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Harper's magazine 35, Aug. 1867, pp. 377-87
What Shall They Do to Be Saved?
I have just returned from forty-eight hours' friendly and professional attendance at a bedside where I would fain place every young person in this country for a single hour before the Responsibilities of Life have become the sentinels and Habit the jailor of his Will.
My patient was a gentleman of forty, who for several years of his youth occasionally used opium, and, for the last eight has habitually taken it. During these eight years he has made at least three efforts to leave it off, in each instance diminishing his dose gradually for a month before its entire abandonment, and in the most successful one holding the enemy at bay but for a single summer. In two cases he had no respite of agony from the moment he dropped till he resumed it. In the third case, a short period of comparative repose succeeded the first fiery battle, but in the midst of felicitations on his victory he was attacked by the most agonizing hemicranial headaches (resulting from what I now fear to have been already permanent disorganization of the stomach), and went back to his nepenthe in a state of almost suicidal despair, only after the torture had continued for weeks without a moment's mitigation.
He had first learned its seductions, as happens with the vast majority of Anglo-Saxon opium-eaters, through a medical prescription. An attack of inflamed cornea was treated with caustic applications, and the pian assuaged by internal doses of M'Munn's Elixir. When my friend came out of his dark room and bandages at the end of a month he had consumed twenty ounces of this preparation, whose probable distinction from the tincture known as laudanum I point out below in the note. [FN*]
* Mr. Frank A. Schlitz has kindly made for me a special analysis of M'Munn's Elixir which seems to prove that the process of its preparation amounts to more than the denarcotization of opium, which is spoken of on the wrapper of each vial. As nearly as can be ascertained, M'Munn's Elixir is simply an aqueous infusion of opium--procured by the ordinary maceration--and preserved from decomposing by the subsequent addition of a small portion of alcohol. Narcotin being absolutely insoluble in water is eliminated as the circular says. This face along would not account for the difference between its action and that of laudanum. This is explained by the fact that all the other alkaloids possess diverse rates of solubility in water, and exist in M'Munn's Elixir in very different relative proportions from those which they bear to each other in the alcoholic tincture called laudanum. _____
Here it may not be superfluous to say that the former preparation has all the essential properties of the latter, save certain of the constipatory and stupefying tendencies which, by a private process known to the assigns of the inventor, have been so masked or removed that it possesses in many cases an availableness which the practitioner can not despise, though compelled by the secrecy of its formula to rank it among quack medicines. The amount of it which my friend had taken during this month's eclipse represents an ounce of dry gum opium--in rough measurement a piece as large as a French billiard ball. I thus particularize because he had never previously been addicted to the drug; had inherited a sound constitution, and differed from any other fresh subject only in the intensity of his nervous temperament. I wish to emphasize the fact that the system of a mere neophyte, with nothing to neutralize the effects of the drug save the absorbency, so to speak, of the pain from which it was given, could so rapidly adapt itself to them as to demand an increase of the dose in such an alarming ratio. There are certain men to whom opium is as fire to tow, and my friend was one of these. On the 1st of October he sensibly perceived the trifling dose of fifty drops; on the first of November he was taking, without increased sensation, an ounce vial of "M'Munn" daily.
From that time--totally ignorant of the terrible trap which lay grinning under the bait he dabbled with--he continued to take opium at short intervals for several years. When by the physician's orders he abandoned "M'Munn," on the subsidence of the eye-difficulty, his symptoms were uneasy rather than distressing, and disappeared after a few days' oppression at the pit of the stomach and a few nights' troubled dreaming. But he had not forgotten the sweet dissolving views at midnight, the great executive achievements at noonday, the heavenly sense of a self-reliance which dare go anywhere, say anything, attempt anything in the world. He had not forgotten the nonchalance under slight, the serenity in pain, the apathy to sorrow, which for one month set him calm as Boodh in the temple-splendors of his darkened room. He had not forgotten that the only perfect peace he had ever experienced was there, and he remembered that peace as something which seemed to blend all the assuaged passion and confirmed dignity of old age with that energy of high emprise which thrills the nerves of manhood. He had tasted as many sources of earthly pleasure as any man I ever knew; but the ecstasies of form and color, wine, Eros, music, perfume, all the luxuries of surrounding which wealth could purchase or high-breeding appreciate, were as nothing to him in comparison with the memory of that time on which his family threw away their sympathy when they called it his "month of suffering."
