menstrual function. Menstrual irregularity, both as regards time and
amount, is succeeded after a time by amenorrhœa. Vicarious hemorrhages
do not occur. Complete amenorrhœa is sometimes established abruptly,
and married women not infrequently suspect for this reason that they
have conceived. In several cases of this kind under the observation of
the writer the absence of enlargement of the breasts, of alteration of
the areola, and of softening of the os after several months, indicated
the improbability of these fears, notwithstanding the irregular
appetite, the morning vomiting, the occasional palpitations and
faintness, the hysterical condition, and the mental peculiarities of
the individuals—phenomena unquestionably due to the action of the
morphine itself. The amenorrhœa of the morphine habit is associated
with sterility—a fact that renders probable the supposition that it is
dependent upon absence of ovulation. Women addicted to the opium habit
are capable of conceiving so long as menstruation persists, those
only, however, going to full term who use very moderate quantities. In
women using large doses abortion invariably occurs. The functional
integrity of the reproductive system is re-established upon the
permanent cessation of the habit. Women who are cured may again
menstruate regularly and may again bear children. Morphine in women,
as in men, is said to increase, when first habitually taken, the
capacity for sexual pleasure.
Levinstein and others have described certain febrile conditions
observed in individuals addicted to morphine. First, a form of
intermittent fever closely resembling malarial fever. This fever of
intermittent type occurs in individuals neither living in malarious
regions nor previously exposed to malaria. In addition to periodicity,
it presents other points of resemblance to malarial intermittent. The
earlier paroxysms cease after the {657} administration of quinine.
They are favorably influenced by change of residence, and recur with
intensity after over-exertion, exposure, and upon the occurrence of
acute maladies. The favorable influence of quinine is only transient;
the febrile paroxysms recur after a time, notwithstanding the
continued use of the medicament. This fever disappears without special
treatment upon the discontinuance of the habit. It is more frequently
of the tertian than of the quotidian type. Its paroxysms are marked by
the symptoms of paludal intermittent. Neuralgias of various kinds,
especially supraorbital, intercostal, and præcordial neuralgias, are
apt to occur. The temperature during the paroxysm ranges from 102.5°
to 104°. The area of splenic dulness is increased. More or less mental
and physical depression follows the paroxysm, continuing in most cases
through the period of apyrexia. These observations require further
confirmation. Secondly, confirmed opium-habitués are peculiarly liable
to transient febrile disturbances from slight causes. Finally,
ephemeral fever, ushered in by chills or rigors and accompanied by
headache, vertigo, thirst, malaise, restlessness, and even mild
delirium, and terminating with profuse perspiration, occasionally
occurs immediately after the injection of large doses of morphine.
The course of the opium habit, when once established, is,
notwithstanding its occasional transient interruptions, gradual and
progressive. Certain individuals endure enormous doses of opium or
morphine for years without serious symptoms. In others moderate doses
give rise in the course of a few months to anorexia, disturbances of
nutrition, neuralgias, fitful and difficult sleep, and serious mental
derangement. These symptoms are usually controlled by increasing doses
and diminution of the intervals. Finally, however, the drug fails to
produce either excitement or repose, and enormous doses are taken with
but insignificant relief. This is the period of grave derangement of
the mental and physical functions and of nutrition amounting to a true
dyscrasia. The phenomena are analogous to those produced by the
withdrawal of the dose. They are the symptoms of inanition, which in
the absence of well-directed and energetic treatment speedily
terminates in death.
