I am of the opinion that a clearer and consequently more thorough understanding of this part of the subject can be obtained by classing the various effects of the continued use of morphine or opium under the headings of the different systems and apparatuses, and have, therefore, adopted this method of presenting these matters to the reader.
THE DIGESTIVE APPARATUS.
(Stomach, Liver and Bowels.)
The first effect of opium or its alkaloid morphia on the stomach is, in the majority of instances, to increase the appetite and cause a pleasant sensation of warmth and a feeling of general contentment. After a time, however, especially if the drug is taken by the mouth, the appetite is materially impaired, the bowels become constipated, there is a sensation of sinking at the pit of the stomach, the circulation through the liver is interfered with, a catarrhal inflammation of the small intestine and stomach supervenes, the opening of the bile duct is partially obstructed by the swollen mucous membrane, and the result is a more or less decided staining of the skin with the biliary coloring matter. This is due, in part, to interference with the cells in the proper performance of their functions, undoubtedly through the medium of the nerves passing to them. At the same time, the gastric juice is diminished in amount and lessened in strength, as is also the case regarding the intestinal and pancreatic secretions, the digestion of food is imperfectly performed, and in consequence, a condition of malnutrition results, showing itself in wasting of the muscles and loss of the fatty tissue beneath the skin, especially of the face, breast and abdomen. As the gastric catarrh increases, nausea and finally vomiting ensue, still further debilitating the patient. Derangements of the stomach, liver and bowels are much more common among those who use the drug by the mouth. I have, however, seen patients who, while using morphia hypodermically, have suffered intensely with jaundice, catarrh of the stomach, nausea and vomiting. When these disorders do arise in the course of the subcutaneous use of morphia they are prone to be very acute in character. A gentleman, aged about 32, came under my notice some months ago, suffering from dropsy of both legs, which, from the middle of the leg to and about the ankles, were covered with collections of minute red spots, evidently points at which the capillary blood vessels had ruptured. An examination of his urine discovered thirty per cent. of albumen and some tube casts from the kidneys. Also a decided amount of morphine, and considerable blood. He was put upon tonic remedies; the legs, previously dressed with sulphate of iron ointment, were tightly bandaged. After about two weeks the dropsy lessened, the spots disappeared and the general health improved sufficiently to allow of a business trip to the West. No sooner had he neared his destination, however, than the dropsy of the legs again appeared, and the old trouble came back in full force. In addition, he became somewhat jaundiced, water made its appearance in the abdomen, and a most distressing nausea harassed him day and night. During all this time he managed to do an unusual amount of literary work, that required both knowledge and tact. On his return to New York, he was in a very weak and debilitated condition. The stomach rebelled at almost every kind of food, the belly was distended with water, the nausea intense, the vomiting frequent, and urine high colored, bloody and containing about sixty per cent. of albumen. While in the West an attempt was made to gradually diminish the amount of morphia, but owing to severe illness, was abandoned. Nor did I think it advisable to try again until the general health was better. Upon iron, in different forms (dialyzed, Bland’s pills, and muriated tincture), strychnia, phosphorus and gentian, he gradually improved, and is now just commencing the treatment by gradual reduction. He consumes daily about ten grains, using it subcutaneously. He contracted the habit some five years ago, through its being administered to him hypodermically, during a severe attack of acute articular rheumatism. Two years ago he was broken of the habit by a physician in this city, who pursued the plan of sudden deprivation, with the result of nearly killing the patient.
While traveling in Germany, for the purpose of reporting certain facts for his paper, he was suddenly taken with congestion of the brain, accompanied by intense pain and a state of semi-consciousness. A German physician who was called in, not knowing the man’s previous history, gave him a subcutaneous injection of morphia, with the result of re-establishing the habit.
Fluid in the abdomen is not a common complication, and when it does occur, crowds the stomach upward, interferes with the circulation of blood in the viscera in the abdominal cavity and renders the nausea and vomiting still more troublesome.
