Was this second morphine dose considered fatal? Did WWII medics use morphine as euthanasia?

A U.S.-issue morphine syrette, a toothpaste tube-like device with an attached hypodermic needle covered by a cap, contained about half a grain (30 mg) of morphine tartrate; the exact LD50 (amount of the substance required to be lethal to 50 percent of a test population) of morphine for a human is not clear, although extensive animal testing has been done on rats, mice, and dogs. A one-time dose of 200 milligrams of morphine is generally accepted to be universally fatal for a normal human, but this can be much higher in some cases, such as in addicts who have developed a tolerance to the drug, or much lower in others, especially in people who are particularly sensitive to opiate painkillers. One "poor quality" study of morphine overdoses among soldiers cited an average of 71 mg for a 98 kg (216-pound) man as a lethal dose.

World War II was the first American war in which medical aidmen were authorized to administer morphine at the front lines. Morphine poisoning first became seriously noticed during the campaigns in Italy in late 1943, during the United States' first hard winter of combat operations where large forces were committed and heavy casualties suffered. When men fell in the snow or wet ground, circulation often slowed or stopped in small blood vessels near the surface of the skin. When morphine was administered, it often had no effect as it was not absorbed, and more doses were given. When the man was warmed up, circulation returned and the several doses were absorbed by the body quickly, sometimes resulting in a fatal overdose, characterized by, among other symptoms, pinpoint pupils, shallow breathing, respiratory arrest, and eventually death. Morphine poisoning could also occur under other conditions where circulation was impaired, such as severe loss of blood.

A consideration of the circumstances...offered an entirely reasonable explanation of what had happened to these wounded men. Early in November 1943, it was cold...where the fighting was taking place. It rained frequently, and snow fell low on the mountainsides. If a man was not wet and chilled before he was wounded, he promptly became wet and chilled after he fell....Often he was subjected to further exposure in the course of a difficult litter carry to the receiving hospital. The result was impairment of the circulation in the skin and subcutaneous tissues. Sometimes the impairment was slight, but sometimes it amounted to almost complete cessation of the local circulation.

Under these conditions, it was not likely that the morphine administered...would be absorbed. That it was not absorbed was proved by the fact that, in many instances, the injection of 30 mg. (gr. 1/2), the amount put up in Army-issue syrettes, brought no relief of pain. A second, and often a third, injection...would therefore be given over a period of hours, each time with no perceptible effect....When they were in good general condition and not in serious shock, an active peripheral circulation was promptly restored as they warmed up in the hospital, even if no other measure of resuscitation was employed. The restoration of the circulation caused the rapid, simultaneous absorption of all unabsorbed deposits of morphine, sometimes many hours after the injections had been made. If shock was present, and resuscitative measures in addition to warming were employed, the restoration of the peripheral circulation often led to dangerously rapid absorption. Either course of events was likely to be followed by morphine poisoning.

It soon became evident that although morphine poisoning was an increased risk in cold weather, it was equally likely to develop, regardless of weather, in the presence of surgical shock, hemorrhage, or any other condition leading to, or associated with, a reduction in the peripheral circulation. It often became evident during anesthesia, in cases in which it was necessary to undertake operation before full resuscitation from shock had been accomplished. The chain of events was as follows: Ether stimulated the respiration. Peripheral vasodilatation then occurred. Morphine, which might have been injected as long as 8 or 10 hours earlier, was rapidly absorbed. When pinpoint pupils and profound respiratory depression developed before the surgical stage of anesthesia had been reached, induction was greatly prolonged, sometimes taking an hour or more.

Guidelines which could be best characterized as cautious, were soon standardized for the use of morphine. Morphine was only to be used for relief of severe pain, and codeine or aspirin for most other cases. It was also revealed that the standard half-grain dose was too large for many men.

1. As a general rule, the amount injected in a single dose did not exceed 15 mg. (gr. 1/4) In patients to be transported by air, in whom respiratory depression was particularly undesirable, the amount was reduced to 8 or 10 mg. (gr. 1/8 or 1/6). Maximum analgesic effects could be secured with these dosages, and the undesirable side effects caused by larger doses were seldom apparent.

