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 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 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 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 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 urine10 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.
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 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.