Chapter M: M——, was a stout Irish woman about forty years of age. She had (10)

IV. Dipsomania.—The diagnostic points are the hereditary transmission of this or other forms of insanity—the mental instability of the patient in early life and in the intervals of the paroxysms, the intermittent or cyclical recurrence of the attack, the morbid impulses of a different kind associated with the impulse to drink, and the struggle of the patient against his recurring impulses to uncontrollable excesses.

PROGNOSIS.—The prognosis in acute alcoholism of the ordinary form is favorable, so far as the immediate attack is in question. The prognosis in rapidly-developing, overwhelming coma from enormous doses of alcohol is in the highest degree unfavorable. Acute coma from moderate doses usually passes off in the course of some hours. It occasionally, however, terminates in fatal pneumonia.

The prognosis in delirium tremens of the ordinary form is favorable. It becomes, however, more and more grave with each recurring attack. Delirium tremens in patients suffering from advanced disease of the heart, lungs, liver, or kidneys, or complicated by acute diseases of these organs, is apt to prove fatal.

The prognosis of chronic alcoholism is gloomy. If the lesions be not advanced, permanent discontinuance of alcoholic habits may be followed by restoration of health, but, unfortunately, the discontinuance is too often merely temporary, the habit being too strong to be permanently broken off.

The prognosis in hereditary alcoholism is unfavorable, both as regards the alcoholic habit and as regards the development of serious diseases of {640} the nervous system under adverse circumstances, even in the absence of the direct action of alcohol.

The prognosis in dipsomania is unfavorable. The paroxysm may recur many times without apparent serious result; the patient in the course of some days or weeks recovers, abandons his evil courses, and resumes his usual occupations. After a time, however, the insanity of which the dipsomania is the recurring manifestation declares itself as a more or less permanent state. The outbreaks become more frequent and more prolonged, the mental condition in the intervals progressively more morbid, until the patient lapses by degrees into confirmed insanity.

The prognosis in all forms of alcoholism, both acute and chronic, is rendered in a high degree uncertain by the psychical disorders which characterize so many of its phases. In consequence of some of these conditions the patient loses at once his appreciation of bodily dangers and his power to avoid them; by reason of others, to escape imaginary evils he plunges into real ones; and finally some of them are of such a nature that they impel him to the blind and unreasoning commission of the most grievous crimes, including suicide and homicide.[52]

[Footnote 52: “I believe that more suicides and combined suicides and homicides result in this country from alcoholism in its early stages than from any other cause whatsoever” (T. S. Clouston, _Clinical Lectures on Mental Diseases_, Am. ed., 1884).]

TREATMENT.—The prophylaxis of alcoholism has regard to communities at large and to individuals. The prevention of the evils of excess by the control of the sale of drink constitutes one of the more important objects of state medicine. At the same time, the traffic in alcohol is curiously evasive of legal enactments. The difficulties attending the enforcement of sumptuary laws are well known. Restrictive laws concerning the making and sale of alcoholic drinks, while partaking of the nature of sumptuary laws are of more comprehensive character, being obnoxious to powerful commercial interests and to the sense of personal liberty of large numbers of persons of all classes. As a result of organized opposition and individual violation they are to a great extent inoperative as regards the prevention of alcoholism.

Aside from the question of revenue from taxation, the practical influence of law is in this matter somewhat limited, being confined chiefly to the prevention of the sale of liquors to minors and persons already intoxicated, and to ineffectual attempts in certain countries to regulate the quality of the drink sold. The penalties for personal drunkenness which does not lead to overt acts are, as a rule, wholly inadequate to restrain it. The best results upon anything like an extended scale have been obtained by the co-operative action of philanthropic individuals in endeavoring to influence the moral tone, especially among workingmen, to diminish temptations, and to provide for leisure hours, in the absence of drink, reasonable amusements and occupation to occupy the time ordinarily spent in taverns and similar places.

The decrease in the consumption of alcoholic drinks in the United States within recent years is doubtless due in part to increasing popular knowledge concerning the dangers of alcoholic excess and to the growth of a more wholesome public sentiment. It is, however, in part also due to poor wages among workingmen.

As regards the individual, prophylaxis against alcoholism consists {641} either in total abstinence from, or in the most guarded indulgence in, alcoholic beverages. It is unfortunate that individuals whose moral and physical organization is such as renders them most liable to suffer from the consequences of alcohol are by that very fact most prone to its temptations, and hence contribute largely to the subjects of alcoholism. These individuals are found among the ignorant, the very poor, and especially among neurotic subjects of all classes of society. Due consideration of this fact cannot fail to establish the responsibility of those fortunately not belonging to these classes, in two respects: first, that of example; and second, that of personal restraint from the standpoint of heredity. The influence of heredity among races addicted to alcohol has not yet attracted the attention it deserves. It is probable that much of the tolerance for alcohol exhibited by individuals, families, or even nations, is to be accounted for by heredity. Still more probable is it that most of the evils and crimes that befall alcohol-drinking communities and individuals are due directly or indirectly to the abuse of this agent. No argument against the indulgence in narcotics can be more potent than that derived from a consideration of the laws of heredity.

