the will and the sense of moral accountability, I may feel it wise to
ask of the friend who accompanies my patient that he go through the
baggage and clothes of the latter before leaving him, and report to me
that no form of opium is contained in them. But in most cases I prefer
to rely entirely upon the good understanding established between my
patient and myself for my guarantee that no opiate is smuggled into
the institution, and upon my own daily examination of the patient to
determine whether this guarantee is kept inviolate. To an expert
reader of opium cases it will soon become apparent whether in any
given case a patient is taking more than the amount prescribed--and
after total abandonment is resolved upon, the question whether the
patient is taking opium at all may be decided by a tyro.
In the case of Mr. Edgerton, who has voluntarily come to ask our help
on the way upward, I proceed by a system of complete mutual
confidence. I tell him that I am sure he feels even more deeply than
myself the necessity of abandoning the drug. I promise him that he
shall never be pushed beyond the limits of endurance, and ask only
that he will allow any dose he may take to pass through my hands. I
request that if he has brought any form of opium with him he will give
it to me, and we enter into a stipulation that he will come to me for
any opiate or other alleviative which he may desire. I bind myself
never to upbraid or censure him--never to reveal to a living soul any
confidence soever which he may repose in me--and then I ask him to
name me the average dose upon which, before his late acute attack, he
has managed to keep comfortable--rather, I should say, before the
overwork and consequent opiate excess which brought it on. During his
terrible six weeks of high-pressure, he tells me, he reached a per
diem as high as 25, on one occasion even 30 grains; but for a year
previous he had never taken more than the equivalent of 18 grains of
morphia a day. This, then, shall furnish our starting-point.
Whether he has previously adopted the same method or not, I divide
this amount into three or more doses to be taken at regular intervals
during the day.
I say "the equivalent of 18 grains of morphia," because although the
majorify of _habitués_ use that principle of opium as their favorite
form, there are some who after many years' use of the drug still
adhere to crude gum opium or laudanum. The portability and ease of
exhibition which belong to morphia--the fact that it fails to sicken
some persons in whom any other opiate produces violent nausea--its
usual certainty, rapidity, and uniformity of action, and the ability
which it possesses to produce the characteristic effects of the
narcotic after other preparations have become comparatively inert,
make it the most general form in use among opium-eaters of long
standing. Still, bearing in mind the wonderful complexity of opium
(_vide_ "What Shall They Do to be Saved?") and the equally marvellous
diversity in the manner in which it affects different people, we can
not wonder at the fact that some of its victims require for their
desired effect either the crude drug or other preparations containing
its principles entire. Morphia is by far the most important of these
principles, and more nearly than any one stands typical of them
all. Still, it is easy to conceive how certain constitutions may
respond more sympathetically to the complex agent of Nature's
compounding than to any one of its constituents. [Footnote: In some
cases, especially of shorter standing, codeia may be used as the form
of opiate to diminish on. In any case its employment is worth trying,
for it possesses much of the pain-controlling efficiency of opium and
morphia, with less of their congestive action upon the brain.
Practically it may be treated in such an experiment as the equivalent
of opium; not that it at all represents all the drug's operations, but
that where crude opium has been the form in use, codeia may be
substituted grain for grain. Some patiets find it quite valueless as
a substitute, but there is always a chance of its proving adequate.
When tried, the best form is a solution similar to Magendie's, but
replacing one grain of morphia by six of codeia.] We may therefore
find it necessary to carry on our reformatory process upan laudanum or
M'Munn's Elixir, but by far the larger number of cases will do better
by being put instantly upon a regimen of Magendie's Solution of
Morphia. The formula for this preparation is:
Rx
Morph. Sulph. . . . . . . . . . . . grs. xvi.
Aqua Destill. . . . . . . . . . . . ounce j
Elix. Vitrioli. . . . . . . . . . . quant. suff.
Mr. Edgerton has used 18 grains of morphia per diem. His equivalent in
Magendie's Solution will be 9 fluid drachms.
