At 9 A. M., on February 25th, I was called to see her. She had had four most violent convulsions during the previous night, and was complaining of terrible pain in the head, with nausea and vomiting. She expressed the conviction that another convulsion was imminent, and begged for relief. I immediately and without hesitation introduced ½ grain of hydrochlorate of morphia under the skin of the forearm, and having other engagements, left her. At 12 M., I was sent for, and informed that shortly after my departure, she sank into a deep sleep with stertorous breathing. All efforts to rouse her, had failed. On examination, she presented the following symptoms: There was total insensibility, except a slight twitching of the eye-lids when the conjunctiva was touched. The pupils were contracted to the size of a pin’s head. Respiration was shallow, irregular and interrupted, and numbered ten to twelve per minute. The extremities were cool and the face somewhat cyanosed. The pulse beat regularly, though feebly, 110 per minute. To my surprise, auscultation showed the absence of all adventitious sounds over the region of the heart.
Despite the gravity of the symptoms, I felt only a slight degree of alarm, when I considered the improbability of so small a dose of morphia proving fatal. Being compelled to leave, I merely directed the attendants to keep up circulation, by friction of the extremities. At 3 P. M., the condition of patient was unchanged, except that the extremities were more difficult to keep warm. Temperature in the axilla was 97.4°. The breathing was not at all better, and insensibility was, if possible, even more profound than at my previous visit. I injected 1–20th grain sulph. of atropia under the skin of the forearm, and during the next hour I made frequent applications of a moderately strong galvano-faradic current, one pole being placed in the epigastrium and moved along the insertion of the diaphragm, while the other was pressed upon the middle of the neck just behind the sterno-mastoid muscle. The heart’s beat was temporarily strengthened, and respiration slightly increased in depth and frequency by each application. At 4 P. M., I injected 1–12th grain of atropia, continuing the use of electricity. At 5 P. M., the circulation appeared to be failing, the pulse being decidedly weaker and the extremities cold. Respiration was about 15 per minute, irregular and shallow. The pupils were still obstinately contracted. I now injected 1–6th grain of atropia and placed a bottle of hot water under each arm, and a large jug to the feet, still employing electricity at intervals. At 6 P. M., the change in my patient was evidently for the worse. To be sure the body was warm (100° F.), but the pulse at the wrist could only irregularly be felt. The heart contracted feebly but regularly 115 times per minute. Respiration was more shallow, although now 18 to 20 per minute. The pupils were unchanged, and there was absolute insensibility of the conjunctiva. I now injected ¼ grain of atropia. In twenty minutes the effect of this dose was perceptible. The pupils were widely dilated, and respiration increased to 30 per minute; but alas, the heart, although it contracted 130 to 140 times per minute, failed to convey even the slightest impulse to the wrist. Cyanosis had disappeared but the insensibility continued.
During the next seven hours, I injected into the bowel ½ oz. of whiskey every half hour. All of it was retained. During this time, the patient occasionally made an unconscious effort to swallow the mucus which accumulated in the fauces, and succeeded so far as to diminish temporarily the rattling and gurgling which now accompanied every respiration. Several times after this effort at swallowing, respiration had to be stimulated by the electrical current. At midnight there was a slight convulsion, after recovery from which the patient again lapsed into the same condition. Gradually there was an increase in the rate both of circulation and respiration, until at 4 A. M., the heart beat 150, and the breathing was 36 per minute. There was no dicrotism, but the heart’s contraction was steadily becoming more feeble and imperfect. The pupils were still widely dilated, the extremities warm, and the temperature 101°. Fifteen minutes later the heart ceased to beat, and death supervened without a struggle.
For my own sake, as well as for the good of the profession, I invite the most rigid criticism of the above report. The case in many ways is both interesting and instructive. Was this a case of opium poisoning? The symptoms appear to answer this question in the affirmative. I have so frequently given a similar, and even a larger dose in pressing emergencies, without the least unpleasant effect, that I find it difficult to realize the fact that this patient was fatally poisoned by ½ grain of morphia. Such an unlooked for result has given a terrible shock to my confidence in the safety of large doses of morphia under any circumstances. The heart lesion of it before existed, evidently did not influence the result, as all signs of it were gone when I examined, three hours after the administration of the morphia, and they were not reproduced, even under the stimulation of electricity, atropia and whiskey.
Did I give too little atropia? Three doses of 1–12th grain each, sufficed to counteract the poisonous influence of 1½ ozs. tinct. opii, in a case which presented much graver symptoms of poisoning, (vide pp. 65 and 66 N. C. Med. Jour., Feb., 1879). Was I too slow in administering the antidote? In the present case the use of atropia was commenced six hours after the morphia was exhibited,—in the case above cited five hours elapsed before any atropia was given. In the case I previously reported, an aggregate of ¼ grain was given within seven hours after the opiate was taken, in the present case ½ grain within eight hours. Did I give too much atropia? At a single dose, Dr. Fothergill gave 1 grain in a similar case, and the patient recovered.[[3]] (Antagonism of Medicines, p. 133). Should I have given digitalis or strychnia hypodermically to further stimulate the heart? That poor organ appeared to be doing its best, and to tell the truth, I felt that I had had enough of hypodermic medication for one day, and felt unwilling to risk anything more, after being so disappointed in my expectation of relief from atropia. I am open to conviction upon any one or all of the questions I have propounded.
In the light of our present knowledge of laceration of the cervix uteri, Dr. Whitehead’s article on “Hypertrophic Elongation of the Cervix Uteri” (Trans. N. C. Medical Society, 1875, p. 90), has peculiar significance.
LARYNGO-TRACHEOTOMY.
By Charles Duffy, Sr., M. D., Catherine Lake, N. C.
Read before the Onslow County Medical Society, September, 1878.