I. The Treatment of Acute Alcoholism.—The medical treatment of mere drunkenness requires no consideration. The rapid elimination of alcohol, and the transient nature of its pathological effects in excesses which are not repeated or prolonged, explain the spontaneous recovery, which is usually sufficiently prompt and permanent. The physical suffering and mental distress following unaccustomed excesses are of salutary influence. Under certain circumstances a powerful effort of the will is sufficient to control, at all events for a time, the more moderate effects of alcohol. A similar result follows the use of cold douches, the Turkish bath, and full doses of certain preparations of ammonium, particularly the officinal solution of the acetate of ammonium. In alcoholic stupor of an acute kind the patient may be left to himself, care being taken that the clothing is loosened and that the position is such as to prevent local paralysis from the nerve-pressure. Alcoholic coma, if of moderate intensity, may be managed in the same way. Profound alcoholic coma requires, however, more energetic measures. Frictions, artificial warmth, stimulating enemata, as of turpentine or of hot salt and water, an ounce to the pint, hypodermic injections of strychnia or atrophia in minute doses and occasionally repeated, inhalations of ammonia, and occasional cold affusions, followed by brisk frictions with warm flannel and faradism of the respiratory muscles, may be needed to tide over the threatened fatal collapse. The stomach should be at once washed out with hot coffee.

In the convulsive form of acute alcoholism chloral in twenty-grain doses, repeated at intervals until sixty grains have been given, usually serves to arrest, or at all events to moderate, the paroxysm. It may be administered by the mouth or in double doses by the rectum. If chloral be inadmissible by reason of weakness of the circulation, paraldehyde may be substituted in doses of from half a drachm to one drachm, repeated at intervals of from one to two hours until quietude is produced. Where the convulsive paroxysms are of great violence it may be necessary to control them by the cautious administration of ether by inhalation.

The mania of acute alcoholism calls for energetic management. To {642} avert injury to the patient himself or to those about him he must be confined, if practicable, in a suitable apartment in a hospital; if not, in his own house and carefully watched. Here, as a rule, paraldehyde, chloral, or large doses of the bromides constitute our most efficient means of medication.

In all forms of acute alcoholism it is a rule admitting of no exception to at once withhold alcohol in every form and all doses. If, under exceptional circumstances, great nervous depression or flagging circulation seems to call for the use of alcohol in small amounts, it is far better to substitute other drugs. The frequently repeated administration of hot beef-tea or rich broths in small doses, with capsicum and the use of the various preparations of ammonia, or small doses of opium with or without quinia and digitalis, proves useful in proportion to the skill and discrimination with which they are selected and repeated. It is a good plan to commence the treatment with an active purge.

In the acute collapse following excessive doses—lethal doses—the stomach is to be immediately emptied by the tube or pump and washed out with warm coffee. In the absence of the stomach-tube emesis may be provoked by the use of mustard or sulphate of zinc or by hypodermic injection of apomorphia. The patient must be placed in the recumbent posture and surrounded with hot blankets. The cold douche may be occasionally applied to the head and face, and the muscles of respiration may be excited to action by faradism. Artificial respiration and friction of the extremities may also be required. Inhalations of ammonia may be used. The flagging heart may be stimulated by occasionally tapping the præcordia with a hot spoon—Corrgan's hammer. Hypodermic injections of digitalis may also be employed. Overwhelming doses of alcohol, leading promptly to collapse, usually prove fatal despite all treatment.

II. The Treatment of Chronic Alcoholism.—Whatever may be the prominence of particular symptoms or groups of symptoms, whether they indicate derangement of the viscera, of the nervous system, or of the mind, whatever their combination, the fundamental therapeutic indication in chronic alcoholism is the withdrawal of the poison. The condition is directly due to the continuous action of a single toxic principle: its relief when practicable, its cure when possible, are only to be obtained by the discontinuance of that poison. This is a matter of great, often of insurmountable, difficulty. The obstacles are always rather moral than physical. Occasional or constant temptation, the iron force of habit, the malaise, the faintness, the craving of the nervous system, and, worse than all, the enfeebled intellectual and moral tone of the confirmed drunkard, stand in the way. Even after success seems to have been attained, and the patient, rejoicing in improved physical health and in the regained companionship and consideration of his family and friends, feels that he is safe, it too often happens that in an unguarded moment he yields to temptation and relapses into his old habits. A patient of the writer, after seven years' abstinence from drink, again became its victim in consequence of the incautious suggestion of a young medical man, met at a summer hotel, to take brandy for some transient disorder, and died after eight months of uncontrollable excesses. It is necessary to guard the patient against the temptation to drink. To secure this he may he sent as a voluntary patient for a length of time to a suitable institution, {643} or, still better, he may place himself under the care of a conscientious, clear-headed country doctor in a sparsely-settled region, preferably in the mountains or at the seaside. The malaise, depression, insomnia, and other nervous symptoms when of moderate degree are best treated by abundance of nutritious and easily-assimilable food, taken often and in moderate amounts. To this end gastro-intestinal disturbances may be practically disregarded, except in so far as they regulate the selection of a highly nutritious diet. As a matter of fact, in the early periods of chronic alcoholism, while visceral lesions of a grave character are yet absent, appetite and digestion alike improve in the majority of cases upon the withdrawal of alcohol, provided a sufficiently abundant and easily assimilable dietary is insisted upon. Grave visceral lesions characterize a more advanced alcoholic cachexia and necessarily complicate the treatment. Nevertheless, even here the indication is the withdrawal of the poison. The nervous symptoms require special medication. The whole group of tonics, from simple bitters to quinia and strychnia, is here available. It is impossible to lay down rules for the treatment of particular cases except in the most general manner. In the absence of conditions calling for special treatment, such as gastritis, hepatic or pulmonary congestion, fatty heart, etc., good results follow the frequent administration of small doses of quinia and strychnia; thus, the patient may take one grain of quinia six or eight times a day, or a little gelatin-coated pill containing 1/200-1/100 of a grain of strychnia every hour during the waking day, amounting in all to one-twentieth, one-tenth, or one-fifth of a grain in the course of twenty-four hours. This treatment is often followed by the relief of tremor, the quieting of nervous irritability, and the production of good general results. The malaise, the general depression, and especially the sinking feeling at the pit of the stomach so often complained of by patients, are best relieved by food. Fluid extract of coca is also useful in these conditions. The value of cocaine in the management of the nervous symptoms of chronic alcoholism, and in particular as a temporary substitute for alcohol, is doubtful. The writer, having used it in a number of cases by the mouth and hypodermically in doses of ¼-1 grain, has had variable results. In some cases it temporarily relieved the craving and concomitant symptoms; in others it failed wholly: in one instance one-fourth of a grain was followed by great nervous depression. It is desirable not to inform the patient of the nature of the remedy, especially if its use be followed by good results, lest the cocaine itself supplant alcohol as an habitual narcotic. Cold or tepid sponging, the occasional hot bath at bedtime, and the Turkish bath are useful adjuvants to the treatment. As a rule, opium is contraindicated. Sleep often follows the administration of a cupful of hot broth or milk at bedtime. Lupulin is here useful, and the writer has come to regard an ethereal extract of lupulin in doses of from one to three grains as a valuable and harmless hypnotic. If necessary, hypnotic doses of chloral or paraldehyde may be used, but care is required in their administration, and their early discontinuance is advisable. If anæmia be profound, chalybeate tonics do good, and among the preparations of iron pills of the dried sulphate with carbonate of potassium (Blaud's pills) are especially useful.

