equivalent of the first question. I have found an absolutely incurable
opium-eater who had never used more than ten grains of morphia _per
diem;_ but he had been taking it habitually for a dozen years. In
another case the patient had for six months repeated before each meal
the ten-grain dose which served the other all day; but he was a man
whose pluck under pain equalled that of a woman's, and after a
fortnight's anguish of such horror that one could scarcely witness it
without being moved to tears, came out into perfect freedom. The
former patient, although he had never in any one day experienced such
powerful effects from opium as the latter, had used the drug so long
that every part of his system had reconstructed itself to meet the
abnormal conditions, and must go through a second process of
reconstruction, without any anodyne to mask the pain resulting from
its decomposition, before it could again tolerate existence of the
normal kind. If opium were not an anodyne the terrible structural
changes which it works would cause no surprise; it would be _felt_
eating out its victim's life like so much nitric acid. During the
early part of the opium-eater's career these structural changes go on
with a rapidity which partly accounts for the vast disengagements of
nervous force, the exhilaration, the endurance of effort, which
characterize this stage, later to be substituted by utter nervous
apathy. By the time the substitution occurs something has taken place
throughout the physical structure which may be rudely likened to the
final equilibrium of a neutral salt after the effervescence between an
acid and an alkali. So to speak, the tissues have now combined with
their full equivalent of all the poisonous alkaloids in opium. Further
use of it produces no new disengagements of nervous force; the victim
may double, quadruple his dose, but he might as well expect further
ebullition by adding more aqua-fortis to a satisfied nitrate as to
develop with opium exhilarating currents in a tissue whose combination
with that drug have already reached their chemical limit. [Footnote: I
say "chemical" because so much it is possible to know experimentally;
and the very interesting examination of such higher forces as
constantly seem to intrude in any nervous disturbance would here
involve the discussion of a theoretical "vital principle"--something
apart from and between the soul and physical activities--which
scientific men are universally abandoning.]
The opium-eater now only continues his habit to preserve the terrible
static condition to which it has reduced him, and to prevent that yet
more terrible dynamic condition into which he comes with every
disturbance of equilibrium; a condition of energetic and agonizing
dissolutions which must last until every fibre of wrongly-changed
tissue is burned up and healthily replaced. Though I have called the
early reactions of opium rapid, they are necessarily much less so than
those produced by a simple chemical agent. No drug approaches it in
the possession of _cumulative_ characteristics; its dependence on
the time element must therefore be always carefully considered in
treating a case. This fact leads us to understand the other element in
the question, how long the torments of the opium-fighter must
continue. Having ascertained the chronology of his case, we must say,
"Given this period of subjection, has the patient enough
constitutional vigor left to endure the period of reconstruction which
must correspond to it?" [Footnote: Not correspond day by day. At that
rate a reforming opium-eater (I use the principle in the
_physical_ sense, for very few opium-eaters are more to blame
than any other sick persons) must pay a "shent per shent" which no
constitution could survive. The correspondence is simply
proportional.]
I am naturally sanguine, and began my study of opium-eaters with the
belief that none of them were hopeless. Experience has taught me that
there is a point beyond which any constitution--especially one so
abnormally sensitive as the opium-eater's--can not endure keen
physical suffering without death from spinal exhaustion. I once heard
the eminent Dr. Stevens say that he made it a rule never to attempt a
surgical operation if it must consume more than an hour. Similarly, I
have come to the conclusion never to amputate a man from his
opium-self if the agony must last longer than three months.
Uneasiness, corresponding to the irritations of dressing a stump--may
continue a year longer; a few victims of the habit outlive a certain
opium-prurience, which has also its analogue in the occasional
titillation of a healed wound--these are comparatively tolerable; but,
if we expect to save a patient's life, we must not protract an agony
which so absolutely interferes with normal sleep as that of the
opium-eater's for longer than three months in the case of any
constitution I have thus far encountered.
