THE URINARY ORGANS.
Albuminuria, usually temporary, is not an uncommon result of the prolonged use of morphia. The deposit, after applying heat and nitric acid, may vary from one-twentieth to one-seventieth per cent. of bulk. In some cases it comes and goes, one day appearing as a slight, hazy cloud, and on another as a measurable deposit. Albuminuria and diabetes are more commonly found in patients who use the drug hypodermically. In some rare instances casts, epithelial, granular, hyaline and bloody, are to be found in the urine, as also free renal cells, apparently healthy. This was the case with the literary gentlemen spoken of in the second chapter. This does not indicate organic disease of the kidney, for after the withdrawal of the drug the albumen and casts gradually disappear.
The specific gravity of the urine varies according to the bodily condition of the patient, the weather and the amount of fluid ingesta used. If sugar is present the gravity is high; if albumen, usually low. In nervous and hysterical women there is a low gravity with an excess of the alkaline phosphates. In nearly all cases the uric acid is increased after the drug has been used for a time, the urea is very materially diminished, due probably to the small amount of food taken, the congested and deranged condition of the liver, and the impeded tissue metamorphosis. The chlorides are always slightly, sometimes markedly, diminished in amount.
Levenstein concludes, from his observations on patients and experiments on animals, in whom the continued use of morphia produced albuminuria, that this affection is due to varying blood pressure in the renal vessels through the nerves supplying them.
Contrary to the experience of Levenstein, I have found sugar in the urine of some (four) of my patients. This, like the albuminuria, was permanent in one case, and came and went in the other three. Its presence was undoubted, it reducing the copper of Fehling’s liquor (previously tested) and answering to the fermentation and bismuth tests. In three of the cases it disappeared after stopping the morphia. The fourth patient is still under treatment.
Levenstein finds that acute poisoning by morphia, in men and animals, is always accompanied by sugar in the urine.
Strangury and retention of urine is occasionally the result of the long continued use of the drug.
The albuminuria of morphia-mania is sometimes accompanied by dropsy of the feet and limbs, less often of the abdomen and pleural sacs. When thus occurring the case is a grave one, and it will take time to decide whether there is not real organic disease of the kidneys, in which case the breaking of the habit may cause death by convulsions.
THE EYES.
It is a rare thing to find actual disease of the eyes that can be traced directly to the abuse of morphia. It is usual to find the retina somewhat congested. Blurring of sight and double vision are sometimes complained of. Muscæ volantes, or specks floating before the eyes, are sometimes seen. One patient of mine who had been near-sighted four years, during which time she had used the drug subcutaneously, claims to have regained full power of sight since the habit has been broken.
The pupils are, as a rule, contracted and regular, occasionally of normal size and irregular.
THE MUSCULAR SYSTEM.
Locomotion is rarely affected during the continuance of the habit, save from weakness. Twitching of isolated muscles, such as the orbicularis palpebrarum of one eye, is sometimes seen. When the doses of opium or morphine become very large, co-ordination is sometimes interfered with. Wasting of the muscles is found in advanced cases, as also is trembling of the hands.
RESPIRATION.
Respiration is rarely affected. In some cases there is shortness of breath on walking fast or going up a long flight of stairs. A low grade bronchitis sometimes exists, as also a short, hacking cough, that seems to come chiefly from irritation in the throat.
THE CIRCULATION.
Circulation is often affected but chiefly through the agency of the nervous system; witness the flushing of the face, and flashes of heat over the body, followed by a cold, exhausting sweat. There is often irregular and weakened action of the heart, and congestion of the brain. The albuminuria already spoken of is due, in all likelihood, to an affection of the vessels of the kidneys, through the nerves supplying them. The blood itself, owing to a general condition of malnutrition and imperfect digestion, is unquestionably deteriorated. In some cases the vessels rupture, giving us purpuric spots on the body and hemorrhage from the kidneys and bowels. Dropsy, which sometimes occurs, is due, in the majority of instances, to variable blood pressure, and a diseased condition of the walls of the vessels, permitting the easy transudition of the watery element of the blood. Headache, flushing of the face, flashes of heat and the like, from suppression of the menses, is seen during the early period of morphia addiction, but later nothing but the nervous symptoms attendant upon this condition are manifested.
