THE TREATMENT OF THE OPIUM AND MORPHIA HABITS.
So many of our fellow-men have been, in the past, are now, and will be,
bound hand and foot in this terrible bondage, from which they seem utterly
incapable of releasing themselves; so many illustrious men have offered
themselves as living sacrifices to this false deity; so many lives have
been ruined, homes desolated, hopes destroyed, ambitions smothered by
it; so many of those dear to us have fallen beneath the shadow of this
sickening evil; so rapidly is the habit spreading, that the question of
its treatment and cure has become one of momentous importance.
Reading the histories of those cases where a cure was effected some
years ago, one’s mind is divided between admiration of the great heroism
displayed by the unfortunates, and pity for the agony which they were
allowed to endure.
Great advances have been made in the treatment of this affection in the
last few years, and to-day, although science is unable to substitute for
the accursed drug one that can fully take its place, still she can lend
a helping hand, whereby the ascent is made easier and more rapid. The
suffering incident to the breaking of the habit can, in a great measure,
be relieved.
The method strongly advocated and practiced by Levenstein, of Germany, I
consider barbarous in the extreme, and dangerous. The following cases,
a type of all, selected from those published in his book,[40] well
illustrate this:—
Mr. von X., sent to the Institution by Professor Westphal, had caught
cold while on a journey, which brought on rheumatic pains. To relieve him
injections of morphia have been administered since 1872, at first by the
medical attendant, and afterward by the patient himself, and in increased
quantities, the largest daily dose having amounted to sixteen grains.
The symptoms showing themselves in consequence of this use were loss of
appetite and sleep, excited condition, emaciation, tremor of the hands.
On October 9, 1875, patient came into the Institution; he had injected
morphia for the last time on the morning of the same day. At 10 P.M.
patient went to bed and at once fell asleep. At 3.30 A.M. he was sick,
felt very weak and prostrate, suffered from twitching in the lower
extremities and diarrhœa.
October 10. In the morning patient had five relaxed motions. Frequent
vomiting during the whole of the day. Excitement and intense craving for
morphia increases hourly. In the afternoon he talks of suicide.
October 11. Patient has had no sleep during the night, but has been
frequently sick. Severe vomiting continued until 11 A.M., but stopped
entirely during the rest of the day. Patient complains of languid pains in
the legs, severe pain in the stomach.
October 12. At 10 P.M. patient suddenly started up, and in a frightened
manner asked, several times, “Was not the doctor in the room just now?”
only the nurse having been present. Until 12 P.M. he laid in bed quietly
without speaking; he afterward raised himself up and screamed out, in
great excitement, “Who is that big fellow in the next room? He is so tall
that he cannot get through the door! And now he is getting taller still.
Now there are several of them; they are ghosts!” His voice was trembling,
his extremities in constant convulsive movements. He was quieted, but only
with great difficulty. Again and again he raised himself and anxiously
looked at the door. Temperature, 38.5° C. (101.3° F.). In the morning the
patient addressed the superintendent, as he entered, as follows: “Ah,
good morning, dear Emily. I am very glad you are coming!” While saying
so he was lying down quietly. Now and then he raised his head slightly
and looked at the wall for a time, as if observing something, and his
lips were moving as if he was talking to somebody. In the course of the
day he vomited considerably, several times. Patient feels very weak, the
speech is unintelligible, the tremor has increased. He entered into a
short conversation, and thinks himself better than yesterday. Although
very tired he cannot get to sleep. Pulse was strong throughout the day.
Auscultation and percussion of the lungs and heart showed a normal
condition. The bladder was empty and no urine was passed until 5 P.M.
Several relaxed motions.
October 13. Toward midnight patient suddenly raised himself up, looked
around, stretched his hands, as if frightened, and called out in a
trembling voice, “What do you want? There is the—the ghost!” The voice
next morning was hoarse, hesitating, unintelligible, devoid of sound. The
features looked worn. During the whole of the day there was diarrhœa and
vomiting. An injection of food into the bowels was given (after Leube).
October 14. Patient has slept for only a quarter of an hour in the night.
The other part of the time he was dozing; vomited four times, and had four
relaxed motions. At 5 A.M. he called out to those watching him during
the night, “Come along, come along, quick, quick!” He gradually lost
consciousness, did not move upon being called. Pulse 40, very small,
hardly to be felt; respiration gasping, slow. Hippocratic face. Injected
one-fourth of a grain of morphia. Pulse and respiration soon became
regular, and he regained his consciousness. There was no vomiting during
the day. The voice is still gone, the features worn. Toward the evening
the patient had an injection of food (Leube) of sixteen and a half ounces.
