GENERAL SYMPTOMS CLASSIFIED AND ANALYZED.
I am of the opinion that a clearer and consequently more thorough
understanding of this part of the subject can be obtained by classing
the various effects of the continued use of morphine or opium under the
headings of the different systems and apparatuses, and have, therefore,
adopted this method of presenting these matters to the reader.
THE DIGESTIVE APPARATUS.
(_Stomach, Liver and Bowels._)
The first effect of opium or its alkaloid morphia on the stomach is, in
the majority of instances, to increase the appetite and cause a pleasant
sensation of warmth and a feeling of general contentment. After a time,
however, especially if the drug is taken by the mouth, the appetite is
materially impaired, the bowels become constipated, there is a sensation
of sinking at the pit of the stomach, the circulation through the liver
is interfered with, a catarrhal inflammation of the small intestine and
stomach supervenes, the opening of the bile duct is partially obstructed
by the swollen mucous membrane, and the result is a more or less decided
staining of the skin with the biliary coloring matter. This is due, in
part, to interference with the cells in the proper performance of their
functions, undoubtedly through the medium of the nerves passing to
them. At the same time, the gastric juice is diminished in amount and
lessened in strength, as is also the case regarding the intestinal and
pancreatic secretions, the digestion of food is imperfectly performed,
and in consequence, a condition of malnutrition results, showing itself
in wasting of the muscles and loss of the fatty tissue beneath the skin,
especially of the face, breast and abdomen. As the gastric catarrh
increases, nausea and finally vomiting ensue, still further debilitating
the patient. Derangements of the stomach, liver and bowels are much
more common among those who use the drug by the mouth. I have, however,
seen patients who, while using morphia hypodermically, have suffered
intensely with jaundice, catarrh of the stomach, nausea and vomiting.
When these disorders do arise in the course of the subcutaneous use of
morphia they are prone to be very acute in character. A gentleman, aged
about 32, came under my notice some months ago, suffering from dropsy of
both legs, which, from the middle of the leg to and about the ankles,
were covered with collections of minute red spots, evidently points at
which the capillary blood vessels had ruptured. An examination of his
urine discovered thirty per cent. of albumen and some tube casts from the
kidneys. Also a decided amount of morphine, and considerable blood. He
was put upon tonic remedies; the legs, previously dressed with sulphate
of iron ointment, were tightly bandaged. After about two weeks the
dropsy lessened, the spots disappeared and the general health improved
sufficiently to allow of a business trip to the West. No sooner had
he neared his destination, however, than the dropsy of the legs again
appeared, and the old trouble came back in full force. In addition, he
became somewhat jaundiced, water made its appearance in the abdomen, and
a most distressing nausea harassed him day and night. During all this
time he managed to do an unusual amount of literary work, that required
both knowledge and tact. On his return to New York, he was in a very
weak and debilitated condition. The stomach rebelled at almost every kind
of food, the belly was distended with water, the nausea intense, the
vomiting frequent, and urine high colored, bloody and containing about
sixty per cent. of albumen. While in the West an attempt was made to
gradually diminish the amount of morphia, but owing to severe illness, was
abandoned. Nor did I think it advisable to try again until the general
health was better. Upon iron, in different forms (dialyzed, Bland’s pills,
and muriated tincture), strychnia, phosphorus and gentian, he gradually
improved, and is now just commencing the treatment by gradual reduction.
He consumes daily about ten grains, using it subcutaneously. He contracted
the habit some five years ago, through its being administered to him
hypodermically, during a severe attack of acute articular rheumatism. Two
years ago he was broken of the habit by a physician in this city, who
pursued the plan of sudden deprivation, with the result of nearly killing
the patient.
While traveling in Germany, for the purpose of reporting certain facts for
his paper, he was suddenly taken with congestion of the brain, accompanied
by intense pain and a state of semi-consciousness. A German physician
who was called in, not knowing the man’s previous history, gave him a
subcutaneous injection of morphia, with the result of re-establishing the
habit.
Fluid in the abdomen is not a common complication, and when it does occur,
crowds the stomach upward, interferes with the circulation of blood in the
viscera in the abdominal cavity and renders the nausea and vomiting still
more troublesome.