THE MIND.
Early in the use of morphia the effects upon the mind are simply those of pleasant exhilaration, a feeling of perfect contentment, good will toward all, increased conversational power and stimulation of the imaginative faculties. Sleep is preceded by a period of luxurious drowsiness, fertile in pleasant retrospective and magnificent anticipation. There is total banishment of pain and care. It is, indeed, the ideal life of a dreamer, moulded and modified according to the temperament and intellectual tendencies of the individual.
As time advances, however, the duration of these periods is found to become shorter, and it is necessary, in order to obtain the same pleasant result, to increase the amount of the drug. It has, also, to be taken oftener. Sleep, when it comes, is less profound, the dreams not so pleasant. Should the patient pass the accustomed time for the drug, the loss is at once felt and the first symptoms of rebellion show themselves. A further and larger dose is taken, to quiet the rebellious demon that rules them, and again comes the pleasure, though not so satisfying as at first. The hours of freedom from the tyrant become shorter and shorter, sleep refuses to come, grave doubts fill the mind, the temper is no longer even and pleasant, but irritable and capricious, pains show themselves in various parts of the body, the nights are long hours of torment, conversation becomes a burden, suspicion shows itself, a desire to be alone is overpowering, better feelings are blunted, benevolence is replaced by selfishness, mental stimulation and exhilarance by torpor. Friends are neglected, the books that were once interesting are no longer so, amusements pall upon the taste, family ties, once so pleasant, are become burdensome, and life a dreary space, marked only by the hour at which the drug is to be taken. The days are filled with repentance, the hours garnished with resolves no sooner made than broken,
the nights years of misery and anguish, teeming with horrors beyond the power of tongue or pen to paint. Here is the plaint of one, now freed from his bondage:[7] “The morphia victim dwells, after the first exhilaration is gone, in a realm of phantoms and shadows. I saw sights more terrible than can be imagined. I felt pains that do not belong to any mortal lesion. I have shrieked my terror, but the shriek only awoke a myriad of devils, who had been sleeping till then unseen by me. Four months of morphia addiction sufficed to bring me to this land of horrors, where no joy came or has come since the making of the world. My days were spent in self-indulgences. Alone in my office, in an easy chair, I could, with poetry and interesting therapeutical works, manage quite comfortably to pass the hours away. But let a patient summon me away from home, and my gloom and despondency was almost insupportable. I was tormented by continual self-conflict. Conscious of the weakness of my efforts to emancipate myself, I kept on planning some new mode of attack, in the nerveless hope that I could defeat the Lethean devil whose thews were strong as steel, and yet I knew, as day followed day, and week followed week, in so far as all this mental warfare was concerned, it could bring me no help in my awful bondage.
“No dark imagery can paint the encompassing horrors of those nights of torment that belonged to the last two months of my twelve months’ morphia addiction. Not one hour that I passed in bed between midnight and noon did I know normal sleep. In dreams that seemed more vivid than reality, I entered gloomy caves, and walked for hours over rotten cadavers, sometimes forced to step on them and be overwhelmed with loathsome odors. I saw faces in the weird darkness, sometimes a thousand at once, and each was made of blood-red flame; they flashed and went out. My nightmared brain was chased and haunted by everything that can exist in a vast hell of phantoms.”
Apropos, the following from Moore’s “Veiled Prophet of Khorassan”:—
Thus it is, pursued to the very grave-edge, these victims loathe the drug they once loved. Business is gone, family broken, friends lost, moral sense blunted or destroyed, mind incapable of healthy action, body wrecked, and they see no hope here or hereafter.
They will lie and steal, do almost anything to obtain the drug with which and without which they are finally in a veritable hell. The face becomes sallow and soggy, the eyes bleared and expressionless, and the final result is either death or insanity. Some persons go on using these drugs for years before the symptoms here described supervene; some are thus affected in a few months.