Great prostration. Skin moist and hot.
October 15. Patient had no sleep, but lay quietly in bed until about 2
A.M., when there was vomiting, oppression, moaning, clonic contractions of
the muscles of the face and extremities. Pulse strong.
October 16. He had three relaxed motions, vomiting and bleeding of the
nose during the night. During daytime patient felt well.
October 17. Patient has had no sleep during the night, but was quiet;
vomiting and diarrhœa. In the day feeling of great weakness. Appetite good.
October 18. No sleep, patient feels thoroughly knocked up. In the
afternoon he slept for a short time.
From this time the patient’s condition was satisfactory. He slept at first
for three hours, afterward for five hours, at last during the whole of the
night; the appetite increased considerably, the disposition was changed.
He left the Institution on November 21st.
_Urine_.—The specific gravity of the urine vacillated between 1.019 and
1.029. A precipitation with alkaline solution of sulphate of copper was
noticeable only occasionally.
The patient, whom I saw six months after his discharge, has had no relapse.
Mrs. Jane G., a patient of Dr. B. Fränkel, of Berlin, 35 years old, eleven
years ago, after having been suffering with typhoid fever, was afflicted
with an abdominal complaint which caused so much pain that the family
doctor had to administer an injection of morphia daily. Ten years ago
patient married, and has given birth to two children one five years, the
other eight years old now. The confinements were protracted; both children
died soon after their birth. During both pregnancies the use of morphia
was discontinued by the doctor, the same taking place during several
occasional journeys to bathing-places made by the patient because of her
complaint. For five years she has injected morphia herself, the largest
dose _pro die_ having been eight grains.
While using the drug, a febris intermittens tertiana showed itself, two
years ago, lasting, with an interruption of four weeks, until November,
1876. Regularly at 4.30 P.M. she had shiverings, followed by burning
heat, and ending in perspiration. The repeated use of quinine, even a
change of air and a sojourn in the country, were unable to suppress the
fever. Dr. B. Fränkel, who had only for three months attended Mrs. G.,
and whom she had never told of her custom of using morphia regularly,
made the diagnosis of morbid craving for morphia only through considering
the intermittent fever. Apart from the latter, the use of the drug had
brought on the following symptoms: sleeplessness, headache, principally in
the region of the right occipital nerve, parched mouth, loss of appetite,
nausea, sickness, constipation, feeling of oppression, mental anxiety,
palpitations of the heart. Patient, after having hardly fallen asleep,
wakes up with dyspnœa, which increases to actual fits of choking; swimming
before the eyes and muscular quivering.
Patient is admitted into the Maison de Santé, and the use of the morphia
is stopped forthwith.
October 16. Hardly any sleep during the night; in the morning patient is
in a happy temper, makes no complaints. Temperature and pulse normal.
In the course of the forenoon there was much perspiration, and patient
complained of headache and nausea. Pupils unequal, _the left smaller than
the right_. Pressure on the stomach, shivering, yawning; in the afternoon,
there is restlessness, stomach-ache, epigastric pain, oppressiveness, much
perspiration, shivering. Poultices were applied to the abdomen. Up to
the evening she had altogether vomited twelve times and had one relaxed
motion. _Pupils unequal, the left wider than the right._ The excitement,
in consequence of the pain in the stomach, increases hourly. Patient moves
about in bed and moans aloud. Frequent spasmodic yawning. At 9 P.M., a
bath with cold douche of a quarter of an hour’s duration is given, after
which she became quieter for a short time.
October 17. Patient has been sick thirteen times during the night; no
sleep; the pains in the abdomen were very severe, having the character of
labor pains. Face pale, pulse 64, full, regular. Frequent yawning, burning
in the throat, and abdominal pains continue during the whole of the day.
Patient looks worn out, is now and then in a half-dozing condition. _Left
pupil wider than the right._ Great prostration, great thirst. In the
course of the day vomited nine times, two relaxed motions.
October 18. No sleep during the night, restless; complains of tearing
pains in the legs, and excessive pain in the stomach; pulse and
respiration normal; vomited four times, one relaxed motion, frequent
sneezing during the day; she is very sensible to every kind of noise.