Usually as early as the third day after its abandonment (unless the
constituion has become so impaired by long habituation that there will
probably be no vital reaction) opium begins to show its dissolutions
from the tissue by a profuse and increasingly acrid bilious diarrhea,
which must not be checked if diagnosis has revealed sufficient
constitutional vigor to justify any attempt at abandonment of the
drug. Hemorrhoids may result; they must be topically treated; mild
astringents may be used when the tendency seems getting out of
eventual control; bland foods must be given as often as the usually
fastidious appetite will tolerate them; the only tonic must be
beef-tea--diffusible stimulus invariably increasing the agony, whether
in the form of ale, wine, or spirits. Short of threatened collapse,
the bowels must not be retarded. There is nothing in the faintest
degree resembling a substitute for opium, but from time to time
various alleviatives, which can not be discussed in an untechnical
article, may be administered with benefit. The spontaneous termination
of the diarrhea will indicate that the effete matters we must remove
have been mainly eliminated, and that we may shortly look for a marked
mitigation of the pain, followed by conditions of great debility but
increasingly favorable to the process of reconstruction. That
process, yet more than the alleviate, demands a book rather than an
article.
I have intentionally deferred any description of the agony of the
opium struggle, as a _sensation_, until I returned from depicting
general symptoms, to relate the particular case which is my text. The
sufferings of the patient, from whom I have just returned, are so
comprehensive as almost to be exhaustively typical.
When simple nervous excitement had for two days alternated with the
already mentioned intervals of delirious slumber, a dull, aching
sensation began manifesting itself between his shoulders and in the
region of the loins. Appetite for food had been failing since the
first denial of that for opium. The most intense gastric irritability
now appeared in the form of an aggravation of the tympanic tightness,
corrosive acid ructations, heart-burn, water-brash, and a peculiar
sensation, as painful as it is indescribable, of _self-consciousness_
in the whole upper part of the digestive canal. The best idea of this
last symptom may be found by supposing all the nerves of involuntary
motion which supply that tract with vitality, suddenly to be gifted
with the exquisite sensitiveness to their own processes which is
produced by its correlative object in some organ of special sense--the
whole organism assimilating itself to a retina or a finger-tip. Sleep
now disappeared. This initiated an entire month during which the
patient had not one moment of even partial unconciousness.
In less than a week from the beginning the symptoms indicated a most
obstinate chronic gastritis. There was a perpetual sense of corrosion
at the pit of the stomach very like that which characterizes the fatal
operation of arsenic. There was less action of the liver than usually
indicates a salvable case, and no irritation of the lowest
intestines. _Pari passu_ with the gastritic suffering, the neuralgic
pain spread down the extremities from an apparent centre between the
kidneys, through the trunk, from another line near the left margin of
the liver, and through the whole medullary substance of the brain
itself. Although I was so unfortunate as not to be beside him during
this stage, I can still infallibly draw on my whole experience for
information regarding the intensity of this pain. _Tic-douloureux_
most nearly resembles it in character. Like that agonizing affection,
it has periods of exacerbation; unlike it, it has no intervals of
continuous repose. Like _tic-douloureux_, its sensation is a curiously
fluctuating one, as if pain had been _fluidized_ and poured in
trickling streams through the tubules of nerve tissue which are
affected by it; but, unlike that, it affects every tubule in the human
body--not a single diseased locality. Charles Reade chaffs the doctors
very wittily in "Hard Cash" on their _penchant_ for the word
"_hyperaesthesia,"_ but nothing else exactly defines that exaggeration
of nervous sensibility which I have invariably seen in opium-eaters.
Some of them were hurt by an abrupt slight touch, and cried out at the
jar of a heavy footstep like a patient with acute rheumatism. Some
developed sensitiveness with the progress of expurgating the poison,
until their very hair and nails felt sore, and the whole surface of
the skin suffered from cold air or water like the lips of a
wound. After all, utterly unable to convey an idea of the _kind_ of
suffering, I must content myself by repeating, of its extent, that no
prolonged pain of any kind known to science can equal it. The totality
of the experience is only conceivable by adding this physical torture
to a mental anguish which even the Oriental pencil of De Quincey has
but feebly painted; an anguish which slays the will, yet leaves the
soul conscious of its murder; which utterly blots out hope, and either
paralyzes the reasoning faculties which might suggest encouragements,
or deadens the emotional nature to them as thoroughly as if they were
not perceived; an anguish, which sometimes includes just, but always a
vast amount of _unjust_ self-reproach, winch brings every failure and
inconsistency, every misfortune or sin of a man's life as clearly
before his face as on the day he was first mortified or degraded by
it--before his face, not in one terrible dream, which is once for all
over with sunrise, but as haunting ghosts, made out by the feverish
eyes of the soul down to the minutest detail of ghastliness, and never
leaving the side of the rack on which he lies for a moment of dark or
day-light, till sleep, at the end of a month, first drops out of
heaven on his agony.