Accordingly, without much more instinct of concealment than if it were an occasional tendency to some slight convivial excess, he had resort to M'Munn, in ounce doses, whenever the world went wrong with him. If he had a headache or a toothache; if the weather depressed him; if he had a certain "stint" of work to do without the sense of native vigor to accomplish it; if he was perplexed and wished to clear his head of passion; if anxieties kept him awake; if irregularities disturbed his digestion--he had always one refuge certain. No fateful contingency could pursue him inside M'Munn's enchanted circle. He was a young and wealthy bachelor, living the life of a refined bon vivant; an insatiable traveler, surrounded by flatterers, and without a single friend who loved him enough to warn him of his danger excepting those who, like himself, were too ignorant to know it. After three years of dalliance he became an habitual user of opium, and had been one for eight years when I was first called to him.
By the time that the daily habit fastened itself he had learned of other opiate preparations than M'Munn's, and finding a certain insufficiency characterize that tincture as he increased the size of the dose, had recourse to laudanum, which contains the full native vigor of the drug unmodified. This nauseated him. He had the same experience with gum opium, opium pills, and opium powder; so that he was driven to that form of exhibition which sooner or later naturally strikes almost every opium-eater as the most portable, energetic, and instantaneous--morphia or one of its salts. My friend usually kept the simple alkaloid in a paper, and dissolved it as he needed it in clear water, sometimes substituting an equivalent of "Magendie's Solution," which contains sixteen grams of the salt diffused through an ounce of water by the addition of a few drops of sulfuric acid. When I first saw him he had reached a daily dose of twelve grains of sulphate of morphia, and on occasions of high excitement had increased his dose without exaggerating the sensible effect to nearly twenty. The twelve which formed his habitual per diem were divided into two equal doses, one taken immediately after rising, the other just before sundown.
As yet he had not begun to feel the worst physical effects which sooner or later visit the opium-eater. His digestion seemed unimpaired so long as he took his morphia regularly; he was sallow and somewhat haggard, but thus far no distressing biliary symptoms had manifested themselves; his sleep was always dreamy, and he woke at short intervals during the night, but invariably slept again at once, and had so adjusted himself to the habit as to show no signs of suffering from wakefulness; his hand was steady; his muscular system easily exhausted, but by no means what one would call feeble. As he himself told me, he had come to the conclusion to emancipate himself because opium-eating was a horrible mental bondage. The physical power of the drug over him he only realized when attempting its abandonment. Its spiritual thralldom was his hourly misery. He was connected by blood and marriage with several of the best families in the land. Money had not been stinted in his education, and his capabilities were as great as his advantages. He was one of the bravest, fairest, most generous natures I ever came in contact with; was versatile as a Yankee Crichton; had ridden his own horse in a trotting match and beaten Bill Woodruff; had carried his own little 30-ton schooner from the Chesapeake to the Golden Gate through the Straits of Magellan; had swum with the Navigators' Islanders, shot buffalo, hunted chamois, and lunched on mangosteens at Penang. Through all his wanderings the loftiest sense of what was heroic in human nature and divine in its purified form, the monitions of a most tender conscience, and the echoes of that Puritan education which above all other schemes of training makes human responsibility terrible, had gone with him like his tissue. He saw the good and great things within reach of a fulfilled manhood, and of a sudden waked up to feel that they could on earth never be his. He was naturally very truthful, and, although the invariable tendency of opium-eating is to extirpate this quality, could not flatter himself. Other minds around him responded to a sudden call as his own did not. Every day the need of energy took him more by surprise.
The image-graving and project-building characteristic of opium, which comes on with a sense of genial radiation from the epigastrium about a quarter of an hour after the dose, had not yet so entirely disappeared from its effect on him, as it always does at a later stage of the indulgence. But instead of being an instigation to the delightful reveries which ensued on his earlier doses, this peculiarity was now an executioner's knot in the hands of Remorse. He was daily and nightly haunted by plans and pictures whose feverish unreal beauty he remembered having seen through a hundred times. Those Fata Morgana plans, should he again waste on them the effort of construction? The result had been a chaos of aimless, ineffectual days. Those pictures, why were they brought again to mock him? Were they not horrible impossibilities? Were they not, through the paralysis of his executive faculties, mere startling likenesses of Disappointment? In his opium dreams he had seen his own ships on the sea; commerce bustling in his warehouse; money overflowing in this bank; babies crowing on his knee; a wife nestling at his breast; a basso voice of tremendous natural power and depth scientifically cultivated to its utmost power of pleasing artists or friends; a country estate on the Hudson, or at Newport, with emerald lawns sloping down to the amber river on the leek-green sea; the political and social influence of a great landholder. How pleasurably he had once perceived all these possible joys and powers! How undeludedly he now saw their impossible execution!
So, coming to me, he told me that his object in trying to leave off opium was to escape from these horrible ghosts of a life's unfulfilled promise. Only when he tried to abandon opium did he realize the physical hold the drug had on him. Its spiritual thralldom was his hourly misery.
For three months I tried to treat him in his own house, here in the city. A practitioner of any experience need not be told with what success. I could reduce him to a dose of half a grain of sulphate of morphia a day, keep him there one week, and making a morning call at the expiration of that time discover that some nocturnal nervous paroxysm had necessitated either a return to five grains or a use of brandy (which, though no drinker, he tried to substitute) sufficient to demand a much larger dose of opium in its reaction. He had lost most of his near connections, and not for one hour could any hired attendant have withstood his appeal, or that marvelous ingenuity by which, without appeal, the opium-eater obtains the drug which, to him, is like oxygen to the normal man.
This ingenuity manifests itself in subterfuges of a complicated construction and artistic plausibility which might have puzzled Richelieu; but it is really nothing to wonder at when we recollect the law of nature by which any extreme agony, so long as it continues remediable, sharpens and concentrates all a man's faculties upon the one single object of procuring the remedy. If my house is on fire, I run to the hydrant by a mere automatic operation of my nerves. If my leg is caught in the bite of a paying-out hawser, my whole brain focuses at once on that single thought, "an axe.' If I am enduring the agony which opium alone can cause and cure, every faculty of my mind is called to the aid of the tortured body which wants it. When a man has used opium for a long time the condition of his brain supervening on his deprivation of the drug for a period of twenty-four hours is such as very frequently to render him suicidal. Cottle tells us how Coleridge one day took a walk along Bristol wharves, and sent his attendant down the pier to inquire the name of a vessel, while he slipped into a druggist's on the quay and bought a quart of laudanum; but in no fibre of his nature could Cottle conceive the awful sense of a force despotizing it over his will, a degradation descending on his manhood, which Coleridge felt as he concentrated on that one single cry of his animal nature and the laudanum which it spoke for, fall the faculties of construction and insight which had created the "Ancient Mariner" and the "Aids to Reflection."