Frequent retching; severe vomiting ten times. _Left pupil wider than the
right._ Patient feels cold. In the afternoon at 5 o’clock patient lisps,
becomes of a pale, death-like color, is very much oppressed, and loses
consciousness; sinks back on to the pillows with closed eyes. Pulse 42,
small, irregular. A quarter of a grain of morphia was at once given, and
repeated after twenty minutes’ time. _Right pupil wider than the left._
After a quarter of an hour patient wakes up, says that she had never felt
so well before; takes milk with relish without bringing it up again. Pulse
60, strong and powerful. This favorable condition lasts till 9 P.M., when
she again has nausea from time to time. At 10 o’clock a bath, with a cold
douche, is given.
October 19. Patient has slept only from 10.30 P.M. to 1.30 A.M. At this
time retching again occurs, vomiting, prostration, pains in the epigastric
region; hallucinations, illusions set in, followed by collapse accompanied
by the symptoms already mentioned, and necessitating the immediate
injection of half a grain of morphia at 2.20 A.M., followed by a weaker
injection of a quarter of a grain of morphia at 4.15 A.M. Afterwards
patient again felt quite well. During the forenoon her condition has been
good only at times, the principal complaints being great prostration,
impossibility to sleep, pains in the stomach, great thirst. _Left pupil
wider than the right._ About 10 A.M. the sickness increased to such an
extent that an injection of one-fifth of a grain of morphia had to be
administered. Feeling well after it, patient partook of a pint of milk
and soup. In the afternoon she had some cocoa, which she has not brought
up. Towards the evening she felt oppressed, which, however, subsided
after a warm bath, with cold douche. At 9.25 P.M. another injection of a
quarter of a grain of morphia had to be given, on account of symptoms of a
collapse showing themselves. Only three-quarters of an hour afterwards the
good effect was visible.
October 20. Patient has slept altogether for five hours during the night,
with many interruptions. During the intervals, besides being restless,
there was prostration, craving for morphia, nausea, and frequent vomiting,
and pains in the stomach. In the morning sneezing and yawning. During
the daytime the condition was comparatively good. _Left pupil wider than
the right, towards the evening the contrary taking place._ At 8.30 P.M.
patient had a bath at 31° R. (87.8° F.) of half an hour’s duration, with
cold douche.
October 21. Restless during the whole of the night, craving for morphia
and increased reflex action. During the daytime the condition of the
patient is satisfactory, excepting some yawning, sneezing, and slight
prostration.
October 22. No sleep during the night, paroxysms of sneezing and yawning.
October 23. Patient slept for three hours with interruptions. Towards the
morning severe sneezing. Appetite good. She had a bath, with cold douche,
morning and night.
October 24. Patient was very restless in the night, moved about in the
bed, and in the morning was much exasperated on account of the bad night.
At 9 P.M. 40 grains of chloral were given in gruel, but were immediately
brought up again.
October 26. Patient slept for two hours with interruptions. During the
remainder of the night she felt oppressed and had palpitations of the
heart. Sneezing the same as yesterday.
October 28. Very restless during the night. Patient had only about one
hour’s sleep towards the morning, and then felt pains in the lower part of
the abdomen.
October 29. Has had hardly any sleep during the night. Mental condition
nevertheless good; appetite the same.
October 31. During the past nights she slept, on the average, for three
hours. Meals are taken regularly. Thirty grains of chloral were given in
capsules. Patient in the daytime complains of labor-like pains in the
lower abdominal region.
November 1. Patient slept for several hours after having taken 30 grains
of chloral. The pains in the hypogastric region are still apparent now and
then; some reddish watery spots show on the linen.
November 2. The pains have increased in the morning; the whole abdominal
region is sensitive to the touch. Poultices were applied. _In the middle
of the day the menstrual discharge shows itself._
November 3. The pains have abated. Patient has slept for four hours.
November 4. Menstrual discharge still continues. While it is said formerly
to have lasted only for a few hours, it has now lasted for forty-eight
hours. Toward midday the patient left her bed and remained on the couch
for several hours.
November 5. Slept from 11 P.M. till 2.30 A.M. Patient felt oppressed in
the night; there was difficult breathing, and she could not remain in bed.
Patient leaves the Institution on November 15th, all bodily functions
having become regular. She has up to the present time had no relapse.