2. Subcutaneous or intramuscular injection was employed when a gradual, prolonged effect was sought, but this route was avoided when the peripheral circulation was slowed....Intravenous injection was then a better choice. It was also a better choice when the immediate relief of pain was desired or when delayed absorption might prove harmful, as in impending shock. When 8 or 10 mg. (gr. 1/8 or 1/6) were given by this route, the full effect was achieved within a few minutes, and there was no possibility of delayed absorption. If the desired results were not obtained...a second could be given...within 15 or 20 minutes. As a practical matter, it was almost never possible to administer morphine intravenously to a wounded man on the battlefield....It was therefore the rule to give the injection on the battlefield intramuscularly (not subcutaneously)....The injection was made low enough on the extremity to permit the placing of a tourniquet above it to slow down the absorption rate if signs of morphine poisoning should develop. The site of the injection, the time it was given, and the size of the dose were recorded on the wounded man's emergency medical tag.

3. Morphine was not administered...to a patient who would be required to walk back to the battalion aid station, nor was it administered at the aid station to a man who would be evacuated to the rear at once as walking wounded....The man might become confused, lie down along the evacuation route, go to sleep, and suffer serious exposure or other untoward consequences. Another reason for withholding morphine from walking wounded was the accumulated evidence that nausea following its use was apt to be much more severe in ambulatory patients than in patients at rest in the recumbent position.

4. It was constantly emphasized to both medical officers and corpsmen that the only justifiable use for morphine was the relief of severe pain. Codeine or aspirin was to be used for mild degrees of pain.

5. In the absence of respiratory depression, morphine could be given in small doses to patients with head or chest wounds.

6. The routine use of morphine was avoided, unless it was required for pain, in the pre-anesthetic medication of seriously wounded patients, in whom anesthesia was usually easy to induce (p. 76).

7. The contraindications...were repeatedly emphasized. It was not to be employed for a sedative effect....It was not to be used to allay fear, to promote sleep, or to control restlessness associated with hemorrhage. It was to be used in these circumstances only if pain was present. Otherwise, phenobarbital or pentobarbital sodium or paraldehyde, all of which were available, met the needs of the patient better than morphine. When pain was present in these conditions, the combination of small doses of morphine and a barbiturate often accomplished better results than large doses of either agent alone.

Marshall R. Doak was a U.S. Navy pharmacist's mate aboard the USS Wakefield (AP-21) when it was sent to Singapore via Canada and Cape Town in November 1942 to drop off British troops for the defense of the island. The ship was bombed by Japanese planes in Keppel Harbor on 30 January 1942, and Doak, in his memoir of his wartime service, described what was essentially the euthanasia of a severely burned shipmate using morphine.

The unfortunate thing was that one of the patients that was brought in was horribly burned with third degree burns. His skin was hanging from everywhere on him and he was screaming so loud....The Doctor had me give morphine to him and then he would give morphine to him. Then he would indicate to me to give more morphine and we were alternating. It was quarter grain morphine syrettes, the little disposable syrettes with a needle on them. I didn't realize what we were doing other than trying to get him to stop screaming. I don't know how many syrettes we'd given him, but he finally quieted down and he passed away. I think it was the doctor's way to say we don't know who euthanized him. This is what we had to do, there was no hope for the man, no hope whatsoever. He had 100% third degree burns over the entire body....I was told later by official reports that there was a burial at sea for him and other dead....I would have known, but there again I didn't sleep for maybe three nights and I wasn't in the best of shape. I should have known about a burial at sea. This was the official report.

Source:

Medical Department, United States Army, Surgery in World War II, Volume II: General Surgery. Edited by Michael E. DeBakey, W. Philip Giddings, and Elizabeth M. McFetridge. Washington, D.C.: Office of the Surgeon General, Department of the Army, 1955.