Having reached this stage they cannot arouse themselves from their terrible infatuation. Gloomy and hopeless, the world and the people in it no longer interest them. A patient whom I saw some years ago, a young Spaniard, was suffering from insanity from the use of morphine. Hour by hour he would sit folding, refolding and cutting paper into small bits with an old lancet. He would speak to no one, notice no one. This went on for months. He was sent to an insane asylum finally, and on searching his trunk some two score morphine bottles, as well as the greater part of the trunk, was filled with these minute scraps of paper. I have never been able to learn what became of him.
A lady patient of mine, well advanced in years, would save scraps of tin, old bits of rags, glass stoppers of bottles, and the like, setting great store by them. She laughed heartily at her collection, and threw them away one week after her emancipation.
Sometimes there is a mawkish sentimentality exhibited toward the opposite sex; sometimes there is mock modesty or direct abhorrence.
In the majority of instances these people are great liars, especially about matters concerning their habituation; often also about trivial things, where falsification is absurd and absolutely without excuse.
Occasionally there is a loss of connection between ideas in talking, incoherence and silliness. The speech is, as a rule, slow and somewhat drawling, and often interrupted to wet the lips, which become dry and parched. Severe pain in the head and about the region of the heart is sometimes complained of, also in the “small of the back.”
In some cases, more especially those of an intensely nervous organization, the prolonged abuse of opium or morphine produces a condition characterized by cerebral excitement, analogous to that of delirium potatorum. These people are, however, less violent, and the affection usually passes away in a short time, without treatment.
THE NERVOUS SYSTEM.
On the nervous system the effects of opium and morphine are most manifest. Taken at first to relieve pain and disorders of this system, having their chief action upon it at all times, their continued use reacts with deadly intensity. Twitching of isolated muscles, trembling of the hands and of the tongue, when protruded, and occasionally paralysis of one eyelid, are seen. The pains that supervene have no distinctive character, as do those that come from the abuse of chloral.
Itching of the whole or parts of the body is sometimes very troublesome. Herpes zoster (shingles), an eruption following the distribution of the nerve filaments upon the trunk, occasionally occurs, as also does urticaria (nettle rash). The very disorder for which the drug was first taken, is, in some instances, aggravated or perpetuated. This was first noticed by Dr. T. Clifford Allbutt[8], of England, and I have seen the same in some instances.
In the condition of delirium sometimes occurring, the pupils, usually contracted, are occasionally irregular and dilated.
The whole nervous system is unstrung, or more properly, too highly strung, so that it vibrates to little things that in health would pass unnoticed. They jump at the falling of a book or the shutting of a door.
Hysterical women still continue to have their customary attacks, sometimes in an aggravated form.
The following interesting case history has been kindly sent me by Dr. Judson B. Andrews:—
A woman,[9] thirty years of age, single, seamstress, with no hereditary tendency to insanity; was of a highly nervous and excitable organization, emotional and irregular in feeling; at times buoyant and lively, and then gloomy and depressed. Her health during early life was delicate, though she suffered from no definite form of disease. At the age of twenty, in April, 1862, she was seized with pain in the head. It was of short duration, but very severe, and during its continuance the patient was delirious. Attacks of the same character, both in the severity of the pain and the mental disturbance, have occurred since, at intervals of from one to three months.[10] In 1864 she had acute rheumatism, and in 1865 a severe attack of diphtheria.
After the local disease of the throat had apparently subsided vomiting supervened, and was repeated every few hours for some five weeks. To relieve this condition and procure sleep, hypodermic injections of morphia were successfully employed for about one week, and the patient rapidly regained her health. Some two years after this, or in July, 1867, she had an attack of inflammation of the bowels and peritoneum, and for four weeks was delirious most of the time. She improved somewhat in health, but for the four months succeeding had frequent attacks of frenzy, during which she often threatened to take her own and her mother’s life, and became very difficult to control. In October following she had improved so far as to pass from the immediate charge of her physician. Soon after this he ascertained she was using hypodermic injections of morphia, to relieve pain in her limbs and different parts of her body. I quote from his letter:—
I was informed that she was using it (morphia) to a considerable extent, and called immediately to explain to her the effects and danger attending the practice. I believe every effort was made that could be to prevail upon her to desist, but all to no purpose. She was cunning and artful, and would almost always study out some plan to get the morphia. She has used as much as two drachms in a week, in one or two well-authenticated instances. The usual amount was one drachm per week. She used but little, if any, for three or four months before she was sent to the asylum, for it was very difficult for her to get it. She has acted very strangely ever since her first sickness. She has been truly a mystery, which no one could solve.