A third element in the suffering must briefly be mentioned. It
results directly from the others. It is that exhaustion of nervous
power which invariably ensues on protracted pain of mind or body. It
proceeds beyond reaction to collapse in a hopeless case; it stops this
side of that in a salvable one.
On reaching his room I found my friend bolstered upright in bed, with
a small two-legged crutch at hand to prop his head on when he became
weary of the perpendicular position. This had been his attitude for
fifty days. Whether from its impeding his circulation, the
distribution of his nervous currents, or both, the prostrate posture
invariably brought on cessation of the heart--and the sense of
intolerable strangling. His note told me he was dying of heart
disease, but, as I expected, I found that malady merely simulated by
nervous symptoms, and the trouble purely functional. His food was
arrow-root or sago, and beef-tea. Of the vegetable preparation he took
perhaps half a dozen table-spoonfuls daily; of the animal variable
quantities, averaging half a pint per diem. This, though small, was
far from the minimum of nutriment upon which life has been supported
through the most critical periods. Indeed, I have known three patients
tided over stages of disease otherwise desperately typhoid by
_beef-tea baths_, in which the proportion of _ozmazone_ was
just perceptible, and the sole absorbing agency was a faint activity
left in the pores of the skin. But these patients had suffered no
absolute disorganization. The practitioner had to encounter a swift
specific poison, not to make over tissues abnormally misconstructed by
its long insidious action. On examination I discovered facts which I
had often feared, but never before absolutely recognized, in my
friend's case. The stomach itself, in its most irreproducible tissue,
had undergone a partial but permanent disorganization. The substance
of the organ itself had been altered in a way for which science knows
no remedy.
Hereafter, then, it can only be rechanged by that ultimate
decomposition which men call death. Over the opium-eater's coffin at
least, thank God! a wife and a sister can stop weeping and say, "He's
free."
I called to my friend's bedside a consultation of three physicians and
the most nearly related survivor of his family. I laid the case
before them; assisted them to a full _prognosis_; and invited
their views. I spent two nights with my friend. I have said that
during the first month of trial he had not a moment of even partial
unconsciousness. Since that time there had been perhaps ten occasions
a day, when for a period from one minute in length to five, his poor,
pain-wrinkled forehead sank on his crutch, his eyes fell shut, and to
outsiders he seemed asleep. But that which appeared sleep was
internally to him only one stupendous succession of horrors which
confusedly succeeded each other for apparent eternities of being, and
ended with some nameless catastrophe of woe or wickedness, in a waking
more fearful than the state volcanically ruptured by it. During the
nights I sat by him these occasional relaxations, as I learned,
reached their maximum length, my familiar presence acting as a
sedative, but from each of them he woke bathed in perspiration from
sole to crown; shivering under alternate flushes of chill and fever;
mentally confused to a degree which for half an hour rendered every
object in the room unnatural and terrible to him; with a nervous jerk,
which threw him quite out of bed, although in his waking state two men
were requisite to move him; and with a cry of agony as loud as any
under amputation.
