[Extracted from the 
Transactions of the Medical Society of the State of Pennsylvania for 1884. ] 
ALARMING AND DANGEROUS DOSES OF THE 
MYDRIATICS. 
By EDWARD JACKSON, M.D., 
OF PHILADELPHIA. 
The dose of any drug may vary widely, with varying circum- 
stances ; but it is always restricted to less than is likely to prove 
fatal. As no understanding of the power we possess, in the influ- 
ence of active remedies over vital processes, is complete without an 
understanding of its limitations; it is worth while to direct our 
attention to the real limits which danger of fatal poisoning imposes 
on the use of the mydriatics. 
Atropia, I believe, is commonly given in doses of one-half to one 
milligramme to of a grain). This is the amount usually 
given, hypodermically or by the stomach, to check sweating, or to 
correct or supplement the action of morphia. This amount, or 
what is deemed an equivalent of some other preparation of bella- 
donna, is mentioned in the various formulas for laxative and anti- 
neuralgic pills, and mixtures; and much the same dose is adminis- 
tered, when solutions of the ordinary strength are applied to the 
conjunctival sac. The other mydriatic alkaloids are not in general 
use ; but I think the common impression is, that the dose of daturia, 
duboisia, or hyoscyamia is about the same as of atropia. 
I do not question the sufficiency of such doses to meet, in most 
cases, what are commonly understood to be the indications for the 
use of these drugs. But in the minds of many practitioners, well 
informed on most subjects, the dose of one milligramme comes to 
hold much the same relation to atropia, as one centigramme holds 
to morphia, or one gramme to chloral. It is not regarded merely 
as a sufficient dose, but rather as the maximum, or near the maxi- 
mum dose, that it is safe to give to any person whose special sus- 
ceptibility to the action of the drug has not yet been tested; and 
I wish by this paper to remind you that such an impression is erro- 
neous, and not supported by the literature of mydriatic poisoning. 
The impression that much more than one milligramme of one of 
1 2 
the mydriatic alkaloids would be an improper or dangerous dose, 
probably rests on the liability of the dose mentioned to cause, in 
susceptible patients, the disorder of vision, dryness of the throat, 
alteration of the pulse-rate and inco-ordination of thought and 
motion, which are the symptoms of slight mydriatic poisoning. 
To the uninformed these symptoms of mydriatic intoxication are 
very alarming; and that many practitioners of medicine are in this 
respect uninformed, would appear from the large number of cases 
of very moderate belladonna or stramonium intoxication, that have 
been looked upon by their medical attendants as of sufficient gravity 
to justify extended record; and in which, the symptoms having 
abated under a certain line of treatment, such treatment is credited 
with the saving of life. That moderate mydriatic intoxication is 
not really indicative of danger, becomes evident when the true dan- 
ger line is shown; and this may be approximately established by a 
review of: First, cases ending in recovery after the manifestation 
of very grave symptoms, or in which the known definite amount of 
the drug used approached or exceeded the minimum fatal dose. 
Second, all which terminated fatally among the two hundred and 
fifty cases of mydriatic poisoning that I have found reported, or 
quoted with sufficient definiteness to make them of value in this 
connection. 
CASES ENDING IN RECOVERY. 
Case 1.-A child, aged three years, swallowed three " homoeopathic 
pellets of belladonna," and became comatose, with scarcely per- 
ceptible pulse and gasping respiration; but recovered. (Lancet, 
1883, i. p. 485.) 
Case 2.-A man applied a belladonna plaster to his back where 
pustulation had been already produced by a similar plaster. Marked 
symptoms appeared in two hours, but the plaster remained on six 
hours longer. There was inability to use the lower extremities, con- 
vulsive catchings, and unconsciousness. He recovered. (William 
Jenner, Med. Times and Gazette, 1856, Nov. 22d.) 
Case 3.-A girl, aged six years, took three-sixteenths of a grain of 
atropia in solution. There occurred delirium, staggering, drowsi- 
ness, sleep ; recovery. (Stevenson, Guy's Hospital Reports, 1872, 
p. 226.) 
Case 4.-A man took one-half grain of atropia in solution ; 
inability to stand, flushed face, alarming vertigo, pulse 140, respira- 
tion " correspondingly increased." (Chas. A. Sewal, Phila. Med. 
Times, vol. xii. p. 492.) 3 
Case 5.-A boy, aged four years,'took about half a grain of atro- 
pia in solution. There was delirium and disordered movements. 
(Lancet. 1864, i. p. 8.) 
Case 6.-A girl, aged two years, took about a half-grain of sul- 
phate of atropia in watery solution, and recovered. (T. Fitzmaurice, 
Lancet, 1881, ii. p. 414.) 