The stools voided by morphia-maniacs are sometimes clay-colored, being
devoid of biliary coloring-matter. The absence of bile in the intestinal
canal allows of decomposition of the food, with the production of
ill-smelling gases which regurgitate through the stomach, or pass by the
bowels. Constipation is the rule. Sometimes it alternates with severe
diarrhœa. In one patient whom I saw, the fæces collected day by day in
the bowels, until impaction resulted and the mass was removed, with the
greatest difficulty, by means of large enemata and the handle of a spoon.
This lady had been using the drug, crude opium, for only eight months.
This constipation from hardened condition of the fæces produces
irritation, intestinal catarrh, and often hemorrhoids accompanied by an
eczematous eruption about the anus.
Heartburn, not from an excess of gastric juice, as is so often supposed,
but from an acid fermentation of the food, is not an uncommon symptom.
Some patients go on for years with no disturbance of the bowels, liver and
stomach, beyond a slight catarrh and some jaundice, but these troubles are
sure to come sooner or later.
In many instances as the appetite for food decreases the appetite for
alcoholic stimulants replaces it. A young lady, of twenty, formerly a
patient of mine, after using the drug subcutaneously for three years, lost
her appetite and subsisted for nearly eight months upon lager beer, a few
crackers and a little toast. She would consume about one gallon of beer a
day. During this time she somewhat diminished the amount of morphine used
(eight grains, dropped to six grains, in twenty-four hours) and gained
in weight and health. At the end of this time, however, severe gastric
disturbance supervened, and she lay for months in a precarious condition.
She is now cured of the habit.
Alcoholic stimulants are used by some habituès to increase the effect of
the morphia, which it does to a certain extent. They delude themselves
into the belief that they will be enabled to thus reduce the amount of
morphia used, but in the majority of cases this is a fallacy. Those
who prefer laudanum and paregoric to opium or morphine often do so on
account of the amount of alcohol contained in these preparations. I knew
a gentleman, some years ago, now dead, an Episcopalian minister, who
became addicted to the use of alcoholic stimulants. His excesses were so
frequent and so degrading that it was found necessary to expel him from
the church. Sobered by the blow, yet unwilling to entirely abandon his
habit, he seized upon the expedient of using large quantities of laudanum,
thus getting the effect of both opium and alcohol. He died some two years
after, from taking an overdose, at the end of a spree, the first and
last one in the two years. His tombstone is a monument to blasted hopes,
unsatisfied ambition, a life ill-spent, and points a very pregnant moral
to those who knew him. Let a man count well the cost before he takes
service with a master who is only satisfied with a blasted life, here and
hereafter.
THE CUTANEOUS SURFACE.
The effects of these drugs upon the skin may be divided into those
relating to _color_, _sensation_ and _nutrition_. The sallow, cadaveric
hue so often seen in advanced cases is partly due to discoloration by the
biliary matters, which are not properly excreted by the liver, and partly
to a condition of malnutrition, so often seen in persons suffering from
cancerous disease. In case there is serious interference with the working
of the kidneys, the sallow color becomes less distinct, diluted expresses
it well, and it has an appearance more like that of old white marble. In
this case the tissue feels doughy and “soggy,” and at points a pit made in
the skin by the pressure of the finger remains. There is also puffiness
under the eyelids and the eyes are bleared and watery. When there is no
dropsy the skin is usually dry and harsh, although at times bathed with
a cold, exhausting perspiration, the odor of which is oftentimes very
offensive. A morphia or opium taker, previously ill-nourished, sometimes
seems to improve, taking on flesh rapidly. The appearance, often best seen
in the face, is very deceptive, and is, in the majority of instances, due
to slight dropsy. It is sometimes seen a few weeks after these patients
commence to use alcoholic stimulants, especially beer. It soon passes
away, leaving them looking thinner and more miserable than before.
In those cases where the habit has not progressed very far, the skin is
usually made redder and coarser than natural, and is dotted here and there
with pustules.
In one case that I have recently had under my care, that of a young lady
who had never used stimulants and who had only used morphia, and that
subcutaneously, for seventeen months, a swollen and reddened condition of
the nose, exactly like that seen in old drunkards, was present. Two weeks
after the morphine was stopped the nose began to lessen in size and the
color to disappear, and the condition was entirely cured at the end of
three weeks. No local applications were used.
