By G. Dennis. Bethany Bible College.

This effect spreads out the initial injected indicator marker as it moves through the vascular system with the blood purchase co-amoxiclav with amex. Eventually the indicator which moves through the vasculature faster than average will reach the sensor which in turn will detect increasing concentrations of indicator* purchase co-amoxiclav with paypal. As time progresses the bulk of the indicator will pass purchase cheap co-amoxiclav, the concentration curve will peak, then return to zero as the slowest moving indicator- carrying blood passes the sensor. As with the Fick method, this equation’s accuracy critically depends on the cardiac output remaining constant from the time of indicator injection until the curve has been measured. Since the definite integral equals the area under the curve, this equation says: the cardiac output equals the amount of indicator injected divided by the area under the concentration vs. The major limitation inherent in this method arises from the circulation being a closed system. The most satisfactory method to account for recirculation is to remove it from the observed indicator washout curve. This correction follows from the observation that once the indicator concentration curve starts dropping, it drops according to the inverse exponential function of time (Ae-kt; with A and k being constants) until recirculation begins. In the vast majority of clinical situations, temperature is now used as the marker in the Indicator-Dilution technique. From a practical point of view, one injects the dye or other indicator into the pulmonary artery or right heart (through which all the blood must flow) through a catheter, then samples from another catheter downstream in the central circulation which yields the concentration-time curve which is recorded on paper (or in a computer) for subsequent analysis. Repeated cardiac outputs may be done at short intervals, if the dye is rapidly cleared from the circulation (this is especially true when a thermistor (thermometer) is used and the indicator is cooled saline solution). Once the catheters and sensors are in place no further cooperation is needed (in contrast to the Fick procedure in which the patient must breathe into a closed system for several minutes). Although sensing in the aorta or pulmonary artery seems necessary, at first glance, this is not the case since as the marker passes out of the aorta into its branches, the wave-front of advancing marker concentration will be more or less the same as it was in the aorta and since it is only concentration versus time we are interested in, sampling can take place in any one of the peripheral arteries (i. As cardiac output falls, the flow rate is (by definition) slower and the area under the curve is larger, with a longer time of inscription. This means that recirculation may occur before the curve is completely described, exaggerating the area under the curve and thus artifactually diminishing the already low cardiac output. A corollary of this is that Indicator- dilution outputs are generally more accurate with high outputs and vice versa. Fick output, on the other hand, are more accurate with low outputs and less so with high outputs having small arteriovenous O2 differences. When the cardiac output is high, one would expect a higher peak concentration of the curve (conc. Although the peak may be slightly higher with a high cardiac output, the slope of decay of the indicator concentration is much more rapid and the area under the curve less. If only a fractional sample of arterial blood goes through the sensor then we are only looking at a fraction of the indicator injected, yet we are dividing this into the whole quantity of indicator. Since the concentration of different substances does not change during the brief time that the blood is in the arterial tree and since we are measuring concentration, this does not introduce an error. The responses to these confusions may be clearer if we examine some examples of the indicator-dilution system at work: (figs. Both the Fick and Indicator-Dilution methods for determining cardiac output, the average volume flow rate of blood pumped from the heart, follow from identifying specific particles of blood and monitoring their movement. In the Fick method, oxygen breathed normally from a room serves as the most natural and common indicator. Both Fick and Indicator-dilution methods produce similar values for cardiac output and both critically depend on satisfying the assumption of steady state: for the Fick method, constant respiratory activity, and for both methods, constant cardiac output. The Fick method is more accurate at low cardiac outputs and the Indicator-Dilution