prominence of particular symptoms or groups of symptoms, whether they
indicate derangement of the viscera, of the nervous system, or of the
mind, whatever their combination, the fundamental therapeutic
indication in chronic alcoholism is the withdrawal of the poison. The
condition is directly due to the continuous action of a single toxic
principle: its relief when practicable, its cure when possible, are
only to be obtained by the discontinuance of that poison. This is a
matter of great, often of insurmountable, difficulty. The obstacles
are always rather moral than physical. Occasional or constant
temptation, the iron force of habit, the malaise, the faintness, the
craving of the nervous system, and, worse than all, the enfeebled
intellectual and moral tone of the confirmed drunkard, stand in the
way. Even after success seems to have been attained, and the patient,
rejoicing in improved physical health and in the regained
companionship and consideration of his family and friends, feels that
he is safe, it too often happens that in an unguarded moment he yields
to temptation and relapses into his old habits. A patient of the
writer, after seven years' abstinence from drink, again became its
victim in consequence of the incautious suggestion of a young medical
man, met at a summer hotel, to take brandy for some transient
disorder, and died after eight months of uncontrollable excesses. It
is necessary to guard the patient against the temptation to drink. To
secure this he may he sent as a voluntary patient for a length of time
to a suitable institution, {643} or, still better, he may place
himself under the care of a conscientious, clear-headed country doctor
in a sparsely-settled region, preferably in the mountains or at the
seaside. The malaise, depression, insomnia, and other nervous symptoms
when of moderate degree are best treated by abundance of nutritious
and easily-assimilable food, taken often and in moderate amounts. To
this end gastro-intestinal disturbances may be practically
disregarded, except in so far as they regulate the selection of a
highly nutritious diet. As a matter of fact, in the early periods of
chronic alcoholism, while visceral lesions of a grave character are
yet absent, appetite and digestion alike improve in the majority of
cases upon the withdrawal of alcohol, provided a sufficiently abundant
and easily assimilable dietary is insisted upon. Grave visceral
lesions characterize a more advanced alcoholic cachexia and
necessarily complicate the treatment. Nevertheless, even here the
indication is the withdrawal of the poison. The nervous symptoms
require special medication. The whole group of tonics, from simple
bitters to quinia and strychnia, is here available. It is impossible
to lay down rules for the treatment of particular cases except in the
most general manner. In the absence of conditions calling for special
treatment, such as gastritis, hepatic or pulmonary congestion, fatty
heart, etc., good results follow the frequent administration of small
doses of quinia and strychnia; thus, the patient may take one grain of
quinia six or eight times a day, or a little gelatin-coated pill
containing 1/200-1/100 of a grain of strychnia every hour during the
waking day, amounting in all to one-twentieth, one-tenth, or one-fifth
of a grain in the course of twenty-four hours. This treatment is often
followed by the relief of tremor, the quieting of nervous
irritability, and the production of good general results. The malaise,
the general depression, and especially the sinking feeling at the pit
of the stomach so often complained of by patients, are best relieved
by food. Fluid extract of coca is also useful in these conditions. The
value of cocaine in the management of the nervous symptoms of chronic
alcoholism, and in particular as a temporary substitute for alcohol,
is doubtful. The writer, having used it in a number of cases by the
mouth and hypodermically in doses of ¼-1 grain, has had variable
results. In some cases it temporarily relieved the craving and
concomitant symptoms; in others it failed wholly: in one instance
one-fourth of a grain was followed by great nervous depression. It is
desirable not to inform the patient of the nature of the remedy,
especially if its use be followed by good results, lest the cocaine
itself supplant alcohol as an habitual narcotic. Cold or tepid
sponging, the occasional hot bath at bedtime, and the Turkish bath are
useful adjuvants to the treatment. As a rule, opium is
contraindicated. Sleep often follows the administration of a cupful of
hot broth or milk at bedtime. Lupulin is here useful, and the writer
has come to regard an ethereal extract of lupulin in doses of from one
to three grains as a valuable and harmless hypnotic. If necessary,
hypnotic doses of chloral or paraldehyde may be used, but care is
required in their administration, and their early discontinuance is
advisable. If anæmia be profound, chalybeate tonics do good, and among
the preparations of iron pills of the dried sulphate with carbonate of
potassium (Blaud's pills) are especially useful.