Loss of elasticity of the skin is a common change. That nutrition is
seriously interfered with is seen by this alteration, the loss of adipose
tissue, the ill-balanced circulation, giving at one time coldness
and paleness, at another flushing and undue warmth, and the variable
secretion. A plump and well nourished person who commences the use of
morphia loses those outlines of health caused by the proper development of
the muscular system and normal distribution of fat beneath the skin. Face
and form are both changed, and certainly for the worse.
These changes are undoubtedly due to a double action of morphine; that on
the alimentary canal preventing the proper digestion and assimilation of
food, and that upon the nerves regulating the supply of blood that passes
to the skin.
Eruptions after a time appear upon various parts of the body, more
especially the face, chest and back. They are usually pustular, with
hard, indurated bases; sometimes papular. Herpes zoster or “shingles” is
occasionally produced, and is attended by most intolerable itching; less
often purpura hemorrhagica. In the case of the literary gentleman already
spoken of this was present, as was also bleeding from the kidneys. When
it does occur the system must be in a greatly exhausted and the blood in
a very poor condition, a condition which it usually takes a long time or
large doses of the drug to produce.
Another symptom dependent on disordered nutrition of the skin is the rapid
or slow falling of the hair that occurs in some patients. However much
hair restorers and scalp tonics may be used in these cases, the hair, once
having commenced to fall, will continue to do so until the general health
improves. When the drug has been stopped a free falling out of the hair
occurs, followed by a new and luxuriant growth. Indeed, sweeping out and
rebuilding seems to be the rule in every tissue. Change in color of the
hair has been noted in some cases.
Those affections of the skin due to the use of dirty solutions and unclean
needles when the drug is given subcutaneously will be spoken of fully
presently.
Sensation is variously altered. Sometimes there is a condition of
hyperæsthesia, the least touch being intensely painful, the contact of
the clothing causing decided irritation. Occasionally a whole limb or
part of a limb or portions of the trunk or face will feel “numb or dead.”
Sometimes there are a series of pricking or tickling sensations that
are very aggravating, as they and the numbness are often looked upon
by patients as precursors of paralysis. Sensitiveness to cold is often
extreme. This and the very hard clay-colored stools are also seen in
saccharine diabetes, and in every case where I have noted them sugar was
found in greater or less quantity in the urine of the patient. What the
connection is I cannot say, but it is worthy of further study.
THE SEXUAL ORGANS.
The continued use of opium or morphine has a decided effect upon the
sexual apparatus. One of the first changes to be noticed in women
is scantiness, then irregularity, and finally, total cessation of
menstruation. In some cases an occasional period is observed, but
as a rule, the stopping is decided and permanent until the habit is
abandoned. Occasionally menstruation occurs when a change is made from one
preparation to another, or from one mode of administering to another.
In one of my patients, not under treatment for that, but still an habituè,
menstruation showed itself, after a three years’ cessation, on changing
from the use of laudanum by the mouth to morphine by the skin. It
occurred, however, but the once.
In the case of the young married lady already referred to, when a
change was made from subcutaneous to rectal injections the flow was
re-established and showed itself, although irregularly, for nearly a year.
Levenstein, who has made some interesting and valuable researches and
experiments upon this matter, believes that this abnormal menopause is due
to the inactivity of the ovaries. He says:—
“According to Pflueger’s theory, in cases of amenorrhœa due to morbid
craving for morphia, the growth of the ovarian cells would be stopped from
one monthly period to another, and consequently there would be a want of
stimulus on the ovarian nerves, causing on the one hand the rupture of
Graaf’s follicles, and producing, on the other hand, a congested state
of the generative organs by reflex action. Hence, the morphia would act
in the same manner on the ovaries as on other secreting glands, _i. e._,
would render them devoid of function under its continued influence. It
is likely, therefore, that the menstrual discharge does not show on
account of no ovulation taking place; this also would account for the
sterility.”[5]
Accompanying this condition of non-menstruation there is always sterility.
That this is due to the habitual use of morphia is proven by the fact that
these women have borne a child or children before the use of the drug was
commenced, and have again become pregnant and gone to full term after the
habit was abandoned. So long, however, as menstruation does occur, there
is a possibility of the woman’s becoming pregnant.
In the majority of instances sensation is finally lost, although it is
usually increased during the first few months’ use of the drug. A patient
of mine, a lady who had used morphine by the mouth for sixteen years,
found her virile power during and at the end of that time in no way
impaired. If anything, it was increased. Her dose of morphine was ten
grains. She had not menstruated for a long time. This was the only case
in which I tried Levenstein’s plan of at once stopping the drug, and I
shall certainly never try it again.