II. Symptoms Due to the Withdrawal of the Drug.—Opium-habitués,
differing as they do among themselves in the manifestations of the
effects of the drug so long as it is freely taken, all alike develop
characteristic symptoms upon its speedy or gradual withdrawal. The
apparent immunity exceptionally observed now comes to an abrupt
termination. The nervous system, whether it has been accustomed for
months merely or for years to the influence of opiates, is upon their
withdrawal forthwith thrown into derangement of the most serious and
widespread kind. In the course of a few hours after the last dose the
steadying influence of the drug disappears. General malaise is
associated with progressive restlessness; the ability to perform the
ordinary duties of life gives way to profound depression and
indifference; præcordial distress, accompanied by cough, is followed
by insomnia, hallucinations, and sometimes by mania. The habitual
pallor of the face is replaced by deep flushing or cyanosis. The
heart's action becomes excited and irregular, then feeble; the pulse,
at first tense, becomes slow, thready, and irregular. Colliquative
sweats appear. Attacks of yawning and sneezing are followed by
convulsive twitching and trembling of the hands. Speech becomes
hesitating, drawling, and {658} stuttering. Troubles of the
accommodation and even diplopia occur, often accompanied by excessive
lachrymation. Transient and varying differences in the pupils are very
frequent. Retinal hyperæsthesia may occur. In the amblyopia
occasionally observed in subjects of the opium habit the
ophthalmoscope reveals persistent anæmia of the retina. These
phenomena are associated with a sense of perfect prostration which
obliges the patient to take himself to his bed. Pain in the back and
limbs, followed by neuralgias, now occurs. Complete anorexia, with
easily-provoked or even causeless vomiting and persistent nausea and
diarrhœa difficult to control, adds to the gravity of the condition.
The abrupt discontinuance of the drug is followed in many individuals
by mental phenomena of a marked character: hallucinations, illusions,
and delirium continue for several days. The hallucinations relate to
all of the senses, but especially to those of sight and hearing. The
sense of smell is also occasionally affected, that of taste rarely.
Syncopal attacks occur. These are usually transient; occasionally,
however, profound syncope calls for the active interference of the
physician. Epileptiform seizures also take place. Women who have
previously suffered from hystero-epilepsy are prone to the recurrence
of severe paroxysms. Trembling of the limbs, and especially of the
lower extremities, rhythmical in time and often violent, must be
ranked among the more characteristic phenomena produced by the
abstinence from the drug. Sweating, although by no means constant, is
among the earlier and more persistent phenomena. Urticaria occurs.
Dyspnœa is common. Sometimes it is provoked by exertion; sometimes
paroxysmal shortness of breath occurs spontaneously. Irritable cough
is frequent. It is in many cases unattended by râles. Pre-existing
bronchitis is of course accompanied by its characteristic signs and
symptoms. Præcordial distress, with palpitation and a sense of
oppression, is common. During the earlier days of abstinence the
evidences of cardiac failure are marked. Enfeeblement of the first
sound, irregularity of the heart's action, and intermission are
common. The pulse phenomena correspond to the heart's action. Thirst
is a very frequent symptom. It is often out of proportion to the loss
of fluid by perspiration and diarrhœa. The urine does not contain
sugar. Salivation is rare and of moderate degree. Nausea is
persistent. Œsophageal spasm, provoked by every effort to swallow,
occasionally occurs and constitutes a distressing symptom. Many
patients also complain of spasmodic contraction of the anus. Neuralgia
of the testicles also occurs. The cure of the opium habit is followed
by rehabilitation of the sexual power in the male and by menstrual
regularity and fecundity in the female. Levinstein has observed sexual
hyperæsthesia during the first weeks of abstinence in both sexes.
Albuminuria occurs in a large proportion of the cases. The albumen
shows itself, as a rule, from the third to the sixth day after the
discontinuance of the morphine, and disappears in the course of a very
few days. It is usually of slight amount.
The behavior of patients undergoing the suffering attendant upon the
abrupt, or even the gradual, withdrawal of the drug is variable. It
depends upon the mental and physical organization of the different
individuals and upon their ability to endure pain. Some rest quietly
in bed, enduring with fortitude suffering from which there is no
escape; others, silent, uncomplaining, and apathetic, present the
{659} appearance of utter despair; a few, more fortunate than their
fellows, lapse into a condition of almost continuous drowsiness. In
the greater number of cases, however, these states of repose are but
momentary or absent altogether. Restlessness is continuous, and very
often intense; the patients are with difficulty kept in bed; if left
to themselves they move frantically about the room, moaning, bewailing
their condition, and begging the attendants for that which alone is
capable of relieving their distress. This condition gradually
subsides, giving way to a state of the most profound exhaustion. The
exhaustion due to the reaction of the nervous system deprived of the
stimulus of the drug is, on the one hand, favored by pre-existent
derangement of the nutritive processes, and on the other increased by
the pain, wakefulness, diarrhœa, and vomiting which accompany it. The
appearance of the patient is now most pitiable; the countenance is
blanched and pinched, the body occasionally drenched with sweat; the
heart's action is feeble, and the pulse thready and irregular. This
condition of collapse is usually of short duration, disappearing in
favorable cases under the influence of appropriate nourishment
administered in small quantities and with regularity. Where, however,
the gastric irritability is unmanageable, an increasing tendency to
collapse may threaten life. In rare cases suddenly-developed fatal
collapse has occurred at a later period in the treatment, even after
the patient has become able to take and retain food. The restlessness
does not, however, always subside in this manner. In a considerable
proportion of cases it increases. Hallucinations and delusions occur,
and a condition of delirium tremens, scarcely differing from the
delirium tremens of chronic alcoholism, is established. Tremor is a
constant phenomenon of this condition. Sometimes the gravest symptoms
of the suppression of the drug are developed with great rapidity.
