IV.--NEUROTIC POISONS. CHAPTER XXII. NARCOTICS. NEUROTICS, ACTING ON THE BRAIN AND PRODUCING SLEEP. Opium.

Opium is the inspissated juice of the unripe capsules of the Papaver somniferum, or white poppy, and is a very complex substance. Its principal properties, however, are due to the presence of morphia, as meconate of morphia; but others of its constituent substances undoubtedly modify its action.

It is sometimes used as a poison in its crude state, but more frequently in solution in alcohol, forming tincture of opium, or laudanum. Unfortunately, opium is the powerful ingredient of most soothing syrups for children, to whom opium is at all times especially dangerous; and many who do not die from its direct effects, do from the wasting indirectly produced.

Of domestic quieting physic the chief preparations are Godfrey’s Cordial, supposed to consist of one grain of opium in two ounces; and Dalby’s Carminative, which is one-fourth weaker.

The smallest quantity of laudanum which is known to have proved fatal to an adult is two drachms, from which death occurred within twelve hours. The exact quantity taken was, however, doubtful. Two grains and a half of the extract, a quantity said to be equal to four grains of crude opium, have produced a similar result. Much larger doses are, however, taken with impunity on many occasions, more especially by those habituated to the use of this drug, who remain almost unaffected by surprisingly large quantities. De Quincey, the English opium-eater, once found in a pirated edition of “Buchan’s Domestic Medicine,” a caution against taking more than “twenty-five ounces” of laudanum at one dose. He says that he always bore this excellent advice in mind; and it does not appear that he ever took more than sixteen ounces of the tincture of opium as his daily allowance. In certain diseases, patients quite unaccustomed to the use of sedatives can take excessive amounts without narcotism being produced. In some cases of tetanus, for example, upwards of four ounces of laudanum have been given daily for a week, without any marked effect.

On the other hand, it must not be forgotten that not a few individuals are unable to take even one-third of a grain without being narcotised. Young children are particularly susceptible of its effects; the tenth and twelfth parts of a grain having respectively proved fatal to infants two and five days old. Dr. Edward Smith has even recorded the case of an infant seven days old, who died comatose eighteen hours after having had administered to it about the twelfth of a grain of opium, or the quantity contained in one drop of laudanum.[C] The smallest fatal dose for a child on record is one of paregoric elixir equivalent to about one-ninetieth of a grain of opium. On the other hand, they sometimes recover from very large doses indeed.

The duration of a fatal case is generally from seven to twelve hours. The shortest period recorded is three-quarters of an hour; the longest, twenty-four hours. If the patient survives twelve hours there is good hope of recovery.

The quantity of Morphia found in opium varies from two to ten per cent. The chief salts of this alkaloid are the acetate, the hydrochlorate, and the sulphate, all being very energetic poisons. They cause symptoms similar to those about to be described as produced by opium. But, in addition, there has been especially noticed great itching of the skin, convulsive twitchings of the muscles of the face and limbs, and occasionally tetanus. Small doses of any of the salts of morphia may cause death. In a delicate woman half a grain is supposed to have proved fatal; in several instances one grain has proved fatal; and certainly a dose of two grains might kill a healthy adult unaccustomed to opiates. Nevertheless, under the influence of custom, large quantities may be taken. A young lady, who has long been under notice, has for the last three years taken daily fifteen grains of the hydrochlorate of morphia, without obtaining more than two or three hours’ sleep from it; while for many days in succession, when suffering much pain, she increases the quantity to one scruple. From attempts to diminish the dose, made without the patient’s knowledge, only mischief has resulted.

Others of the opium alkaloids are poisonous; but instances of poisoning by their means have not occurred, except one doubtful instance of poisoning by narcotine, recorded by Sonnenschein.

Symptoms.—When a large dose of opium or its tincture has been taken the symptoms usually manifest themselves in about twenty or thirty minutes. They commence with giddiness, drowsiness, and stupor; then ensues insensibility. The patient appears as if in a sound sleep, from which he can be roused by a loud noise, &c., although he quickly relapses. As the poisoning progresses the breathing becomes slow and stertorous, the pulse weak and feeble, and the countenance livid. The eyes are closed, while the pupils are generally contracted, often almost to the size of a pin’s point, and insensible to the stimulus of light. In some instances the skin is cold and livid, in others it is bathed in sweat. So also the countenance may be either ghastly or placid, the pupils may even be dilated, and the pulse may be unaffected, or so small and frequent as to be scarcely appreciable. Vomiting sometimes occurs, with slight reaction, so that hopes of recovery are entertained. But frequently there is a relapse, the comatose state returns, and death quickly follows, occasionally preceded by convulsions.