The obesity of drunkards, as a rule, diminishes on the withdrawal of
alcohol. Under circumstances of partial or complete abstinence from
{644} drink measures to reduce the weight of such patients are wholly
inadmissible.
In conditions characterized by failure of mental power, in beginning
dementia or threatened insanity, the syrup of the hypophosphites, the
compound syrup of the phosphates, or cod-liver oil should be
administered. These remedies are likewise useful in various forms of
alcoholic paralysis, as are also faradism and galvanism employed
secundum artem. The various forms of alcoholic insanity require
special treatment, only to be had in institutions designed for the
care of patients suffering from mental diseases in general.
Whilst it is desirable in the treatment of all forms of chronic
alcoholism to secure the permanent discontinuance of the alcoholic
habit, the skill, judgment, and experience of the physician must
determine the degree of rapidity with which this, when practicable, is
to be done. The number of cases in which alcohol can be discontinued
at once and finally is limited; those in which it can be wholly given
up in the course of a few days constitute the largest proportion of
the cases; finally, in a small number of cases alcohol can only be
withdrawn cautiously and by degrees.[53] Whilst it is in most cases
essential to remove the patient from his customary surroundings and
companionships, it is in the highest degree important to provide for
him mental occupation and amusement. To this end a wholesome open-air
life, with sufficient daily exercise to induce fatigue, is highly
desirable, as indeed is the companionship of interested and judicious
friends.
[Footnote 53: It must be borne in mind that in chronic alcoholism
acute maladies of all kinds, including traumatism, both accidental and
surgical, act as exciting causes of delirium tremens. The part played
by the abrupt diminution or withdrawal of alcohol under such
circumstances is often an important one. It is the opinion of the
writer that a certain amount of alcohol should be administered for a
time at least in the accidental injuries and acute sicknesses of
alcoholic subjects, and that the reduction should be gradually made.]
The Treatment of Delirium Tremens.—The patient should be confined in a
large, well-aired apartment, without furniture except his bed, and
when practicable he should have a constant attendant. The favorable
influence of a skilful nurse in tranquillizing these patients is very
great. The custom of strapping them to the bed by the wrists and
ankles is to be deprecated. If the case be a mild one, and especially
during convalescence, open-air exercise in the sunshine with an
attendant is of benefit; care must, however, be taken to guard against
the danger of escape.
Under no circumstances should visitors be permitted to see the
patient. In young persons the treatment may be preceded by an active
saline or mercurial purge. In elderly persons, those suffering from
cachectic conditions, or in cases characterized by marked debility and
feeble circulation—conditions frequent in persons who have had
repeated attacks—it is not desirable to purge. Alcohol should be
either wholly withdrawn or more or less rapidly diminished. It must be
replaced by abundant food in the form of concentrated broths or
meat-extracts. In cases of vomiting these must be given hot and in
small doses frequently repeated. Bitter infusions may also be given,
or milk or equal parts of milk and Vichy water. If there be thirst,
the effervescent waters may be given freely. Patients often drink with
satisfaction and apparent benefit hop tea, which may be made simply
with water or with equal parts of water and porter.
{645} The medicinal treatment will depend to a large extent upon the
peculiarities of the case. In mild cases a combination of the watery
extract of opium in small doses, not exceeding a quarter of a grain,
with quinia and digitalis, repeated every four or six hours, is often
useful. Although the view once entertained that the graver symptoms
were the result of prolonged sleeplessness is no longer tenable, the
induction of sleep, or at all events of mental and physical repose, is
among the more important therapeutical indications. For this purpose
hypnotic doses of opium are not only not desirable, but are even, in
the majority of instances, attended with danger. The sleep which
follows repeated and increasing doses of opium in delirium tremens has
too often terminated in coma deepening into death. As calmatives,
extract of cannabis indica, hyoscyamus, or the fluid extract of
piscidia are useful. As hypnotics, the bromides, chloral, and
paraldehyde yield, in the order here given, the best results. The
bromides are better in large single doses than in small doses often
repeated, better in combination than singly. Chloral, either by the
mouth or by the rectum, in doses of from twenty to forty grains, is
often followed by beneficial sleep. It is contraindicated where the
heart's action is much enfeebled. Paraldehyde, in doses of half a
drachm to one drachm, repeated at intervals of two or three hours
until sleep is induced, is still more efficient. This drug may be
administered without the fear of its exerting a depressing influence
upon the heart. The depression characteristic of grave delirium
tremens may be combated by repeated small doses of champagne or by
carbonate of ammonium in five- or ten-grain doses; the vomiting, by
withholding food and medication by the mouth, and giving them for some
hours wholly by the rectum or hypodermically. Excessive restlessness
is sometimes favorably influenced by cold affusion, followed by brisk
friction and warm blankets with continuous artificial heat. The cold
pack has proved useful.