method more accurate at high outputs. When the cardiac output is low the difference between arterial and venous oxygen concentrations tend to be high; therefore, a given absolute measurement error induces a small percentage error in the difference Co- Ci. High cardiac outputs go with lower Co- Ci, so the same absolute measurement error in oxygen content will induce a much larger percentage error. On the other hand, in the Indicator- Dilution method recirculation introduces relatively greater errors when cardiac output is low than when it is high because it appears earlier in washout. Chapter 1: Normal Cardiac Output and its Variations; Chapter 2: Measurement of Cardiac Output by the Direct Fick Method; Chapter 3: Indicator-Dilution Methods for Determining Cardiac Output. Chapter 2: Foundations of Indicator Dilution Theory; Chapter 3: A Method for Performing an Indicator-Dilution Curve to Measure Cardiac Output. Zierler: Circulation Times and The Theory of Indicator-Dilution Methods for Determining Blood Flow and Volume. To estimate the area work in mm deflection of the recorder, then convert to mg/L using the calibration factor 5 mg/L = 55. Replot the washout curve on semilog paper then extrapolate the exponential decay to negligible concentration, and plot the resulting extrapolation on the original washout curve (Fig. Find the area under the resulting curve and convert to the actual units: c(t) dt = Area = 10690 mm2 • 5 mg dye/L • sec = 96. It is the purpose of this presentation to review current methods of diagnostic cardiac catheterization with particular reference to studies of the right heart, pulmonary circulation and the left heart. The hemodynamics of the pulmonary and systemic circulation, cardiac output measurements, valvular stenosis and pericardial disease are presented elsewhere. Pressures were recorded on a smoked drum via a long air filled rubber tube with a balloon at each end. In 1870 Adolph Fick described the method of determining cardiac output by a knowledge of the oxygen content of mixed venous blood, the arterial blood and the oxygen consumption. However it was not until 1925 that the 25 year old Werner Forssmann inserted a ureteral catheter in his own antecubital vein and guided it by fluoroscopy into his right atrium. He then walked upstairs to the Radiology Department where a chest film confirmed the position of the catheter Forssman was a surgeon and did not realize the potential diagnostic value of his procedure. He thought that it might be a method of central administration of drugs where peripheral venous access was difficult. It was not until 1941 when Richards and Cournand began a series of cardiac catheterizations at Bellevue Hospital in New York City that right heart catheterization became accepted as an important method of studying the circulation. Subsequent developments are listed next: 1947 - Pulmonary artery and pulmonary wedge pressure measurements; Dexter 1947 - Diagnosis of congenital heart disease-valvular stenoses and shunt flows; Bing - Dexter 1950 - Retrograde catheterization of the left ventricle; Zimmerman 1953 - Seldinger technique of percutaneous arterial catheterization 1959 - Transseptal left atrial catheterization; Ross and Cope 1959 - Selective coronary arteriography; Sones 1970 - Balloon tipped flow guided catheter; Swan & Ganz Cardiac Output and Catheterization – Rajesh Dash, M. The fluid filled catheter is then advanced under fluoroscopic control to the right atrium, right ventricle and pulmonary artery for pressure measurements, blood sampling or injections of dye or cold saline to measure cardiac output. Right atrial mean pressure using the midchest in the supine position as a reference point will provide a rough estimate of the intravascular fluid volume if cardiac function is normal, a low pressure 0-2 mm indicating hypovolemia and a high pressure >12 mm indicating hypervolemia. With the advent of the Swan-Ganz catheter -a balloon tipped flow guided catheter that can be inserted percutaneously at the bedside-pulmonary artery catheterization has been greatly simplified and is the most common method of right heart catheterization employed in intensive care units. Inflation of the balloon will obstruct flow in the catheterized branch of the pulmonary artery and the retrograde pressure of the left atrium can be measured (pulmonary wedge or capillary pressure). A second proximal lumen will permit blood sampling or injection of dye or cold saline in the pulmonary artery. When the pulmonary artery balloon is inflated (Swan-Ganz catheter) or an ordinary cardiac catheter is advanced so that it "wedges" in a small pulmonary artery the retrograde pressure reflects left atrial pressure minus about 2 mmHg.