The obesity of drunkards, as a rule, diminishes on the withdrawal of alcohol. Under circumstances of partial or complete abstinence from {644} drink measures to reduce the weight of such patients are wholly inadmissible.

In conditions characterized by failure of mental power, in beginning dementia or threatened insanity, the syrup of the hypophosphites, the compound syrup of the phosphates, or cod-liver oil should be administered. These remedies are likewise useful in various forms of alcoholic paralysis, as are also faradism and galvanism employed secundum artem. The various forms of alcoholic insanity require special treatment, only to be had in institutions designed for the care of patients suffering from mental diseases in general.

Whilst it is desirable in the treatment of all forms of chronic alcoholism to secure the permanent discontinuance of the alcoholic habit, the skill, judgment, and experience of the physician must determine the degree of rapidity with which this, when practicable, is to be done. The number of cases in which alcohol can be discontinued at once and finally is limited; those in which it can be wholly given up in the course of a few days constitute the largest proportion of the cases; finally, in a small number of cases alcohol can only be withdrawn cautiously and by degrees.[53] Whilst it is in most cases essential to remove the patient from his customary surroundings and companionships, it is in the highest degree important to provide for him mental occupation and amusement. To this end a wholesome open-air life, with sufficient daily exercise to induce fatigue, is highly desirable, as indeed is the companionship of interested and judicious friends.

[Footnote 53: It must be borne in mind that in chronic alcoholism acute maladies of all kinds, including traumatism, both accidental and surgical, act as exciting causes of delirium tremens. The part played by the abrupt diminution or withdrawal of alcohol under such circumstances is often an important one. It is the opinion of the writer that a certain amount of alcohol should be administered for a time at least in the accidental injuries and acute sicknesses of alcoholic subjects, and that the reduction should be gradually made.]

The Treatment of Delirium Tremens.—The patient should be confined in a large, well-aired apartment, without furniture except his bed, and when practicable he should have a constant attendant. The favorable influence of a skilful nurse in tranquillizing these patients is very great. The custom of strapping them to the bed by the wrists and ankles is to be deprecated. If the case be a mild one, and especially during convalescence, open-air exercise in the sunshine with an attendant is of benefit; care must, however, be taken to guard against the danger of escape.

Under no circumstances should visitors be permitted to see the patient. In young persons the treatment may be preceded by an active saline or mercurial purge. In elderly persons, those suffering from cachectic conditions, or in cases characterized by marked debility and feeble circulation—conditions frequent in persons who have had repeated attacks—it is not desirable to purge. Alcohol should be either wholly withdrawn or more or less rapidly diminished. It must be replaced by abundant food in the form of concentrated broths or meat-extracts. In cases of vomiting these must be given hot and in small doses frequently repeated. Bitter infusions may also be given, or milk or equal parts of milk and Vichy water. If there be thirst, the effervescent waters may be given freely. Patients often drink with satisfaction and apparent benefit hop tea, which may be made simply with water or with equal parts of water and porter.

{645} The medicinal treatment will depend to a large extent upon the peculiarities of the case. In mild cases a combination of the watery extract of opium in small doses, not exceeding a quarter of a grain, with quinia and digitalis, repeated every four or six hours, is often useful. Although the view once entertained that the graver symptoms were the result of prolonged sleeplessness is no longer tenable, the induction of sleep, or at all events of mental and physical repose, is among the more important therapeutical indications. For this purpose hypnotic doses of opium are not only not desirable, but are even, in the majority of instances, attended with danger. The sleep which follows repeated and increasing doses of opium in delirium tremens has too often terminated in coma deepening into death. As calmatives, extract of cannabis indica, hyoscyamus, or the fluid extract of piscidia are useful. As hypnotics, the bromides, chloral, and paraldehyde yield, in the order here given, the best results. The bromides are better in large single doses than in small doses often repeated, better in combination than singly. Chloral, either by the mouth or by the rectum, in doses of from twenty to forty grains, is often followed by beneficial sleep. It is contraindicated where the heart's action is much enfeebled. Paraldehyde, in doses of half a drachm to one drachm, repeated at intervals of two or three hours until sleep is induced, is still more efficient. This drug may be administered without the fear of its exerting a depressing influence upon the heart. The depression characteristic of grave delirium tremens may be combated by repeated small doses of champagne or by carbonate of ammonium in five- or ten-grain doses; the vomiting, by withholding food and medication by the mouth, and giving them for some hours wholly by the rectum or hypodermically. Excessive restlessness is sometimes favorably influenced by cold affusion, followed by brisk friction and warm blankets with continuous artificial heat. The cold pack has proved useful.