Likewise I suppose there are very few people who could patiently regard the fact that one of the very purest and bravest souls I ever knew had become so demoralized by the perseverance of disease and suffering as to deal like a lawyer with his best friends, and shuffle to the very edge of falsehood, when his nature clamored for opium. I was particular to tell him whenever I detected any evasion (an occasion on which his shame and remorse were terrible to witness) that I, personally, had nonetheless respect for him. I knew he was dominated, and in no sense more responsible for breaking his resolution than he would have been had he vowed to hold his finger in the gas-blaze until it burned off. In this latter case the mere translation of chemical decomposition into pain, and round the automatic nerve-arc into involuntary motion, would have drawn his finger out of the blaze, as it did in the cases of Mutius Sevola and Cranmer, if they ever attempted the feat credited them by tradition. In his case the abandonment of opium brought on an agony which took his actions entirely out of voluntary control, eclipsing the higher ideals and heroisms of his imagination at once, and reducing him to that automatic condition in which the nervous system issues and enforces only those edicts which are counseled by pure animal self- preservation. Whatever may have been the patient's responsibility in beginning the use of narcotics or stimulants (and I usually find, the case of opium-eaters, that its degree has been very small indeed, therapeutic use often fixing the habit forever before a patient has convalesced far enough even to know what he is taking) habituation invariably tends to reduce the man to the automatic plane, in which the will returns wholly to the tutelage of sensation and emotion, as it was in infancy; while all the Intellectual, save Memory, and the most noble and imperishable among the Moral faculties may survive this disorganization for years, standing erect above the remainder of a personality defrauded of its completion to show what a great and beautiful house might have been built on such strong an shapely pillars. Inebriates have been repeatedly known to risk imminent death if they could not reach their liquor in any other way. The grasp with which liquor holds a man when it turns on him, even after he has abused it for a lifetime, compared with the ascendancy possessed by opium over the unfortunate habituated to it for but a single year, is as the clutch of an angry woman to the embrace of Victor Hugo's Pieuvre. A patient whom, after habitual use of opium for ten years, I met when he had spent eight years more in reducing his daily dose to half a grain of morphia, with a view to its eventual complete abandonment, once spoke to me in these words:
"God seems to help a man in getting out of every difficulty but opium. There you have to claw your way out over red-hot coals on your hands and knees, and drag yourself by main strength through the burning dungeon- bars."
This statement does not exaggerate the feeling of many another opium- eater whom I have known.
Now, such a man is a proper subject, not for reproof, but for medical treatment. The problem of his case need embarrass nobody. It is as purely physical as one of small-pox. When this truth is as widely understood among the laity as it is known by physicians, some progress may be made in staying the frightful ravages of opium among the present generation. Now, indeed, it is a difficult thing to prevent relatives from exacerbating the disorder and the pain of a patient, who, from their uninformed standpoint, seems as sane and responsible as themselves, by reproaches at which they would shudder, as at any other cruelty, could they be brought to realize that their friend is suffering under a disease of the very machinery of volition; and no more to be judge harshly for his acts than a wound for suppurating or the bowels for continuing the peristaltic motion.
Finding--as is common with all physicians I have found so many times before--that no control of the case could be obtained while the patient stayed at home, and deeply renewing my often-experienced regret that the science and Christian charity of this country have perfected no scheme by which either inebriates or opium-eaters may be properly treated in a special institution of their own, I was at length reluctantly compelled to send my friend to an ordinary water-cure at some distance from town.
The cause of my reluctance was not the prospect of a too liberal use of water, for by arrangement with the heads of the establishment I was able to control that as I chose; moreover, an employment of the hot-bath in what would ordinarily be excess is absolutely necessary as a sedative throughout the first week of the struggle. I have had several patients whom during this period I plunged into water at 110 degrees Fahrenheit as often as fifteen times in a single day--each bath lasting as long as the patient experienced relief. In some cases this Elysium coming after the rack has been the only period for a month in which the sufferer had anything resembling a doze. My reluctance arose from the necessity of sending a patient in such an advanced state of the opium disease so far away from me that I must rely on reports written by people without my eyes, for keeping personally au courant with the case; that I must consult and prescribe by letter, subject to the execution of my plans by men, who, though excellent and careful, were ignorant of my theories of treatment, and had never made this particular disease a specialty. I accordingly sent Mr. A. away to the water-cure, all friendless and alone to fight the final battle of his life against tougher odds than he had ever before encountered. At no time in my life have I realized with greater bitterness the helplessness of a practitioner who has no institution of his own to take such cases to than when I shook his poor, dry sallow hand and bade him goodbye at the station.