Jouet relates a case of a patient at the Salpêtrière who during a
temporary absence from the hospital forgot her syringe and solution;
her return being delayed from some cause, she, notwithstanding her
struggles against the symptoms caused by the want of her habitual
dose, suddenly fell in the street, her countenance haggard and
anxious, her hands shrivelled, and her whole body bathed in drenching
sweat. She immediately became maniacal, and demolished the glass and
lamps of the coupé in which she was taken to the hospital. No sooner
had she received her ordinary hypodermic dose than she recovered her
usual quietude. This patient was neither hysterical nor had she
previously suffered from nervous paroxysms. She was, however,
accustomed to administer to herself at four o'clock every day a large
hypodermic dose of morphine, and it was at a few minutes past four
that the above-described seizure occurred.
DIAGNOSIS.—The diagnosis of the opium habit is in many cases attended
with considerable difficulty. Many habitués, it is true, do not
hesitate to admit the real cause of their symptoms; others, while
seeking to conceal it, do so in such an indifferent manner that
detection is not difficult; but the greater number for a long time
sedulously conceal their passion, not only from their friends, but
also from the physician whom they consult voluntarily or at the
solicitation of those interested in them. If inquiries be made upon
the subject, they deny the habit altogether, often with vehement
protestations. If forced to admit it, they are very apt to misstate
the amount employed or the frequency of the repetition of the dose. As
a rule—to which there are, however, not infrequent {660}
exceptions—emaciation is marked, appetite is diminished and variable,
the pulse is small, the circulation feeble, the respiration shallow
and occasionally interrupted by long-drawn sighs, the pupils are as a
rule contracted, constipation is present, often alternating with
diarrhœa. When to these conditions, for which no cause can be found
upon careful examination, there are added marked change in
disposition, periods of unaccountable dulness and apathy alternating
with unusual vivacity and brightness, especially when insomnia
alternates with periods of prolonged and heavy sleep, the abuse of
morphia may be suspected. If the hypodermic syringe be used the wounds
made by the needle confirm the diagnosis. These punctures are usually
found in groups upon the thighs, legs, arms, and abdomen. Close
inquiry into the habits of the patient, who either goes himself or
sends at short intervals for unusual quantities of opium or morphia to
some neighboring apothecary, is sometimes necessary to confirm the
diagnosis. Finally, the presence of morphine in the urine[10] renders
the diagnosis positive, notwithstanding the most vehement assertions
of the patient as regards his innocence of the habit and the extreme
cunning with which it is concealed.
[Footnote 10: “According to Bouchardat, morphine, when taken in the
free state or under the form of opium, speedily appears in the urine,
and may be detected by the liquid yielding a reddish-brown precipitate
with a solution of iodine in iodide of potassium. Since, however, as
we have already seen, this reagent also produces similar precipitates
with most of the other alkalies and with certain other organic
substances, this reaction in itself could by no means be regarded as
direct proof of the presence of the alkaloid. Moreover, we find that
the reagent not unfrequently throws down a precipitate from what may
be regarded as normal urine, while, on the other hand, it sometimes
fails to produce a precipitate even when comparatively large
quantities of the alkaloid have been purposely added to the liquid”
(Wormley, _Micro-chemistry of Poisons_).
The presence of meconic acid or morphine in the urine can only be
positively determined by elaborate chemical analysis. In cases of
doubt the urine should be submitted to a competent analyst. To make
sure that opium or its derivatives are not being taken, the feces must
also be examined.]
