This section is from the book "A Treatise On Therapeutics, And Pharmacology Or Materia Medica Vol1", by George B. Wood. Also available from Amazon: Part 1 and Part 2.
It has been said that poisonous quantities of opium sometimes occasion no stimulant effect whatever, but are immediately sedative. I have never seen a case which would justify this statement, and do not think that the fact stated is possible. Opium is not sufficiently stimulant to overwhelm the stomach, as enormous quantities of alcohol may do, and produce almost instant death, without directly reaching the brain. Before any very powerful effect can take place, time must be allowed for absorption. The drug cannot all be absorbed at once. A small portion must first enter the circulation, and. when this reaches the brain, it must act upon it as a stimulant. And such I believe to be invariably the case, when opium has been swallowed. I have no doubt, moreover, that a careful examination made at the beginning will discover evidences of this stimulation. I have heard of one instance in which an individual, who had taken a poisonous dose, walked a distance exceeding a mile, and back again, before the narcotic effects were experienced. A very powerful emotion, wholly preoccupying the mind, may have the effect of postponing the operation of the poison, and in some measure counteracting it, as physical pain is known to do, for example, in violent colic and tetanus. But, generally speaking, the larger the quantity of the opium taken, especially in a liquid form, the shorter is the period of unmixed stimulation. In a very short time, under a poisonous dose, drowsiness comes on, soon followed by profound stupor. The patient becomes apparently quite senseless, and lies without other observable motion than that of respiration, which is very slow, and not unfrequently stertorous. A dark suffusion of the countenance comes on, with an utter want of expression. So common is this, that, by its absence, I have been able to detect a case of pretended poisoning from opium. The eyes are closed, and the pupils almost always contracted at this stage. The pulse is slow, and generally full and strong, not unlike that of apoplexy, and indicating anything but feebleness in the heart's contractions. I have known it to be so extremely forcible as almost irresistibly to call for the use of the lancet, lest injury might be done to the brain. The coma, however, is not complete for several hours. The patients are almost always capable of being roused and kept for a time partially awake, by being dragged, half walking, around the apartment. Under such circumstances, however, they are extremely desirous to be allowed to sleep; and the only motive by which. in some instances, I have been able to induce them to swallow the drink or medicine offered, has been to assure them that, if the would take i; they should be allowed to rest for a time. During this half-awake condition, it is surprising to notice the change in the colour of the surface. which, before almost purplish from the venous hue of the blood, now re-assumes, in a considerable degree, its natural appearance; but the instant the patient is permitted to lie down and sleep, the dark suffusion of face returns, with the slow, laboured breathing. Convulsions are said sometimes to occur; but, though I have seen numerous cases of poisoning from opium, I have met with them in no one instance. The whole of the voluntary muscles appear relaxed and powerless. The skin, too, is relaxed, but not often perspiring at this period. Death seldom takes place in this Stage of cerebral oppression. After a few hours, the coma becomes more profound, so that the patient can no longer be roused. The venous suffusion of the countenance begins to give way to paleness. The skin becomes cooler and mora relaxed. The pulse, though in general still slow, diminishes gradually in fulness and strength. The breathing becomes slower and slower, till at length a considerable interval elapses between the successive inspirations. I was once struck with this state of respiration in a child, whom I had been attending for catarrhal fever. Suspecting that some mistake had been made in the prescription, and that opium had been given in a large dose, I took the parent of the child with me to the shop of the druggist, and found that a cough mixture had been prepared with at least twelve times the quantity of morphia directed. Happily, though alarmingly ill, the child recovered under supporting measures At length a condition of utter prostration ensues; the pulse ceases to be perceptible at the wrist; there is a universal cold clammy sweat over the body: the respiration, occurring at lengthening intervals, at last ceases; and death apparently takes place. The heart, however, yet beats very feebly; and a short period is still allowed for the application of restorative measures, before the case becomes quite hopeless.