In favor of this plan of treatment Levenstein urges the following:
“Confidence in the medical adviser is strengthened in consequence of
the short duration of the severe symptoms, and the improvement already
experienced after a few days; the patients take courage, look forward to
their complete recovery, and submit with patience and resignation to the
few days of suffering.” And again: “The human organization, as we know
from our surgery, midwifery, etc., will, in general, submit more easily
to sudden and energetic treatment, even when acting powerfully, than to a
milder influence. The gradual deprivation requiring a long time, excites
the physical and moral powers to a greater extent, because every dose,
smaller than the previous days’ quantity, will produce new symptoms of
reaction. The constant mental anxiety in which these patients live, while
expecting a smaller dose on the following day, makes them fretful and
irritable; their intention of submitting till the end of the cure, and
their energy, begin to decline, and they try to evade the treatment. They
set up intrigues against the officials and nurses; they simulate morbid
appearances, in order to excite the pity of their relations and friends;
they lose confidence in themselves and in their doctor, whose full and
absolute authority is indispensable for the successful treatment of
abstinence.”
This is certainly true of those cases where the treatment is by very
gradual reduction, not at all so of those where it lasts but from four to
seven days; ten at the most. The latter plan combines all the advantages
of Levenstein’s method, and escapes the danger and misery of his, and that
of the long protracted course.
In many instances persons addicted to this habit gradually reduce the
quantity they have been using to a certain point, beyond which they seem
unable to go. Thus, a physician who came under my care reduced his dose
from three grains to one-twelfth of a grain in the twenty-four hours,
and maintained it at this point for a long time. Finally, however, he
returned to the use of the full amount. He employed the subcutaneous
method. The majority of patients express their willingness to be rid of
the habit, and do endeavor, up to a certain point, to assist themselves,
but at this period will power, naturally weakened, gives way, and good
resolves are thrown to the wind. It is at this time that every facility
for full control of the patient is necessary, for without it the sufferer
will invariably stop treatment, claiming that the suffering is beyond his
strength, bemoan his sad fate and return to the old habit with renewed
force, exclaiming, with Coleridge’s son—
“O woeful impotence of weak resolve.”
The treatment of these cases at the homes of the habituès is rarely
successful. Some ruse, some strategy, some deception is sure to be
practiced, either by the patient, the friends, the relatives or the
nurse. Very often the relatives, not understanding the meaning of
certain symptoms, distressed beyond measure by the pitiful pleadings of
the sufferer, will interpose and at once put an end to treatment, thus
unwittingly and with well meaning doing the patient an injury of the
gravest kind. For, the treatment, persisted in almost to the point of cure
and then abandoned, so thoroughly disheartens the person that it takes a
long time for him to make up his mind to try it again.
Those who are the most likely to behave in a manner such as to cause
their friends to interfere, from fear of death or insanity resulting, are
hysterical females. Absolute committal to a public or private institution,
where the nurses can be _absolutely_ relied upon, and where obedience to
the physician’s orders are _rigidly_ enforced, is the only rational plan
for treating these cases. Then, too, conveniences for baths of different
kinds and temperatures, and varied electrical appliances, not found in
patient’s houses, are necessary; more necessary than drugs.
It is best for the patient, if an adult, or the parents of the patient,
if he is a minor, to sign a paper, submitting him fully to the entire
control of the physician for ten days. On leaving home his trunk and
clothing should be thoroughly searched, and any form of opium or morphine
should be removed. On entering the institution in question, the person is
allowed from twenty-four to forty-eight hours’ rest, to recover from the
effects of the journey, to become acquainted with his surroundings, and to
allow the physician in charge to judge fully the amount of morphine taken,
and the condition of the different organs. The urine should be carefully
analyzed and the result saved for future reference. The windows in the
rooms are to be firmly secured, and no extra furniture, sharp instruments,
or projections from which hanging could be possible, are to be allowed.
Low, iron bedsteads are to be preferred, and the room heated by furnace or
steam pipes, well protected.
On commencing the treatment, the patient is required to give up all money
or valuables he may have about him, for which he is given a receipt. He
is then undressed by a nurse, wrapped in a blanket, and taken to the
bath-room, where he is given a bath. While this is being done, another
nurse, under the supervision of the physician, searches everything the
patient has brought with him, including the clothes just removed, and
takes away any morphine or opium that may have been secreted, as, also,
scissors, knife, needles, etc. The search must be very thorough, as I have
known patients to sew packets of morphine into the lining and waistbands
of their clothing. The patient is then brought back to his room, the nurse
fully instructed, and the treatment by _rapid_ reduction commenced.
