Chapter 21

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 none the less 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 Scaevola 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 counselled 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, in 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 and 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 ascendency 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 stand-point, 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 judged harshly for his acts than a wound for suppurating or the bowels for continuing the peristaltic motion.

Finding--as in 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° 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 any thing resembling a doze. My reluctance arose from the necessity of sending a patient in such an advanced stage 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 good-bye 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 in places 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 my 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, pencilled 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 un-technical 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 absolute 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 battle-field 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, contain 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 _dénouement_ of bad cases--ether--nitrous oxyd. 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 oxyd 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 anæsthetic 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, bichlorid 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 face, 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 _habitué'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 in ten years, 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-oxydizes 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 water-cure 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 any body 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 equalled that of 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. [Footnote: I say "chemical" because so much it is possible to know experimentally; 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 fibre 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?" [Footnote: Not correspond day by day. At that rate a reforming opium-eater (I use the principle 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; a 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 constituion 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 alleviatives, 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.