which the opium habit and kindred affections are induced, of the
serious character of these affections, and of the dangers attendant
upon an ignorant and careless employment of narcotics, would
constitute an important measure of prophylaxis. I am fully aware of
the evils resulting from the publication of sensational writings
relating to this subject. Notwithstanding these dangers, I am
convinced that a reasonable and temperate presentation of the facts in
the popular works upon hygiene used in schools and in the family would
exercise a wholesome influence in restraining or curing the tendency
to the practice of these vices.
Where these habits have resulted in consequence of the medicinal abuse
of narcotics in acute cases from which the patient has long recovered,
a determined effort to break them up should at once be instituted.
_b_. The Curative Treatment.—The responsibility assumed by the
physician in attempting to cure patients suffering from the confirmed
abuse of narcotics is often a serious one. Much judgment must be
exercised in the selection of cases. The responsibility of the
physician, beginning as it does with the judicious selection of the
cases, does not cease with the active management of the patient until
the habit has been completely broken up, but involves for a
considerable period of time such continued personal influence and
supervision as is needed to avert relapse. It is needless to say that
such supervision and influence must, after a more or less extended
period, in nearly every case come to an end, but the important fact is
to be borne in mind that the danger of relapse becomes less and less
with the progress of time; therefore, the more extended the period
during which the personal control of the physician may act as a
safeguard to his patient the better.
The question as to whether the cure should be attempted in the
patient's own home or away from it does not appear to the writer to
admit of discussion. Some trustworthy observers[12] have reported
successful cases not only {671} of the home-treatment of
opium-addiction, but even under circumstances in which the patients
have been permitted to go at large. Many physicians do not hesitate to
undertake the treatment with certain precautions at the home of the
patient. On the other hand, those whose experience in the management
of these cases is most extended look upon attempts of this kind as
likely to be unsuccessful in the great majority of the cases of the
opium or morphine habit. In cases of chloralism and the abuse of less
formidable narcotics, as cannabis indica, paraldehyde, etc., the
home-treatment, if judiciously carried out, usually succeeds, but the
cases in which the home-treatment proves successful in curing the
confirmed addiction to opium or morphine must be looked upon as
exceptional. The reasons for this are obvious. They relate to a
variety of circumstances which tend to weaken the mutual relations of
control and dependence between the physician and his patient. The
doubts, criticisms, remonstrances, even the active interference, of
the patient's friends tend to weaken the authority of the physician
and to hamper him in the management of the case; the discipline of the
sick-room is maintained with greater difficulty; the absolute
seclusion of the attendant with his patient is a practical
impossibility. Affectionate but foolish friends come with sympathy at
once disturbing and dangerous. Some devoted and trusty servant
cunningly conveys from time to time new supplies of the coveted drug,
or, if these accidents be averted, the very consciousness of the
separation which amounts to a few feet of hall-way only is in itself a
source of distress to the patient and his friends alike. Furthermore,
the period of convalescence following the treatment is attended with
the greatest danger of relapse—a danger which is much increased by the
facility of procuring narcotics enjoyed by the patient in his own home
as contrasted with the difficulties attending it away from home under
the care of a watchful attendant. The desirability of undertaking the
treatment away from the patient's home can therefore scarcely be
questioned. That this plan is more expensive, and that it involves a
radical derangement of the ordinary relations of the patient's life,
are apparent rather than real objections to it. The very expense of
the cure within the limits of the patient's ability to pay, and the
mortification and annoyance of temporary absence from usual
occupations and seclusion from friends, are in themselves hardships
that enhance the value of the cure when achieved, and constitute, to a
certain extent, safeguards against relapse. Whether the treatment can
be more advantageously carried out in a private asylum designed for
the reception of several such cases, or in a private boarding-house,
or at the home of the physician himself, is a question to be
determined by circumstances. The writer is of the opinion that with
well-trained and experienced attendants, well-lighted, airy rooms in
the upper part of a private house are to be preferred on account of
the seclusion thus secured.
[Footnote 12: See, for example, Waugh, “A Confirmed Case of
Opium-addiction treated Successfully at the Patient's Home, with
Remarks upon the Treatment, etc.,” _Philadelphia Medical Times_, vol.
xvi., March 20, 1886.]
In general, two methods are recognized: (_a_) that of the abrupt
suppression of the drug, and (_b_) that of the gradual diminution of
the dose. Both of these methods demand the isolation of the patient,
and to some extent at least the substitution of other narcotics. The
isolation of the patient under the care of skilled and experienced
attendants may be secured in a suitable private boarding-house, in the
home of a physician, or in a private room of a well-appointed general
or special hospital. Favorable opportunities are also afforded in
private institutions devoted {672} to this purpose. The apartment
occupied by the patient should be so arranged as to guard against
attempts at suicide, and the furniture should be of the simplest
character. The heating and lighting arrangements must be such as to
render any accidental injury to the patient during paroxysms of sudden
maniacal excitement quite impossible. From the beginning of the
treatment the patient must under no circumstances be left alone. Two
attendants are required, one for the day and one for the night. They
should be not only skilful and experienced, but also patient and firm;
and, as a considerable proportion of the patients are persons of
education and refinement, intelligence and good manners are desirable
on the part of those who must be for a length of time not only the
nurses, but also the companions, of the sufferer. It is desirable that
the separation of the patient from his family and friends should be
made as complete as possible. During the continuance of the active
treatment no one should be admitted to the patient except his
physician and regular attendants. Communication with his friends by
letter should be interdicted. The enforcement of this rule must be
insisted upon. So soon as the acute symptoms caused by the withdrawal
of the drug subside and convalescence is fairly established, brief
visits from judicious members of the family in the presence of the
nurse may be permitted. At the earliest possible moment open-air
exercise by walking or driving must be insisted upon, and change of
scene, such as may be secured by short journeys or by visits to the
seashore, is useful. These outings require the constant presence of a
conscientious attendant.
The Treatment of the Opium and Morphine Habit.—_a_. The Abrupt
Discontinuance of the Drug: the Method of Levinstein.—This method is
thus described by the observer whose name it bears: Directly upon
admission the patient is given a warm bath, during which time careful
examination of his effects is made by a responsible person for the
purpose of securing the morphine which the patients, notwithstanding
their assertions to the contrary, frequently bring with them. These
measures of precaution are by no means unnecessary. An officer had
saturated his cigarettes and cigars with a solution containing opium,
and smoked for twenty-four hours almost without interruption. Another
officer had slipped morphine between the soles of new slippers. Other
individuals concealed immediately after their arrival morphine in
powder in the upholstery of the sofa, upon the canopy and in the
ventilators of the windows. Other patients enclosed morphine in
envelopes of thin paper, which were placed between the leaves of their
books, stitched it in the folds and lining of their garments, etc.
The first symptoms of the withdrawal of the drug show themselves in
delicate individuals at the end of three or four hours, and in robust
persons about fifteen hours, after the last dose. These symptoms
consist of malaise, restlessness, a sense of muscular tension, chilly
sensations, and the like, but do not demand treatment. As soon as
shivering commences the patient must be put to bed—a measure to which,
as a rule, he readily assents on account of the sense of muscular
fatigue now experienced. For the relief of the headache, which is
rarely absent, applications of cold water or of ice or ether-douches
to the forehead may be employed. For the distressing gastralgia
compresses moistened with chloroform may be applied to the
epigastrium. The colic, which is often distressing, {673} may be
treated by sinapisms or hot compresses. The nausea and vomiting and
epigastric distress, which are apt to continue for several days, may
be treated by a solution of bicarbonate of sodium with tincture of nux
vomica and essence of mint. If the vomiting be excessive, recurring
twenty or thirty times in the course of twenty-four hours, small doses
of morphine by the mouth must be given. If by reason of the continued
vomiting and inability to retain nourishment dangerous exhaustion
develops, nutritive enemata must be administered. The diarrhœa
requires little treatment during the early days. If, however, it be
excessive and persists beyond the third or fourth day, large enemata
of warm water of a temperature of 98° F., repeated two or three times
during the day, are attended by excellent results. The insomnia, which
constitutes a most distressing symptom, defies every kind of treatment
during the first three or four days. During this time prolonged baths
are not well borne, and even when they are employed they scarcely
produce more than half an hour or an hour of sleep. Chloral is also,
under these circumstances, inadmissible, whether administered by the
stomach or by the rectum. It does not induce sleep, and its employment
is very often followed by a high degree of excitement. After the
fourth day it is well borne by many persons, and manifests its usual
hypnotic property. Warm baths of five minutes, followed by cold
affusions, exert an excellent influence upon the general debility and
mental depression of the first days. The objections of patients to
these baths cease after they have experienced the excellent results
which follow their use. During the bath stimulants, such as champagne,
port, and hot bouillon, may be given. Care must be paid to the
alimentation from the very beginning of the treatment. During the
first days liquid nourishment should be given, and abundance of wine
and other alcoholic beverages according to the previous habits of the
patient. Some nourishment is to be given every hour or every two
hours. Many patients experience an intense craving for alcoholic
drinks; others, on the other hand, are unable to take them. To the
former wine, beer, etc. may be given freely during the first three or
four days; to the latter a restricted milk diet may be given, one to
two quarts in the course of twenty-four hours. Such is the method of
Levinstein, to which he adds, however, important modifications for
those—and their number is large—who are unable to bear the abrupt
withdrawal of the drug.
