The narcotic drug diseases and allied ailments; pathology, pathogenesis, and treatment

Front matter

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THE NARCOTIC DRUG DISEASES

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Contents

CHAPTER PAGE

INTRODUCTORY v

I. History, Definitions, Pathology, Etiology 1-27

Chapter I. History, Definitions, Pathology, Etiology

As it is the purpose of the author to make this work one of an intensely practical nature, to record the conclusion of the author based solely upon his own clinical experience, it is not considered in harmony with that purpose to enter upon a lengthy historical consideration of the uses of narcotic drugs. Suffice it to say that the effects of the cruder forms of narcotic drugs were known to the ancients, and these were used from time to time for their pain-relieving and hypnotic effects; but, it is not believed that the habitual use of any of these agents existed to any considerable extent until after the discovery of morphine, the principal alkaloid of opium.

The writings of DeQuincy during the early part of the last century doubtless did more to publish and to popularize the use of opium than any other, or possibly than all other influences had done up to that time. His exaggerated descriptions of the pleasurable effects of opium led many to experiment upon themselves with it, and often these experiments resulted in complete enslavement. These influences, however, led them to the uses of gum opium, or liquid preparation made from it, by the mouth, and the resulting addiction was supposed to depend mainly upon a cultivated appetite for the drug, spoken of usually as a craving. This appetite or craving was regarded as the essential basis of the so-called habit. This was the accepted view up to the time of Magendie.

After the discovery of the alkaloid morphine and the perfection of the hypodermic syringe, Magendie intro-

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duced his solution of morphine for hypodermic use, and among the other claims made for this method of administration it was urged that its use, hypodermically, would not produce an addiction, the theory being advanced that, since its use subcutaneously could not create an appetite accompanied by craving for the drug, as such, it did not establish an addiction, or, as it is erroneously spoken of, a habit.

Both the profession and the faity, in following these teachings, found after it was too late that the hypodermic use not only formed an addiction, but that the resulting condition was the worst form of addiction.

The author had, recently, under his care a Harvard graduate who, with a class of four others, became addicted to morphine during the last year of their medical course, they having the assurance of one of the faculty that the use of morphine hypodermically would not produce addiction. Four of this quintet died prematurely, two committing suicide, while the fifth after thirty-seven years of enslavement was finally released by treatment.

These fallacious teachings did much to increase the number of habitual users of opium, but aside from these influences the discovery of morphine and the perfection of the hypodermic syringe have been the greatest factors in extending the use of narcotics.

"In 1864 the first case was reported in which the hypodermic injection of morphine had induced the condition known as morphinism. Dr. Bertrand was the first who published a case in which morphine was used hypodermically, the patient being the wife of Dr. Wood, of Edinburgh, who taught the method to Dr. Bertrand. Dr. Bertrand remarks that Cassargne, in 1836, first recommended such a mode of administration to the Paris Academy. This method, however, soon fell into oblivion,

Essential Nature of Addiction.

and was reintroduced by Dr. Wood, of Edinburgh." ("Amer. Text Book of Applied Therapeutics.")

It has only been during the last quarter of a century, however, that narcotic addiction has grown to such proportions as to attract much attention. The evil is now recognized as alarmingly extensive and rapidly spreading. It is hardly profitable, therefore, at this time to consider farther the origin and growth of the addiction. This has been sufficiently done by others.

DEFINITIONS.

The term "morphinism," or morphine disease, is used in this work to include all forms of opium disease. In fact, it is intended in most instances to be the equivalent of narcotic disease. While sixteen alkaloids have been isolated from opium, morphine is present in so much larger quantities, and is so much more potent than any of the other alkaloids, that practically all the medicinal or narcotic effects of that drug are due to the alkaloid morphine.