Contra-indications order co-amoxiclav visa, adverse effects order co-amoxiclav 625mg with mastercard, precautions – Do not administer to patients with severe hepatic impairment purchase 625mg co-amoxiclav. Remarks – For the prophylaxis of pneumocystosis, pentamidine may be used by inhalation of nebulised solution using suitable equipment. If necessary, a second dose of 5 to 10 mg/kg may be administered 15 to 30 minutes after the first dose. Contra-indications, adverse effects, precautions – Do not administer in patients with severe respiratory depression. Do not use oral route in newborns at high risk (preterm neonates, jaundice, neonatal diseases; newborns whose mother is treated with enzyme-inducing drugs). Dosage and duration Dosage depends on the severity of hypokalaemia and the patient’s underlying condition. The infusion may be repeated if severe symptoms persist or if the serum potassium level remains <3mmol/litre. Contra-indications, adverse effects, precautions – Administer with caution to elderly patients. If more than 30 minutes have elapsed since the heparin injection, the dose of protamine to be given should be one half the dose of heparin injected. Contra-indications, adverse effects, precautions – May cause: hypotension, bradycardia and dyspnoea; allergic reactions, notably in diabetics treated by protamine-insulin. Dosage the dosage is expressed in terms of salt; it is the same for quinine dihydrochloride or for quinine formate: – child and adult: • loading dose: 20 mg/kg administered over 4 hours, then keep the vein open with an infusion of 5% glucose over 4 hours • maintenance dose: 8 hours after the start of the loading dose, 10 mg/kg every 8 hours (alternate quinine over 4 hours and 5% glucose over 4 hours) for adults, administer each dose of quinine in 250 ml. Do not administer a loading dose to patients who have received oral quinine, mefloquine or halofantrine within the previous 24 hours: start with maintenance dose. Duration – change to oral treatment as soon as possible with a 3-day course with an artemisinin-based combination (if patient developed neurological signs during the acute phase, do not use the combination artesunate- mefloquine) or oral quinine to complete 7 days of treatment. Contra-indications, adverse effects, precautions – May cause: hypoglycaemia; auditory and visual disturbances, cardiac disorders (especially in the event of overdose), hypersensitivity reactions, cardiac depression if injected undiluted by direct Iv route. If contractions persist, increase the rate by 10 to 20 drops/minute every 30 minutes until uterine contractions cease. Continue for one hour after contractions have ceased, then reduce the rate by half every 6 hours. Duration – 48 hours maximum Contra-indications, adverse effects, precautions – Do not administer to patients with pre-eclampsia, eclampsia, uterine haemorrhage, intra- uterine infection, intra-uterine foetal death, placenta praevia, placental abruption, rupture of membranes, multiple pregnancy, severe cardiopathy. Therapeutic action – Antibacterial (group of aminoglycosides) 2 Indications – Second choice treatment of gonococcal infections Presentation and route of administration – Powder for injection in 2 g vial, to be dissolved with the diluent supplied by the manufacturer (3. Dosage – child over 30 kg and adult: 15 mg/kg (12 to 18 mg/kg/day) once daily; maximum 1 g/day 1 g vial to be dissolved in 4 ml Weight (207 mg/ml) Dose in mg Dose in ml 30 to 33 kg 500 mg 2. Dosage and duration – Patients must be treated in hospital, under close medical supervision. In the event of anaphylactic reaction, the patient should never receive suramin again; • proteinuria (renal toxicity), diarrhoea, haematological disorders (haemolytic anaemia, agranulocytosis, etc. Suramin is also used at the meningoencephalitic stage until the woman can be given melarsoprol after delivery, as melarsoprol is contra-indicated during pregnancy. Remarks – Suramin is not administered at the meningoencephalitic stage (except in pregnant women) as it poorly penetrates into the cerebrospinal fluid. Contra-indications, adverse effects, precautions – Do not administer in the event of severe respiratory depression and to patients that risk seizures (e. The neonate may develop withdrawal symptoms, respiratory depression and drowsiness in the event of prolonged administration of large doses at the end of the 3rd trimester. Monitor the mother and the neonate: in the event of excessive drowsiness, stop treatment. Precautions for the use of infusion fluids – Carefully read the labels on the infusion bottle to avoid mistakes. Remarks – If ready-made 10% glucose solution is not available: add 10 ml of 50% glucose solution per 100 ml of 5% glucose solution to obtain a 10% glucose solution. Example: Plasmion® Haemaccel® Modified fluid gelatin 30 g/litre – Polygeline – 35 g/litre Sodium (Na+) 150 mmol (150 mEq) 145 mmol (145 mEq) 3 Potassium (K+) 5 mmol (5 mEq) 5. Contra-indications, adverse effects, precautions – May cause: allergic reactions, possibly severe (anaphylactic