Digitalis may be employed, ex indicatione symptomatica, but the enormous doses of tincture of digitalis used by the late Jones of Jersey and others are here mentioned only to be condemned.

To sum up, the chief indications for treatment are complete isolation, the withdrawal of alcohol, abundant, readily assimilable, nutritious food, and control of the reflex excitability of the nervous system.

III. Hereditary Alcoholism.—The treatment of the vicious propensities of the descendants of alcoholic parents does not fall directly within the province of the physician. It is among the most difficult problems of education. The recognition of the cause of evil traits manifested in childhood and youth may do something to avert dangers commonly unsuspected. All things considered, the outlook is not hopeful. The recognition, on the part of the physician, of the influence of hereditary alcoholism in cases of arrested development, feeble organization, or declared disease of the nervous system will perhaps do less to aid his treatment in many cases than to reconcile him to its want of full success. The cry of warning is to those who are eating sour grapes that the teeth of their children will be set on edge.

IV. Dipsomania.—The general indications for the treatment of dipsomania are two: first, the management of the paroxysm; second, the control of the general condition itself.

First, then, during the paroxysm the patient must be saved, in so far {646} as is possible, from the danger of injuring himself or others and from squandering his property. If the excesses are of such a degree as to render it practicable, the same treatment must be carried out as in cases of acute alcoholic mania and delirium tremens—namely, confinement in a suitable apartment under the care of an experienced nurse and the control of the doctor. Unfortunately, this plan is not always practicable in the early days of the outbreak. Here tonics, coca, and repeated small doses of quinia and strychnia are of advantage. Courses of arsenic at the conclusion of, and in the intervals between, the paroxysms are of use, on account of the excellent influence they exert on the general nutrition. These may be advantageously alternated with iron, cod-liver oil, and the compound syrup of the phosphates or of the hypophosphites. Hydrotherapy may also be used with advantage, and the influences of a well-regulated hydropathic establishment are much more favorable than those of institutions specially devoted to the treatment of alcoholic subjects. In the latter the moral atmosphere is apt to be bad; the patients support each other, and too often conspire to obtain in secret that which is denied them openly, or, if the discipline be too strict for this, they sympathize with each other in their restraint, react unfavorably upon each other in the matter of shame and loss of self-respect, and plot together to secure their liberty.

Few dipsomaniacs in the earlier periods are proper subjects for treatment in hospitals for the insane. If cerebral excitement or sleeplessness persist after the paroxysms, chloral, paraldehyde, or the bromides in large doses may be used to secure sleep. Various combinations of the bromides are often of use where the single salts fail. It must not be forgotten that during the paroxysm there is great danger lest the patient do himself or others harm. When there are indications of an impending attack, and during the period of depression following the attacks, benefit is derived from the daily use of bitter infusions. As a matter of fact, however, the management of these cases is among the most unsatisfactory of medical undertakings. The difficulty is increased by the latent character of the mental disorder in the intervals between the attacks. Even when such patients voluntarily enter hospitals for the insane, they cannot be retained there sufficiently long to derive any permanent benefit. What we want is, in the words of Clouston, “an island where whiskey is unknown; guardianship, combined with authority, firmness, attractiveness, and high, bracing moral tone; work in the open air, a simple natural life, a return to mother Earth and to Nature, a diet of fruits, vegetables, bread, milk, eggs, and fish, no opportunity for one case to corrupt another, and suitable punishments and deprivations for offences against the rules of life laid down. All these continued for several years in each case, and the legal power to send patients to this Utopia for as long a period as medical authority determines, with or without their consent.”

{647}

THE OPIUM HABIT AND KINDRED AFFECTIONS.

BY JAMES C. WILSON, M.D.

Next in order to alcohol, opium and morphine are habitually abused to a greater extent than any other narcotic. Chloral is used in the same way by a large number of individuals. Paraldehyde, cannabis indica, ether, chloroform, and cocaine are also used to a less extent. The scope of this article does not include the consideration of acute poisoning by these drugs.

The habit of taking narcotics, whether medicinally or as a mere matter of indulgence, is apt speedily to become confirmed. The physiological dose more or less rapidly loses its power to affect the nervous system in the ordinary way. Tolerance increases with increasing doses, and in a comparatively short space of time poisonous doses are taken with impunity as far as immediate danger to life is concerned. The toxic effects of the poison are shown in characteristic perversion of the functions of the nervous system and of the mind. A condition is established in which the ordinary functions of life are properly performed only under the influence of the habitual narcotic, and in which its absence results in languor, depression, and derangement of bodily and mental processes. The habit, once established, thus makes for itself a constantly recurring plea for its continuance. Especially is this true of opium and morphia.

Opium and Morphine.