Whether the addiction be to the habitual use of crude opium or to an extract or tincture made from it, or to the active principle, morphine, or to one of its derivatives, the essential nature of the ailment is the same. Therefore, it is merely a waste of time and unnecessary multiplication of words to consider separately the opium addiction, the laudanum addiction, the morphine addiction, the codeine addiction, the heroin addiction, etc., since, no matter in what form the narcotic is used, the pathology and treatment are practically the same.

The only essential difference presented by users of various preparations of opium is in the time required for the disease to be confirmed, and in the prognosis. One of these differences is that codeine and heroin can be used for a longer period without formation of addiction than any of the other preparations of opium, and the other is that those addicted to opium smoking are more prone to relapse after being cured than those who use opiates in other forms. With these two modifications borne in mind, the various forms of opium disease may be considered identical. The prolonged use of any drug the effects of which retard excretion of the products of waste results in the formation of an addiction, or, more correctly speaking, causes a disease.

Other Definitions and Distinction of Terms. — Most writers on morphinism use the terms "morphinism" and "morphinomania" interchangeably, as meaning one and the same thing. The author considers this an error. The classes of persons to which these terms should be applied differ widely, and the conditions presented by them differ in etiology, treatment, and prognosis ; therefore, each of these terms should be restricted in its use to the particular class of persons to which it properly applies.

Morphinism grows out of the prolonged use of morphine by a person of any type or character ; no agency, except the use of the drug, enters into its production. Such a person is properly spoken of as a morphinist. In such cases the use of the drug is begun for the relief of pain; or, inadvertently, without any element of dissipation entering into it. The use of the drug is continued in such cases because of the continuation of the causal suffering or because of the difficulties involved in its renunciation. No mental element which properly could be held to be a mania is present or contributed in any way to the production of the addiction (disease). Probably 75 per cent, of all morphine users in the United States are morphinists.

The Elements of "Habit.'

Morphinomania, on the other hand, not only involves the habitual use of morphine, as in the case of morphinism, but in addition to that a mania for the drug exists. This mania may have arisen from inherited or acquired mental and nervous characteristics, or it may be the product of experiences to which the individual was subjected after the addiction (disease) was formed; but in either case it will be found to be the most troublesome factor during treatment and the one which will most influence the prognosis.

Most emphatically the terms morphinism and morphinomania should not be used interchangeably ; the two classes of patients differ in all respects as greatly as do sane and insane persons suffering from any other ailment.

Morphine Habit; Opium Habit. — The author considers it very unfortunate that the terms "morphine habit" and "opium habit" have been, and are still, so universally employed when referring to narcotic addiction (disease). They are misleading and do not, in any wise, accurately describe the condition present.

Habit implies the continued repetition of an act, because it has been so often done before that it does not require a new or repeated exercise of one's volition to accomplish it. The act is automatic or so nearly so that it does not require the conscious act of the will to accomplish it.

Habit is established according to the laws of the transmission of nerve impulses. An impulse in traversing a certain course meets with greater resistance the first time than afterward. The oftener it is repeated, the less resistance it meets in traveling over the same path. As these acts are frequently repeated the impulse travels over this well-worn path with almost no resistance, and then habit is fully established, but all that is necessary to interrupt this course of action and suspend it altogether is the existence or generation of a purpose to have it arrested and the exercise of the will to carry out that purpose.

The exercise of the will alone is sufficient to interrupt and suspend any course of conduct arising entirely from force of habit. That is not true of narcotic disease ; therefore, it is not a mere habit and should not be spoken of as such.

The habitual use of the drug is in response to an irresistible demand. That demand is the result of a toxic diathesis produced by the administration of the drug. The condition often exists without any psychological element entering into it, and the patient may bear no moral responsibility with reference to it. He is diseased, and is entitled to the same consideration accorded victims of any other disease.

The repeated administration of narcotic drugs will inevitably result in the demand for continued and constant use. In some cases narcotic drugs may be used repeatedly with a greater degree of safety than in other cases, but this does not alter the fact that the most adamant character and the most superb physique will ultimately succumb to the continued administration of narcotic drugs for an indefinitely prolonged period. Such a condition cannot with justice be called "habit" or "addiction."

The "habit" of using a drug is only a symptom, just as the habit of coughing is a symptom of some chronic ailments. The use of the drug produced the disease; the disease produced the habit.

Why are certain drugs "habit" producing and others non-"habit" producing? Out of the discriminate answer

Pathology. 7

to this question comes justice to the morphine user and a rational conclusion in regard to therapeutic measures for the aid of the unfortunate.

The entire pharmacopeia can be divided into two classes: the "habit"-producing drugs and the non- "habit"-producing drugs. The first class consists of the narcotics and hypnotics or toxic drugs which render torpid the vital functions of secretion and excretion, resulting in toxemia.

The non-"habit"-producing drugs can be given repeatedly and for prolonged periods without the formation of "habit," and their use can be discontinued without discomfort. They do not lock up the secretions ; their use does not produce toxemia and does not result in the formation of "habit." These incontrovertible facts furnish a key to the pathogenesis of the drug habit as well as an index to the therapeutic measures likely to be of greatest service in the treatment of that condition.

PATHOLOGY.

Much confusion has existed and still exists as to the pathology of narcotic addiction. It has usually been classed as a neurosis. Thousands of pages have been written, giving fine-spun theories as to the possible existence of some obscure, undefined brain or nerve lesion, which would account for the symptoms attending the use of narcotic drugs, and especially for the symptoms which attend or follow the withdrawal of narcotics from those addicted to their use.

The resources of the microscope and of the clinical laboratory have been exhausted in an effort to demonstrate the presence of such a structural lesion, but without avail. The only structural lesions that have been demonstrated in these conditions are the changes in the blood, and these do not differ from those existing in other anemic conditions. Most medical writers, not accepting these fine-spun theories of neurologists, dismiss this part of their subject with the statement that the pathology is nil.

The structural pathologists, those who insist that every pathological condition is the result of a structural lesion, have had the ear of the profession, and have so dominated professional opinion during the last halfcentury, that few men have been bold enough to insist that a real pathological condition could exist without an underlying or attending structural lesion.

During the last few years, however, professional opinion has undergone a considerable change and it is not at this time considered lese-majesty to say that a disease may be purely functional and yet be of such gravity as not only to require active treatment, but to cause death, if not so treated.

Those who have studied the subject have been confronted by conditions which they have interpreted in divers ways, but in their efforts to reason backward from effect to cause they have been lost in the hazy marsh of superstition as completely as those who wrote on malaria and yellow fever a generation ago. Their bewilderment was increased and the truth longer concealed by the dogmatic teaching of structural pathologists.

Writers on drug addiction (disease), being guided by such teachings, have striven in every way to demonstrate a structural lesion in drug addiction. Every structure of the body has been minutely examined, but the microscope has steadily refused to verify the presence of any lesion which would account for the conditions present. The manifestations which were most prominent being of a nervous character, some obscure lesion

Erroneous Views of Pathology.

of the nervous system has been supposed to exist, but no one has been able to demonstrate its presence.

At this point, writers have diverged in their views. Some, while being unable to demonstrate the presence of a structural pathology, have still held that it did exist, and that this obscure, undennable, undemonstrable lesion was the cause of all the manifestations of disease seen in these cases. Being uncertain as to pathology, their suggestions as to treatment were as full of unreason and superstition as their views of pathology were vague. They, however, took refuge in a generic term, neurosis, and classed these addictions as such and advised symptomatic treatment.

The nervous manifestations presented in these cases were so nearly innumerable and so mystifying that the practical man who attempted to treat a patient of this class symptomatically soon found himself in deep water, and very shortly would throw up his hands in horror and cry out with Da Costa and others, "There is no remedy for the opiate habit," and "There is no help for the widow's son." Those who held the views of writers of this class, practically, gave up these cases as hopelessly incurable.

Other writers, more materialistic, but less consistent, not recognizing any other than a structural pathology for disease, and being unable to demonstrate the presence of a structural lesion in narcotic addiction (disease), took the position that there was no pathology. Writers of this class dismiss that part of the subject with a sweeping statement couched in four words, "The pathology is nil"

These writers, however, were still confronted with the manifestations attending the uses of narcotic drugs. They were still confronted by living facts for which they must account in some way. In an effort to escape from this dilemma they took refuge in the word "vice." They therefore classed narcotic-drug addiction as a mere vice, a perversion of the will, a degenerate state into which the victim entered from choice, claiming that in pursuing such a course he was prompted or led by inherited or acquired degeneracy, asserting that all who fell into the use of narcotic drugs were, primarily, neurotic weaklings who, by yielding to the influence of the drug, had been made doubly unreliable. They made free use of such terms as "perverts," "fiends," "inveterate liars," etc., and classed every drug user as one who had willfully yielded his God-given powers of self-control, and voluntarily accepted the dominion of a mere vice. These views are not tenable.

While it is true that many nervous manifestations attend the use of narcotics, and especially the disuse of narcotics by those who are habituated to their use, still the condition is not in any sense a true neurosis; but it is purely and solely a toxemia, and as such it belongs to the field of internal medicine and not to neurology.

The author is aware that this classification will be objected to, but it is confidently believed that before this treatise shall have been completed the evidence produced will be such as to sustain his position.

There is as much reason to classify typhoid fever as a neurosis as there is to classify narcotic-drug addiction (disease) as such. The exaggerated nervous condition manifested by typhoid patients is equally as marked as that seen in drug addiction, yet we know that typhoid fever is an infection and a toxemia combined.

More than ten years ago the author reached the conclusion that the essential pathology of narcotic-drug ad-

Suffering from Withdrawal, Avoidable. 11

diction (disease) is a toxemia, a toxemia of drug, auto-, and intestinal origin.

This view was the outcome of the study and treatment of about 150 drug patients. But, while the proposition was then announced, its full significance was not really comprehended. Clinical observation made during the treatment of more than 3000 patients of this class since that time has given the author ample opportunity to verify, in every detail, the claim then made.

The author feels fully warranted in saying that every symptom attendant upon the use or the disuse of a narcotic drug is the direct outcome of drug, auto-, and intestinal toxemia. Just in proportion to which the toxic condition of the system is overcome, all these nervous manifestations disappear.

It is the belief of the author that if a drug patient could be made cell clean, that is, if every cell and structure of the body could be entirely freed from toxic matter, there would be no nervous manifestations or suffering incident to or following the withdrawal of narcotics from an habitue.

It is impossible to perfectly cleanse the system of a drug user, so long as any quantity of the drug is taken. Still, the nearer this ideal condition is approached, the less suffering accompanies or follows the withdrawal of the opiate.

While we have been unable, by laboratory methods, to demonstrate the pathology of morphinism, we have reached the conclusion by clinical experience, acquired in handling a wide and varied series of narcotic patients, that this view of the pathology is unquestionably correct. In such circumstances as this, where we have not the data to enable us to reason from cause to effect, the most practical mode open to us of studying such questions, is to reason backward from effect to cause.

If in pursuing this course with reference to the pathology of narcotic-drug addiction (disease), we take up the impressions made by the narcotic on the system and analyze them, we find the following conditions to exist : The first dose of morphine brings about a state of quietude or torpor which is soon succeeded by sleep, accompanied by diminished or completely arrested peristaltic action. This is followed by constipation, with reduced activity of all the secreting and excreting glands. In the course of from eight to twelve hours the hypnotic effect and most of the other effects have subsided, and the functional activity of the system has become normal, and possibly secretion and excretion are carried on at a slightly accelerated rate ; but it requires several days for this increased activity of the excreting organs to free the system from the products of wastes which should have been eliminated during the time these functions were retarded by the benumbing influence of the narcotic.