shock). Contra-indications, adverse effects, precautions – In cases of metabolic alkalosis, diabetes, severe hepatic failure, head injury: isotonic solution of NaCl 0. It contains lactate which is converted to bicarbonate for correction of metabolic acidosis when it exists (if haemodynamic and liver function are normal). Remarks – For correction of hypovolaemia due to haemorrhage; administer 3 times the lost volume only if: • blood loss does not exceed 1500 ml in adults; • cardiac and renal function are not impaired. However, at least 12 hours before reconstitution of the vaccine, the diluent must be refrigerated between 2°C and 8°C so that the diluent and lyophilised powder are at the same temperature: a temperature difference during reconstitution may reduce vaccine efficacy. It is recommended to administer the 1st dose at 6 weeks of age, the 2nd dose at 10 weeks of age and the 3rd dose at 14 weeks of age. If a child has not been vaccinated at 6 weeks of age, start vaccination as soon as possible. Remarks – If the vaccination is interrupted before the complete series has been administered, it is not necessary to start again from the beginning. Continue the vaccination schedule from where it was interrupted and complete the series as normal. Vaccination should be postponed in the event of severe acute febrile illness (minor infections are not contra-indications). Continue the vaccination schedule from where it was interrupted and complete the series as normal. For information, for travellers: 3 injections on Day 0, Day 7 and Day 28; a booster dose every 3 years if risk persists. An accelerated schedule is possible (3 doses on Day 0, Day 7 and Day 14) but this is likely to result in lower antibody levels than the standard schedule. The 3rd dose should be given at least 10 days before departure to ensure an adequate immune response and access to medical care in the event of adverse reactions. Contra-indications, adverse effects, precautions – Do not administer to patients with history of an allergic reaction to a previous injection of Japanese encephalitis vaccine. However, at least 12 hours before reconstitution of the vaccine, the diluent must be refrigerated between 2°C and 8°C so that the diluent and lyophilised powder are at the same temperature: a temperature difference during reconstitution may reduce vaccine efficacy. Contra-indications, adverse effects, precautions – Do not administer to patients with severe immune depression or history of an allergic reaction to a previous injection of measles vaccine. Remarks 4 – Immunity develops 10 to 14 days after injection, and lasts for at least 10 years (when administered at 9 months). However, at least 12 hours before reconstitution of the vaccine, the diluent must be refrigerated between 2°C and 8°C so that the diluent and lyophilised powder are at the same temperature: a temperature difference during reconstitution may reduce vaccine efficacy.

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Practitioners should check with their Medical Devices department which type is used in their organisation cheap co-amoxiclav 625 mg with visa. The British National Formulary also carries some limited information about compatibilities in the section ‘Prescribing in palliative care’ safe co-amoxiclav 625mg. If it is not possible for a practitioner to verify whether a particular combination of drugs is compatible purchase co-amoxiclav with a mastercard, options include: * For a given indication, seeking alternate drugs for which compatibility has been validated * Using a second driver at a different site * Administering some drugs as subcutaneous injections, e. Check that the driver is in full working order, and does not require a new battery. Calculate the volume of drugs to be given (before dilution) and pick an appropriate size of syringe to hold the final volume. Consideration should be given to the order in which the drugs are introduced into the Appendix 9 Syringe drivers | 895 syringe because of possible incompatibilities during the preparation process. The syringe should be labelled with the patient’s name, the time and date of preparation and the drugs and doses contained. The label should not totally obscure the fluid in the barrel as this requires subsequent measurement. The infusion set can then be primed if necessary with the infusion fluid to expel all the air from the tubing. This length is dialled into the driver to set the rate of movement of the plunger over the next 24 hours. Theskin isreleased and the butterfly is secured in position with a clear film dressing. The start button can now be pressed, the transparent cover placed on the driver and the device placed in a safe, convenient place next to the patient. A fabric bag with a drawstring opening is often used to conceal the driver in a discreet fashion. The driver should also be checked to ensure that it is functioning correctly and there is no sign of precipitation in the syringe. Because of minor variations the accuracy of syringe driver infusion rates, the driver should be checked at