The result of our consultation was a unanimous agreement not to press
the case further. Physicians have no business to consider the
speculative question, whether death without opium is preferable to
life with it. They are called to keep people on the earth. We were
convinced that to deprive the patient longer of opium would be to kill
him. This we had no right to do without his consent. He did not
consent, and I gave him five grains of morphia [Footnote: To the
younger men of the profession rather than to the public generally I
need here to say that this dose is not as excessive as it would
naturally appear to be in the case of a man who had used no form of
opium for ninety days. When you have to resume the drug, go
cautiously. But you will generally find the amount of it required to
produce the sedative effects in any case which returns to opium, after
abandonment of a long habitation, _startlingly large_, and
_slow in its effects_.] between 8 and 12 o'clock on the morning
of the day I had to return here. He was obliged to eat a few mouthfuls
of sago before the alkaloid could act upon his nervous system. I need
only point out the significance of this indication. The shallower-lying
nervous fibres of the stomach had become definitely paralyzed, and
such _digestion_ as could be perfected under these circumstances
was the only method of getting the stimulant in contact with any
excitable nerve-substance. In other words, mere absorbent and
assimulative tissue was all of him which for the purpose of receiving
opium partially survived disorganization of the superficial nerves. Of
that surviving tissue, one mucous patch was irredeemably gone. (This
particular fact was the one which cessation from opium more distinctly
unmasked.) At noon he had become tolerably comfortable; before I left
(7 P.M.) he had enjoyed a single half-hour of something like normal
slumber.
He will have to take opium all his life. Further struggle is
suicide. Death will probably occur at any rate not from an attack of
what we usually consider disease, but from the disintegrating effects
on tissue of the habit itself. So, whatever he may do, his organs
march to death. He will have to continue the habit which kills him
only because abandoning it kills him sooner; for self-murder has
dropped out of the purview of the moral faculties and become a mere
animal question of time. The only way left him to preserve his
intellectual faculties intact is to keep his future daily dose at the
tolerable minimum. Henceforth all his dreams of entire liberty must be
relegated to the world to come. He may be valuable as a monitor, but
in the executive uses of this mighty modern world henceforth he can
never share. Could the immortal soul find itself in a more
inextricable, a more _grisly_ complication?
In publishing his case I am not violating that Hippocratic vow which
protects the relations of patient and adviser; for, as I dropped my
friend's wasted hand and stepped to the threshold, he repeated a
request he had often made to me, saying:
"It is almost like Dives asking for a messenger to his brethren; but
tell them, tell _all young men,_ what it is, 'that they come not
into this torment.'"
Already perhaps--by the mere statement of the case--I might be
considered to have fulfilled my promise. But since monition often
consists as much in enlightenment as intimidation, let me be pardoned
for briefly presenting a few considerations regarding the action of
opium upon the human system while living, and the peculiar methods by
which the drug encompasses its death.
WHAT IS OPIUM?
It is the most complicated drug in the Pharmacopoeia. Though
apparently a simple gummy paste, it possesses a constitution which
analysis reveals to contain no less than 25 elements, each one of them
a compound by itself, and many of them among the most complex
compounds known to modern chemistry. Let me concisely mention these by
classes.
First, at least three earthy salts-the sulphates of lime, alumina, and
potassa. Second, two organic and one simpler acid--acetic (absolute
vinegar), meconic (one of the most powerful irritants which can be
applied to the intestines through the bile), and sulphuric. All these
exist uncombined in the gum, and free to work their will on the mucous
tissues.
A green extractive matter, which comes in all vegetal bodies developed
under sunlight, next deserves a place by itself, because it is one of
the few organic bodies of which no rational analysis has ever been
pretended. Though we can not state the constitution of this
chlorophyl, we know that, except by turning acid in the stomach, it
remains inert on the human system, as one might imagine would happen
if he swallowed a bunch of green grass. _Lignin_, with which it
is always associated, is mere woody fibre, and has no direct physical
action. In no instance has any stomach been found to _digest_ it
save an insect's--some naturalists thinking that certain beetles make
their horny wing-cases of that. I believe one man did think he had
discovered a solvent for it in the gastric juice of the beaver, but
that view is not widely entertained. So far as it exists in opium it
can only act as a foreign substance and a mechanical irritant to the
human bowels. Next come two inert, indigestible, and very similar
gummy bodies, _mucilagin and bassorine_. Sugar, a powerfully
active volatile principle, and a fixed oil (probably allied to
turpentine) are the only other invariable constituents of opium
belonging to the great organic group of the hydro-carbons.