PROGNOSIS.—The prognosis is favorable as regards the discontinuance of
the habit for a time, doubtful as regards a permanent cure. Relapses
are apt to occur. They are more common in men than in women, in the
aged than in middle life, and in persons of feeble physical and mental
organization than in those who are possessed of bodily and mental
vigor. Relapses also occur more frequently in those individuals
addicted to alcohol, and in those who are habitually subjected to
temptation by reason of their avocation, such as doctors, nurses, and
apothecaries, than in others. The danger of relapse is greater where
the habit has been formed in consequence of chronic painful affections
than where it has been rapidly developed in the course of acute
illnesses. Of 82 men treated by Levinstein, relapses occurred in 61;
of 28 women, in 10; of 38 physicians, in 26. The danger of relapse
diminishes with the lapse of time; nevertheless, a single dose of
morphine or a hypodermic injection may, after an abstinence of months,
precipitate a relapse. Indeed, the return of the habit is in the
majority of instances caused by the thoughtlessness of medical men in
prescribing in these cases opiates for maladies which are often in
themselves insignificant.
Chloral Hydrate.
The prediction made by B. W. Richardson, within two years of
Liebreich's announcement of the medicinal properties of chloral, that
its {661} abuse would become widespread, has been abundantly
fulfilled. The consumption of this substance as a narcotic has reached
an extent in certain classes of society which raises it, after alcohol
and opium, to the third place among such agents.
SYNONYMS.—The Chloral habit, Chloralism.
ETIOLOGY.—_A_. Predisposing Influences.—Age exerts but little
predisposing influence. Cases occur almost exclusively in adults, and
the greater proportion of these are in middle life. The abuse of
chloral is relatively somewhat more common among males than among
females. Individuals addicted to this habit usually belong to the
refined and educated classes of society; the fascinations of chloral
remain thus far unknown to the great mass of the people. Professional
men and those engaged in literary work form a very considerable
proportion of the cases. Chloral is occasionally used by hospital
nurses, and very frequently by prostitutes. Chronic alcoholism is an
important predisposing element in the formation of the chloral habit;
in fact, morbid conditions attended by insomnia from whatever cause
tend to the formation of this habit.
_B_. The Exciting Cause.—Chloral is a powerful hypnotic, usually
without unpleasant after-effects. In full doses it is a depressant to
the nerve-centres at the base of the brain and to the spinal cord. It
enfeebles the action of the heart, depresses respiration, and lessens
reflex activity. It has no action on the secretions except that of the
kidneys, which it frequently augments.
The habit has in some few instances been developed in consequence of
the indulgence in a morbid desire to experience the effects of the
drug. In a majority of instances it is due to the continuance of the
medicine indefinitely after the sickness in which it was originally
prescribed has ceased. I have known apothecaries to renew
prescriptions of chloral often enough to supply a daily dose of from
forty to sixty grains for years—in one instance for more than four
years.
The dose taken by victims of the chloral habit varies greatly. Thirty
or forty grains daily is a moderate amount. Not rarely this quantity
is repeated twice or oftener within the space of twenty-four hours.
The tolerance after a time exhibited by the organism for enormous
doses of alcohol and opium is not established, as a rule, in regard to
chloral. The victim of the latter after a little time discovers the
average dose required to produce narcotic effects, and, while he may
vary it within limits, he is liable to acute toxic effects if it be
greatly exceeded. Death from such excesses is not uncommon.
SYMPTOMATOLOGY.—I. Symptoms Due to Habitual Excesses.—The habitual use
of chloral, notwithstanding its ruinous consequences in a certain
proportion of the cases, is less dangerous than that of opium or
morphine. Many individuals take chloral in considerable doses for
years without obvious ill effect. The craving for it is much less
intense than that for opium or morphine, and is readily satisfied by
other drugs. In point of fact, persons addicted to chloral very
frequently exchange it for other narcotics. For these reasons the
chloral habit is more easily cured.
Derangements of the digestive system are common, but by no means
constant. They are (1) primary, and due to the direct irritant action
of the drug upon the mucous tissues of the month and stomach; and (2)
secondary, due to its effects upon the nervous system and the
circulation. {662} Irritation of the mucous membranes is very common.