Case 7-A woman, aged twenty-one years, took about two-thirds 
of a grain of atropia in watery solution. There was loss of voice, 
unconsciousness, twitching of the facial muscles, pulse 130 and 
weak, restlessness and delirium continuing until the third day, but 
recovery. (James Andrews, Month.. Journ. Med. Sci. (Edinburgh), 
1852, p. 34.) 
Case 8.-A male infant, aged nineteen months. " The amount 
of atropia taken was not less than three-fourths of a grain," in so- 
lution. " Entire surface bright scarlet, violent delirium, constant 
and violent spasmodic action of the limbs, intense restlessness." Re- 
covered. (D. W. Prentiss, Phila. Med. Times, vol. x. p. 167.) 
Case 9.-A man, aged thirty-four years, took three-fourths of a 
grain each of the sulphates of morphia and atropia. Recovered. 
(Dr. Seargent, Louisville Med. News, Aug. 27, 1881.) 
Case 10.-A woman, aged twenty-six years, swallowed five centi- 
grammes of atropia sulphate. Furious delirium and aphonia. Re- 
covered. (M. C. Paul, Gaz. Heb. de Med. et de Chir., 1875, p. 
125.) 
Case 11.-A youth, aged nineteen years, took nine-tenths of a 
grain of atropia in watery solution. Unconsciousness, respiration 
40 to 50, pulse 140 to 150 per minute. He recovered. This case 
was reported by Prof. Purjez. It is quoted in the British Medical 
Journal, 1881, ii. p. 26. What I take to be the same case is referred 
to in the Phila. Medical Times, vol. x. p. 415 ; but it is there stated 
that the amount taken was two and one-half grains. I have been 
unable to examine the original report of the case. 
Case 12.-A physician took one grain of atropia in solution. (J. 
B. Cox, Phila. Med. Times, vol. xiii. p. 377.) 
Case 13.-A child, aged three and one-half years, swallowed one 
grain of atropia in solution. (Quoted in the Amer. Journ. Med. 
Sciences, Jan. 1869, p. 275.) 
Case 14.-In the Leeds General Infirmary, a man aged seventy, 
after cataract extraction, developed iritis, for which "six drops of 
a solution of atropine containing ten grains to the ounce, were 
ordered to be placed in the eye every third hour." Unpleasant 
symptoms developed, including paralysis of the lower extremities. 
Mr. Porritt, who reports the case, remarks : " The solution of atro- 4 
pine was placed in the eye eight times, the quantity used being 
equivalent to one grain of the alkaloid. This strong solution has 
been used on many occasions without any untoward effects." (Lan- 
cet, 1880, i. p. 682.) 
Ca.se 15.-A.man took one grain of atropia sulphate in solution, 
but recovered. (H. Leach, Med. Times and Gazette, 1865, ii. p. 34.) 
Case 16.-An advocate swallowed one decigramme of atropia 
sulphate in solution. He remained unconscious and undiscovered 
until the next day, and recovered without treatment. (M. Gubler, 
Gaz. Heb. de Med. et de Chir., 1875, p. 125.) 
Case 17.-A woman, aged 43, and her daughter, aged thirteen, 
drank a solution containing about three grains of atropia sulphate. 
At three hours they were seen with staggering gait and greatly ex-' 
cited ; at four hours they were becoming comatose ; at four and one- 
half hours the child vomited, and soon after began to improve. The 
mother continued violent and partly unconscious until next morn- 
ing; but they "both left the hospital recovered," twenty-four hours 
after taking the drug. (Lancet, 1878, i. p. 165.) 
Case 18.-A woman, aged thirty, swallowed with suicidal intent 
about twelve centigrammes of atropia in solution. Delirium, ex- 
treme agitation, unconsciousness, pulse 150 per minute and de- 
pressed; but she recovered. (Roux, Gaz. des Hopitaux, May 31, 
1860.) 
Case 19.-A woman, aged forty-two years, took two and a quar- 
ter ounces of belladonna liniment. Her symptoms were very severe, 
but she recovered. (Dr. Grattan, Brit. Med. Journ., 1881, i. p. 594.) 
Case 20.-Four children, aged from six to nine years, ate seeds 
of the datura stramonium. Confusion of intellect ensued, with entire 
loss of power to direct the motions of the limbs, and stupor. They 
recovered. (H. Y. Evans, Amer. Journ. Med. Sciences, July, 1866, 
p. 278.) 