Her mother says:—
That for years she has complained of pain, and pressed her hand on either side of her head, with the exclamation, “Oh, mother, mother, I shall die!” That for six years she has complained of such soreness of the head that when she passed her hand over it, in smoothing her daughter’s hair, she would cry out: “Oh, mother, don’t; it hurts me so!” That five years ago, in 1867, she was obliged to call in help, as the patient threatened and intended to take her own life. That both before and after she began the use of morphia, her conduct was peculiar and erratic; that she was emotional and easily disturbed by trifles. That after the morphia habit was known, her conduct for many years preceding was wrongly attributed to this cause.
A few weeks before she was sent to the asylum she passed into an acutely maniacal condition, in which she was sleepless, ate little and irregularly, lost flesh and strength rapidly, and became quite feeble. She was destructive of clothing, pulled her hair out, was noisy, incoherent and violent; opposed care, wandered about, and was with difficulty controlled. In this condition she was admitted to the institution, on the fifth of May, 1871. She was carried to the ward and placed in bed. Examination revealed scars and ecchymosed spots, covering nearly the whole of the body which could be reached by her own hand. She asserted that she had employed the hypodermic injections for three and one-half years, once, and much of the time twice, a day, making in all about two thousand injections; that during the last few months of its continuance she had used a drachm and one-half of morphia per week; that she inserted the needle perpendicularly to the surface, and often carried its full length into the tissues. For two days she was sleepless and retained no nourishment. Chloral, in thirty-grain doses, was then administered, which was tolerated by the stomach, and secured sleep. The vomiting gradually became less frequent and soon ceased. She ate well, gained flesh and strength, all maniacal symptoms subsided, and in twenty days she was up and about the ward. Menstruation, as she said, had been suppressed for two years. As she complained of pain in the back and other symptoms which usually preceded it, she was placed on the use of capsules of apiol, and on the 24th of June began to menstruate, but the flow was scanty, and accompanied by much pain.
During the month following she steadily gained in mental strength, and became quite stout. At time of next menstrual period the right breast swelled to an extraordinary size, so that we were obliged to suspend it with adhesive straps. It was hard and extremely sensitive to the touch. This condition of swelling and tenderness extended in a narrow ridge to the spine. The state of the breast was at first supposed to be owing to the sympathetic action of the organ with the renewed activity of the menstrual function. For two weeks applications were employed, without success, to relieve the pain and tension. At this time, on the 13th of August, the patient, in rubbing her hand over the breast, discovered an elevated point just under the skin, which, on pressure, gave a pricking sensation. This was cut down upon, and a broken needle extracted. On the 15th another needle was removed. The breast was now inflamed and extremely sensitive. August 28th, another needle was taken out. August 29th, menstruation began again. The flow was profuse, and she became at once delirious. Was talkative, restless, profane and obscene, and pulled her hair out. She continued in this condition some twelve hours, and, as she stated the next day, was entirely unconscious of what had occurred.
From this time till September 28th, from one to five needles were removed daily from the breast. Menstruation then occurred again, and was characterized as before by a similar attack of mental disturbance. After this, during the months of October and November, needles were taken from various parts of the body; from the left breast, the abdominal parietes, the mons veneris, the labia, and vagina. Of these latter, some passed across the urethra and rendered urination difficult and painful; others across the vagina, either end being imbedded in opposite sides. Some were removed from the thighs, from the leg, down to the ankle, from the buttocks, from about the anus, from the back as high up as between the shoulders. The largest number extracted in any one day was twelve.
On one occasion ether was administered, but the difficulty experienced in bringing her under its influence, and the mental disturbance produced by it were so great that it was not again resorted to. During the whole period, to her final illness, she retained her flesh, though she ate and slept irregularly, under use of tonics and sedatives. She was in a variable mental state, at times irritable, petulant, fault-finding, attempting to create ill-feeling between attendants, and demanding unnecessary care and waiting upon. At other times she was abnormally cheerful, gay, pleasant, and fulsome of praise of all around her.