Now, if before that is accomplished another dose of the drug is taken, the eliminating organs are again interfered with in their work, and if this is repeated from day to day the system soon becomes surcharged with the products of tissue disintegration and their fermentative compound.

These waste products play a much more important role in causing the difficult complications met upon the withdrawal of morphine, known as abstinence symptoms, than does the drug itself. After the use of the drug is kept up for a time, upon examination of the patient, we find the skin dry and crusty, the tongue coated, breath foul, bowels habitually constipated, digestion impaired, heart action defective, and other evidences of portal engorgement.

Symptoms Incident to Withdrawal.

When the administration of the drug is discontinued and the patient is allowed to go for a time without it, some of these symptoms give way to others of a different character, while others of them are merely intensified, but not changed in character. The dry skin gives way to excessive sweating, the constipation to diarrhea, colic, nausea, and other evidence of gastrointestinal disorder. With this clinical picture before us, we could arrive at no other conclusion but that the patient's system was intensely saturated with toxins of intestinal and auto-origin.

With toxins existing in the system to the degree indicated by this clinical picture, we should have no difficulty in accounting for the perverted functional activity of every organ in the body, as well as for the various and sundry nervous manifestations incident to the withdrawal of the drug. So long as the drug is taken at regular intervals, in the accustomed dose, the nerve centers are kept benumbed so as not to be responsive to the irritating effects of this toxic accumulation. But if the drug is withheld in whole or in part the nervous system soon becomes sensitive and therefore responsive to toxic irritation, and various functional derangements are at once apparent.

Among the early symptoms incident to the withdrawal is a slight rising of temperature, and as the hours following the withdrawal of the drug pass this temperature rise increases, and if left uncontrolled will run to very high degrees. This fever is accompanied by the most intense aching of the bones, limbs, and in fact every part of the body is in more or less discomfort. Every nerve in the body seems to be on the outside and as if it were being lacerated by some instrument of torture.

Appearing about the same time as the beginning of this rise of temperature can be noted a zone of. uneasiness about the umbilicus, known as colic. This increases as the system becomes less and less under the influence of the drug until the pain is distressing. The heart action grows much more rapid and the pulse is small and jerky. This difficult heart action is usually attended by excessive sweating, intermittent in type, resembling to some extent intermittent fever, that is, the skin will be dry and there will be an abrupt rise of temperature due to the irritative effects of the toxins, and this seems to overpower the heart and the circulation becomes deficient, and then the body soon becomes bathed in a cold, clammy sweat, during which there is a recession of the fever.

Nausea and vomiting usually precede or appear synchronously with the excessive diaphoresis and persistently continue until some relief of the engorged condition of the gastrointestinal system is effected. If diarrhea sets in, the nausea will not be so marked, but so long as the bowel is not moving freely the vomiting continues and often becomes stercoraceous.

The suffering of the patient under such circumstances is extreme, and it could not be expected that one would stand so intense suffering without doing anything in his power to obtain relief. This urgent physical demand for the quieting effects of the narcotic has been interpreted as being a mania for the drug, but it should not be so classed.

These symptoms have a real physical basis.

In examining more minutely into the condition of the various organs we find that the activity of the liver and intestinal glands is diminished. The rhythmic motion of the intestines is suspended, alvine dejections are arrested, and the excretion of urea is slightly decreased.

The effects of the drug, continually used, result in the retention of a large percentage of the products of

Influence of Narcotics on Intellect. 15

tissue waste. The presence of this excrementitious matter in the system leads to the formation of ptomaines and other ferments, digestion and assimilation are thereby much impaired, and the victim soon becomes intensely self-poisoned and, later, profoundly anemic.

The nervous system under the constant influence of this toxic matter becomes unsteady and irritable, and in a short time the patient presents a picture of an aged, neurotic, anemic wreck.