21.-In twelve cases of poisoning by stramonium reported 
by H. T. 0. Morsly, there was delirium, unconsciousness, intermit- 
tent action of the heart, apparent syncope, and approaching death • 
yet all recovered. (Quoted in Journ. of Amer. Med. Assoc., vol i. 
p. 22.) 
Case 22 A man, recovering from cataract extraction, took one 
teaspoonful of a solution of duboisia sulphate one grain to the ounce 
of water. (E. L. Holmes, Chicago Med. Journ. and Exam., Nov. 
1880.) 
Case 23.-A woman, aged forty-six years, took one-half grain of 
hyoscyamia in solution. "Apparently comatose," pulse 120, and 5 
temperature 103° F. Recovered. (J. G. S. Coghill, Lancet, 1880, 
ii. p. 152.) 
In the cases above cited, as in most of those to follow, which ter- 
minated fatally, no mention has been made of the many different 
lines of treatment pursued. Any attempt to attach to each of these 
its proper value, would have extended this paper far beyond the 
limits of my time and your patience. Let me dismiss the matter 
with this one remark: Excepting the prompt emptying of the 
stomach, I am not convinced that any line of treatment has averted 
a fatal result in mydriatic-poisoning. 
FATAL CASES. 
Case 24-A man, aged thirty-three years, had a blistered surface, 
on the neck dressed with an ointment of atropia sulphate, fifteen 
parts to seven hundred parts of lard. In a few minutes he "sprang 
from his seat in a state of indescribable anguish, he ran about the 
room crying out that he was suffocated." "Dysphagia and dys- 
pnoea increased . . . convulsions resembling those of chorea 
set in, breathing became very frequent, soon became interrupted;" 
the pulse rose to 150 per minute, and death occurred within two 
hours after the application of the drug. This man was suffering at 
the time with laryngeal disease. This case is reported by H. Ploss, 
of Leipsic (quoted in Brit. Med. Journ., 1865, i. p. 68, and elsewhere). 
6AW) 25.-A man ate of a tart made of belladonna berries. There 
ensued delirium, unconsciousness, convulsions, coma, and death 
within twenty-four hours. A boy ate of the same tart, and also 
died. (Lancet, 1846, ii. p. 251.) 
Case 26.-A boy, aged four years, ate belladonna berries. There 
were delirium, inability to stand, convulsive attacks, temperature 
110° F., and death after seventeen hours. (McNab, Brit. Med. 
Journ., Sept. 23, 1882.) 
Case 27.-A boy, aged five years, ate belladonna berries, and 
died in convulsions in fifteen hours. (Taylor's Med. Jar. and Toxi- 
cology.) 
Case 28.-A woman, aged twenty-seven years, used a decoction 
made from eighty grains of the root as a clyster. Death in five 
hours. (Taylor's Med. Jur. and Tox.) 
Case 29.-A woman, aged sixty-six, took a teaspoonful of bella- 
donna liniment, became deeply comatose, and died in sixteen hours. 
(Lancet, 1870, ii. p. 83.) 
Case 30.-A boy, aged sixteen years, swallowed one drachm of 
extract of belladonna in a half-teacupful of warm water. Uncon- 6 
sciousness, violent agitation of the limbs, coma, and death within 
three hours. (R. H. Taylor, Brit. Med. Journ., 1869, ii. p. 555.) 
Case 31.-Mr. Harris was poisoned by atropia taken in milk, 
amount unknown. He died in twelve hours. (Lancet, 1872, i. 
p. 241.) 
Case 32.-A man, aged forty-five, swallowed one drachm of liquor 
atropise sulphatis, B. P. Being treated by emetics, the stomach- 
pump, a drachm of tincture of digitalis, brandy, black coffee, castor- 
oil by enema, and mustard to the feet and over the heart; he grew 
better of the symptoms of poisoning, but later pneumonia set in, 
and he died on the fourth day. The autopsy showed besides exten- 
sive recent hepatization, chronic organic disease of both lungs and 
heart. (A. S. Greenway, Brit. Med. Journ., 1878, October 5th.) 
Case 33.-A young man took two grains of atropia at bedtime, 
and was found dead next morning. ( Taylor's Med. Jur. and Tox.) 
Case 34.-A woman, aged forty-three years, swallowed three 
grains of atropia. Violent delirium, trismus, and later muscular 
relaxation; sudden appearance of symptoms of suffocation, and 
death about fifteen hours after taking the drug. (S.W. Gross, Am. 
Journ. of Med. Sci., October, 1869, p. 401.) 
Case 35-The case of a soldier who died from eating the shoots 
of the Datura stramonium was reported by Barton. (Beck's Med- 
ical Jurisprudence.) 