This method is attended in all cases by indescribable sufferings, and
in many by serious dangers. Among the last, collapse and delirium
tremens demand special consideration. The collapse which occurs in a
certain proportion of the cases requires prompt and energetic
treatment. The pulse becomes feeble, small, gradually or suddenly
diminishes in frequency; the countenance is pale; the previous
agitation gives place to an ominous calm; there is a tendency to
syncope, accompanied by persistent somnolence and slowing of the
respiration. Inhalations of ammonia and the administration of aromatic
spirits of ammonia, champagne, brandy, or hot coffee, with frictions
of the surface and cold applications to the head, may occasionally
produce reaction. As a rule, however, it is necessary to administer a
hypodermic injection of morphine. This condition of collapse, once
having shown itself, is apt to recur upon the same or the following
day. The treatment of the delirium tremens {674} consists in
isolation, the administration of abundant nourishment, the use of the
bromides, chloral, or paraldehyde, with alcoholic stimulants. As this
complication is unattended by danger to life, and usually disappears
in the course of a few days, the administration of morphine is not
required.
The modifications of this method suggested by Levinstein for those who
are unable to bear the abrupt suppression of the drug are as follows:
The patient is isolated and guarded; for two or three days his
habitual dose is administered, this duty being performed by the
physician himself. The drug is then abruptly discontinued. At the end
of twenty-four hours the phenomena of abstinence are manifested; the
pulse loses its regularity, distressing diarrhœa and vomiting occur,
etc. These symptoms are controlled by the injection of morphine, the
dose being much smaller than that to which the patient has been
accustomed. By this means the sufferings of the patient are
ameliorated, and the dangers attendant upon the rapid suppression of
the drug are averted. At the end of twenty-four hours it becomes
necessary to again administer the drug, but in diminished dose. After
a time it is discontinued altogether.
_b_. The Gradual Diminution of the Dose.—This method is now generally
employed. It consists in isolation of the patient with proper
attendants and the progressive diminution of the dose. The drug should
always be administered by the physician himself. The rapidity with
which it is suppressed will be determined by the circumstances of the
individual case. The time occupied should not exceed ten days. In the
majority of cases it will be much shorter than this. If the
administration of morphine to correct urgent symptoms be at all
required after this time, it will be at most on one or two occasions
at intervals of twenty-four or forty-eight hours. When the process of
reducing the dose is too greatly prolonged, the sufferings of the
patient are unnecessarily aggravated. As the diminution progresses the
relief produced by each dose is followed by distressing reaction. The
anticipation of smaller doses from time to time or from day to day is
a matter of great distress to patients. After a while their courage
and endurance fail them, and they seek by every possible means to
secure at least one good dose of the coveted drug.
The symptoms produced by the suppression of the drug speedily show
themselves, increasing in intensity as the dose diminishes. Temporary
amelioration is, however, produced by each of the successively
diminishing doses of the drug. Whatever may have been the method
followed by the patient, the hypodermic injection of morphine is to be
preferred in the treatment. The disturbances of the digestive system
which speedily appear require but little special medication. The
danger of inanition which attends the complete loss of appetite, the
inability to take ordinary food, and the frequent often uncontrollable
vomiting, are best met by the systematic administration of easily
assimilable liquid diet, consisting of lime-water and milk, milk and
Vichy water, pancreatized milk, koumiss, concentrated broths, the
expressed juice of fresh partly-cooked beef, and the various
commercial foods used in the artificial feeding of infants. Vomiting
rarely occurs immediately after the ingestion of articles of this
kind. If it takes place in the course of an hour, some degree of
digestion and absorption will have taken place. Should, however, all
food be rejected by the stomach, efforts at rectal {675} alimentation
must be attempted. Efforts to control the vomiting by medicines other
than the administration of opium or morphine in some way are not
usually attended by success. The diarrhœa is usually frequent, the
stools being liquid, sometimes small, often copious, and amounting in
number from eight or ten to thirty or more in the course of
twenty-four hours. They are not usually attended by pain. Some relief
to this symptom follows the administration for a time of large doses
of bismuth subnitrate (grs. xx to xxx) every second, third, or fourth
hour. The sinking feeling at the pit of the stomach and the epigastric
pain are to some extent alleviated by external applications. Hot
fomentations or compresses containing a few drops of chloroform or
turpentine are also useful.
The derangement of the respiratory system, which consists usually in a
certain amount of bronchitis with more or less cough and some dyspnœa
aggravated by exertion and movement, does not usually require special
treatment.
