By repeating small doses frequently, the stimulus may be kept up for a considerable time in some people. In this way are produced the remarkable effects said to be experienced by opium-eaters in the east. These effects seem to be in the first instance stimulant, the imagination being rendered brilliant, the passions exalted, and the muscular force increased; and this state endures for a considerable time before the usual stage of collapse supervenes. A very poetical, but I believe also a faithful, picture of the phenomena now alluded to is given in the Confessions of an English Opium-eater,—a work well known to be founded on the personal experience of the writer. It is singular that our profession should have observed these phenomena so little, as to be accused by him of having wholly misrepresented the action of the most common drug in medical practice. In reply to this charge the physician may simply observe, that he seldom administers opium in the way practised by the opium-eater; that when given in the usual therapeutic mode it rarely causes material excitement; that some professional people prefer giving it in frequent small doses, with the view of procuring its sedative effect, and undoubtedly do succeed in attaining their object; that in both of these medicinal ways of administering it, excitement is occasionally produced to a great degree and of a disagreeable kind; that the latter phenomena have been clearly traced to idiosyncrasy; and therefore that the effects on opium-eaters are probably owing either to the same cause, or to the modifying power of habit. This much at all events is certain,—that in persons unaccustomed to opium it seldom produces material excitement in a single small dose, and does not always cause continuous excitement when taken after the manner of the opium-eater. The effect of a full medicinal dose of two or three grains of solid opium, or forty or sixty grains of the tincture, is to produce in general a transient excitement and fulness of the pulse, but in a short time afterwards torpor and sleep, commonly succeeded in six, eight, or ten hours by headache, nausea, and dry tongue.
The symptoms of poisoning with opium, administered at once in a dangerous dose, begin with giddiness and stupor, generally without any previous stimulus. The stupor rapidly increasing, the person soon becomes motionless and insensible to external impressions; he breathes slowly; generally lies still, with the eyes shut and the pupils contracted; and the whole expression of the countenance is that of deep and perfect repose. As the poisoning advances, the features become ghastly, the pulse feeble and imperceptible, the muscles excessively relaxed, and, unless assistance speedily arrive, death ensues. If recovery take place, the sopor is succeeded by prolonged sleep, which commonly ends in twenty-four or thirty-six hours, and is followed by nausea, vomiting, giddiness, and loathing of food.
The period which elapses between the taking of the poison and the commencement of the symptoms is various. A large quantity, taken in the form of tincture, on an empty stomach, may begin to act in a few minutes; but for obvious reasons it is not easy to learn the precise fact as to this particular. Dr. Meyer, late medical inspector at Berlin, has related a case of poisoning with six ounces of the saffron tincture of opium, where the person was found in a hopeless state of coma in half an hour,[[1707]] and M. Ollivier has described another instance of a man who was found completely soporose at the same distance of time after taking an ounce and a half of laudanum.[[1708]] In these cases, the symptoms must have begun in ten or fifteen minutes at farthest. In a case noticed by M. Desruelles the sopor was fairly formed in fifteen minutes after two drachms of solid opium were taken.[[1709]] For the most part, however, opium, taken in the solid form, does not begin to act for half an hour or even almost a whole hour,—that period being required to allow its poisonous principles to be separated and absorbed by the bibulous vessels. It is singular that an interval of an hour was remarked in a case where the largest quantity was taken which has yet been recorded. The patient swallowed eight ounces of crude opium; but in an hour her physician found her able to tell connectedly all she had done; and she recovered.[[1710]] In some rare cases the sopor is put off for a longer period: thus, in a case mentioned in Corvisart’s Journal, there seems to have been no material stupor till considerably more than an hour after the person took two ounces and a half of the tincture with a drachm of the extract.[[1711]]
The result of almost universal observation, however, is, that in pure poisoning with opium the commencement of the symptoms is not put off much beyond an hour. Such being the fact, it is extremely difficult to account for the following extraordinary case, which was communicated to me by Dr. Heude, of the East India Company’s service. A man swallowed an ounce and a half of laudanum, and in an hour half as much more, and then lay down in bed. Some excitement followed, and also numbness of the arms and legs. But he continued so sensible and lively seven hours after the first dose was taken, that a medical gentleman, who saw him at that time and got from him a confession of what he had done, very naturally did not believe his story. It was not till at least the eighteenth hour that stupor set in; but two hours later, when Dr. Heude first saw him, he laboured under all the characteristic symptoms of poisoning with opium in an aggravated degree. The stomach-pump brought away a fluid quite free of the odour of opium. In seven hours more, under assiduous treatment, after having been in an almost hopeless state of insensibility, he had recovered so far as to be safely left in charge of a friend; and eventually he got quite well. No particular cause could be discovered for the long apparent suspension of the usual effects of opium.