Case 36.-A woman drank a decoction of bruised stramonium 
seeds, and died in seven hours. (Taylor's Med. Jur. and Tox.) 
Case 37.-A male convict ate a large quantity of stramonium 
seeds. He was found insensible, with stertorous breathing, and 
pulse 120 per minute, and died an hour later. (Robert Allan, 
Lancet, 1847, ii. p. 298.) 
Case 38.-A delicate girl, aged two and one-half years, ate over 
one hundred seeds (weighing sixteen grains) of Datura stramo- 
nium. Spasm of the glottis, twitching and tetanic spasms, and 
coma, pulse 200, respirations upward of 100 per minute. Death 
within twenty-four hours. Reported by her father. (E. W. Duffin, 
Lond. Med. Gaz , 1834, vol. xv. p. 194.) 
39.-Two fatal cases of poisoning by hyoscyamus are re- 
ferred to by Christison in his work on poisons. 
40.-Datura poisoning is very common in the East, and 
Taylor and Tardieu both mention that Dr. Brown, in a work on 
" The Poisons of Punjab," published in 1863, had collected twenty- 
one that terminated fatally. It is probable that some of these cases 
are mentioned above. 7 
A careful examination of the literature of this subject seems to 
me to justify these conclusions :- 
First. For adults the minimum fatal dose of atropia is certainly 
not less than the minimum fatal dose of morphia. 
Second. The minimum fatal dose for children of two years of 
age and upwards is not less than for adults. 
Third. There is every probability that the same is true of the 
other mydriatic alkaloids. 
These conclusions are supported by those cases in which large 
doses of the mydriatics have been given medicinally. Dr. S. B. 
Foreman, of Lancaster, used fifteen and twenty grain doses of the 
extract of belladonna, per rectum, relieving a case of obstinate con- 
stipation. {Practitioner (Lancaster, Pa.), 1883, p. 10.) Dr. J. M. 
Fothergill gave one grain of atropia hypodermically in a case of 
opium poisoning, saving his patient. (Lancet, 1878, i. 354.) One 
and one-sixth grains were given in a case of strychnia poisoning, 
and the patient recovered. (Hdinburgh Med. Journ., September, 
1873.) Dr. Henry W. Fuller, of London (Med. Times and Gazette, 
1859, July 23d), gave very large doses of extract of belladonna and 
atropia to twelve children suffering from chorea. " The result was 
in all cases the same, namely, extraordinary tolerance of the 
remedy. . . . The tolerance of the drug being so great that one 
girl, aged ten, took seventy grains of the extract of belladonna 
daily, and a total amount of one thousand and nineteen grains, or 
rather more than two ounces in twenty-six days; whilst the child, 
aged fourteen, to whom the atropine was administered, took no less 
than thirty-seven grains in eighteen days." Abundant crystals of 
atropia were obtained from the urine and feces of a patient, " who 
at the time was taking sixty-four grains of the extract of belladonna 
daily." 
Dr. Sydney Ringer, in his Hand-book of Therapeutics (sixth 
edition, p. 530), narrates a very interesting case, where large doses 
of the mydriatic alkaloids were given to a woman, aged twenty-two 
years, suffering from acute mania. During three weeks atropia 
sulphate was given in one-quarter grain dose once, in three-fourths 
grain dose once, in one grain doses five times; daturia, in one grain 
doses four times; and hyoscyamia in one grain doses seven times. 
Under this treatment the patient improved. 
I would not plead for any indiscriminate or useless increase of 
the dose of these drugs; but cases occur in which there is urgent 
need that they be used freely; and practitioners sometimes fail to 
meet the plainest indications for treatment, because of this erroneous 
impression, that any decided increase over the common dose would 8 
be dangerous. Those of us who are engaged in ophthalmic prac- 
tice, see instances of this in eyes seriously damaged by iritic adhe- 
sions, that have formed while a one-fourth or one-half per cent, 
solution of atropia was being instilled, one drop at a time with 
intervals of several hours. 
Of course, in using the mydriatics freely, there is risk of causing 
the symptoms of mydriatic intoxication; but this may be largely 
guarded against by the simultaneous use of ordinary medicinal 
doses of morphia, or perhaps pilocarpin, or chloral; and if it cannot 
be thus entirely prevented, the physician can simply and truthfully 
say that delirium, unnatural voice, and irregular locomotion indicate 
no more danger when produced by a mydriatic than when produced 
by alcohol. We every day cause the deepest intoxication with 
ether, to give relief from evils less serious than the loss or impair- 
ment of an eye. Let us use the mydriatics as rationally, remem- 
bering that with them there is an exceptionally wide interval between 
the alarming and the fatal dose.