As I said in the beginning, I am just home from seeing the result. Mr. A. has fared as special cases always do where there is no special provision for them. To speak plainly, he had been badly neglected; and that, undoubtedly, without the slightest intention on the part of the heads of the house to do other than their duty. Six weeks ago I heard from the first physician that any friend was entirely free from opium, and, though still suffering, was steadily on the mend. I had no further news from him till I was called to his bedside by a note which said he feared he was dying, penciled in a hand as tremulously illegible as the confession of Guy Fawkes. I was with him by the earliest train I could take, after arranging with a neighbor for my practice, and found him in a condition which led him to say, as I myself said at the commencement of this article: "Would to God that every young person could stand for a single hour by this bedside before Life's responsibilities have become the sentinels and Habit the jailer of the Will!"
I had not been intelligently informed respecting the progress of his case. He had been better at no time when I was told he was so, though his freedom from opium had been of even longer duration than I was advised. For ninety days he had been without opium in any form. The scope of so untechnical an article leaves no room to detail what had been done for him as alleviation. His prostration had been so great that he could not correspond with me himself until the moment of his absolutely extremity; and only after repeated entreaties to telegraph to myself and his family had been refused on the ground that his condition was not critical, he managed to get off the poor scrawl which brought me to his side.
For the ninety days he had been going without opium he had known nothing like proper sleep. I desire to be understood with mathematical literalness. There had been periods when he had been semi-conscious; when the outline of things in his room grew vaguer and for five minutes he had a dull sensation of not knowing where he was. This temporary numbness was the only state which in all that time simulated sleep. From the hour he first refused his craving, and went to the battlefield of bed, he had endured such agony as I believe no man but the opium-eater has ever known. I am led to believe that the records of fatal lesion, mechanical childbirth, cancerous affection, the stake itself, contains no greater torture than a confirmed opium-eater experiences in getting free. Popularly this suffering is supposed to be purely intellectual-- but nothing can be wider of the truth. Its intellectual part is bad enough, but the physical symptoms are appalling beyond representation. The look on the face of the opium sufferer is indeed one of such keen mental anguish that outsiders may well be excused for supposing that is all. I shall never forget till my dying day that awful Chinese face which actually made me rein my horse at the door of the opium hong where it appeared, after a night's debauch, at six o'clock one morning when I was riding in the outskirts of a Pacific city. It spoke of such a nameless horror in its owner's soul that I made the sign for a pipe and proposed, in "pigeon English," to furnish the necessary coin. The Chinaman sank down on the steps of the hong, like a man hearing medicine proposed to him when he was gangrened from head to foot, and made a gesture, palms downward, toward the ground, as one who said, "It has done its last for me--I am paying the matured bills of penalty." The man had exhausted all that opium could give him; and now, flattery past, the strong one kept his goods in peace. When the most powerful alleviative known to medical science has bestowed the last Judas kiss which is necessary to emasculate its victim, and, sure of the prey, substitutes stabbing for blandishment, what alleviative, stronger than the strongest, shall soothe such doom? I may give chloroform. I always do in the denouement of bad cases--ether--nitrous oxide. In employing the first two agents I secure rest, but I induce death nine cases out of ten. Nothing is better known to medical men than the intolerance of the system to chloroform or ether after opium. Nitrous oxide I am still experimenting with, but its simple undiffused form is too powerful an agent to use with a patient who for many days must be hourly treated for persevering pain. So the opium-eater is left as entirely without anesthetic as the usual practice leaves him without therapeutic means. Both here and abroad opium-eaters have discovered the fact that, in an inveterate case, where opium fails to act on the brain through the exhausted tissues of the stomach, bichloride of mercury in combination with the dose behaves like a mordant in the presence of a dye, and, so to speak, precipitates opium upon the calloused surfaces of the mucous and nervous layers. This expedient soon exhausts itself in a death from colliquative diarrhea, produced partly by the final decompositions of tissue which the poisonously antiseptic property of opium has all along improperly stored away; partly by the definite corrosions of the new addition to the dose. But in no case is there any relief to a desperate case of opium-eating save death.