least 1 hour before the anticipated finish of the infusion to check that a replacement is not required. Drivers should be cleaned after each use with a disposable cloth dampened with a mild detergent. Troubleshooting If the infusion has finished early this may indicate that:1 * The rate was incorrectly set. If the infusion finishes late this may indicate that: * The rate was incorrectly set. Protocol for the use of Graseby syringe drivers for subcu- taneous use in palliative care. The drug might therefore accumulate in the body, potentially resulting in serious adverse effects. In order to prevent this, the dose should be adjusted or the drug avoided altogether if necessary. The monographs in this book give some guidance on this but specialist texts such as The Renal Drug Handbook should be consulted if necessary. F Âð140ÀageÞÂweight ðkgÞ* Creatinine clearance ðmL=minuteÞ¼ Serum creatinine ðmicromol=LÞ where F¼1. Appendix 10 Ideal bodyweight, dosing in patients with renal or hepatic impairment | 897 Dose adjustment in impaired liver function Drugs metabolised or excreted by the liver may accumulate in the body if liver function is impaired. The monographs in this book give some guidance on this, but determining the degree of hepatic impairment is much more difficult than with renal function. Several methods exist but the most commonly used is the Child--Pugh classification,4 which has been developed as a prognostic tool in chronic liver disease. For the Child--Pugh classification, five clinical measures of liver disease are given scores of 1, 2 or 3 points in increasing severity as shown in Table A10. The scores for each parameter are added together and the degree of hepatic impairment is categorised as Child--Pugh class A to C as follows: * 5--6 points Class A * 7--9 points Class B * 10--15 points Class C Table A10. For the purposes of certain monographs this classification is all that may be needed. As a prog- nostic tool, however, the classification is used by clinicians to determine the survival chances of apatient. The risk scores are presented as a grid displaying pictorial icons for theindividual risk category and the score is the summation of these categories. The eight risk categories are: Therapeutic risk: where there is a significant risk of patient harm if the injectable medicine is not used as intended. Use of a concentrate: where further dilution after reconstitution is required before use, i. Complex calculation: any calculation with more than one step required for prep- aration and/or administration, e. Complex method: where more than five non-touch manipulations are involved, or other steps including syringe-to-syringe transfer, preparation of a burette, the use of a filter. Reconstitution of powder in a vial: where a dry powder has to be reconstituted with a liquid. Use of a part vial or ampoule, or use of more than one vial or ampoule is required: e. This risk is symbolised by showing more than one vial with the second vial only half used. Use of a pump or syringe driver: all pumps and syringe drivers require some element of calculation and therefore have potential for error; and the potential risk is considered less significant than the risks associated with not using a pump when indicated. Appendix 11 Risk ratings | 899 Use of non-standard giving set/device required: examples include light-pro- tected products, low adsorption, use of an in-line filter or air inlet. This risk is symbo- lised by a square peg in a round hole to indicate something of a non-standard nature. Itispossible thattheriskscoremayvarydependingonthemethodofadministration;for example, a direct intravenous injection may score lower than an infusion as there is no further dilution involved and therefore one less risk factor. In these scenarios the risk rating at the end of each monograph is always for the highest rated assessment unless otherwise stated. It is vital that a local risk assessment accounts for method of administration in any given clinical area, so the risk score may be moderated to reflect local practice. In all areas, appropriate competence is essential for healthcare professionals working with injectable medicines to give assurance of safety. Local policies and procedures must be adhered to but individuals should also include injectable therapy in their continuing professional development. Hodder Headline’s policy is to use papers that are natural, renewable and recyclable products and made from wood grown in sustainable forests. The logging and manufacturing processes are expected to conform to the environmental regulations of the country of origin. Whilst the advice and information in this book are believed to be true and accurate at the date of going to press, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made. In particular, (but without limiting the generality of the preceding disclaimer) every effort has been made to check drug dosages; however it is still possible that errors have been missed. Furthermore, dosage schedules are constantly being revised and new side-effects recognized.