Opium-eating is chiefly practised in Asia Minor, Persia, and India. It is also prevalent in Turkey. It has been practised in India from very ancient times. The prevalence of this habit in the East is probably largely due to the restrictions placed upon the use of alcoholic beverages among the Mohammedans, and to some extent also to the long religious fasts observed by the Buddhists, Hindoos, and Moslems, during which opium is often used to allay the pangs of hunger. The prevalence of the opium habit in India is shown by the fact that the license fees for a single year amounted to nearly five hundred thousand pounds sterling. It is stated that in Samarang, a town of 1,254,000 inhabitants, the average quantity of opium consumed monthly is 7980 pounds. The town of Japava, with 671,000 inhabitants, consumed in fifteen days 5389 pounds {648} of opium. In 1850, 576,000 pounds of opium were imported into Java, besides an unknown quantity smuggled.[1]

[Footnote 1: _Archiv für Pharmazie_, 1873, cited by Von Beck, _Ziemssen's Cyclopædia_, vol. xvii.]

The habit is not confined to Oriental countries, but is also practised in various forms in the West. It is by no means rare on the continent of Europe. In certain districts of England, especially in Lincolnshire and Norfolk, more opium is consumed than in all the rest of the United Kingdom. Shearer[2] states that the increase in the practice of opium-eating among the workpeople of Manchester is such that on Saturday afternoons the druggists' counters are strewed with pills of opium of one, two, and three grains, in preparation for the known demand of the evening. The immediate occasion is said to be the lowness of wages, opium being used as a cheap substitute for alcohol or as a food substitute, or with the view of removing the effects of disease and depression. According to the same observer, laudanum is more or less in use as a narcotic stimulant in the cotton-spinning towns, where female labor is in requisition and is well paid. Children are accustomed to it from their earliest infancy. Their parents drug them with daily potions of Godfrey's cordial, Dalby's carminative, soothing syrup, and laudanum itself, during the long hours of their absence from home. While the habit of opium-eating cannot be said to be generally prevalent in any part of the United States, instances of it are frequently encountered in all classes of society, and particularly among people of means and refinement. The preparations employed in this country are crude opium, tincture of opium or laudanum, camphorated tincture of opium or paregoric, McMunn's elixir, Dover's powder, and the salts of morphia. All of these preparations are used by the mouth; opium is very frequently, especially among women of the better classes of society, habitually taken in the form of suppositories; finally, the acetate and sulphate of morphine are used by means of the hypodermic syringe. While it will be necessary to point out some differences in the effects of these drugs due to the preparation used or to the method in which it is employed, the distinction between the opium habit and the morphine habit, in itself an artificial one, will not be regarded in the course of the present article.

[Footnote 2: _Opium-smoking and Opium-eating, their Treatment and Cure_, by George Shearer, M.D., F. R. S.]

Opium-smoking is chiefly practised by the inhabitants of China and of the islands of the Indian Archipelago. It has been imported into those countries where Chinese labor is largely employed. The Chinese have transmitted it, to an extent which is fortunately very limited, to the inhabitants of certain of our cities. Opium-smoking is habitually practised in this country only among the more debased orders of society.

SYNONYMS.—Opiophagia, Morphiopathy, Morphinism, Morphinomania, Morphiomania, Morpheomania, are terms occasionally employed to designate the opium or morphia habit.[3] Landowski, Levinstein, Jouet, and others use the term morphinism to denote the condition of the body; morphinomania, the condition of the mind in chronic morphine-poisoning. This distinction may be misleading. In effect, the pathological condition is complex, including derangements both somatic and psychical.

[Footnote 3: The word morphiomania, used by writers, is contrary to all etymological rule (Zambaco, _De la Morphéomania_, Paris, 1883).]

{649} ETIOLOGY.—_A_. Predisposing Influences.—Pain holds the chief place among the influences which predispose to the formation of the opium habit. By far the greater number of cases have taken origin either in acute sickness, in which opium administered for the relief of pain has been prolonged into convalescence until the habit has become confirmed, or in chronic sicknesses, in which recurring pain has called for constantly repeated and steadily increasing doses of opiates. In view of the frequency and prominence of pain as a symptom of disease, and the ease and efficiency with which opium and its preparations control it, the remote dangers attending the guarded therapeutic use of these preparations are indeed slight. Were this not so, the number of the victims of the opium habit would be lamentably greater than it is. In a considerable proportion of cases of painful illness the relief afforded by opiates is attended by at least some degree of malaise, nausea, vomiting, and vertigo—symptoms which render the speedy discontinuance of the remedy scarcely less desirable than the control of the pain for which it was administered. Occasionally these symptoms are so distressing as to render opium wholly inadmissible. In other instances each successive dose is attended by an aggravation of the distress. More commonly, especially in acute illnesses, decreasing pain may be controlled by diminishing doses, thus rendering practicable entire discontinuance of the drug before those modifications of the nervous system, and especially before that tolerance for large doses, which constitutes the beginning of the opium habit, are established. For these reasons the use of opiates in acute sickness, if properly regulated, is attended with but little danger. Far different is it, however, in chronic painful illnesses. Here to procure relief by opium is too often to pave the way not only to an aggravation of the existing evils, but also to others which are often of a more serious kind. Opium is at once an anodyne and a stimulant. The temptations to its use are of a most seductive character. To the overworked and underfed mill-operator it is a snare more tempting than alcohol, and less expensive. It allays the pangs of hunger, it increases the power of endurance, it brings forgetfulness and sleep. If there be myalgia or rheumatism or neuralgia, and especially the dispiriting visceral neuralgias so common and so often unrecognized among the poorer classes of workpeople, opium affords temporary relief. The medical man suffering from some painful affection, the worst symptoms of which are relieved by the hypodermic injection of morphine, falls an easy prey to the temptation to continue it—a danger increased by the fact that he is too often obliged to resume his work before convalescence is complete. Indeed, the self-administered daily doses of physicians sometimes reach almost incredible amounts. To women of the higher classes, ennuyée and tormented with neuralgias or the vague pains of hysteria and hypochondriasis, opium brings tranquillity and self-forgetfulness.