With the suppression of the menstruation, there sometimes come the usual
symptoms attending the suppression of this function in non-habituès.
Levenstein states that ladies suffering from leucorrhœa are often cured of
this complaint by the habitual use of morphia; the discharge returning,
however, as soon as the habit is broken, and causing labor-like pains.
Certain it is that most female patients, on breaking the habit, suffer
from a severe leucorrhœa, whether or not they had such a discharge
previous to commencing the use of the drug. One of my lady patients who
used six grains a day, subcutaneously, had a leucorrhœal discharge before
she began the use of morphia, and upon which a four years’ habituation
had no curative or modifying effect. As soon, however, as the habit was
broken, the discharge increased greatly in quantity, and changed in
character, becoming more tenacious.
Spasmodic closure of the mouth of the vagina on attempting to introduce
the finger or a speculum, I have noticed in two cases. It, also, readily
passes away after the use of morphia is abandoned.
A woman becoming pregnant in the early course of her addiction to this
habit will, in the majority of cases, abort before reaching full term,
especially if the amount used is large. Levenstein has noted the fact that
wives of men addicted to the habitual use of this drug in large doses had
in the last two years never carried children to full term, although young,
healthy, and having borne children before the husband became an habituè.
There is no question in my mind but that the excessive use of this drug
by one or both parents, but especially the mother, in case she is able to
carry her child to full term, will modify disadvantageously the physical,
mental, or moral development of the child thus born. A physician from the
South tells me of the case of a lady who commenced the use of opium at the
beginning of her pregnancy. She was delivered of a fair-sized child that
grew up in fair, though not robust health, and menstruated at the proper
age. She is, however, very simple and childish, still plays with dolls,
although a young lady, is very eccentric, and shuns the society of young
men. The mother, who is still living, ceased to menstruate at the age of
30 and has never menstruated since, some twenty years. For the past two or
three years she has been using sixty grains of gum opium daily.
Dr. Alonzo Calkins[6] relates several cases where the children of such
parents were either physically or intellectually deficient. I give but
one of them: “At an inquest held by Dr. Macnish it appeared that a child
five years of age, though to appearance only so many weeks old, had never
been able to walk, nor so much as utter an articulate sound. The mother,
during her gestation (as was in evidence), had taken to morphine, using a
drachm a day in the months just preceding her demise. A child born before
the habit had become fixed showed a normal development and the aspect of
general health.” Another case is related where both parents were “healthy
and robust by original constitution and by habits of life too, with the
exception that the woman had, for a very considerable period, been in
the practice of using morphine regularly and to great excess. An infant
born subject to the liabilities, had only a very imperfect physical
organization, with weak intellectual indications.”
By carefully conducted experiments on animals (pregnant dogs and
rabbits), Levenstein found that the continued use of morphia invariably
produced abortion, the fœtus being born dead.
With the cessation of the menses the breasts usually dwindle in size, and
the voice attains a more masculine tone.
In man the first indication of an effect on the sexual organs is
increased desire; this, however, giving way sooner or later to partial
or total impotence. The fact, noted by Levenstein, regarding the rarity
of conception and parturition in the wives of habituès, has already been
spoken of. If the amount of opium or morphine used is small, impotence
may not come for a number of years. The power of partial or full
erection, without emission, is preserved by some. In those cases where
there is inability to impregnate the female, there undoubtedly exists a
deterioration of the functional power of the testes. In one case which I
saw the testicles were markedly atrophied. In two cases I was fortunate
to be able to examine the seminal fluid, a few days after the habit had
been broken. These patients, as is usual on recovery, were troubled with
erections and nocturnal emissions. In both instances the zoosperms were
small, and present in less than the normal quantity. In one case, where it
was possible, owing to the patient’s having been previously instructed, I
was able to examine this fluid once or twice weekly for nearly two months.
Each succeeding examination showed a larger number of zoosperms, each
sample apparently better developed than the preceding.
Even large doses sometimes fail to produce impotence. One young man,
twenty-five years of age, who has been taking, subcutaneously, ten grains
of morphia, for over three years, is a confirmed masturbator, and seems to
have frequent emissions.