Chapter 22
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 tympanic tightness, corrosive acid ructations, heart-burn, 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 unconciousness.
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 centre 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, winch 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 day-light, 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 arrow-root or sago, and beef-tea. Of the vegetable preparation he took perhaps half a dozen table-spoonfuls daily; 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 a 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 state 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 [Footnote: 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 habitation, _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 fibres 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 assimulative 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 Pharmacopoeia. 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, alumina, and potassa. Second, two organic and one simpler acid--acetic (absolute vinegar), meconic (one of the most powerful irritants which can be applied to the intestines through the bile), and sulphuric. All these 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 can not state the constitution of this chlorophyl, 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 fibre, 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 bassorine_. Sugar, a 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, atropin, 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 (cotarnin) 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 coats. (_Pseudo-morphia_ when it occurs belongs to these.) So do _porphyroxin; narcein_; probably _papaverin_ 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 paramorphta or thebain. (It may interest amateur chemists to know that its difference from strycchnia 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; narcotin; codein; 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-grain doses; [Footnote: American Journal of Pharmacy, September, 1861.] opianin in its physical effects closely approximates morphia; codein 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 marvellous complexity of opium we might be led to the _apriori_ supposition that its versatility of action on the human system must be equally marvellous. 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, thebain) are swifter agents; but this perilous opium quintette sings 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 _dysouria_. 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 complexly 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. [Footnote: 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 stand-still, which demanded an increase of stimulus.
"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: