then a small lings Jackson,2 Sir J. Crichton Browne,3 and Dr. Kelley.4 For plug of curd, followed by a stream of milk. From each the notes of this case we are indebted to Dr. Harold C. - duct a plug of curd had to be driven before milk Way, house physician. came. Finally, there issued streams of milk in many direcA married woman aged fifty-three years was admitted to tions as water from the rose of a gardener’s watering-pot. the hospital on Nov. 23rd, 1895, paralysed on the left side of Directly milk flows tension is relieved and further pressure the body. She had had influenza in the previous March, does not cause so much pain. The amount of pressure re- which was followed constant headache and occasional by quired when the breast was so over-distended as in the cases vomiting lasting for a period of five or six weeks. She then ailluded to indicated clearly that suction would have been went away for three months and returned to her home in quite inadequate, whilst the fact that each duct was plugged August almost well. After this the pain over the by curd showed why the milk was retained and how inevit- whole of the topquite of her head gradually became worse, but able must have been decomposition and suppuration. In there was no sickness. On Nov. 9th she complained of my last case a small areolar abscess had already formed and numbness in the left arm and on the left side of tingling and blocked the nipple by its pressure. The abscess was the face. On waking in the morning of the 10th she opened under nitrous oxide gas and nearly a pint of sweet found she was completely paralysed on the left side of the milk expressed. No further suppuration ensued. Afterwards On the llth she had a fit with twitching which the women have been ordered to foment and to squeeze the body. Similar fits were was confined to the left side of the body. breast frequently and to take iodide of potassium for a few said to have recurred daily in batches until the date of days. admission. There was a history of insanity in the family, Brook-street, W. and four years ago her friends said she was completely " off her head " for some months which they had attributed to RUPTURE OF THE TERMINAL EXPANSION OF THE family troubles. Since then she had been mentally dull and childish. There was no-history of syphilis, and previously EXTENSOR COMMUNIS DIGITORUM. her health had been good. On admission her condition was BY F. G. WALLACE, M.B., B.C. CANTAB., ETC., as follows. She was constantly muttering and crying out with LATE NON-RESIDENT HOUSE PHYSICIAN TO ST. THOMAS’S HOSPITAL, ETC. pain in her head ; the pain was not localised and there was no seen
-
ALTHOUGH perhaps coming under the head of " minor ail’mentsIthink that the following case is interesting, partly from its rarity and partly from its causation.
I
2 4
1 THE LANCET, June 20th, 1874. Medical Times and Gazette, 1881, vol. i., p. 185. 3 THE LANCET, Aug. 15th, 1874. Medical Times and Gazette, 1878, vol. ii., p. 216.
548
hwe to b3 suported in their last days and finally buried by the inhabitants of up-country health resorts six thousand miles f] om home. Honor Oak, S.E.
in the case of a piece of needle it would not only show it if present, but also indicate the direction in which it lay. Mr. Rowland kindly took a photograph of the hand, and discovered the piece of needle lying across the metacarpo-phalangeal joint, but would not say whether on the anterior or posterior aspect of the joint. This was, however, A NEEDLE EXTRACTED FROM THE HAND decided by the condition of the part. On Feb. 21st I made an incision in the long axis of the thumb in a BY THE ASSISTANCE OF THE line corresponding to the interval between the abductor ROENTGEN RAYS. pollicis and the opponens pollicis, almost down to the joint, BY W. H. BATTLE, F.R.C.S. ENG., and exposed the end of the needle at once, which ASSISTANT SURGEON TO ST. THOMAS’S HOSPITAL AND TO THE ROYAL appeared as a little black spot in granulation tissue. It was FREE HOSPITAL. readily extracted with dissecting forceps, and was about half an inch long and the eye-end of a fine needle. A CASE which has recently been under treatment at the Mansfield-street, W. Royal Free Hospital gives proof of the occasional usefulness of the new method of photography. A woman aged thirty years had been sent to me on account of pain in the region of the metacarpo-phalangeal joint of the right thumb, which she said was due to the presence of part of a needle which AND she ran into this part of her hand nine months before. A THERAPEUTICAL. medical man had failed in an attempt to find the needle three months previously. There was an appearance of slight SULPHATE OF ATROPINE IN THE TREATMENT OF POISONING BY OPIUM. ________________
Clinical Notes:
MEDICAL, SURGICAL, OBSTETRICAL,
I
BY B. LEWIS
PATON, M.B., C.M. EDIN.
sulphate of atropine in the treatment of poisoning by opium seems to be shown by the following THE value of
case.