For the first two months but comparatively little pain was felt in the extraction of the needles. The skin was thickened, harsh and dry, and almost insensible, from the prolonged and distributed use of the injections. Afterward, she suffered acutely, and often begged, with tears, that their removal might be postponed from day to day. About a month before death she had an attack of localized pneumonia, affecting the lower portion of right lung. This was accompanied by stridulous breathing, spasm of the glottis, globus hystericus, crying, and other hysterical manifestations. It was followed by an attack resembling muscular rheumatism, characterized by great pain and hyperæsthesia of surface. The right arm was swelled, hot and extremely sensitive. It was supported on a pillow and kept bathed in anodyne lotions. She lost appetite and sleep, became much depressed, and gave up all hope of recovery. Her tongue became dry and brown, pulse rapid, secretions offensive, and mind very feeble. A diarrhœa supervened and the evacuations of bowels and bladder were involuntary. She became unconscious, and finally comatose, and died on the 25th of December, 1871.
No needles were removed during the last two weeks; 286 were taken from her body during life; 11 were found in the tissues after death; 3 were passed from the rectum during sickness; making a total of 300 needles and pieces. Of this number, 246 were whole, and 54 were parts of needles. One was a No. 7 sewing machine needle, and several were bent. They varied in size from No. 4 to No. 12. As regards position in the body, they were distributed about as follows: in right breast 150; left breast, 20; abdomen, 60; genitals, 20; thighs and legs, 30; back, 20. Of those removed after death, 5 were found in the right and 3 in the left breast; one in a small abscess in the epigastric, and one in the right iliac region, the point impinging upon the peritoneum, which was discolored with rust; and one in the upper part of lower lobe of left lung. The presence and position of the needles were indicated to the patient by the pricking sensation occasioned by muscular movements. They were removed in a few instances at first, by cutting down upon them. This proved to be a painful, and, from the movements of the needles in the tissues, a difficult process. Hemorrhage from the small vessels, at times, gave some trouble. Afterwards, by manipulation, the ends of the needles were engaged between the thumb and forefinger, and the points, forced through the skin, were seized and the needles extracted with forceps. Sometimes much force was required to withdraw them. They changed position quite readily, and frequently moved from one to two inches in a day. They produced little local irritation or trouble beyond the pricking sensation, and did not seem to have contributed in any notable degree toward producing the fatal result. In regard to the presence of this large number of needles in the system, no information could be obtained. The patient repeatedly and persistently denied any knowledge of having introduced them, either by the stomach or through the skin. Her mother, who visited the Asylum, could throw no light upon the subject, and was entirely ignorant of the fact until informed by us. She, however, recalled the circumstance that the patient purchased, at one time, ten papers of needles, and could account for only two of them. They were not obtained or introduced while in the Asylum. She was under strict surveillance, and had no means of obtaining any number of needles, and those removed were all rusted and bore evidence of having been a long time in the body. The stomach was closely examined after death, and was in a perfectly healthy condition, with no evidence of any previous inflammatory action.
The only theory which seems to us at all tenable, is that they were introduced through the skin while she was under the influence of morphia, hypodermically administered, and while suffering from hysteria. That some were found in positions where they could not have been inserted by the patient, can be accounted for by their movements in the tissues, which were observed so often during the life of the patient.
The diseased condition of the brain and its membranes was a cause sufficient to account for the abnormal mental action and conduct of her who had been “truly a mystery which no one could solve.” We close this remarkable case with a transcript of the post-mortem examination.
Autopsy.—Rigor present; body well nourished; anterior surface thickly studded with small cicatrices; abdomen covered with thick layer of fat. A small abscess in abdominal wall, two inches above umbilicus, three inches by one and one-half, was filled with pus and contained one needle. A second abscess, two inches above and to the right of the symphysis pubis, immediately under Poupart’s ligament, contained another needle. This pressed upon the peritoneum, which, though discolored by rust, was not inflamed. From the right breast, one whole and four broken needles, and from the left one whole and two broken needles, were removed.