Although the symptoms are very rarely postponed beyond an hour in pure poisoning with this substance, there is some reason for thinking that the interval may be much longer, if at the time of taking the opium the person be excited by intoxication from previously drinking spirits. Mr. Shearmen has related a striking case of an habitual drunkard, who took two ounces of laudanum while intoxicated to excitement with beer and spirits, and had no material stupor for five hours, during which period vomiting could not be induced. Five hours afterwards, he was found insensible, and he eventually died under symptoms of poisoning with opium.[[1712]]
The most remarkable symptom in the generality of cases of poisoning with opium is the peculiar sopor. This state differs from coma, in as much as the patient continues long capable of being roused. It may be difficult to rouse him; but unless death is at hand, this may be commonly accomplished by brisk agitation, tickling the nostrils, loud speaking, or the injection of water into the ear. The state of restored consciousness is always imperfect, and is speedily followed again by lethargy when the exciting power is withheld.—It has been already remarked, that the possibility of thus interrupting the lethargy caused by opium is in general a good criterion for distinguishing the effects of this poison from apoplexy and epilepsy.
It was observed, in describing the mode of action of opium, that convulsions, although very frequently produced by it in animals, are rarely caused in man. It is not easy to account for this difference. Orfila has endeavoured to explain it, by supposing that convulsions are produced only by very large doses; but there are many facts incompatible with that supposition.
While convulsions are certainly not common in the human subject, yet when they do occur they are sometimes violent. Tralles mentions that he had himself several times seen convulsions excited in children by moderate doses.[[1713]] The Journal Universel contains the case of a soldier who took two drachms of solid opium, and died in six hours and a half, after being affected with locked-jaw and dreadful spasms.[[1714]] A case is related in the Medical and Physical Journal of a young man, who, three hours after swallowing an ounce of laudanum, was found insensible, with the mouth distorted, the jaws fixed, and the hands clenched; and who, soon after the insensibility was lessened by proper remedies, was seized with spasms of the back, neck, and extremities, so violent as to resemble opisthotonos.[[1715]] Another good case of the kind is related by Mr. M’Kechnie, where the voluntary muscles were violently convulsed in frequent paroxysms, and affected in the intervals with subsultus, for three hours before the sopor came on.[[1716]] Two instances of convulsions alternating with sopor are shortly related by Dr. Bright.[[1717]] The convulsions sometimes assume the form of permanent spasm, which may affect the whole muscles of the body, as in a case related in Corvisart’s Journal.[[1718]]—Another rare symptom of poisoning with opium is delirium. It appears to occur occasionally along with convulsions, as happened in Mr. M’Kechnie’s case, and in one related by M. Ollivier.[[1719]]
The state of the pulse varies considerably. In an interesting case described by Dr. Marcet it is mentioned that the pulse was 90, feeble and irregular; and such appears to be its most common condition when the dose has been so large as seriously to endanger life.[[1720]] Frequently, however, it is much slower; and then it is rather full than feeble, just as in apoplexy. In cases where convulsions occur, it is for the most part hurried, and does not become slow till the coma becomes pure. In Mr. M’Kechnie’s case the pulse was at first 126; but when the convulsions ceased, and pure sopor supervened, it fell to 55. It always becomes towards the close very feeble, and at length imperceptible.
The respiration is almost always slow. In Dr. Marcet’s case, as in some others, it was stertorous; but this is not common. On the contrary, it is more frequently soft and gentle, as it has been in all the cases I have witnessed; and sometimes it can hardly be perceived at all, even in persons who eventually recover, as in an instance of recovery recorded by Dr. Kinnis.[[1721]]