The physician himself administers the drug, whether by the mouth or by the
skin. I usually reduce the quantity used in twenty-four hours one-third,
sometimes one-half, the first day. The following case will illustrate the
plan pursued:—
Miss B. (sent to me by Drs. Claggett and Walls, of Baltimore), single,
aged twenty-seven, born in Virginia. Tall, thin, emaciated. Weight about
ninety-eight pounds. Complexion reddish. Dark-brown hair, grayish-blue
eyes. Height five feet seven and one-half inches. Extremely nervous
temperament. Pupils irregular and contracted. Entered my house for
treatment October 16, 1880. Had been taking morphia subcutaneously for
eighteen months. It was first given her by a physician, to relieve
the intense pain of an attack of pelvic cellulitis. At the end of the
treatment, being still a sufferer, she procured a syringe, and continued
the injections herself, gradually increasing the dose until the daily
amount reached six grains. Sometimes it would be less than this. She was
accustomed to take three injections in the twenty-four hours; one in the
early morning, one about midday, and one late in the afternoon. She ceased
to menstruate three months after she commenced to use the drug, and had
not menstruated up to the time of admission. No history of alcoholic
excesses in ancestors. Has one sister who is extremely nervous, and a
brother just recovering from paralysis of one side of the face.
Her face is dotted with pustules, as also the chest. Body and limbs
marked by cicatrices of old and recent punctures. Appetite fair, bowels
constipated. Somewhat lethargic and stupid in mind, but, withal, very
nervous. Is despondent, and cries easily, but is very anxious to abandon
the habit. There is some vaginismus and spasm of the sphincter of the
bladder.
October 15, 1880. Seen by Dr. T. Addis Emmet, who pronounced her to be
free from all uterine and ovarian disease, beyond the remains of an old
pelvic cellulitis, by which the uterus was drawn somewhat to one side. He
recommended the injection of large quantities of hot water.
October 16. Was given four grains of morphia, subcutaneously, in two
doses, one at 7 A.M., the other at 3 P.M. Is feeling very much depressed
and homesick.
October 17. Passed a fair night. Very nervous in the morning. Given one
hundred grains of the bromide of potassium. Fluid extract of coca (Parke,
Davis & Co.), in half-ounce doses, at 9 and 11 A.M., 2, 4 and 9 P.M.; also
one-half grain pills of cannabis indica, at 8 and 10 A.M., 3, 5, 7 and 10
P.M. Given two grains of morphia at 7 A.M., and one grain at 2 P.M. More
quiet; using beef tea (the juice of steak squeezed into boiling water and
seasoned), sherry and bottled beer. Some pain over left ovary. Ice cream
and milk for supper. 8 P.M., Pulse 100. Less nervous; more talkative and
pleasant; expressed a desire for oysters. Pain over left ovarian region
somewhat relieved by poultices. Bowels have not moved for two days.
_Urine._—Specific gravity 1.018; reaction acid; color pale amber; odor
normal; sediment slight; microscopically nothing; chemically nothing save
an excess of phosphates.
October 18. Passed a good night. Pupils of medium size and regular.
Craves food. Given two-thirds of a grain of morphia, at 7 A.M. Obliged
to draw her water; this had been her habit for a long time. Poultices to
left ovarian region. Bromide and other medicines continued as before.
Two-thirds of a grain of morphia at 3 P.M. Rather nervous and restless,
but bright. Appetite good. Given—
℞. Mass. hydrarg.,
Ext. colocynth co., āā gr. iij.
At bedtime.
One bottle of beer and some sherry wine. Two-thirds of a grain of morphia
at bedtime. Left pupil larger than the right; both somewhat dilated. Is
suffering slightly from bromism.
During the day she has taken the following mixture every three hours,
while awake:—
℞. Strychniæ sulphat., gr. ss.
Tinct. belladonnæ,
Tinct. capsicum, āā ʒ iij M.
SIG.—Take ten drops every three hours, increasing three drops
each day.
October 19. Slept well all night. Two-thirds of a grain of morphia at
5.30 A.M. Bright. Appetite good. Dressed herself and came down stairs.
Half a grain of morphia at 3 P.M. Medicines continued as usual, with the
exception of the bromide, which was given in the form of an elixir (ten
grains to the drachm), one drachm after each hemp pill. Pupils regular.
Pulse good. 6 P.M., had a severe hysterical convulsion, brought on by
talking and thinking about home. Given two-thirds of a grain of morphia.
Some headache. Bowels have not moved yet. Given seidlitz powder.
October 20. Rather nervous during the night. Tossed from side to side of
bed. Bowels moved naturally about 2 A.M. Two-thirds of a grain of morphia
at 6 A.M. Pupils contracted and even. Slight headache. Restless. One-third
of a grain of morphia at 3 and 9 P.M. Much headache.