The stools voided by morphia-maniacs are sometimes clay-colored, being devoid of biliary coloring-matter. The absence of bile in the intestinal canal allows of decomposition of the food, with the production of ill-smelling gases which regurgitate through the stomach, or pass by the bowels. Constipation is the rule. Sometimes it alternates with severe diarrhœa. In one patient whom I saw, the fæces collected day by day in the bowels, until impaction resulted and the mass was removed, with the greatest difficulty, by means of large enemata and the handle of a spoon. This lady had been using the drug, crude opium, for only eight months.
This constipation from hardened condition of the fæces produces irritation, intestinal catarrh, and often hemorrhoids accompanied by an eczematous eruption about the anus.
Heartburn, not from an excess of gastric juice, as is so often supposed, but from an acid fermentation of the food, is not an uncommon symptom.
Some patients go on for years with no disturbance of the bowels, liver and stomach, beyond a slight catarrh and some jaundice, but these troubles are sure to come sooner or later.
In many instances as the appetite for food decreases the appetite for alcoholic stimulants replaces it. A young lady, of twenty, formerly a patient of mine, after using the drug subcutaneously for three years, lost her appetite and subsisted for nearly eight months upon lager beer, a few crackers and a little toast. She would consume about one gallon of beer a day. During this time she somewhat diminished the amount of morphine used (eight grains, dropped to six grains, in twenty-four hours) and gained in weight and health. At the end of this time, however, severe gastric disturbance supervened, and she lay for months in a precarious condition. She is now cured of the habit.
Alcoholic stimulants are used by some habituès to increase the effect of the morphia, which it does to a certain extent. They delude themselves into the belief that they will be enabled to thus reduce the amount of morphia used, but in the majority of cases this is a fallacy. Those who prefer laudanum and paregoric to opium or morphine often do so on account of the amount of alcohol contained in these preparations. I knew a gentleman, some years ago, now dead, an Episcopalian minister, who became addicted to the use of alcoholic stimulants. His excesses were so frequent and so degrading that it was found necessary to expel him from the church. Sobered by the blow, yet unwilling to entirely abandon his habit, he seized upon the expedient of using large quantities of laudanum, thus getting the effect of both opium and alcohol. He died some two years after, from taking an overdose, at the end of a spree, the first and last one in the two years. His tombstone is a monument to blasted hopes, unsatisfied ambition, a life ill-spent, and points a very pregnant moral to those who knew him. Let a man count well the cost before he takes service with a master who is only satisfied with a blasted life, here and hereafter.
THE CUTANEOUS SURFACE.
The effects of these drugs upon the skin may be divided into those relating to color, sensation and nutrition. The sallow, cadaveric hue so often seen in advanced cases is partly due to discoloration by the biliary matters, which are not properly excreted by the liver, and partly to a condition of malnutrition, so often seen in persons suffering from cancerous disease. In case there is serious interference with the working of the kidneys, the sallow color becomes less distinct, diluted expresses it well, and it has an appearance more like that of old white marble. In this case the tissue feels doughy and “soggy,” and at points a pit made in the skin by the pressure of the finger remains. There is also puffiness under the eyelids and the eyes are bleared and watery. When there is no dropsy the skin is usually dry and harsh, although at times bathed with a cold, exhausting perspiration, the odor of which is oftentimes very offensive. A morphia or opium taker, previously ill-nourished, sometimes seems to improve, taking on flesh rapidly. The appearance, often best seen in the face, is very deceptive, and is, in the majority of instances, due to slight dropsy. It is sometimes seen a few weeks after these patients commence to use alcoholic stimulants, especially beer. It soon passes away, leaving them looking thinner and more miserable than before.
In those cases where the habit has not progressed very far, the skin is usually made redder and coarser than natural, and is dotted here and there with pustules.
In one case that I have recently had under my care, that of a young lady who had never used stimulants and who had only used morphia, and that subcutaneously, for seventeen months, a swollen and reddened condition of the nose, exactly like that seen in old drunkards, was present. Two weeks after the morphine was stopped the nose began to lessen in size and the color to disappear, and the condition was entirely cured at the end of three weeks. No local applications were used.
