If the dose taken be a lethal one, the symptoms increase in severity. The face becomes at first more cyanotic, then, as death approaches, pale and livid. The pupils contract to the size of a pin's point. The respirations now drop to four or five per minute, and become irregular and shallow. The pulse becomes weak and compressible; the skin cold and cov ered with a clammy perspiration. There is complete muscular relaxation; the lower jaw drops. The reflexes are abol ished. The patient cannot now be aroused. Death occurs by respiratory paralysis, although, on account of the asphyxia, the heart ceases its action al most simultaneously. Dilatation of the pupils is found only after death. Death, in the adult, has followed the ingestion of 2 grains of the extract of opium, 4 grains of powdered opium, 1 grain of morphine, and 1 drachm of laudanum. The amount that can be taken without producing death by those habituated to its use is incredible. Taylor reports the death of a child of 4 weeks of age after 2 minims of paregoric.
(For the symptoms and treatment of chronic poisoning by opium, see M011 PIIINTSM.) Several fatal cases of opium poisoning have, after being unconscious for a long time, opened their eyes, moved their hands, and shown other signs of return ing consciousness, but died almost im mediately afterward. Carl Johnson (Tied. News, May 19, '94).
Case of idiosyncrasy to codeine re ported. Patient was given grain internally and grain by hypodermic injection. In about an hour the pa tient was swelled from head to foot, face and body intensely red, as if stung by bees, and skin so hypermsthetic that the slightest touch on any part of it caused her to cry out with pain. The lower extremities were cold and purple, with a death-like feeling, the heart sounds feeble and irregular, and the pulse at the wrist almost imperceptible. Large doses of digitalis and whisky, with hot applications to feet and limbs, soon restored the failing circulation. In five or six hours she felt as well as if nothing had occurred. J. S. Duff (Columbus Med. Jour., June, '94).
Differential Diagnosis of Acute Poison ing by Opium.—Some cases of acute poi soning by opium bear a close resemblance to cases of urTinic coma, alcohol ication, and cerebral apoplexy (especially haemorrhage into the pons Varolii). In all these conditions we may have coma, stertorous breathing, slow respiration and pulse, and congestion of the face.
The history of the case may or may not aid us. In urTrnic coma there is ally more or less oedema present. The presence of albumin and casts would point to but albumin may be present in the urine after an apoplectic seizure or an intracranial hemorrhage, although the kidneys were in a perfectly healthy condition prior to the attack.
Alcoholic intoxication may be suspected from the odor of spirits or of ethers on the breath or about the person. In alco holic intoxication the patient can be roused and will answer questions. The pupils may be contracted in acute alco holism, but will dilate when the patient is aroused. The possibility of double poi soning by opium and alcohol should be borne in mind. In cerebral apoplexy, except where limorrhage has invaded the pons Varolii, the pupils are not con tracted or are unsymmetrical; there is strabismus, sometimes facial asymmetry, and usually paralysis of one limb or both. In apoplexy the onset of the symptoms is sudden, there is often no history of having taken food or medicine, and the face, although congested or pale, is not swelled and cyanosed as in opium narcosis. Hmmorrhage into the pans Varolii is rare and generally fatal; the attack is sudden and the entire body is relaxed, with involuntary evacuations of bladder and bowel, which is not usual in opium poisoning.
In the third stage opium poisoning is sometimes differentiated with great diffi culty from urmmic coma, alcoholic nar cosis, cerebral haemorrhage, and the con dition following an epileptic convulsion. In urnmic coma the pupils are usually normal or dilated, but may be con tracted; convulsions generally occur, and anasarca is usually present. The urine is always loaded with albumin, and the temperature is said to be always below normal. In alcoholic narcosis the pupils are normal or dilated, the respira tions are not as slow as in opium poison ing, and the pulse is slow and full. Too much dependence must not be placed upon the odor of alcohol, as the patient may have taken opium while intoxi cated. An hypodermic injection of iipo morphine will cause a man unconscious from alcohol to vomit, but will have no effect if the case be one of opium poison ing. In case of cerebral haemorrhage there is usually more or less paralysis of the cranial nerves, with some differ ences in the reflexes of the two sides of the body, and in the size of the two pupils. In the coma following an epi leptic convulsion the tongue will prob ably be bitten, the pupils dilated. and the respirations but little slower than normal. The history and surroundings are often more valuable aids to diagnosis than the physical condition. The occur rence of a convulsion at the beginning of the attack will exclude opium poison ing, although it may occur in anyone of the other conditions named. Carl Johnson (Med. News, Mar. 20, '97).