October 21. Bowels moved naturally during the night. One-third of
a grain of morphia at 6 A.M.; one-third of a grain at 2.30 P.M., and
one-sixth of a grain at 6 P.M. Appetite excellent. Took some exercise in
the yard. Hysterical attack at 5 P.M., after reading a letter from home.
Given twelve grains asafœtida. Bromide eruption on chest and back. Urine
slightly albuminous and containing a trace of sugar.
The spasm consisted of moaning, with greatly labored breathing, the moan
being made at each full expiration. There was trembling of the hands
and twitching of the muscles, accompanied by a feeling of suffocation.
Pulse small and frequent. At 6.30 P.M. was sufficiently recovered to eat
a hearty supper. During the evening she felt well. One-sixth of a grain
of morphia at 9 P.M. Ordered half an ounce of tincture of hyoscyamus at
bedtime.
October 22. Restless all night. Hyoscyamus did not produce more than two
hours’ sleep. One-sixth of a grain of morphia at 6 A.M. Very nervous and
restless all morning. One-sixth of a grain of morphia at 3 P.M. Complains
of pain in body, limbs and side. Given a very hot sitz-bath, followed by
belladonna plaster to ovarian region. One-twelfth of a grain of morphia
at 6 P.M. Less nervous at 7 P.M. Vomited once. One-sixth of a grain of
morphia at 9 P.M. Still restless. All medicines continued. Pupils dilated
and irregular; right larger than the left.
October 23. Passed a sleepless night. Very nervous in the morning.
One-sixth of a grain of morphia at 6 A.M. Distressing nausea and vomiting.
Given ice and wine. In the afternoon there were some symptoms of collapse.
One-twelfth of a grain of morphia at 1 P.M., one-half grain at 4 P.M.,
one-twelfth grain at 5 P.M., and one-sixth grain at 9.30 P.M. Towards
night the nausea ceased. Complains of severe pains in limbs and back.
Is thoroughly rubbed with whiskey and water. Pupils contracted. 4 P.M.
slight symptoms of collapse. Gave stimulants. In place of belladonna,
strychnia and capsicum mixture, ordered the following:—
℞. Strychniæ sulph., gr. ss.
Tinct. belladonnæ, ʒ ij
Tinct. lobeliæ, ʒ j
Tinct. stramonii, ʒ j
Tinct. capsicum, ʒ ij. M.
SIG.—Take twenty drops every three hours, increasing three drops
daily.
Continued the other medicines in the same way as before. Urine passing
freely. Albumen one-twentieth of the bulk. No sugar. Hysterical attack at
9 P.M.
October 24. Slept well all night. Given four ounces of milk and lime
water every two hours; also some milk punch. Severe hysterical tetanoid
seizure on rising from commode. Lasted over an hour. Great difficulty in
overcoming spasm of respiratory muscles. Expiration loud and forcible.
Hands clenched. Fingers and toes forcibly flexed. Clonic spasm of muscles
of face and jaw. Face purple, veins distended, pulse at wrist hardly
perceptible. She was put fully under the influence of ether, with good
result. Complained of headache, nausea and soreness of muscles, after the
effect of the ether wore off. Says that when she stood, a pain darted into
the left ovary, and threw her into the spasm. Medicines continued. Gave
hot hip bath, followed by cold douche, and the interrupted current along
spine and over ovary. Also massage, which greatly relieved pains in limbs
and soreness of muscles.
12 M. Feeling bright and cheerful. Took some bottled beer. Bowels have
not moved for two days. Poultice over abdomen. One-twelfth of a grain of
morphia at 3 P.M., also one-twelfth grain at 8 P.M. This was the last
dose of morphia. At 9 P.M. another hysterical spasm. Again etherized. Soon
after this the bowels moved.
12 midnight. _Left_ pupil larger than the right. Slept from 2 to 5 A.M.
October 25. Very nervous and restless. Complains of constriction of chest
by an imaginary band. Dyspnœa. At 6 A.M. another spasm on rising from
commode. Again resorted to ether, after three hundred and thirty grains of
bromide of potassium in an hour and a half’s time had failed to relieve. A
few whiffs of ether were sufficient. Some nausea from the ether. 9 A.M.,
symptoms of collapse that yielded readily to brandy. In a quiet state all
day. Stimulants and liquid nourishment every hour. Some vomiting, sneezing
and hiccough. Diarrhœa during the day. Face purplish red. Respiration 36;
pulse 120. Stupid but not sleeping.