Head.—Arachnoid opaque and thickened over right hemisphere. The left hemisphere was covered by a thin layer of pus, contained in the sub-arachnoid space. Marked depression of convolutions at vertex of both hemispheres. The brain substance was firmer than normal. The ventricles were empty, and the choroid plexus contained numerous small cysts upon its surface, filled with serum.
Thorax.—The lower lobe of the right lung was hepatized. A whole needle was found in the upper part of the lower lobe of the left lung.
Abdomen.—The liver was soft and fatty, and the spleen enlarged; kidneys were normal. The stomach was subjected to a critical examination. It was found normal, and there was no evidence that the needles were introduced into the system through that organ.
The vascular system, through the agency of the nerves, is profoundly affected, as already shown.
Spasm of the muscles of the bladder and rectum is sometimes present, and in some cases is distressing and lasts for a considerable time.
Symptoms resembling those produced by malaria are occasionally found. Levenstein, who was the first to call attention to this, says: “Intermittent fever, in consequence of a morbid craving for morphia, seems to be due to a certain neuropathic disposition, as it does not show itself with many patients, although they have taken large doses of the drug, and for years together. It was, however, impossible to fix on any other cause for the development of intermittent fever but the use of morphia, as the respective patients lived in regions free from malaria, and as none of the other members of the family living under the same conditions showed any similar symptoms.
“We may distinguish a light and a severe type of intermittent fever, when brought on by a morbid craving for morphia. Both forms resemble real malarial fever, inasmuch as the first paroxysms, occurring at regular intervals, seemed to disappear after the use of quinine, returning, however, very soon, although the febrifuge was continually given; that, furthermore, they were improved by change of air, but came on again from the simplest causes, such as boating, errors of diet, etc.
“The characteristic symptoms of this fever are the same as those caused by malaria: chilly feeling, up to regular shivering, headache, oppression, heat and perspiration. They differ from one another in this respect, that immediately the morphia is discontinued, the attacks disappear without any treatment, although they may have existed a long time.
“In some cases the intermittent fever sets in in an erratic manner. The patient, at irregular times, experiences an attack of fever, with chill, heat and sweating. These attacks occur from three to six times, at long intervals, not showing themselves hereafter any more at all, or only after a great lapse of time. In most cases the attacks of intermittent fever, in morbid craving for morphia, shows a tertian, rarely a quotidian, type. They are sometimes ante-, sometimes post-ponent. The attacks last from four to ten hours, and are followed by a normal condition.
“The paroxysms disappear only in exceptional cases, without the morphia being stopped. In this case the patients complain of experiencing an uncomfortable sensation, principally of an exhausting character, at the usual time of the attacks.
“The feverish attacks are accompanied by neuralgic affections of the different nerves, principally in the region of the supra-orbital, intercostal and cardiac nerves. The temperature is increased in all cases, varying from 38.5° C. to 40° C. (101.3° F. to 104° F.). The spleen is generally enlarged. The attack is followed by sediments in the urine. In the severest forms of intermittents the patients get delirious when the fever has reached its maximum, cannot be kept in bed and may become maniacal. Both forms cause great weakness and exhaustion, which last during the intervals.”
I have seen but two cases that could at all be classed as such. In one there was no fever, and the chill came every morning at daybreak, for three mornings, missed one morning and occurred again the next. It was followed by profuse sweating, that lasted the whole day. In the other case, that of the lady who had used the drug by the mouth for sixteen years, there was fever and some intercostal neuralgia, occurring every other day, for ten days, but not followed by perspiration. A few doses of quinine broke it up. It was for this that I was first called to attend her, her husband believing her to be suffering from malarial fever. In neither of these cases was there any enlargement of the spleen. I then discovered that she was a morphine habituè, much to her chagrin and her husband’s surprise, he never having suspected it. The two following cases are those given as examples by Levenstein:—
CASE I.—INTERMITTENT FEVER IN CONSEQUENCE OF MORBID CRAVING FOR MORPHIA.