Remembering that Chinaman's faced I can not wonder at the popular notion regarding the abandonment of opium. Men say it is a mental pain; because spiritual woe is the expression of the sufferer's countenance. And so it is, but this woe is underlain by the keenest brute suffering. Let me sketch the opium-eater's experience on the rugged road upward.
Let us suppose him a resolute man, who means to be free, and with that intent has reduced to a hundred drops the daily dose which for several years had amounted to an ounce of laudanum. I am not supposing an extreme case. An ounce of laudanum is a small per diem for any man who has taken his regular rations of the drug for a twelvemonth. In the majority of cases I have found an old habitue's daily portion to exceed three, or the equivalent of that dose in crude opium or morphia; making seventy-two grains of the gum or twelve of its most essential alkaloid. In one most interesting case I found a man who having begun on the first of January with one half a grain of sulphate of morphia for disease, at the end of March was, to all appearance, as hopeless an opium-eater as ever lived, taking thirty-two grains of the salt per day in the form of Magendie's Solution. This, however, was an unusual case. According to my experience the average opium-eater reaches twelve grains of morphia [microfiche illegible]... and may live after that to treble the amount: the worst case I ever knew attaining a dose of ninety grains, or one and a half of the drachm vials ordinarily sold. I am happy, in passing, to add that for more than two years both the extreme cases just mentioned have been entirely cured.
If the opium-eater has been in the habit of dividing his daily dose he begins to feel some uneasiness within an hour after his first deprivation, but it amounts to nothing more than an indefinite restlessness. In any case his first well-marked opium torments occur early after he has been without the drug for twenty-four hours.
At the expiration of that time he begins to feel a peculiar corded and tympanic tightness about the epigastrium. A feverish condition of the brain, which sometimes amounts to absolute phantasia, now ensues, marked off into periods of increasing excitement by a heavy sleep, which, after each interval, grows fuller of tremendous dreams, and breaks up with a more intensely irritable waking. I have held a man's hand while he lay dreaming about the thirty-sixth hour of his struggle. His eyes were closed for less than a minute by the watch, but he awoke in a horrible agony of fear from what seemed to have been a year-long siege of some colossal and demoniac Vicksburg.
After the opium-eater has been for forty-eight hours without his solace this heavy sleep entirely disappears. While it stays it never lasts over half an hour at a time, and is so broken by the crash of stupendous visions as not to amount to proper slumber. During its period of continuance the opium-eater woos its approaches with an agony which shows his instinct of the coming weeks of sleeplessness. It never rests him in any valid sense. It is a congestive decomposition rather than any normal reconstruction of the brain. He wakes out of it each time with a heart more palpitating; in a perspiration more profuse; with a greater uncertainty of sense and will; with a more confused memory; in an intenser agony of body and horror of hopelessness.
Every nerve in the entire frame now suddenly awakes with such a spasm of revivification that no parallel agony to that of the opium-eater at this stage can be adduced, unless it be that of the drowned person resuscitated by artificial means. Nor does this parallel fully represent the suffering, for the man resuscitated from drowning re-oxidizes all his surplus carbon in a few minutes of intense torture, while the anguish which burns away that carbon and other matter, properly effete, stored away in the tissues by opium, must last for hours, days, and weeks. Who is sufficient for this long, long pull?