I now come to a group by far the most important of all. Almost
without exception the vegetable poisons belong to what are called the
"nitrogenous alkaloids." Strychnia, brucia, ignatia, calabarin,
woovarin, atropin, digitalin, and many others, including all whose
effect is most tremendous upon the human system, are in this
group. Not without insight did the early discoverers call nitrogen
_azote_, "the foe to life." It so habitually exists in the things
our body finds most deadly that the tests for it are always the first
which occur to a chemist in the presence of any new organic poison.
The nitrogenous alkaloids owe the first part of their name to the fact
of containing this element; the second part to that of their usually
making neutral salts with acids, like an alkaline base. The general
reader may sometimes have asked himself why these alkaloids are
diversely written--as, e.g., sometimes "_morphia,_" and sometimes
"_morphine,_" The chemists who regard them as alkalies write them
in the one way, those who consider them neutrals, in the other. Of
these nitrogenous alkaloids, even the nuts of the tree, which
furnishes the most powerful, _swift_ poison of the world,
contains but three--the above-named strychnia, brucia, and
ignatia--principles shared in common with its pathological congener,
the St. Ignatius bean. Opium may be found to contain _twelve_ of
them; but as one of these (cotarnin) may be a product of distillation,
and the other (pseudo-morphia) seems only an occasional constituent, I
treat them as ten in number--rationally to be arranged under three
heads.
First, those whose action is merely acrid--so far as known expending
themselves upon the mucous coats. (_Pseudo-morphia_ when it
occurs belongs to these.) So do _porphyroxin; narcein_; probably
_papaverin_ also; while _meconin_, whose acrid properties in
contact with animal tissue are similar to that of meconic acid, forms
the last of the group.
The second head comprises but a single alkaloid, variously called
paramorphta or thebain. (It may interest amateur chemists to know that
its difference from strycchnia consists only in having two less
equivalents of hydrogen and six of carbon--especially when they know
how closely its physical effects follow its atomic constitution.) A
dose of one grain has produced tetanic spasms. Its chief action
appears to be upon the spinal nerves, and there is reason to suppose
it a poison of the same kind as nux vomica without the concentration
of that agent. How singular it seems to find a poison of this totally
distinct class--bad enough to set up the reputation of any one drug by
itself--in company with the remaining principles whose effect we
usually associate with opium and see clearest in the ruin of its
victim!
The remainder, five in number, are the opium alkaloids, which act
generally upon the whole system, but particularly, in their immediate
phenomena, upon the brain. I mention them in the ascending order of
their nervine power; narcotin; codein; opianin; metamorphia, and
morphia.
The first of these the poppy shares in common with many other narcotic
plants--tobacco the most conspicuous among the number. In its
anti-periodic effects on the human system it has been found similar to
quinia, and it is an undoubted narcotic poison acting on the nerves of
organic life, though, compared with its associates in the drug,
comparatively innocent.
The remaining four act very much like morphia, differing only in the
size of the dose in which they prove efficient. Most perfectly fresh
constitutions feel a grain of morphia powerfully; metamorphia is
soporific in half-grain doses; [Footnote: American Journal of
Pharmacy, September, 1861.] opianin in its physical effects closely
approximates morphia; codein is about one-fifth as powerful; a new
subject may not get sleep short of six grains; its main action is
expended on the sympathetic system. It does not seem to congest the
brain as morphia does; but its action on the biliary system is
probably little less deadly than that of the more powerful narcotic.
Looking at the marvellous complexity of opium we might be led to the
_apriori_ supposition that its versatility of action on the human
system must be equally marvellous. Miserably for the opium-eater,
fortunately for the young person who may be dissuaded from following
in his footsteps, we are left in no doubt of this matter by the
conclusions of experience. In practical action opium affects as large
an area of nervous surface, attacks it with as much intensity, and
changes it in as many ways as its complexity would lead us to
expect. I have pointed out the existence in opium of a convulsive
poison congeneric with brucia. The other chief active alkaloids, five
in number, are those which specially possess the cumulative
property. Poisons of the strychnia and hydro-cyanic acid classes
(including this just mentioned opium alkaloid, thebain) are swifter
agents; but this perilous opium quintette sings to every sense a
lulling song from which it may not awake for years, but wakes a slave.
Every day that a man uses opium these cumulative alkaloids get a
subtler hold on him. Even a physician addicted to the practice has no
conception how their influence piles up.