A system of practical medicine. By American authors. Vol. 5

by Unknown

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 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 Levinstein⁹ has pointed out, these changes in the urine are often transitory, disappearing upon the suppression of the opium habit.

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 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 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.

Among women the morphine habit invariably produces derangement of the 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.