Disturbances of the circulation constitute a very important group of
symptoms, and require close watching always, active interference
frequently. For the relief of the phenomena due to flagging action of
the heart the recumbent posture, external warmth, friction of the
extremities, the application of turpentine stupes or mustard to the
præcordial and epigastric regions, the inhalation of ammonia or the
administration of preparations of ammonia, and sometimes digitalis,
which may be given either by the mouth or hypodermically, will be
required. Alcohol, however, will prove in the greater number of cases
a most useful remedy—in many an indispensable one. It may be given in
the form of milk-punch, hot toddy, or of port, champagne, etc.,
according to the requirements of the case. Failure of the circulation
may, notwithstanding every effort to control it, reach such a degree
as to jeopardize the patient's life. Under such circumstances the
treatment must be interrupted by the immediate administration of small
but efficient doses of morphine, which, if necessary, must be
repeated. As diarrhœa increases the quantity of urine excreted rapidly
diminishes. It may not exceed eight or ten fluidounces in the course
of twenty-four hours. After the third or fourth day of the treatment
the urine in a considerable proportion of cases contains albumen and
occasionally casts. The oliguresia is largely due to the excessive
loss of fluid by the bowel, and does not require treatment. Nor,
indeed, is active treatment demanded by the albuminuria, which usually
spontaneously subsides in the course of a few days, although it
sometimes persists for some weeks or months. Persistent albuminuria
requires appropriate treatment.
The nervous symptoms, which constitute a most important group, are
favorably influenced by methodical alimentation and the free use of
alcoholics. Care must be taken to reduce the amount of alcohol
administered as convalescence progresses. With the re-establishment of
the normal functions of the body, the disappearance of insomnia, and
improved nutrition, alcohol may in the majority of cases be rapidly
diminished or wholly withdrawn. This course, favored by the regular
life which the patient should be obliged to lead on becoming
convalescent, and the feeling of general bienaise which is gradually
developed as the cure progresses, is rendered especially important by
the fact that a considerable proportion of opium-habitués are
individuals of unstable nervous organization, which in itself
constitutes a powerful predisposing influence to alcoholism.
{676} It seems hardly necessary to describe in detail the treatment
demanded for the relief of the varied disturbances of the nervous
system. The use of coca in the form of a good preparation of the wine
or fluid extract in appropriate doses, to which may be added tincture
of cannabis indica, exerts a favorable influence. The administration
of cocaine by the mouth and hypodermically has in some instances
seemed to me to be followed by favorable results. It is not, however,
to be adopted as a routine practice, by reason of its occasional
depressing effect and the possible danger of replacing the opium habit
by a craving for cocaine. Lupulin, and in particular an ethereal
extract of lupulin, exerts a favorable but not very powerful influence
in tranquillizing the nervous system. With the view of controlling to
some extent the insomnia, the hypodermic injections should, during the
early part of the treatment, be so timed that the period of sleep or
drowsiness which they produce should occur during the night. As soon
as the number of injections is reduced to one daily, that one should
be administered at the latest convenient hour before midnight. For
twenty-four or forty-eight hours after the final discontinuance of
morphine but little effect may be expected from ordinary doses of
other sleep-inducing drugs. Chloral in single large doses (grs. xx to
xxx), either alone or associated with a corresponding large dose (grs.
xl to lx) of one of the bromides, administered on the second or third
night after total suppression, is very often followed by prolonged,
tranquil, and refreshing sleep. Caution must be observed, however, in
administering chloral so long as the indications of feeble circulation
persist. Paraldehyde, although less certain, is a less dangerous
hypnotic under such circumstances. Massage, hot baths, and the cold
pack are all useful adjuvants to the treatment. The sweating when
copious and distressing is favorably influenced by sponging with hot
alcohol.
The abject mental state of the patient calls for much firmness,
gentleness, and tact on the part of the physician and attendants.
Every effort should be made to inspire courage and hope. Neither the
importance of the symptoms nor the intensity of the sufferings of the
patient should be underrated; nevertheless, the ordeal is a limited
one. In the majority of instances, to get rid of the opium means to
get well, because opium, unlike alcohol, does not leave permanent
structural lesions of any organ. The expectation of a radical cure
must therefore be confidently presented to the patient as a
consolation in his sufferings.
With the return of convalescence sexual power is restored and
menstruation is re-established. Insomnia and muscular weakness usually
persist into the convalescence for some weeks, and only gradually
yield to careful regulation of the daily life of the patient, with
abundant nutritious food, open-air exercise, and change of scene. The
insomnia of this period constitutes a serious symptom, for the reason
that it constantly subjects the patient to the temptation to return to
the use of hypnotics. In the course of time, however, the normal
physical and mental condition is regained, and the patient may be
permitted to return to his former pursuits and associations.