From the hour this pain begins to manifest itself it continues (in any average case of a year's previous habituation to the drug) for at least a week without one second's lull or exhaustion. A man may catch himself dozing between spasms of tic-douloureux or toothache; he never doubts whether he is awake one instant in the first week after dropping his opium. One patient whom I found years ago at a watercure followed the watchman all night on crutches through his tour of inspection around the establishment. Other people, after walking a long time, shift from chair to chair in their rooms, talking to anybody who may happen to be present in a low-voiced, suicidal manner, which inexperience finds absolutely blood-freezing. Later such rock to and fro, moaning with agony, for hours at a time, but saying nothing. Still others go to their beds at once, and lie writhing there until the struggle is entirely decided. I have learned that this last class is generally the most hopeful.
The period during which this pain is to continue depends upon two elements.
1st. How long has the patient habitually taken opium?
2d. How much constitutional strength remains to throw it off?
"How much has he taken in the aggregate?" is practically not an 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 equaled 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. FN* _____ *FN I say "chemical" because so much it is possible to known experientally; 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 fiber 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?" ** FN ------- ** (FN) Not correspond day by day. At that rate a reforming opium-eater (I use the particle 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; and 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 constitution 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 alleviates, 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 typantic tightness, corrosive acid ructations, heartburn, 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 unconsciousness.
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 center 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 which 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 daylight, 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 arrowroot or sago, and beef-tea. Of the vegetable preparation he took perhaps half a dozen tablespoonfuls a day; 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 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 stage 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** FN ----- ** (FN) 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 habituation, 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 fibers 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 assimilative 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 Pharmacopeia. 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, alumia, and potassa. Second, two organic and one simpler acid--acetic (absolutely vinegar), meconic (one of the most powerful irritants which can be applied to the intestines through the bile), and sulfuric. All three 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 cannot state the constitution of this chlorophyll, 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 fiber, 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 bassorin. Sugar, are 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, atropine, 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 (cotarnine) 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 coasts. (Pseudo-morphia when it occurs belongs to these.) So do porphyroxin; narceine; probably papaverine 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 paramorphia or thebaine. (It may interest amateur chemists to know that its difference from strychnia 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: narcotine; codeine; 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-gain doses (American Journal of Pharmacy, September, 1861); opianin in its physical effects closely approximates morphia; codeia 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 marvelous complexity of opium we might be led to the a priori supposition that its versatility of action on the human system must be equally marvelous.
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, thebaine), are swifter agents; but this perilous opium quintette signs 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.
At length some terrible dawn rouses him out of a bad sleep into a worse consciousness. Though the most untechnical man, he must already know the disorder which has taken place in his moral nature and his will. For a knowledge of his physical condition he must resort to his medical man, and what, when the case is ten years old, must a practitioner tell the patient in any average case?
"Sir, the chances are entirely against you, and the possession of a powerfully enduring constitution, if you have it, forms a decided offset in your favor."
He then makes a thorough examination of him by ear, touch, conversation. If enough constitution responds to the call, he advises an immediate entrance upon the hard road of abnegation.
If the practitioner finds the case hopeless he must tell the patient so, in something like these words:
"You have either suffered a disorganization of irreproducible membranes, or you have deposited so much improper material in your tissue that your life is not consistent with the protracted pain of removing it.
"One by one you have paralyzed all the excretory functions of the body. Opium, aiming at all those functions for their death, first attacked the kidneys, and with your experimental doses you experienced a slight access of dysuria. As you went on, the same action, progressively paralytic to organic life, involved the liver. Flatulence, distress at the epigastrium, irregularity of bowels, indicated a spasmodic performance of the liver's work, which showed it to be under high nervous excitement. your mouth became dry through a cessation of the salivary discharge. Your lachrymal duct was parched, and your eye grew to have an arid look in addition to the dullness produced by opiate contraction of the pupil.