M. H., law student, 24 years old, sent to the Institution by Dr. Ewald in 1874, was suffering from acute articular rheumatism when the first injection of morphia was administered. After his recovery, although not compelled to do so through pain, he continued the injections several times in the day, increasing the doses, for the sole reason that he felt elated by them. The principal symptoms that resulted therefrom were loss of appetite, progressive emaciation, loss of strength, and increased perspiration, which frequently caused the patient to become wet all over while in a cold room and quite quiet.
Before his admission into the Maison de Santé he was troubled with feverish attacks, which came on every two or four days, at different times in the day, in the following manner: first there was a chilly feeling for half an hour, followed by heat and profuse sweating. The latter was accompanied by the general symptoms of every feverish attack, enlargement of the spleen also being present.
Present State.—Patient is a tall, muscular man; the examination of the internal organs shows no abnormal condition, excepting an enlarged spleen. Pupils of middle size, equal, reacting well. On December 10, 1875, the afternoon, patient received the last injection of morphia.
December 12. Patient slept in the night. In the course of the day he only feels a little sleepy. The face is red, the skin moist. Toward the evening there is nausea, pressure in the epigastrium, great restlessness, and stomach-ache. Patient moves about in bed, complains of headache, cannot get to sleep. Three relaxed motions.
December 22. Patient has had no sleep during the night, three relaxed motions, vomited once. He complains of giddiness, restlessness and palpitation of the heart. In the morning there is a chill followed by heat and profuse sweating. Vomiting, diarrhœa. Until the afternoon he felt very prostrate and exhausted. Between 3 and 5 P.M. he got up. Soon, however, the symptoms of the morning returned again, and pain in the knees, exhaustion and restlessness compel him to go to bed.
December 23. Has slept from 2 to 5 A.M. with interruptions. Profuse perspiration, nausea, intense craving for morphia, frequent paroxysms of sneezing. The sickness stopped in the course of the day. At 8 P.M. 30 grains of chloral were given.
December 24. Only three hours’ rest. Feels knocked up. One relaxed motion. Much sneezing; craving for morphia. At 9 P.M. 45 grains of chloral were given, but were immediately brought up again.
December 25. Patient has had hardly any rest. One relaxed motion. Has been sneezing frequently. Emission of semen. Great prostration, even in the horizontal posture; red cheeks; craving for morphia continues for the whole of the day. Appetite small. At 10 P.M. 45 grains of chloral.
December 26. He has slept well during the night, only woke up two or three times. Pressure in the stomach, headache and palpitation of the heart come on now and then in the course of the day. At 11 P.M. 40 grains of chloral were given.
December 27. Restless sleep, much interrupted. Patient went about the room on waking up. During the day he complained of heavy pressure in the head.
December 28. Patient has slept for about three hours. Sneezing. The red color of the face of the past days was still present to-day. Although tired he could get no rest. Two relaxed motions. In the morning a warm bath with cold douche was given.
December 29. Patient has slept for nearly eight hours. Head not well yet. Severe sneezing. He feels better in himself. Toward the evening, however, an uneasy feeling came on in the legs. Three relaxed motions.
January 1, 1876. Except the sleep being restless, patient feels well.
January 3. Slept only from 3 A.M.; ran about in a restless manner previously. Three relaxed motions. In the afternoon warm bath with cold douche.
January 13. The bodily functions are all in a normal condition. General health good. There have been no further attacks of fever.
January 14. Patient left the Institution.
He has had no relapse.
Urine.—The specific gravity varied from 1.012 to 1.020. Reduction of oxide of copper was noticed.
CASE II.—INTERMITTENT FEVER IN CONSEQUENCE OF MORBID CRAVING FOR MORPHIA. (IMPOTENCE. DISORDERED SPEECH. ALBUMINURIA.)
Captain B., sent to the Institution by Staff-Surgeon Dr. Peltzer, had been using injections of morphia in consequence of severe pains from a gunshot wound in 1871. For a time his medical attendant diminished the drug, but soon, by the advice of the latter, he purchased a syringe and bought the morphia, first at a chemist’s, and afterward at a shop where they sold chemicals; he injected gradually as much as twenty-four grains per day. Several times his wife tried to stop the injections or at least to diminish the dose, but this was followed by vomiting, diarrhœa and loss of sleep, so that the doctor again recommended its further use.