Digitalis may be employed, ex indicatione symptomatica, but the
enormous doses of tincture of digitalis used by the late Jones of
Jersey and others are here mentioned only to be condemned.
To sum up, the chief indications for treatment are complete isolation,
the withdrawal of alcohol, abundant, readily assimilable, nutritious
food, and control of the reflex excitability of the nervous system.
III. Hereditary Alcoholism.—The treatment of the vicious propensities
of the descendants of alcoholic parents does not fall directly within
the province of the physician. It is among the most difficult problems
of education. The recognition of the cause of evil traits manifested
in childhood and youth may do something to avert dangers commonly
unsuspected. All things considered, the outlook is not hopeful. The
recognition, on the part of the physician, of the influence of
hereditary alcoholism in cases of arrested development, feeble
organization, or declared disease of the nervous system will perhaps
do less to aid his treatment in many cases than to reconcile him to
its want of full success. The cry of warning is to those who are
eating sour grapes that the teeth of their children will be set on
edge.
IV. Dipsomania.—The general indications for the treatment of
dipsomania are two: first, the management of the paroxysm; second, the
control of the general condition itself.
First, then, during the paroxysm the patient must be saved, in so far
{646} as is possible, from the danger of injuring himself or others
and from squandering his property. If the excesses are of such a
degree as to render it practicable, the same treatment must be carried
out as in cases of acute alcoholic mania and delirium tremens—namely,
confinement in a suitable apartment under the care of an experienced
nurse and the control of the doctor. Unfortunately, this plan is not
always practicable in the early days of the outbreak. Here tonics,
coca, and repeated small doses of quinia and strychnia are of
advantage. Courses of arsenic at the conclusion of, and in the
intervals between, the paroxysms are of use, on account of the
excellent influence they exert on the general nutrition. These may be
advantageously alternated with iron, cod-liver oil, and the compound
syrup of the phosphates or of the hypophosphites. Hydrotherapy may
also be used with advantage, and the influences of a well-regulated
hydropathic establishment are much more favorable than those of
institutions specially devoted to the treatment of alcoholic subjects.
In the latter the moral atmosphere is apt to be bad; the patients
support each other, and too often conspire to obtain in secret that
which is denied them openly, or, if the discipline be too strict for
this, they sympathize with each other in their restraint, react
unfavorably upon each other in the matter of shame and loss of
self-respect, and plot together to secure their liberty.
Few dipsomaniacs in the earlier periods are proper subjects for
treatment in hospitals for the insane. If cerebral excitement or
sleeplessness persist after the paroxysms, chloral, paraldehyde, or
the bromides in large doses may be used to secure sleep. Various
combinations of the bromides are often of use where the single salts
fail. It must not be forgotten that during the paroxysm there is great
danger lest the patient do himself or others harm. When there are
indications of an impending attack, and during the period of
depression following the attacks, benefit is derived from the daily
use of bitter infusions. As a matter of fact, however, the management
of these cases is among the most unsatisfactory of medical
undertakings. The difficulty is increased by the latent character of
the mental disorder in the intervals between the attacks. Even when
such patients voluntarily enter hospitals for the insane, they cannot
be retained there sufficiently long to derive any permanent benefit.
What we want is, in the words of Clouston, “an island where whiskey is
unknown; guardianship, combined with authority, firmness,
attractiveness, and high, bracing moral tone; work in the open air, a
simple natural life, a return to mother Earth and to Nature, a diet of
fruits, vegetables, bread, milk, eggs, and fish, no opportunity for
one case to corrupt another, and suitable punishments and deprivations
for offences against the rules of life laid down. All these continued
for several years in each case, and the legal power to send patients
to this Utopia for as long a period as medical authority determines,
with or without their consent.”