All this time you continued to absorb an agent which directly acts for what by a paradox may be called fatal conservation of the tissues. Whether through its complexity combined nitrogen, carbon, or both, the drug has interposed itself between your very personal substance and those oxidations by which alone its life can be maintained. It has slowed the fires of your whole system. It has not only interposed but in part it has substituted itself; so that along with much effete matter of the body stored away there always exists a certain undecomposed quantity of the agent which sustains this morbid conservation. **FN ----- ** (FN): I frequently use what hydropaths call "a pack" to relieve opium distress, and with great benefit. After an hour and a half of perspiration, the patient being taken out of his swaddlings, I have found in the water which was used to wash out his sheet enough opium to have intoxicated a fresh subject. This patient had not used opium for a fortnight. -----
"When this combination became established, you began losing your appetite because no substitution of fresh matter was required by your body for tissue wrongly conserved. The progressive derangement of your liver manifested itself in increased sallowness of face and cornea; the organ was working on an inadequate vital supply because the organic nervous system was becoming paralyzed; the veins were not strained of that which is the bowels' proper purgative and the blood's dire poison. You had sealed up all but a single excretory passage--the pores of the skin. Perhaps when you had opium first given you you were told that its intent was the promotion of perspiration but did not know the rationale. The only way in which opium promotes perspiration is by shutting up all the other excretory processes of the body, and throwing the entire labor of that function upon the pores. (When the skin gives out the opium- eater is shut up like an entirely choked chimney, and often dies in delirium of blood-poisoning.)
"For a while--the first six years, perhaps--your skin sustained the work which should have been shared by the other organs--not in natural sweat, but violent perspiration, which showed the excess of its action. Then your palms became gradually hornier--your whole body yellower--at the same time that your muscular system grew tremulous through progressively failing nervous supply.
"About this time you may have had some temporary gastric disturbance, accompanied with indescribable distress, loathing at food, and nausea. This indicated that the mucous lining of the stomach had been partially removed by the corrosions of the drug, or that nervous power had suddenly come to a standstill, which demanded an increase of stimulation.
"Since that time you have been taking your daily dose only to preserve the status in quo. The condition both of your nervous system and your stomach indicate that you must always take some anodyne to avoid torture, and your only anodyne is opium.
"The rest of your life must be spent in keeping comfortable, not in being happy.:
Opium-eaters enjoy a strange immunity from other disease. They are not liable to be attacked by miasma in malarious countries; epidemics or contagions where they exist. They almost always survive to die of their opium itself. And an opium death is usually in one of these two manners:
The opium-eater either dies in collapse through nervous exhaustion (with the blood poisoning and delirium above-mentioned), sometimes after an overdose, but oftener seeming to occur spontaneously; or in the midst of physical or mental agony, as great and irrelievable, as men suffer in hopeful abandonment of the drug, and with a colliquative diarrhea, by which--in a continual, fiery, acrid discharge--the system relieves itself during a final fortnight of the effete matters which have been accumulating for years.
Either of these ends is terrible enough; let us draw a curtain over their details.
Opium is a corrosion and paralysis of all the noblest forms of life. The man who voluntarily addicts himself to it would commit in cutting his throat a suicide only swifter and less ignoble. The habit is gaining fearful ground among our professional men, the operatives in our mills, our weary sewing women, our fagged clerks, our disappointed wives, our former liquor-drunkards, our very day-laborers, who a generation ago took gin; all our classes, from the highest to the lowest, are yearly increasing their consumption of the drug. The terrible demands, especially in this country, made on modern brains by our feverish competitive life, constitute hourly temptations to some form of the sweet, deadly sedative. Many a professional man of my acquaintance, who twenty years ago was content with his tri-diurnal "whiskey," ten years ago, drop by drop, began taking stronger "laudanum cocktails," until he became what he is now--an habitual opium-eater. I have tried to show what he will be. If this article shall deter any from an imitation of his example, or excite an interest in the question--"What he shall do to be saved?"--I am content.
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