This not rarely amounts to gastro-duodenal catarrh with its
characteristic symptoms. Jaundice is common, sometimes intense. A
sense of fulness with pain and tenderness in the hepatic region is
frequent. Constipation, with clay-colored stools, is the rule. It
occasionally alternates with diarrhœa. The tongue is often coated and
the breath foul. On the other hand, in a fair proportion of the cases
the digestive organs are not affected. Chloral has been said to
occasionally exert even a favorable influence upon appetite and
digestion when taken before meals. The recent observations of Fiumi
and Favrat[11] in a man suffering from a gastric fistula and insomnia
have shown that chloral hydrate in twenty- or forty-grain doses,
administered before or at the beginning of a meal, retarded digestion
by increasing the secretion of mucus in the stomach. The acidity of
the gastric juice is diminished temporarily. The secretion of pepsin
is not changed. Taken two hours after meals, doses not exceeding forty
grains caused no derangement of gastric digestion.
[Footnote 11: _Archives Ital. de Bioloqie_, vol. vi. No. 3.]
Persons not habituated to chloral usually experience a sense of
constriction upon swallowing it, and a disagreeable after-taste.
The circulation is much affected. Chloral weakens, and finally
paralyzes, the vaso-motor centre, and thus dilates the vessels; it at
the same time weakens the action of the heart. Its habitual use is
attended by flushing of the face, congestion of the eyes, and fulness
of the head. The heart's action is weak, intermittent, irregular;
palpitation occurs; the pulse is full and compressible or small and
weak. It is usually slow.
The blood undergoes changes corresponding to the general disturbances
of nutrition. What the special changes in its composition may be is
not known. Many of the cases, even after the prolonged use of the drug
in considerable doses, show few evidences of malnutrition or of
anæmia. In the greater number, however, wasting is marked, and the
physical signs and rational symptoms of profound anæmia are present.
Deterioration in the composition of the blood is further indicated by
petechiæ, hemorrhage from mucous surfaces, sponginess of the gums, and
serous effusions.
The respiration is not permanently affected, save in grave cases. It
is then slow, irregular, and shallow. Dyspnœa is common and easily
provoked. It is usually accompanied by cough and abundant frothy
expectoration. These symptoms vanish upon the discontinuance of the
drug. In a fatal case of chloral-poisoning seen by the writer, in
which the daily use of the narcotic in non-poisonous amounts had been
for a long time varied at intervals of five or six weeks by doses
sufficient to induce prolonged coma, death was preceded by
Cheyne-Stokes respiration. This patient was a retired dentist, and
kept the solution of chloral in a large unlabelled bottle. The actual
doses taken were not ascertained.
The muscular system shares in the general malnutrition. The muscles
become flabby and wasted. Persons addicted to chloral are very
frequently of nervous organization and sedentary habits, and hence of
poor muscular development prior to the use of the drug.
The kidneys show no constant derangement. In a certain proportion of
the cases chloral acts as a diuretic, largely increasing the urinary
excretion. Albumen is present in a certain proportion of the graver
{663} cases, when it is apt to be associated with anæmia, serous
effusions, and a tendency to hemorrhages from mucous tracts. The
occurrence of casts and the persistence of albuminuria after the
discontinuance of chloral suggest an antecedent or coincidently
developed nephritis. The reducing substance present in the urine after
small doses of chloral is uro-chloralic acid (Mering and Musulus). It
gives the reaction of sugar with the copper and bismuth tests, but is
levogyrate. Glycosuria is occasionally encountered.
Vesical and urethral irritation occurs in a small proportion of the
cases. When these symptoms vanish upon the discontinuance of the drug
and recur upon its resumption, it may be fairly assumed that they are
due to its action. A great number of morbid phenomena relating to the
genito-urinary tract and to the urine, that have been ascribed to the
action of chloral in those addicted to its use, are due to associated
conditions rather than to the drug itself.
It has been claimed upon evidence that does not appear to the writer
adequate that chloral sometimes acts upon the sexual system as an
aphrodisiac, sometimes as the reverse. More or less complete
impairment of sexual power and appetite is the rule in individuals
addicted to great excesses in narcotics of all kinds. Menstruation is
not arrested by chloral as by morphine, nor does it necessarily cause
sterility in the female.