Loss of elasticity of the skin is a common change. That nutrition is seriously interfered with is seen by this alteration, the loss of adipose tissue, the ill-balanced circulation, giving at one time coldness and paleness, at another flushing and undue warmth, and the variable secretion. A plump and well nourished person who commences the use of morphia loses those outlines of health caused by the proper development of the muscular system and normal distribution of fat beneath the skin. Face and form are both changed, and certainly for the worse.
These changes are undoubtedly due to a double action of morphine; that on the alimentary canal preventing the proper digestion and assimilation of food, and that upon the nerves regulating the supply of blood that passes to the skin.
Eruptions after a time appear upon various parts of the body, more especially the face, chest and back. They are usually pustular, with hard, indurated bases; sometimes papular. Herpes zoster or “shingles” is occasionally produced, and is attended by most intolerable itching; less often purpura hemorrhagica. In the case of the literary gentleman already spoken of this was present, as was also bleeding from the kidneys. When it does occur the system must be in a greatly exhausted and the blood in a very poor condition, a condition which it usually takes a long time or large doses of the drug to produce.
Another symptom dependent on disordered nutrition of the skin is the rapid or slow falling of the hair that occurs in some patients. However much hair restorers and scalp tonics may be used in these cases, the hair, once having commenced to fall, will continue to do so until the general health improves. When the drug has been stopped a free falling out of the hair occurs, followed by a new and luxuriant growth. Indeed, sweeping out and rebuilding seems to be the rule in every tissue. Change in color of the hair has been noted in some cases.
Those affections of the skin due to the use of dirty solutions and unclean needles when the drug is given subcutaneously will be spoken of fully presently.
Sensation is variously altered. Sometimes there is a condition of hyperæsthesia, the least touch being intensely painful, the contact of the clothing causing decided irritation. Occasionally a whole limb or part of a limb or portions of the trunk or face will feel “numb or dead.” Sometimes there are a series of pricking or tickling sensations that are very aggravating, as they and the numbness are often looked upon by patients as precursors of paralysis. Sensitiveness to cold is often extreme. This and the very hard clay-colored stools are also seen in saccharine diabetes, and in every case where I have noted them sugar was found in greater or less quantity in the urine of the patient. What the connection is I cannot say, but it is worthy of further study.
THE SEXUAL ORGANS.
The continued use of opium or morphine has a decided effect upon the sexual apparatus. One of the first changes to be noticed in women is scantiness, then irregularity, and finally, total cessation of menstruation. In some cases an occasional period is observed, but as a rule, the stopping is decided and permanent until the habit is abandoned. Occasionally menstruation occurs when a change is made from one preparation to another, or from one mode of administering to another.
In one of my patients, not under treatment for that, but still an habituè, menstruation showed itself, after a three years’ cessation, on changing from the use of laudanum by the mouth to morphine by the skin. It occurred, however, but the once.
In the case of the young married lady already referred to, when a change was made from subcutaneous to rectal injections the flow was re-established and showed itself, although irregularly, for nearly a year.
Levenstein, who has made some interesting and valuable researches and experiments upon this matter, believes that this abnormal menopause is due to the inactivity of the ovaries. He says:—
“According to Pflueger’s theory, in cases of amenorrhœa due to morbid craving for morphia, the growth of the ovarian cells would be stopped from one monthly period to another, and consequently there would be a want of stimulus on the ovarian nerves, causing on the one hand the rupture of Graaf’s follicles, and producing, on the other hand, a congested state of the generative organs by reflex action. Hence, the morphia would act in the same manner on the ovaries as on other secreting glands, i. e., would render them devoid of function under its continued influence. It is likely, therefore, that the menstrual discharge does not show on account of no ovulation taking place; this also would account for the sterility.”[5]
Accompanying this condition of non-menstruation there is always sterility. That this is due to the habitual use of morphia is proven by the fact that these women have borne a child or children before the use of the drug was commenced, and have again become pregnant and gone to full term after the habit was abandoned. So long, however, as menstruation does occur, there is a possibility of the woman’s becoming pregnant.
In the majority of instances sensation is finally lost, although it is usually increased during the first few months’ use of the drug. A patient of mine, a lady who had used morphine by the mouth for sixteen years, found her virile power during and at the end of that time in no way impaired. If anything, it was increased. Her dose of morphine was ten grains. She had not menstruated for a long time. This was the only case in which I tried Levenstein’s plan of at once stopping the drug, and I shall certainly never try it again.