Of 100 cases collected by Jouet,[4] the habit followed the therapeutic use of morphine in 32 cases of ataxia, 24 of sciatica and other neuralgias, 8 of asthma, 2 of dyspepsia, 4 of hypochondriasis, 2 of madness, 9 of painful tumors, 2 of prostatic inflammation, 7 of nervous conditions (not specified), 1 of peritonitis, 2 of periostitis, 1 of gastro-enteralgia, 4 of pleuritic pains, 1 of contracture, and 1 case of hæmoptysis.

[Footnote 4: _Étude sur le Morphinism chemique_, Thèse de Paris, 1883.]

The responsibility of the physician to his patient becomes apparent {650} when we reflect that with very few exceptions the opium habit is the direct outcome of the use of the drug as a medicine.

The decade of life at which the opium habit is most common is between thirty and forty. But it may be developed at any age. Even infants are not rarely made the subjects of chronic opium narcotism by the use of soothing syrups and other poisonous nostrums.

Sex in itself exerts very little influence as a predisposing cause. Owing to collateral circumstances, the number of women addicted to opium is greater than the number of men. Kane[5] states that females more frequently fall victims to these drugs than males, in the proportion of three to one, and attributes this excess to the fact that women more often than men are afflicted with diseases of a nervous character in which narcotic remedies are used for long periods. This observer suggests as an additional explanation the occasional preference on the part of women for opium as a stimulant in place of alcohol, its effects being less noticeable and degrading. On the other hand, Levinstein observed in 110 cases 82 men and 28 women. He does not, however, regard the conclusion that the use is more common among men as warranted by these figures. The habit resulted in these 110 cases from the following causes: In 20 men and 6 women after acute affections; in 46 men and 17 women after chronic affections, these diseases being in each instance accompanied by great pain. One man began to use morphine as an antiaphrodisiac. Either to produce mental excitement simply or to cause forgetfulness of the ordinary cares of daily life, 15 men and 5 women indulged to an uncontrollable extent.

[Footnote 5: _Drugs that Enslave_, Philadelphia, 1881. I refer with pleasure to the early labors of this observer. His later publications tell their own story.]

Occupation has in some respects much to do in favoring the development of the opium habit. Familiarity with the use of drugs exerts a powerful influence. Of Levinstein's 110 cases, 47 occurred in persons belonging to the medical profession or dependent upon it; thus, 32 physicians, 8 wives of physicians, 1 son of a physician, 4 nurses, 1 midwife, and 1 student of medicine.

A predisposing influence of more importance than would at first sight appear is found in sensational popular writings upon the subject. As Kane has well said, “At the time in which De Quincey, Coleridge, and Southey lived the people and the profession knew little of the opium habit save among foreign nations. The habitués were few in number, and consequently when De Quincey's article appeared it created a most decided impression upon the popular mind—an impression not yet effaced, and one which bore with it an incalculable amount of harm. Men and women who had never heard of such a thing, stimulated by curiosity, their minds filled with the vivid pictures of a state of dreamy bliss and feeling of full content with the world and all about, tried the experiment, and gradually wound themselves in the silken meshes of the fascinating net, which only too soon proved too strong to admit of breaking.” There can be no question that a percentage of cases of the opium habit, small though it be, is even in our day to be attributed to this cause.

Somewhat analogous in its etiological importance is the influence of example upon persons of idle and luxurious habits. Nowhere in Western countries, with the exception of the opium-smoking dens of the {651} Chinese and their depraved associates, are there public places of resort devoted to the practice of the opium and morphine habits, as there are in Turkey and the East. According to Jouet—whose statements are corroborated by occasional statements in French newspapers—the habitual injection of morphine is to-day, in France at least, almost a matter of fashion. Landowski states that friendship is occasionally pushed to the extent of the exchange of pretty syringes in silver cases as presents, and that a patient received upon his birthday a hypodermic syringe as a present from his sister. Zambaco, whose observations were made at Constantinople, states that among the Moslems the opium habitués prefer the crude drug, either alone or associated with certain aromatic substances, such as ambergris, canella, or saffron, which are used for their aphrodisiac effect. These mixtures are prepared openly in the family, and carried upon the person in the form of pills in rich boxes of gold and enamel among the better classes. This observer further says that the ladies of the better classes carry jewelled cases containing hypodermic syringes and artistic flaçons for the seductive solution, and that they avail themselves of favorable opportunities to take an injection of morphine even when together.

In addition to the predisposing influences already mentioned, it has been customary to regard insanity as a cause of the opium habit. Laehr[6] and Fidler[7] have gone so far as to class the morphine habit among the psychoses. This view appears to be no longer tenable. The opium habit must be classed with the taste for alcohol, gambling, avarice, and lust as among human passions. That nervous subjects, invalids, and individuals wanting in moral and physical tone are specially prone to it is obvious. It constitutes in these cases, however, an expression of the morbid constitution rather than a substantive affection in itself. In the same manner, the opium habit in insane persons must be looked upon as an epiphenomenon of the morbid mental condition.

[Footnote 6: _Allgemeine Zeitschrift für Psychiatrie_, 1872.]

[Footnote 7: _Jahresb. der Gesellschaft für Natur und Heilkunde_, Dresden, 1876.]