6 P.M. Improving. Recognizes faces; talks rationally, but speech thick.
Takes food well and seems to enjoy it. _Double Vision_. 9 P.M., restless.
Wants to get up and walk about the room. Given a subcutaneous injection of
water. Slept for two hours. Medicines continued.
October 26. Yawning, gaping and sneezing. Complains of pain in limbs, also
of vesical and rectal tenesmus. An examination reveals a small hemorrhoid.
Given a suppository containing half a grain of extract of belladonna,
which seemed to afford some relief. Pulse stronger. Dyspnœa less marked.
Given a hypodermic injection of water at 8 A.M., 3 and 9 P.M., much to her
relief. Doubts as to whether there was morphine in the solution used, were
dissipated by letting her touch her tongue to the needle, which had been
previously dipped in tincture of nux vomica. Complexion clearer; eyes
bright; speech not so thick. Strychnia mixture stopped.
8 P.M. Great rectal tenesmus, with small, offensive stool. Given one grain
of extract of belladonna, by suppository, and a capsule containing—
℞. Mass hydrargyri,
Ext. colocynth co., āā gr. iv
The mouth tasting badly, she was given the following as a wash:—
℞. Sodæ hyposulphite, ʒ ss.
Tinct. kino,
Tinct. myrrhæ, āā ʒ j
Ol. gaultheriæ, gtt. xvj
Aq. rosæ, ad ℥ iij. M.
SIG.—Teaspoonful in half a glass of water.
Pains in limbs and body still severe. Much relieved by a hot bath,
followed by the cold douche. Hemp pills stopped. Stimulants and liquid
food continued.
State of partial collapse at 5 P.M. Relieved by the free use of stimulants.
October 28. Slept well. From this time she improved rapidly. She was put
upon cod-liver oil, cream, milk, generous diet and the following tonic:—
℞. Strychniæ sulph., gr. 1/24
Tinct. cinchona co., ʒ ij
Three times daily.
In nine weeks’ time her weight increased from about 100 to 146 pounds.
The bromide eruption, which was severe, was treated with a wash of sodæ
salicylate, ten grains to the ounce.
November 11. Some puffiness of abdomen and pain in left ovarian region.
Given aloes, iron and myrrh, until bowels were moved freely.
November 17. _Menstrual flow established._ Passed through period with but
little pain. Some leucorrhœa followed. Partly relieved by injections of
infusion of white oak bark.
December 11. Again unwell. Less pain.
December 23. Discharged well. Absolutely no craving for morphia.
In this case the hysterical element was decided, and somewhat modified the
treatment.
The symptoms that follow the sudden deprivation of morphia are so vividly
and well described by Levenstein, who has treated many cases in this way,
that I cannot refrain from giving his own words:—
“Although persons who suffer from morbid craving for morphia show
different symptoms, some of them beginning to feel the effects of the
poison after using it for several months, while others enjoy comparatively
good health for years together, there is no difference between them as
regards the consequences upon the partial or entire withdrawal of the
narcotic drug.
“In this respect they are all equal. None of them have the power of
satisfying their passions unpunished.
“Only a few hours have passed since using the last injection of morphia,
and already the feeling of comfort brought on by the action of the
drug is passing off. They are overcome by a feeling of uneasiness and
restlessness; the feeling of self-consciousness and self-possession
is gone, and is replaced by extreme despondency; a slight cough
gradually brings on dyspnœa, which is increased by want of sleep and by
hallucinations.
“The vaso-motoric system shows its weakness by abundant perspiration, by
the dark color of the face, which replaces the pale condition apparent
during the first few days.
“Flow of blood to the head and palpitation of the heart, with a hard
pulse, soon show themselves. The latter symptom often disappears suddenly,
and is replaced by a slow, irregular, thread-like pulse, which is the sign
of the beginning of a severe collapse.
“The reflex irritability increases, the patients begin to sneeze and to
have paroxysms of yawning; they start if any one approaches them; touching
their skin causes crampy movements or convulsions; the trembling of
the hands, if not already evident, now becomes distinctly perceptible.
The power of speech is disordered; lisping and stammering take place.
Diplopia, and disorders of the power of accommodation, frequently
accompanied by increased secretion of the lachrymal glands, show
themselves. The patients are overcome by a feeling of weakness and total
want of energy, and are thus compelled to lay in bed.
“Neuralgic affections of various parts of the body, pain in the front and
back of the head, cardialgia, abnormal sensations in the legs, associated
with salivation, coryza, nausea, vomiting and diarrhœa, tend to bring them
into a desperate condition.