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It may be given to eject bodies from the esophagus to evacuate the stomach after the injection of poisons discount 625mg co-amoxiclav visa, and in extreme asthmatic or catarrhal attacks order co-amoxiclav amex. A field of action has developed for this remedy buy co-amoxiclav 625 mg with mastercard, outside of its influence as an emetic, which is important. One writer says that in wild delirium, sleep may be induced with this remedy, and a restful quiet. It should be given in doses of from one one-hundredth to one-thirtieth of a grain, hypodermically injected. The dose is less than the emetic dose, and yet sufficient to produce a physiological effect. It is not given until after the patient is undressed and in bed ready to go to sleep. Where it is used for its hypnotic effect alone, and the patient has not previously taken it, it might be well to beg in with a dose as small as the one one hundredth of a grain. The influence of the agent is not protracted, and in some cases it must be repeated in two or three hours. In others it produces a restfulness, which results in sleep, independent of further action of the remedy. In hysterical attacks, the agent is valuable, as it produces general quiet, and refreshing sleep. It may be used in the place of morphine and opium with those who are addicted to a habit for these drugs, and it will produce the same results. The drug is a treacherous one, and consequently dangerous, and must therefore be given with care. In very minute doses, it is given in bronchitis, where there is a deficiency of secretion, or in croup, producing relaxation and expectoration. It is given as an expectorant in cough mixtures, with good results, but its emetic influence should not be induced. One one-hundredth of a grain, repeated every two hours, will be sufficiently large dosage. It produces a Ellingwood’s American Materia Medica, Therapeutics and Pharmacognosy - Page 314 watery secretion of mucus, which is often undesirable. It should be used only with adults, as stated, as children are too susceptible to its influence. Kinnett has used it in pain from spasms of the pyloris, and others mention its influence for spasmodic pain in severe, acute stomach disorder in sthenic cases. Dice believes apomorphine given in small doses frequently repeated in the initial stage of appendicitis will prevent the development of many cases of this disease. He dissolves also a dram of sulphate magnesium in four ounces of water and gives a teaspoonful every two hours with it. Apomorphine in doses of One-thirtieth of a grain or less, frequently repeated controls some very severe cases of vomiting. In the treatment of alcoholism, this agent is given in sufficient quantity to produce mild nausea; then one-thirtieth of a grain of strychnine or other indicated stimulant is given for its influence upon the nervous system at the same time. Occurrence—An alkaloid of opium closely related to morphine, often, if not carefully prepared, containing a certain proportion of morphine. Character—White octahedral crystals, bitter, odorless, permanent, soluble in eighty parts of water and in three parts of alcohol. Physiological Action—Its influence is that of an anodyne and antispasmodic, more active as an antispasmodic than morphine and much less narcotic. It controls pain without checking secretion to as great an extent as the other alkaloids of opium. Therapy—It has a more marked influence upon pain in the abdomen and in the pelvic organs. Spasms, neuralgia and other painful conditions in these parts are well controlled by codeine. It has been given in doses of fifteen or twenty grains daily for this purpose, in some cases with permanent results. Ellingwood’s American Materia Medica, Therapeutics and Pharmacognosy - Page 315 Codeine has a marked influence upon spasmodic cough. It is often given to soothe irritable conditions of the air passages and to control persistent annoying and exhausting cough. Opium is stimulant and narcotic, according to the dose and susceptibility of the patient. Infants and old people are easily poisoned by the drug, while those addicted to alcohol can take very large doses without any bad effects; and those accustomed to the drug can take a poisonous dose with impunity. In the healthy adult a moderate dose of opium stimulates all the nervous functions of the body, raises the spirits and excites intellectual action; this gives way to a condition of placidity, freedom from care, and a state of quiet enjoyment. In an hour or less, con-sciousness is lost in sleep, which may continue for eight hours or longer. On waking there is evidence of disturbance of the functions of the organism, such as nausea, vomiting, headache, constipation and diminished secretion, except that of the skin. In a dose sufficient to cause death the period of excitement is short, while the strength of the system rapidly gives way to drowsiness and apoplectic sleep. There is stertorous breathing, dusky countenance, slow pulse, nearly total insensibility, only responding slightly to violent agitation, with confusion of the mind, and an inclination to continue in a comatose state with increasing debility. After a few hours, six to twelve, according to the dose and the resisting power of the patient, the face becomes pale, the pulse from being full and strong becomes weak and thready, with cold extremities, a cool and clammy skin, a slow gasping respiration; a condition from which it is impossible to rouse the patient and death soon follows. The pulse is first slow from stimulation of the vasomotor nerve centers, and becomes rapid as these become paralyzed. The pupil is first contracted by stimulation of the oculo-motor nerves, and dilates as death approaches and these become paralyzed. With some individuals there appears to be an inherent and usually Ellingwood’s American Materia Medica, Therapeutics and Pharmacognosy - Page 316 permanent idiosyncrasy against the action of opium and morphine. These are nausea or violent vomiting, spasm of the stomach and loss of appetite, obstinate constipation or abdominal pain. In others there is nervous excitement, restlessness, headache, tremors, general distress and an increase of pain. Given under the conditions we have named as contraindications, it will often produce these phenomena; where there is an absence of idiosyncrasy, and where given under the proper conditions, the effects would be desirable. Itching of the skin, inducing an apparent miliary eruption, is one of the unpleasant effects of its use, which, like any one of the others, may be always greatly exaggerated in certain individuals. By using water as a solvent, or combining opium with ipecac or camphor, or in some cases with the bromides, these unpleasant effects can, in great measure, be overcome. It has poisoned infants while nursing, the mother either taking it as medicine or habitually.

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