Levinstein has with reason insisted upon the essential difference between the disturbances resulting from chronic poisoning by alcohol, lead, arsenic, etc., and that produced by morphine. In the former group the mental conditions are expressions of physical and chemical alterations of the central nervous system, which, once established, persist for an indefinite period, whereas in morphinomania the troubles of the nervous system are chiefly functional and of a transitory character. He regards the nervous disorders developed from the prolonged use of morphine as the result simply of depression of the nervous system, and the extreme suffering experienced on the withdrawal of the regular dose to which the subject has been accustomed as a trouble of innervation rather than as a psychical derangement. This physical suffering and the mental depression which accompanies it have their analogues in the angina occasionally seen in paroxysmal affections of the heart, the blood-vessels, and the respiratory organs. Certain it is that individuals addicted to opium and morphine excesses in a high degree not only frequently retain full possession of their intellect, but occasionally achieve and maintain great distinction in professional and scientific life. Furthermore, subjects of the opium habit, notwithstanding the gravest mental disturbance manifested during the {652} continuance or upon the cessation of the habit, usually exhibit when cured no further indication of mental disorder.

_B_. The Exciting Cause.—In addition to the usual constituents of vegetable substances, mucilage, albumen, proteids, fat, volatile substances, and salts of ammonium, calcium, and magnesium, opium contains a number of alkaloids, two neutral substances, and meconic acid. Some of the alkaloids are probably derivatives from morphia. The three most important alkaloids are morphine, codeine, and thebaine. The neutral substances are meconin and meconiasin. Morphinæ hydrochloras, acetas, and sulphas, codeina, and apomorphinæ hydrochloras are officinal in the United States Pharmacopœia. Opium and its alkaloids act principally on the central nervous system, and in mammals on the brain. The functions of the nervous system, as Brunton has pointed out, are abolished in the order of their development, the highest centres being the first affected. In man the action of opium is chiefly manifested upon the brain. With small doses a stage of excitement, attended by increased activity of the circulation, augmented nervous energy, and under favorable circumstances an agreeable languor, followed by quiet sleep, constitute the effects of the drug; with larger doses, of from one to two grains, the transient stage of excitement is followed by deep sleep, the awakening from which is marked by headache, nausea, and evidences of gastro-intestinal catarrh; with still larger doses, of three grains or more, deep sleep is produced, which speedily passes into coma. The drug has an especial action on the vaso-motor system, which is manifested in its power to diminish congestion and relieve inflammation. With the exception of the urine and the sweat, the secretions of the body are diminished by opium. The action of the drug upon the intestines varies with the dose. In moderate doses it diminishes peristalsis and causes constipation; in very small doses it increases peristalsis; in large doses peristaltic action ceases. Morphine is eliminated unchanged by the kidneys. It is eliminated also by the gastro-intestinal mucous membrane, having been found in the stomach after hypodermic injection. The action of opium and its derivatives, as that of other narcotics, is much influenced by habit. In those accustomed to the drug large (and sometimes enormous) quantities are required to induce the characteristic manifestations. Not rarely these manifestations are much retarded. The enormous amount of two pints of tincture of opium has been taken in the course of a day; a female patient afterward successfully treated by the writer took habitually for a long period of time from ten to twelve grains of morphine per diem, hypodermically. Diedriech[8] assumes that a portion of the morphine introduced into the organism is converted into oxydimorphine or other analogous substances which have the property of counteracting to some extent the toxic effects of the morphine.

[Footnote 8: _Ueber oxydimorphine_, Inaug. Diss., Göttingen, 1883.]

Levinstein concludes as a result of experiments upon animals that morphine, besides its influence upon the nervous system, exerts an especial action upon two sets of organs: first, upon the digestive tube; and second, upon the sudoriferous glands. Taken by the mouth, it irritated the gastric mucous membrane. Whether taken by the mouth or hypodermically, it diminishes the secretion of gastric juice and the peristaltic movements of the intestine. These disturbances serve to explain not {653} only certain of the phenomena of the opium habit itself, but even more fully some of the symptoms manifested upon its discontinuance. The nausea, vomiting, and constipation occurring during the continuance of the habit must be looked upon as a result of the derangement of function of the gastro-intestinal glandular apparatus and the chronic catarrh which accompanies it. The abrupt discontinuance of the drug is followed by the sudden return of functional activity, hence salivation, persistent vomiting, anorexia, and diarrhœa.

The effects of habitual excesses in opium and morphine upon the nervous system are in essential particulars the same. Upon the functions of the digestive system and upon nutrition they differ to a considerable extent. Opium, as a rule, soon produces gastro-intestinal derangements of a marked kind. These derangements consist in loss of appetite, enfeebled digestion, nausea, vomiting, and constipation alternating with occasional diarrhœa. The anorexia is usually persistent and of a high degree, and has much to do with the development of the wasting which is so common and so marked. The occasional excessive appetite for food manifested by opium-eaters is of brief duration. Its gratification aggravates the functional disturbances, provokes gastro-intestinal catarrh, and thus tends to increase the general malnutrition. On the other hand, morphine is much better borne. At the present time almost all morphine habitués use the hypodermic syringe, and, notwithstanding the elimination of the drug in part by the gastric mucous membrane, thus escape in part its evil effects upon the organs of digestion, and remain for a long time, often despite enormous excesses, free from the nutritive disturbances which are almost characteristic of the habitual abuse of crude opium.

SYMPTOMATOLOGY.—The symptoms of the confirmed opium habit may be divided into two principal groups: first, the symptoms of chronic opium- or morphine-poisoning; and second, the symptoms due to the withdrawal of the drug.