From a grosser anatomical standpoint, no structural lesions result from the prolonged use of opiates, but a careful physical examination reveals unmistakable evidence of the most widespread functional derangements : the blood is thin and deficient in the oxygen-carrying red corpuscles; the mucous membranes are pale, — in fact, all the structures show signs of profound anemia; the abdomen is full and unduly indurated; the liver is enlarged and the portal system engorged; tongue coated; breath foul; skin alternately dry or excessively active, but always swarthy and yellow; heart action variable, depending upon the stage of narcotic impression; nervous reflexes either blunted or exaggerated; the muscles are flabby and relaxed ; the memory is impaired ; mind inactive, and the entire bearing of the patient is one of dejection and hopelessness.

To sum up, the evidence clearly indicates a condition of intense intoxication, with profound anemia, attended by derangement of the nervous system and impaired mentality.

The powers of perception are materially blunted, and actions based on perception may not represent the real intent of the individual, because erroneous conclusions are likely to be drawn from these impressions; actions based upon such conclusions would be correspondingly erroneous or untrue to the real intent of the individual, but actions arising from a concept do usually represent the real purposes of the individual.

A person in such condition is unable to acquire new facts for the reason that the perceptive faculties — in fact, the entire nervous system — are so blunted that impressions coming from without are not distinctly perceived, and, as these are received in a blurred and indistinct manner, they are not registered with such completeness as to be recalled accurately by a future effort of the memory. It is almost out of the question for one in this condition to memorize any composition, or to recall with perfect accuracy impressions received from without.

This defect, or inability to reproduce accurately impressions received from without, has done much to create the impression that all drug habitues are notoriously untruthful. This, as applied to many of them, is an unjust accusation.

It is true that many drug habitues do not make any approach to truthfulness, but, when the influences under which this state of affairs has developed are considered, it will be found that many influences other than the effects of the drug itself have contributed to the development of their untruthful habits. This phase of the subject, however, will be more fully considered in a later chapter of this work.

The most satisfactory evidence of the correctness of the views of the pathology of narcotic addiction (disease), herein stated, will be found in the results of the treatment based on such views. This evidence will be presented in detail in the chapters on Treatment.

If the long sought for brain or nerve lesion exists as a pathological factor in these cases all evidence of its existence certainly disappears under rational treat-

Etiology. 17

ment based upon the pathology herein denned. Since the cure of the patient is the object of this study, and since this is accomplished by treatment based on the views herein stated, the author has no inclination to enter into a "hair-splitting" discussion as to the possibilities of the existence of a disease without an underlying structural lesion.

ETIOLOGY.

The alarming rate at which the habitual use of narcotic drugs has increased during the last four decades is a matter which should give us the deepest concern. Two or three factors have contributed to this result. The first and most important is the popularizing of the hypodermic syringe which has occurred during that time.

Before the introduction of the hypodermic syringe, people had not been taught to expect immediate relief as soon as the physician arrived. Then, the physician was free to administer such remedies as were indicated, and the patient had no other idea than that he must wait a reasonable time for relief from them.

But during recent years the people have been taught to expect relief from pain as soon as the physician arrives. They understand that he can give a hypodermic dose and immediate arrest of pain will follow. This demand is so urgent and universal that many physicians fail to withstand it. Every physician understands that if he refuses to yield, another may be called in his stead who will do so. As he does not wish to surrender his case to a competitor, he feels almost compelled to comply with the demand of the patient or his friends for immediate relief. He gives the soothing potion, and thus unwittingly contributes his moiety to the education of the public in the wrong direction.

Should the patient's ailment be a chronic and painful one, the repetition of these doses often leads to complete enslavement. A majority of the victims of narcotic drugs among the laity trace their addiction to the administration of drugs by a physician.

It should be a universal rule, however, among physicians to use an opiate only where one or two doses will suffice. When the ailment is a chronic painful one it is worse than folly to begin to relieve that pain with an opiate. This should not be done, not only because it generally leads to enslavement, but because it is not a curative treatment. On the contrary, opiates check secretion, and therefore perpetuate and aggravate any existing painful ailment.