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.
The voluptuous play of the imagination ascribed to the action of the
drug by Orientals is for the most part absent among opium-takers in
this country. If present at all, it occurs only to a limited degree.
The corresponding fact is also worthy of note—namely, so long as the
habit is continued the depression between the doses is less profound
than that described as occurring in the East. One of the mental
peculiarities of individuals addicted to the opium habit is
secretiveness concerning their vice. Not infrequently, the real cause
of the grave derangements of health thus produced is wholly
unsuspected by the family or friends of the patient. When the habit is
suspected or admitted, the amount and frequency of the dose are rarely
fully known, patients almost invariably deceiving their friends in
regard to the particulars of their indulgence. Individuals above
reproach in other matters, and previously of unquestioned veracity,
lie without any hesitation in this matter. A patient under my care who
had secreted in her room a quantity of morphine when about to undergo
treatment, denied either having taken or then having {656} in her
possession any opium or morphine whatever, using the expression, “I
call God to witness that I neither now have, nor have had since I
began the treatment, any preparation of opium or morphine whatever.”
Within ten minutes sixty quarter-grain pills of morphine were
discovered secreted under the bolster. This patient was a devout,
refined, and, in regard to other matters, a trustworthy person.
The functions of the reproductive organs both in the male and in the
female are seriously deranged. In the male sex enfeeblement of the
sexual function is manifested in all degrees, even to complete loss of
sexual desire and sexual power. In certain individuals opium and
morphine in moderate doses produce some increase of sexual desire and
power, which is, however, speedily lost on the continuance of the
habit. Some doubt exists whether this is of psychical or physical
origin—a question at once difficult to decide by reason of the
reticence of opium-habitués upon this subject, and unimportant in
itself. Levinstein makes the interesting statement that in no cases
coming under his observation did the wives of morphomaniacs who had
injected as high as fifteen grains of morphine a day reach the full
term of pregnancy for two years prior to the treatment,
notwithstanding the fact that they were still young, that they had
borne children before their husbands had become addicted to morphine,
and that they had not, up to the time of the formation of the habit by
their husbands, suffered from premature accouchements.