I. Symptoms of Chronic Poisoning.—A considerable percentage of the individuals addicted to the opium habit preserve for a longer or shorter period of time the appearance of health; indeed, it is possible for very large doses of opium to be occasionally taken by certain individuals without appreciable impairment of the functions either of the body or the mind. These cases must, however, be looked upon as exceptional. It is estimated that from one-fourth to three-tenths of the entire population of China are addicted to the habit of opium-smoking. The statements of travellers concerning the effect of this habit are somewhat conflicting. When practised within bounds it appears to resemble in its effects the moderate use of alcoholic stimulants, increasing the ability to endure fatigue and diminishing for a time the necessity for food. In moderation it appears to have little injurious effect upon the general health. On the other hand, in the greater number of individuals the confirmed opium habit causes in a variable period of time symptoms of the most decided character; the appetite and general nutrition fail; emaciation is often rapid, commonly marked, and sometimes extreme. There are thirst and anorexia; a little later the patient begins to suffer from nausea with occasional vomiting. At this time a loathing for food alternates with boulimia. These occasional excesses in food are followed by epigastric {654} distress, heartburn, and great mental depression. The skin becomes relaxed, inelastic, and dull. Exceptionally, especially in women who use morphine hypodermically, embonpoint is preserved and the skin retains its normal tension and appearance. The countenance is pale, muddy, and sometimes slightly cyanotic. There is increased tendency to perspiration. Acne and urticaria are common. Herpes zoster is encountered with considerable frequency among opium subjects. In cases in which morphine is administered by means of the hypodermic syringe the resulting lesions of the skin are of importance. If the habit be concealed or denied, they are of diagnostic value. Not rarely they constitute serious affections in themselves. They are of all grades, from mere inflammatory points to coarse infiltration and ulceration. The wounds are frequently so thick set over the greater part of a limb as to present the appearance of a continuous eruption. In other cases scattered points of ulceration occur or extensive surfaces are occupied by a series of ulcerations varying in size from a split pea to an inch or more in diameter. Purulent inflammation of the subcutaneous tissues, with burrowing, also occurs. Numerous scars bear witness to the duration and extent of the habit. These lesions are usually due to unclean needles and impure solutions; in certain cases they are to be explained by the peculiarities of the individual as regards the tendency to inflammation of the integumentary structures; finally, instances are related in which immunity from skin lesions has existed in spite of rusty needles and carelessly kept solutions.

The expression of the countenance is sometimes dull, much more frequently furtive and timid. The repetition of the dose renders it eager and bright. The pupils are commonly contracted, sometimes enlarged, and occasionally unequal. Diminished power of accommodation is common, and diplopia has been occasionally observed.

The action of the heart is often irregular and weak. Disturbances of the vaso-motor system give rise to flushing of the face, irregular sensations of heat over the body, and sweating. It is probable that the albuminuria hereafter to be described is due to disturbance of the circulation in the kidneys. The pulse is variable; it is sometimes tense and full, sometimes small and thready, often irregular. The volume, tension, and rhythm of the pulse depend largely upon the state of the vaso-motor and general nervous systems. They vary according to the periods of stimulation, following doses or the periods of depression characterizing the intervals between the doses. Palpitations occasionally occur. Respiration is, as a rule, normal. Transient dyspnœa sometimes occurs after doses a little larger than usual. Subacute bronchitis is common. The urine is often diminished in quantity. Its specific gravity varies within extreme limits, being influenced rather by collateral circumstances than by the dose of opium or morphine consumed. In grave cases albuminuria occurs. Casts of various kinds are also encountered. As Levinstein[9] has pointed out, these changes in the urine are often transitory, disappearing upon the suppression of the opium habit.

[Footnote 9: _La Morphiomanie_, 2d ed., Paris, 1880.]

In confirmed cases uric acid is increased and urea diminished. The chlorides are also diminished in amount. Vesical irritation is likewise common. It is apt to be accompanied by neuralgia of the urethra and {655} of the rectum. Strangury and retention of urine also occur in old cases. These complications are often followed by vesical catarrh.

Derangements of the central nervous system are constant and serious. The disorders which originally led to the use of opiates are in many instances intensified. The temper is capricious, fanciful, and discontented. There are giddiness, headache, and vertigo. Disturbed sleep, irregular flying neuralgic pains, and hyperæsthesia also occur. Spinal tenderness is occasionally encountered, with characteristic painful spots. Reflex excitability is augmented, but in aggravated cases the tendon reflexes are often impaired. Itching is common and troublesome. It may be local or general. Trembling of the hands and of the tongue also occurs. This tremor resembles in all particulars the tremor of chronic alcoholism, and, as many individuals addicted to the opium habit also abuse alcohol, it is not always easy to say to which of these poisons the symptom in question is to be referred: it may be due to their combined action. Disturbances of speech are not very uncommon. Sleeplessness is troublesome, but absolute insomnia is rare. The sleep which is obtained is late, irregular, and unrefreshing. In several cases that have occurred under the observation of the writer there has been habitual inability to sleep during the night, the patients wandering about, occupying themselves in attempts to read or write until toward morning, and then, under the influence of repeated doses, falling into a more or less profound slumber, which has often been prolonged till after midday. The effects of the dose upon the mind are in the early periods of the habit agreeable exhilaration, increased activity of imagination, and stimulation of the powers of conversation. These effects are sometimes manifested for a long period, and in many instances the most brilliant conversation, and among professional men and public speakers the ablest efforts, have followed the taking of large doses of opiates, and been followed in turn by periods of the most profound physical and mental depression. In the absence of the necessity for intellectual effort, and in individuals incapable of it, the mental condition produced by the dose is one of profound revery, largely influenced by the mental organization of the subject. This state is described, and in many particulars much exaggerated, in the writings of De Quincey, Coleridge, and others.