The pupils are always at least sluggish in their contractions, often quite insensible;—sometimes, it is said, dilated:[[1722]] but much more commonly contracted, and occasionally to an extreme degree. In the case last noticed, they were no bigger than a pin’s head. The pupils have been so invariably found contracted in all recent cases of poisoning with opium, that some doubt arises whether they are ever otherwise, and whether the earlier accounts, which represent them to have been dilated, may not be incorrect, and the result of hasty observation.
The expression of the countenance is for the most part remarkably placid, like that of a person in sound natural sleep. Occasionally there is an expression of anxiety mingled with the stupor. The face is commonly pale. Sometimes, however, it is flushed;[[1723]] and in rare cases the expression is furious.[[1724]]
In moderately large doses opium generally suspends the excretion of urine and fæces; but it promotes perspiration. In dangerous cases the lethargy is sometimes accompanied with copious sweating. In a fatal case, which I examined judicially, the sheets were completely soaked to a considerable distance around the body.
A remarkable circumstance, which has been noticed by a late author, is the sudden death of leeches applied to the body. The patient was a child who had been poisoned by too strong an injection of poppy-heads.[[1725]]
In some instances the symptoms proper to poisoning with opium become complicated with those which belong rather to organic affections of the brain, in consequence of such affections being suddenly developed through means of the cerebral congestion occasioned by the poison. Thus, in a case related in Corvisart’s Journal, there were convulsions and somnolency on the third day, and palsy of one arm for four days; and for nearly two months afterwards the patient complained of occasional attacks of weakness and numbness, sometimes of one extremity, sometimes of another.[[1726]] Here the brain must have sustained some more permanent injury than usual.—A more remarkable illustration once occurred to Dr. Elliotson. A young man, seven hours after swallowing two ounces of laudanum, presented the usual effects of opium, such as contracted pupils, redness of the features, a frequent feeble pulse, coldness of the integuments, and stupor, from which he could be roused without particular difficulty. The stomach-pump brought away a fluid which had not any odour of opium; powerful stimulants were given, such as ether, ammonia and brandy; and he was kept constantly walking between two men. In an hour and a half, when sensibility had been materially restored, his head suddenly dropped down upon his breast, and he fell down dead. The sinuses and veins of the brain were turgid, and a moderately thick layer of blood was effused over the arachnoid membrane.[[1727]]—Under the same head must be arranged the following extraordinary case related by Pyl. That author admits it as one of simple poisoning, with a complete remission of the symptoms for several days. But the possibility of such a remission must be received with great hesitation. It is well known that most of the symptoms may be dispelled by vigorous treatment, and the patient nevertheless relapse immediately if left to himself, and even die. This is acknowledged on all hands. Pyl, however, admits the possibility of a much more complete and longer interval. His case is shortly as follows. A man who had taken a large quantity of opium, and became very dangerously ill, was made to vomit in twelve hours, and regained his senses completely. The bowels continued obstinately costive; but he had for some days no other symptom referrible to the poison; when at length the whole body became gradually palsied and stiff, and he died on the tenth day. No importance can be attached to a solitary case differing so widely from every other. The only way in which opium could cause death in such a manner, must be by calling forth some disposition to natural disease. Pyl’s case was probably one of supervening ramollissement, or inflammation of the substance of the brain.[[1728]]
Notwithstanding the purely narcotic or nervous symptoms, which opium produces in a vast proportion of instances, there is no doubt that it also excites in a few rare cases those of irritation. Thus, although it generally constipates the bowels, it has been known to induce diarrhœa or colic in particular constitutions. In the first volume of the Medical Communications, it is observed by Michaëlis that both diarrhœa and diuresis may be produced by it. The soldier, whose case was quoted as having been accompanied with convulsions, had acute pain in the stomach for some time after swallowing the poison; and in the case just quoted from Corvisart’s Journal, the accession of somnolency was attended with excruciating pain of two days’ duration.
Another and more singular anomaly is the spontaneous occurrence of vomiting. Sometimes a little vomiting immediately succeeds the taking of the poison. This may not interrupt, however, the progress of the symptoms;[[1729]] but more commonly it is the means of saving the person’s life, as in a striking case described by Petit of an English officer,[[1730]] who, in consequence of vomiting immediately after taking two ounces of laudanum, had only moderate somnolency. At other times vomiting occurs at a much later period. Pyl, in his Essays and Observations, gives a case in which, some hours after thirty grains were swallowed, vomiting took place spontaneously, and recurred frequently afterwards; in the same paper is an account of another case by the individual himself, who attempted to commit suicide by taking a large dose of laudanum, but was disappointed in consequence of the poison being spontaneously vomited after the sopor had fairly set in;[[1731]] and a similar case is related by M. Mascarel, where, after seven ounces of Sydenham’s laudanum had been taken, vomiting occurred spontaneously, and was followed only by inconsiderable stupor.[[1732]]—Vomiting is a common enough symptom after the administration of emetics, or subsequent to the departure of the somnolency.[[1733]]
The ordinary duration of a fatal case of poisoning with opium is from seven to twelve hours. Most people recover who outlive twelve hours. At the same time fatal cases of longer duration are on record: Réaumur mentions one which proved fatal in fifteen hours,[[1734]] Orfila another fatal in seventeen hours,[[1735]] Leroux another fatal in the same time,[[1736]] Alibert another fatal in nearly twenty-four hours.[[1737]] An instance has even been related, which appeared to prove fatal not till towards the close of the third day;[[1738]] but the whole course of the symptoms was in that case so unusual, that some other cause must have co-operated in occasioning death. Sometimes, too, death takes place in a shorter time than seven hours; six hours is not an uncommon duration; I once met with a judicial case, which could not have lasted above five hours; an infirmary patient of my colleague, Dr. Home, died in four hours; in the 31st volume of the Medical and Physical Journal, there is one which proved fatal in three hours.[[1739]] This is the shortest I have read of.