{647}
THE OPIUM HABIT AND KINDRED AFFECTIONS.
BY JAMES C. WILSON, M.D.
Next in order to alcohol, opium and morphine are habitually abused to
a greater extent than any other narcotic. Chloral is used in the same
way by a large number of individuals. Paraldehyde, cannabis indica,
ether, chloroform, and cocaine are also used to a less extent. The
scope of this article does not include the consideration of acute
poisoning by these drugs.
The habit of taking narcotics, whether medicinally or as a mere matter
of indulgence, is apt speedily to become confirmed. The physiological
dose more or less rapidly loses its power to affect the nervous system
in the ordinary way. Tolerance increases with increasing doses, and in
a comparatively short space of time poisonous doses are taken with
impunity as far as immediate danger to life is concerned. The toxic
effects of the poison are shown in characteristic perversion of the
functions of the nervous system and of the mind. A condition is
established in which the ordinary functions of life are properly
performed only under the influence of the habitual narcotic, and in
which its absence results in languor, depression, and derangement of
bodily and mental processes. The habit, once established, thus makes
for itself a constantly recurring plea for its continuance. Especially
is this true of opium and morphia.
Opium and Morphine.
Opium-eating is chiefly practised in Asia Minor, Persia, and India. It
is also prevalent in Turkey. It has been practised in India from very
ancient times. The prevalence of this habit in the East is probably
largely due to the restrictions placed upon the use of alcoholic
beverages among the Mohammedans, and to some extent also to the long
religious fasts observed by the Buddhists, Hindoos, and Moslems,
during which opium is often used to allay the pangs of hunger. The
prevalence of the opium habit in India is shown by the fact that the
license fees for a single year amounted to nearly five hundred
thousand pounds sterling. It is stated that in Samarang, a town of
1,254,000 inhabitants, the average quantity of opium consumed monthly
is 7980 pounds. The town of Japava, with 671,000 inhabitants, consumed
in fifteen days 5389 pounds {648} of opium. In 1850, 576,000 pounds of
opium were imported into Java, besides an unknown quantity
smuggled.[1]
[Footnote 1: _Archiv für Pharmazie_, 1873, cited by Von Beck,
_Ziemssen's Cyclopædia_, vol. xvii.]
The habit is not confined to Oriental countries, but is also practised
in various forms in the West. It is by no means rare on the continent
of Europe. In certain districts of England, especially in Lincolnshire
and Norfolk, more opium is consumed than in all the rest of the United
Kingdom. Shearer[2] states that the increase in the practice of
opium-eating among the workpeople of Manchester is such that on
Saturday afternoons the druggists' counters are strewed with pills of
opium of one, two, and three grains, in preparation for the known
demand of the evening. The immediate occasion is said to be the
lowness of wages, opium being used as a cheap substitute for alcohol
or as a food substitute, or with the view of removing the effects of
disease and depression. According to the same observer, laudanum is
more or less in use as a narcotic stimulant in the cotton-spinning
towns, where female labor is in requisition and is well paid. Children
are accustomed to it from their earliest infancy. Their parents drug
them with daily potions of Godfrey's cordial, Dalby's carminative,
soothing syrup, and laudanum itself, during the long hours of their
absence from home. While the habit of opium-eating cannot be said to
be generally prevalent in any part of the United States, instances of
it are frequently encountered in all classes of society, and
particularly among people of means and refinement. The preparations
employed in this country are crude opium, tincture of opium or
laudanum, camphorated tincture of opium or paregoric, McMunn's elixir,
Dover's powder, and the salts of morphia. All of these preparations
are used by the mouth; opium is very frequently, especially among
women of the better classes of society, habitually taken in the form
of suppositories; finally, the acetate and sulphate of morphine are
used by means of the hypodermic syringe. While it will be necessary to
point out some differences in the effects of these drugs due to the
preparation used or to the method in which it is employed, the
distinction between the opium habit and the morphine habit, in itself
an artificial one, will not be regarded in the course of the present
article.
[Footnote 2: _Opium-smoking and Opium-eating, their Treatment and
Cure_, by George Shearer, M.D., F. R. S.]