The principal complaints of the patient, on account of which he, on December 20, 1875, sought admission into the ‘Maison de Santé,’ were: The appetite is bad, the bowels are so much constipated that they are sometimes not relieved for eight days. From time to time patient suffers from disordered micturition, having to strain rather long before the water passes. Very frequently there was congestion to the head, and during sleep quivering of the muscles of the face and extremities. Now and then he suffered from giddiness and headache. He feels unwell, principally in the morning. Impotent for three years. He was obliged to resort to alcoholic beverages as stimulants, but he was no drunkard. From September 12 until the end of October, 1874, the patient had had a shivering lasting two hours daily, followed by half an hour’s heat and two or three hours’ profuse perspiration. Large doses of quinine taken daily for a period of three weeks are said to have cured the fever; it is worthy of notice that the patient stopped the use of the morphia during the latter period of the feverish attacks. Taking to it again, there was the same characteristic attack every week or fortnight at first; gradually, however, the free intervals became shorter, and at the time of his admission into the Institution the intermittent had again returned to the quotidian type. A treatment with large doses of quinine for several months, resorted to by his medical attendant, proved of no avail. Patient is pretty tall; muscles and subcutaneous areolar tissue very well developed. Face red. Eyes bright. Tremor of hands, slight degree of difficulty in speaking. Patient shows great vivacity in talking; his features move quickly; his movements are brisk. The physical examination of the thoracic and abdominal organs shows no abnormal condition, except a considerable enlargement of the spleen.
The morphia was at once withheld.
December 21. Patient had a restless night, feels exhausted and knocked up; yawns, complains of cold, loss of appetite, severe headache on moving the head, and pains in the back; this is followed by nausea and at night by vomiting. Profuse perspiration.
December 22. Patient was very restless in the night; got out of bed, ran about, laid down again, perspired freely, asked for morphia. The abundant perspiration lasted till midday and was accompanied by determination of blood to the head. Patient suffered from giddiness and felt greatly tired. Appetite poor. Frequent retching, but no vomiting.
December 23. Patient has slept little. Three relaxed motions in the morning. Symptoms the same as on the previous day. New symptoms: twitchings in the extremities, excitement, sensitiveness to the light, and epigastric pains. To remove the latter symptom sinapisms to the stomach, hot poultices and cupping (four times) were attended with success. Frequent vomiting.
December 24. Patient has only slept for a few hours. A great deal of sneezing; eight relaxed motions. In the course of the day he felt well.
December 25. The pains and pressure in the region of the stomach have returned and he had also palpitation of the heart, was very much exhausted and suffered from tenesmus. Two seminal emissions.
December 26. Four relaxed motions, shivering, feels uncomfortable.
December 28. Patient has only had two hours’ rest. Hands and feet burning hot. Eight motions; during the day he felt weak, complains of formication in the hands and feet.
December 29. Uncomfortable feeling continuing the whole of the day. Patient’s face was of a dark red hue; he complained of hyperæsthesia in the feet and of cold. While reading a letter from his wife he began to cry, although the contents showed no reason for his doing so. Appetite good. Two relaxed motions.
December 30. Slept from 3 to 7 A.M. Two relaxed motions. A great deal of sneezing, pressure in the epigastrium, appetite small.
January 3, 1876. Slept from 12 to 4 A.M., after running about in a restless manner. Formication in hands and feet.
January 6. General condition satisfactory. Appetite increased.
January 14. The patient has continued to recover his strength. Bodily functions normal. Sexual power has returned.
Urine.—During the first weeks of abstinence from morphia the urine contained albumen.
Patient left the Institution on January 22, in perfect health. He has not had a relapse.
Neuralgia of one-half of the face, in all respects like malarial hemicrania, I have seen in two cases. In neither were there other symptoms of malarial trouble. Both cases yielded to quinine and arsenic.
Super-sensitiveness of the skin, sometimes of the whole body, more often of a limb, or a feeling of numbness, is not uncommon.
A fact that I had noticed before I commenced the special study of this subject is, that those opium eaters who live past middle age usually die from paralysis. In four instances I have seen this. In all four cases the persons took laudanum.