With the suppression of the menstruation, there sometimes come the usual symptoms attending the suppression of this function in non-habituès.
Levenstein states that ladies suffering from leucorrhœa are often cured of this complaint by the habitual use of morphia; the discharge returning, however, as soon as the habit is broken, and causing labor-like pains.
Certain it is that most female patients, on breaking the habit, suffer from a severe leucorrhœa, whether or not they had such a discharge previous to commencing the use of the drug. One of my lady patients who used six grains a day, subcutaneously, had a leucorrhœal discharge before she began the use of morphia, and upon which a four years’ habituation had no curative or modifying effect. As soon, however, as the habit was broken, the discharge increased greatly in quantity, and changed in character, becoming more tenacious.
Spasmodic closure of the mouth of the vagina on attempting to introduce the finger or a speculum, I have noticed in two cases. It, also, readily passes away after the use of morphia is abandoned.
A woman becoming pregnant in the early course of her addiction to this habit will, in the majority of cases, abort before reaching full term, especially if the amount used is large. Levenstein has noted the fact that wives of men addicted to the habitual use of this drug in large doses had in the last two years never carried children to full term, although young, healthy, and having borne children before the husband became an habituè.
There is no question in my mind but that the excessive use of this drug by one or both parents, but especially the mother, in case she is able to carry her child to full term, will modify disadvantageously the physical, mental, or moral development of the child thus born. A physician from the South tells me of the case of a lady who commenced the use of opium at the beginning of her pregnancy. She was delivered of a fair-sized child that grew up in fair, though not robust health, and menstruated at the proper age. She is, however, very simple and childish, still plays with dolls, although a young lady, is very eccentric, and shuns the society of young men. The mother, who is still living, ceased to menstruate at the age of 30 and has never menstruated since, some twenty years. For the past two or three years she has been using sixty grains of gum opium daily.
Dr. Alonzo Calkins[6] relates several cases where the children of such parents were either physically or intellectually deficient. I give but one of them: “At an inquest held by Dr. Macnish it appeared that a child five years of age, though to appearance only so many weeks old, had never been able to walk, nor so much as utter an articulate sound. The mother, during her gestation (as was in evidence), had taken to morphine, using a drachm a day in the months just preceding her demise. A child born before the habit had become fixed showed a normal development and the aspect of general health.” Another case is related where both parents were “healthy and robust by original constitution and by habits of life too, with the exception that the woman had, for a very considerable period, been in the practice of using morphine regularly and to great excess. An infant born subject to the liabilities, had only a very imperfect physical organization, with weak intellectual indications.”
By carefully conducted experiments on animals (pregnant dogs and rabbits), Levenstein found that the continued use of morphia invariably produced abortion, the fœtus being born dead.
With the cessation of the menses the breasts usually dwindle in size, and the voice attains a more masculine tone.
In man the first indication of an effect on the sexual organs is increased desire; this, however, giving way sooner or later to partial or total impotence. The fact, noted by Levenstein, regarding the rarity of conception and parturition in the wives of habituès, has already been spoken of. If the amount of opium or morphine used is small, impotence may not come for a number of years. The power of partial or full erection, without emission, is preserved by some. In those cases where there is inability to impregnate the female, there undoubtedly exists a deterioration of the functional power of the testes. In one case which I saw the testicles were markedly atrophied. In two cases I was fortunate to be able to examine the seminal fluid, a few days after the habit had been broken. These patients, as is usual on recovery, were troubled with erections and nocturnal emissions. In both instances the zoosperms were small, and present in less than the normal quantity. In one case, where it was possible, owing to the patient’s having been previously instructed, I was able to examine this fluid once or twice weekly for nearly two months. Each succeeding examination showed a larger number of zoosperms, each sample apparently better developed than the preceding.
Even large doses sometimes fail to produce impotence. One young man, twenty-five years of age, who has been taking, subcutaneously, ten grains of morphia, for over three years, is a confirmed masturbator, and seems to have frequent emissions.