Opium-smoking is chiefly practised by the inhabitants of China and of
the islands of the Indian Archipelago. It has been imported into those
countries where Chinese labor is largely employed. The Chinese have
transmitted it, to an extent which is fortunately very limited, to the
inhabitants of certain of our cities. Opium-smoking is habitually
practised in this country only among the more debased orders of
society.
SYNONYMS.—Opiophagia, Morphiopathy, Morphinism, Morphinomania,
Morphiomania, Morpheomania, are terms occasionally employed to
designate the opium or morphia habit.[3] Landowski, Levinstein, Jouet,
and others use the term morphinism to denote the condition of the
body; morphinomania, the condition of the mind in chronic
morphine-poisoning. This distinction may be misleading. In effect, the
pathological condition is complex, including derangements both somatic
and psychical.
[Footnote 3: The word morphiomania, used by writers, is contrary to
all etymological rule (Zambaco, _De la Morphéomania_, Paris, 1883).]
{649} ETIOLOGY.—_A_. Predisposing Influences.—Pain holds the chief
place among the influences which predispose to the formation of the
opium habit. By far the greater number of cases have taken origin
either in acute sickness, in which opium administered for the relief
of pain has been prolonged into convalescence until the habit has
become confirmed, or in chronic sicknesses, in which recurring pain
has called for constantly repeated and steadily increasing doses of
opiates. In view of the frequency and prominence of pain as a symptom
of disease, and the ease and efficiency with which opium and its
preparations control it, the remote dangers attending the guarded
therapeutic use of these preparations are indeed slight. Were this not
so, the number of the victims of the opium habit would be lamentably
greater than it is. In a considerable proportion of cases of painful
illness the relief afforded by opiates is attended by at least some
degree of malaise, nausea, vomiting, and vertigo—symptoms which render
the speedy discontinuance of the remedy scarcely less desirable than
the control of the pain for which it was administered. Occasionally
these symptoms are so distressing as to render opium wholly
inadmissible. In other instances each successive dose is attended by
an aggravation of the distress. More commonly, especially in acute
illnesses, decreasing pain may be controlled by diminishing doses,
thus rendering practicable entire discontinuance of the drug before
those modifications of the nervous system, and especially before that
tolerance for large doses, which constitutes the beginning of the
opium habit, are established. For these reasons the use of opiates in
acute sickness, if properly regulated, is attended with but little
danger. Far different is it, however, in chronic painful illnesses.
Here to procure relief by opium is too often to pave the way not only
to an aggravation of the existing evils, but also to others which are
often of a more serious kind. Opium is at once an anodyne and a
stimulant. The temptations to its use are of a most seductive
character. To the overworked and underfed mill-operator it is a snare
more tempting than alcohol, and less expensive. It allays the pangs of
hunger, it increases the power of endurance, it brings forgetfulness
and sleep. If there be myalgia or rheumatism or neuralgia, and
especially the dispiriting visceral neuralgias so common and so often
unrecognized among the poorer classes of workpeople, opium affords
temporary relief. The medical man suffering from some painful
affection, the worst symptoms of which are relieved by the hypodermic
injection of morphine, falls an easy prey to the temptation to
continue it—a danger increased by the fact that he is too often
obliged to resume his work before convalescence is complete. Indeed,
the self-administered daily doses of physicians sometimes reach almost
incredible amounts. To women of the higher classes, ennuyée and
tormented with neuralgias or the vague pains of hysteria and
hypochondriasis, opium brings tranquillity and self-forgetfulness.
Of 100 cases collected by Jouet,[4] the habit followed the therapeutic
use of morphine in 32 cases of ataxia, 24 of sciatica and other
neuralgias, 8 of asthma, 2 of dyspepsia, 4 of hypochondriasis, 2 of
madness, 9 of painful tumors, 2 of prostatic inflammation, 7 of
nervous conditions (not specified), 1 of peritonitis, 2 of
periostitis, 1 of gastro-enteralgia, 4 of pleuritic pains, 1 of
contracture, and 1 case of hæmoptysis.
[Footnote 4: _Étude sur le Morphinism chemique_, Thèse de Paris,
1883.]
The responsibility of the physician to his patient becomes apparent
{650} when we reflect that with very few exceptions the opium habit is
the direct outcome of the use of the drug as a medicine.