The stage of prostration usually commences from four to six hours after the swallowing of the poison, and sooner if it has been removed artificially from the stomach; and death generally occurs in from six to twelve hours. If the patient survive the twelfth hour, he usually recovers, though instances are on record in which the fatal termination has taken place much later. It has sometimes also occurred before the sixth hour, even so early, it is asserted, as the third. In such a case, the patient dies from the immediate influence of the opium on the brain. as in congestive apoplexy. Ordinarily, I believe, death results from the vast prostration of the nervous power, consequent upon the previous excessive excitement: and, if the patient can be supported through this period of collapse, he will in all probability recover. From a quantity just insufficient to cause death, the prostration following the congestive influence of the poison is extreme; but, at the lowest point, the system begins to react, and gradually returns to health, though frequently through a series of nervous disorder and variously deranged function, which mark the violent strain to which the brain has been subjected.
The quantity of opium which may prove fatal varies so much with constitutional peculiarities, or the existing state of the system from any cause, that it is quite impossible even to approximate the fatal dose in reference to any particular individual. Dr. Christison, in his treatise on poisons, mentions an apparently well authenticated case, in which death took place, in an adult man, from four grains and a half of opium with nine grains of camphor; whereas half a fluidounce of laudanum has been repeatedly known to be taken, by persons not accustomed to the use of opium, without such a result. Death often occurs from quantities varying from half a fluidounce of laudanum to two or three fluidounces, or from about twenty grains to one or two drachms of opium. Infants are peculiarly susceptible to the poisonous influence of the drug. I was once called to see a child, between one and two years old, in a dying state, to whom its mother had given, rubbed up with water, the residuary matter in a teaspoon, after the evaporation of some laudanum which had been left in it. She thought she might be able to obtain enough in this way for a dose. Dr. Alison, of Edinburgh, has seen death result in a child, a few weeks old, from four drops of laudanum; and two and a half drops killed another child, three days old. (Christison on Poisons.) The inference to be drawn from these facts is, that great caution should be observed in exceeding the ordinary full dose of opium, which experience has shown to be safe. It may be very frequently done with impunity, but at any time a fatal result may occur. I do not think that it is ever necessary, under any circumstances, to give more than two grains, as a beginning dose, to an adult wholly unaccus-tomed to the medicine. It can be repeated in a short time, if necessary, and may be increased after testing the susceptibility of the patient. For an infant, during the first week or two, not more than half a drop of laudanum should be given at first, and to one a year old not more than two drops.
In some rare instances, after a poisonous dose of opium has been swallowed, vomiting has come on spontaneously, and saved the life of the patient by discharging the poison.
Opium may prove poisonous, as well when injected into the rectum as when given by the mouth; but it is probable that a larger quantity would be required to produce fatal effects. Some doubts, however, hare been thrown upon the supposed relative insusceptibility of the rectum; and cases have occurred in which comparatively small doses, exhibited by enema, have produced alarming effects. An instance has been reported by Dr. Anstie, of London, in which a man died from the effects of three grains of morphia injected into the rectum. (Med. T.andGaz.. Feb. 1863, p. 134.) Still, such cases may be regarded as exceptional, depending on idiosyncrasies of the patients; and the opinion that more of the narcotic is required to produce a given effect administered by the rectum than by the stomach is probably true as a general rule. Opium is asserted to have destroyed life by application to the surface of the body. A flaxseed poultice saturated with laudanum, and applied to the leg of a soldier affected with erysipelas, is said to have proved fatal. (Christison on Poisons ) The case of a young man is reported in the Annuaire de Therapeutique (a.d. 1843, p. 5), who was thought to have perished through the effects of a cataplasm to his epigastrium, upon which the contents of a laudanum bottle had been poured. A medical friend of my own, in whose word I place entire reliance, reported to me the case of a child destroyed by the repeated external application of laudanum. In these cases, it is not specially stated whether there was or was not abrasion of the skin; but, if the poison is fatal upon the sound skin, how much more likely to be so upon a denuded surface, or upon an ulcer or wound! Laudanum should never, therefore, be used recklessly even as an external remedy.
The morbid appearances after death from laudanum are, as a general rule, congestion of the brain, with more or less serous effusion, congestion of the lungs, a livid hue of the surface, and a liquid state of the blood. In a few instances, effusion of blood has been found.