On Oct. 12th, 1895, a Chinese woman, married, aged twenty-nine, living in Amoy, tried to poison herself by taking, according to her own statement, two ounces of prepared opium in a cold infusion of some sort which she bad made overnight. She drank the mixture at about daylight, but it
was not found out till some hours afterwards. Native methods were used to produce vomiting, so that by the time I was asked to see her she had already vomited frequently, the vomited matter, according to the statements of those who saw it, giving unmistakable evidence that opium had been taken. I was not at first allowed to see the patient, but her hand was thrust through the bed-curtain to enable me to feel the pulse, and by asking her questions I gathered that she was already
drowsy. A mixture containing atropine sulphate prescribed to be taken at frequent intervals. In the afternoon I was again sent for, and was now allowed to see the patient, whom I found in bed and deeply comatose, it being difficult to rouse her. She was unable to swallow, so that the medicine could not now be taken by the mouth. The friends were indignant when I suggested that she should somewhat was
The
positio1. photograph
of the needle
having
hv -Mi,. Rowland, was for Mr.Battle’s better information.
been detected upon the him in white
painted by
swelling in the neighbourhood of the joint, considerable tenderness, with some thickening, but no foreign body could
be felt. She had difficulty in flexing the thumb and was unable to use the hand properly. The only way in which it could be proved that there was a piece of metal in the hand was either by a special electrical apparatus or by means of the new photography; the latter possessed special advantages; as
be got out of bed, moved about, and any and every means used to keep her awake. How could they treat a lady in I then suggested the use of the hypodermic that way ?‘! needle and the injection of a drug which was believed to be antagonistic to opium. Strange to say, the husband gave his consent, for the Chinese are not yet sufficiently acquainted with this method of introducing a drug into the system. The patient was now lifted out of bed and put in a chair, and the hypodermic injection was begun at 3 P.M., a solution of atropine sulphate of 2 grains to the ounce of distilled water being employed, 20 minims of which were injected. This wasdone four times-viz., at 3 P.M., 3.15 P. 3.30 P.1L, and 3 45 P.M. ; 80 minims, or about one-third of a grain of the sulphate, being injected in all. There was very little change in the condition, and as the husband was unwilling to have the injections continued I then left, asking that word might be sent in an hour or two. ’When next sent for I found the coma somewhat deeper, the head was thrown back, and the neck rigid. It was impossible now to make her walk about, even had the friends been willing, as there was rigidity of all the joints. If she was made to stand it was with the greatest ditficulty that the hip- and knee-joints could be bent toenable her to be seated again. The injections were now recommenced, but of double the strength, 4 grains to the ounce being now used. I should mention that the respirations were now only 4 or 5 per minute and were of the Clheyne-Stokes’ character, the face becoming somewhat cyanosed in the long intervals. Twenty minims wereinjected five times as follows: at 5.45 P.M., 6.15 P )1., 7.45 P.M., 8.30 P.M., and 9.30 P.M. By this time there waan improvement in the number of respirations. They laa6
CLINICAL NOTES.-HOSPITAL MEDICINE AND SURGERY.
549
The rigidity, too, was A woman aged twenty-nine years came to me on Christmas or 10 per minute. passing off, and freshly pounded carbonate of ammonium Day, 1895, complaining of inability to completely extend applied to the nostrils began to have some effect in rousing the terminal phalanx of the middle finger of the left hand. her. Just before midnight I visited the patient again and She alleged that a few hours previously, while pulling up her injected 15 minims, which brought the total amount injected stocking, in some way she caught the finger and heard a to 115 minims, or about 1 grain of the sulphate. Next snap, although she felt no pain. On her attempting extenmorning I was not allowed to do more than feel the pulse, sion the terminal phalanx formed an angle of 135° with the the hand being thrust through the bed-curtain as at the rest of the finger. There were tenderness and swelling over first visit. She was then quite conscious; the pulse was 128 the back of the joint and some pain over the middle of the and she had some fever. As the bowels had not been moved dorsum of the middle phalanx. It was put up in a splint, and the bladder emptied since the day before taking the with the terminal phalanx as far as possible in a, state of opium an aperient with some quinine was prescribed. I hyper-extension. Though the patient removed the splint heard no more of the case for a week or two, when I was several times, it was reapplied each time and kept on" for told that by the afternoon of the day of my last visit the about ten days, after which a splint with a spring which patient was perfectly well. The total amount of sulphate pressed back the terminal phalanx was worn for a fortnight.
ircreased to 9
Some improvement has resulted, attempted extension producing an angle of 160°. Some tenderness over dorsum of the middle phalanx still remains.
of atropine injected was about 1,3’ grain. The patient had at one time smoked opium, but according to the statement of her friends had given up the habit about a year ago. Amoy, China.
now
the
Earl’s-court-road, W.
NOTE ON THE PREVENTION OF LARGE MAMMARY ABSCESSES BY EXPRESSION OF THE MILK. BY WALTER G. SPENCER, F.R.C.S. ENG.,
A Mirror OF
SURGEON TO THE OUT-PATIENTS AND TO THE THROAT DEPARTMENT, WESTMINSTER HOSPITAL, ETC.
HOSPITAL PRACTICE, BRITISH AND FOREIGN.