The dose of opium requisite to cause death has not been determined. Indeed it must vary so much with circumstances, that it is almost vain to attempt to fix it. Pyl relates a case, quickly fatal, where the quantity taken was 60 grains;[[1740]] Lassus an instance of death from 36 grains;[[1741]] Wildberg has related a fatal case caused by little more than half an ounce of the Berlin tincture,[[1742]] which contains the soluble matter of forty grains; and Mr. Skae has mentioned a case fatal in about thirteen hours, where the dose seems to have been well ascertained not to have exceeded half an ounce of common laudanum, or about twenty grains of opium.[[1743]] Dr. Paris, without quoting any particular fact, says four grains may prove fatal.[[1744]] I should have felt some difficulty in admitting this statement, as I have repeatedly known persons, unaccustomed to opium, take three or four grains without any other effect than sound sleep. But I have been favoured with the particulars of a case by Mr. W. Brown of this city, where a dose of four grains and a half, taken by an adult along with nine grains of camphor, was followed by the usual signs of narcotism, and death in nine hours. The man took the opium for a cough at seven in the morning; at nine his wife found him in a deep sleep, from which she could not rouse him; nothing was done for his relief till three in the afternoon, when Mr. Brown found him labouring under all the usual symptoms of poisoning with opium, contracted pupils among the rest; and death ensued in an hour, notwithstanding the active employment of remedies. On examining the body no morbid appearance was found of any note except fluidity of the blood,—a common appearance in those who have died of the effects of this drug.
It is more important than may at first sight be imagined to acquire an approximative knowledge of the smallest fatal dose. For, in consequence of the dread entertained of opium by many unprofessional persons, it is currently believed to be much more active than it is in reality; and instances of natural death have been consequently imputed to medicinal doses taken fortuitously a short time before. The facts stated above comprehend the only precise information I have been able to collect as to the smallest fatal doses in adults. I may add some farther observations, however, on the smallest fatal doses in children. Very young children are often peculiarly sensible to the poisonous action of opium, so that it is scarcely possible to use the most insignificant doses with safety. Sundeling states in general terms that extremely small doses are very dangerous to infants on account of the rapidity of absorption. This opinion is amply supported by the following cases.—An infant three days old got by mistake about the fourth part of a mixture containing ten drops of laudanum. No medical man was called for eleven hours. At that time there was great somnolency and feebleness, but the child could be roused. The breathing being very slow, artificial respiration was resorted to, but without advantage: the child died in twenty-four hours, the character of the symptoms remaining unchanged to the last. At the inspection of the body, which I witnessed, no morbid appearance was found.—Of the same kind was a case communicated to me by Dr. Simson of this city, where the administration of three drops of laudanum in a chalk mixture, for diarrhœa, to a stout child fourteen months old, was followed by coma, convulsions, and death in about six hours. Dr. Simson satisfied himself, as far as that was possible, that the apothecary who made up the mixture did not commit a mistake.—Dr. Kelso of Lisburn met with a similar case in an infant of nine months, who died in nine hours after taking four drops.[[1745]]—My colleague, Dr. Alison, tells me he has met with a case where an infant a few weeks old died with all the symptoms of poisoning with opium after receiving four drops of laudanum, and that he has repeatedly seen unpleasant deep sleep induced by only two drops.—These remarks being kept in view, it will, I suspect, be difficult to go along with an opinion against poisoning expressed by a German medico-legal physician in the following circumstances. A child’s maid, pursuant to a common but dangerous custom among nurses, gave a healthy infant, four weeks old, an anodyne draught to quiet its screams. The infant soon fell fast asleep, but died comatose in twelve hours. There was not any appearance of note in the dead body; and the child was therefore universally thought to have been killed by the draught. But the inspecting physician declared that to be impossible, as the draught contained only an eighth of a grain of opium and as much hyoscyamus.[[1746]] In the first edition of this work an opinion was expressed to the same purport. But the facts stated above throw doubt on its accuracy, and rather show that the dose was sufficient in the circumstances to occasion death.