The possibility of rousing a patient during the earlier portion of the progress of these symptoms will assist in diagnosing the effects of poisoning by opium from those due to apoplexy, epilepsy, &c. The contracted condition of the pupil will also assist; but it must not be forgotten that in lesion of the pons Varolii the pupils are also contracted. When permanent recovery ensues it is complete; but it is usually preceded for a day or two by severe nausea, a sense of weariness, constipation, and headache.

The habitual use of opium is most injurious. Dr. Oppenheim, in his description of the state of medicine in Turkey, tells us that persons seldom attain the age of forty who have begun the practice early. The opium-eater may be known by his attenuated body, withered yellow countenance, stooping posture, and glassy, sunken eyes. He has no appetite, his bodily powers are destroyed, and he is obliged continually to increase the dose of his “grief-assuaging remedy” to obtain the wished-for effect.

Post-mortem appearances.—The appearances in acute poisoning by opium are not very characteristic. The most prominent are, great turgescence of the vessels of the brain, with effusion of serum into the ventricles and at the base. The turgid condition of the vessels often continues down the spinal cord, &c. The lungs are usually gorged with fluid blood, and the skin is of a livid hue.

Treatment.—The first object is to remove all the poison from the stomach, and this cannot be effected in any way so well as by the stomach-pump. In the absence of this instrument, emetics of half a drachm of sulphate of zinc, or a tablespoonful of mustard, must be employed. The patient at the same time is to be prevented as far as possible from going to sleep. When the stomach has been thoroughly emptied, every means must be adopted to keep the patient roused. This is to be effected by dashing cold water over his head and chest, walking him up and down or shaking him between two attendants in the open air, irritating his legs by flagellation with a wet towel, applying electro-magnetic shocks to the spine, and administering strong coffee. Bleeding has been recommended; but it is only to be used after the poison has been removed from the stomach, and when from the coma and full pulse we are sure that there is cerebral congestion. In extreme cases artificial respiration must be tried.

The remedies recommended must be perseveringly used, remembering that as long as life lasts hope of recovery is not to be banished. In the great majority of cases the treatment is successful.

Tests.—There are no direct means by which opium may be detected. We endeavor therefore to obtain evidence of the presence of morphia and meconic acid. The two substances may be separated from organic admixture by the following process: The suspected matters should be well boiled with distilled water, and spirit acidulated with acetic acid, and strained. To the fluid which has passed through, acetate of lead is to be added until precipitation ceases, and the whole, after standing, is to be thrown on a filter. The insoluble meconate of lead remains on the filter, the morphia passing through as acetate. To separate the meconic acid the substance on the filter is to be diffused through water, and sulphuretted hydrogen passed for a time. Sulphide of lead is thus thrown down and may be separated by filtration, the meconic acid remaining in solution. On concentration this should give the requisite reactions.

In the search for morphia the filtered fluid above referred to is also to be treated with sulphuretted hydrogen, to secure the precipitation of all acetate of lead, &c., which is next to be carefully separated from it by further filtration. The fluid now passing through, containing the acetate of morphia, is next to be concentrated by evaporation over a water bath, and carefully neutralized by bicarbonate of potass, if it be desired to obtain the pure alkaloid; but this is not necessary, as the acetate responds to all reagents. The acetate may be dissolved out of the mass in dilute alcohol (it is not soluble in ether), again filtered, the filtrate being finally evaporated to dryness and tested.

Morphia.—The best tests for this alkaloid, in substance or in solution (substance is preferable) are:

1. Nitric acid, which strikes an orange red color, varying in intensity with the strength of the acid and the concentration of the morphia solution. Ruddy fumes are also developed.

2. Neutral perchloride of iron, strikes a rich blue color with morphia when added in small quantity; if added in excess, the yellow of the test, combining with the blue, may produce a green. This blue is destroyed by acids and by heat. Nitric acid not only destroys the blue produced by this test, but replaces it with the orange-red color; so that the nitric acid test may be applied to the same portion of morphia after the iron test, but not vice versÂ.

3. Iodic acid. This acid becomes decomposed, owing to the reducing action of morphia, setting free the iodine. The latter is detected by its brown color, and the blue which it strikes with starch. The iodic acid should be previously tested to ascertain its purity, as it occasionally contains free iodine.

4. Bichromate of potassium gives a green with morphia, passing to a dingy brown.

Meconic Acid.—This is obtained from solutions of opium, in the form of little scaly crystals of a reddish tint, which are decomposed by heat and partly sublimed. In solution it may be detected by its acquiring a blood-red color on the addition of the perchloride of iron. A similar color is produced by sulphocyanide of potassium, as found in the saliva; but the color of the meconate is not discharged by chloride of gold; the sulphocyanide is.

Narcotine dissolves in sulphuric acid with a yellow color, converted into a carmine red by the addition of a trace of nitric acid.