UNFORTUNATELY cases of large mammary abscesses are too often in the wards of a general hospital. A woman has been exhausted by the previous pregnancy and lactation Nulla autem est alia pro certo noscendi via, nisi qnamplurtmas et m orhistorias, tum aliorum tum proprias collectas and is usually more or less worried about her family. Gene- borum etetdissectionum inter se oomparare.—MoBGAeNi De Sed. et Cau8. Jforb., habere, rally more than one incision has to be made, the sinuses are lib. iv. Prooemium. long in healing, sometimes the removal of the whole breast UNIVERSITY COLLEGE HOSPITAL. has been required, and even after healing the scars which EPILEPTIC HEMIPLEGIA ; VERY NUMEROUS FITS OF JACKDoubtless remain may become later the site of cancer. SONIAN TYPE; RECOVERY. with proper care the breast need never become so overwhen it is the distended, but beyond powers of suction to (Under the care of Dr. CHARLTON BASTIAN, F.R.S.) empty it the application of hot fomenta.tions, poultices, or SOME of our readers may recollect a lecture by Dr. Bastian1 belladonna plaster is surely a mistake, for all the secondary ducts must quickly become converted into abscess cavities which was published in THE LANCET on the subject of In that lecture he included two unless the milk be first removed. Professor Tarnier Epileptic Hemiplegia. some years ago devoted a clinical lecture to the subject. distinct classes of cases under this head. There are. first, have had some half a dozen cases during the last the cases referred to in a previous lecture, in which a very two years among the out-patients at the Westminster brief and is apt to follow certain severe temporary hemiplegia Hospital. In all instances the breasts were extremely attacks of unilateral convulsions, the hemiplegic condition disteaded, lactation having been recently interrupted ; the in these cases being presumably due merely to vascular skin over the breast was, however, still free from induration, spasms plus certain molecular changes in definite parts so that the full ducts could all be felt. By the forcible expres- of the brain. Secondly, there is the much more forsion of half to a pint of milk suppuration was prevented. In midable group of cases in which we have to do with distinct two of the cases nitrous oxide gas was given ; the other and obvious organic lesions in the brain, giving rise both to patients bore the pressure without an anavsthetic. Taking the epileptiform mode of onset and to the more persistent the breast in the hollow of the hands and increasing the hemiplegic condition. Dr. Todd wrote on this subject. Our pressure very gradually and as uniformly as possible there readers will also find interesting contributions by Dr. Hughfirst oozed from the nipple a few drops of whey, then a small lings Jackson,2 Sir J. Crichton Browne,3 and Dr. Kelley.4 For plug of curd, followed by a stream of milk. From each the notes of this case we are indebted to Dr. Harold C. - duct a plug of curd had to be driven before milk Way, house physician. came. Finally, there issued streams of milk in many direcA married woman aged fifty-three years was admitted to tions as water from the rose of a gardener’s watering-pot. the hospital on Nov. 23rd, 1895, paralysed on the left side of Directly milk flows tension is relieved and further pressure the body. She had had influenza in the previous March, does not cause so much pain. The amount of pressure re- which was followed constant headache and occasional by quired when the breast was so over-distended as in the cases vomiting lasting for a period of five or six weeks. She then ailluded to indicated clearly that suction would have been went away for three months and returned to her home in quite inadequate, whilst the fact that each duct was plugged August almost well. After this the pain over the by curd showed why the milk was retained and how inevit- whole of the topquite of her head gradually became worse, but able must have been decomposition and suppuration. In there was no sickness. On Nov. 9th she complained of my last case a small areolar abscess had already formed and numbness in the left arm and on the left side of tingling and blocked the nipple by its pressure. The abscess was the face. On waking in the morning of the 10th she opened under nitrous oxide gas and nearly a pint of sweet found she was completely paralysed on the left side of the milk expressed. No further suppuration ensued. Afterwards On the llth she had a fit with twitching which the women have been ordered to foment and to squeeze the body. Similar fits were was confined to the left side of the body. breast frequently and to take iodide of potassium for a few said to have recurred daily in batches until the date of days. admission. There was a history of insanity in the family, Brook-street, W. and four years ago her friends said she was completely " off her head " for some months which they had attributed to RUPTURE OF THE TERMINAL EXPANSION OF THE family troubles. Since then she had been mentally dull and childish. There was no-history of syphilis, and previously EXTENSOR COMMUNIS DIGITORUM. her health had been good. On admission her condition was BY F. G. WALLACE, M.B., B.C. CANTAB., ETC., as follows. She was constantly muttering and crying out with LATE NON-RESIDENT HOUSE PHYSICIAN TO ST. THOMAS’S HOSPITAL, ETC. pain in her head ; the pain was not localised and there was no seen
-
ALTHOUGH perhaps coming under the head of " minor ail’mentsIthink that the following case is interesting, partly from its rarity and partly from its causation.
I
2 4
1 THE LANCET, June 20th, 1874. Medical Times and Gazette, 1881, vol. i., p. 185. 3 THE LANCET, Aug. 15th, 1874. Medical Times and Gazette, 1878, vol. ii., p. 216.