“Some persons will bear up with fortitude under all these trials; they
will quietly remain in bed, and will endure the unavoidable suffering,
hardly uttering a complaint. Of the others, although the great minority of
them sleep and doze during this trying time, some can find rest nowhere;
they jump out of bed, run about the room in a state of fear, crying and
shrieking. Gradually they become calmer, although occasionally their
excitement increases. A state of frenzy, brought on by hallucinations and
illusions of all the sensitive organs, at last causes a morbid condition,
to which I have given the name of delirium tremens, resulting from morbid
craving for morphia, it being similar to that caused by alcohol. Some of
the patients, however, will be found walking about in deep despair, hoping
to find an opportunity of freeing themselves forever from their wretched
condition.”
The patient whom I treated by the sudden deprivation of the drug was
a married lady, aged forty-five, stout and flabby. She had been using
morphia by the mouth for nearly sixteen years, in the last year taking
from seven to ten grains daily. I saw her one afternoon and commenced
treatment the next morning. The drug was taken away at once. That day she
began to complain of salivation, dyspnœa, intense grinding pains in the
calves of the legs, headache, pain about the heart and a strong desire
for morphia. The first night she did not sleep at all. Was feverish and
restless, tossing from side to side of the bed, moaning, occasionally
crying out. Toward morning she became delirious, ran about the room,
screamed, attacked the nurse, attempted to jump out of the window and
battered at the door. By 8 A.M. she had sunk into a stupor, from which she
was occasionally roused by fits of sneezing. A hard, dry, hacking cough
supplemented the dyspnœa. Nausea was intense and vomiting frequent. She,
on the third day, knew none of those about her, saw imaginary men and
animals, wept, laughed, moaned and muttered incoherently. Sordes formed
upon teeth and lips; the fæces and urine were passed in the bed. In this
state she remained for six weeks, in spite of every effort to arouse
her. All day in a typhoid condition; at night staggering about the room,
screaming, crying and attacking the nurse. In the seventh week she began
to recognize faces, although her hallucinations and delusions continued.
She very slowly regained strength. Pains persisted in the limbs. There
was trembling of the hands and tongue, inability to read, and she would
cry at the most trivial thing. Her nights were filled with terrible sights
and dreams, the memory of which lasted her the whole of the following
day. Several times there was severe collapse, necessitating the free use
of stimulants and an occasional small dose of opium. During all this time
tonics, concentrated food, baths and electricity were given. _It was fully
four months before her mind regained its balance._ She was seen once, in
consultation, by Dr. G. H. Wynkoop, of this city.
That was my first case, and I shall never try the experiment again. I know
of several instances where physicians have tried this plan and abandoned
it.
Her urine contained both sugar and albumen in large amount. This afterward
wholly disappeared.
Here is further testimony as to the efficacy of the treatment by sudden
deprivation:—
“Dr. Osgood (_Quart. Jour. Inebriety_, June, 1879,) has, in a hospital,
during the past two years, treated 800 cases of opium inebriety. His plan,
in general, is: (1) The absolute and total discontinuance of the use of
opium from the beginning of treatment. (2) A trusty attendant to be with
the patient day and night for the first three days. (3) Chloral hydrate
for the first three nights, if required. (4) Good food, milk, raw eggs,
brandy (in some cases), chicken broth. (The above to be taken in small
quantities.) (5) In diarrhœa give two-drachm doses of a mixture of equal
parts of tincture of catechu and tincture of ginger. (6) Vomiting will
frequently yield to bismuth in fifteen-grain doses; and in some cases a
single dose of calomel has acted like a charm. Ice is of advantage in some
cases. (7) Throughout the entire treatment it should be remembered that
the patient is below par, and requires tonics. Quinine and tincture of
iron have a prominent place in our list. (8) The patient should expect
to suffer more or less for the first three days, and should make himself
a prisoner for that time. By the fourth day there is usually marked
improvement. (9) Usually by the sixth day all desire for opium is gone.
The patient then requires a change of air and surroundings, and tonics for
a few weeks. Out of one hundred cases thus treated there was but one death
and that from apoplexy.”
However well this plan may answer for the Germans and Chinese, it
certainly is a dangerous and barbarous practice when applied to American
and English people.
The dangerous collapse that so often occurs in the carrying out of this
method Levenstein combats by small, subcutaneous injections of morphine,
stimulants, dropping ether on the skull, etc.