This amount I divide into three equal doses--one to be administered
after each meal. By administering them after meals I give nutrition
the start of narcotism, prevent the violent action possessed by
stimulants and opiates on the naked stomach, and secure a slower, more
uniform distribution of the effects throughout the day. The position
of the third dcse after the 6 o'clock meal of the day is particularly
counselled by the fact that opium is only secondarily a narcotic, its
sedative effects following as a reaction upon its stimulant, and the
third dose accordingly begins to act soporifically just about
bed-time, when this action is especially required.
I keep a glass for each of my patients, upon which their "high-water
mark" is indicated by a slip of paper gummed on the outside. When
Mr. Edgerton, pursuant to our stipulation, comes to me for his dose, I
drop into the glass before his eyes a shot about the size of a small
pea--then fill the glass with Magendie's Solution up to the mark
indicated. (This shot varies in each case with the rapidity of
diminution I think safe to adopt. In some cases it is a buckshot or a
small pistol bullet.) Every day a new shot goes in--and if he bears
that rate of progress I may even drop one into the glass with each
alternate dose.
Midway between the doses of morphia I give Mr. E. a powder of bromide
of potassium, amounting to 30 or even 40 grains at a time, and an
average of about 100 grains per day. The value of this remedy has been
a matter of much controversy--some practitioners lauding it to the
skies as one of the most powerful agents of control in all disorders
of the nervous system, others pronouncing it entirely inert. Where it
has proved the latter it has probably been given in too small doses or
not persevered in for a sufficient length of time. (The timidity with
which it is often prescribed may be seen in the fact that one of the
principal druggists on Broadway lately warned a person to whom I had
given a prescription for 30 grain doses that he was running a very
dangerous risk in taking such a quantity!) Its operation is so
entirely different from that of the vegetable narcotics that people
looking for their instantaneous sedative effect can not fail to be
disappointed. It is very slowly cumulative in its action, seeming to
act upon the nervous system by a gradual constitutional change rather
thin any special impetus in a given direction. Because that is its
_modus operandi_, I begin to give it thus early; and it is of
peculiar value now, not only as making the daily diminution of the
opium more tolerable, but as preparing the system for the time when
the drug is to be abandoned altogether and the hardest part of the tug
comes.
In Mr. Edgerton's case the gradual descent to 1/2 grain per diem, when
we leave off the opium entirely, consumes let us say a period of one
month. It is not to be expected that this period will pass without
considerable discomfort and some absolute suffering, for the nervous
system can not be dealt with artfully enough to hide from it the fact
that it is losing its main support. It is the nature of that system
not even to rest content with the continuation of the same dose. It
grows daily less susceptible to opium and more clamorous of
increase. When the dose does not even remain _in statu quo_ but
suffers steady diminutions however small, the nerves can not fail to
begin revenging themselves. Still, this period may be made very
tolerable by keeping the mind diverted in every pleasant occupation
possible, such as I shall presently refer to as abounding on our
Island. Our physical treatment for the month is especially directed to
the establishment of such healthy nutrition and circulation as shall
provide the nervous system with a liberal capital to for at least the
first ten days or fortnight after the complete abandonment of
opium. The patient's digestion must be carefully attended to, and kept
as vigorous as is consistent with the still continued use of the
drug. Beef-tea, lamb-broth with rice, all the more concentrated forms
of nutriment, are to be given him, in small quantities at a time, as
frequently as his appetite will permit; and if progressive gastric
irritability does not develop itself as the diminution of the narcotic
proceeds, he is to have generous diet of all kinds. We must pay
particular attention to the excretory functions--getting them as
nearly as possible in complete working order for the extra task they
have presently to fulfill when the barriers are entirely withdrawn and
the long pent-up effete matters of the body come rushing forth at
every channel. The bowels must be trained to perfect regularity, and
the skin roused to the greatest activity of which it is capable.
Exercise, carried to the extent of healthy fatigue, but rigorously
kept short of exhaustion, may be secured in our bowling-alley,
gymnasium, and that system of light gymnastics perfected by Dio
Lewis--a system combining amusement with improvement to a remarkable
degree, as being a regular drill in which at certain regular hours all
those patients, both ladies and gentlemen, who are able to leave their
rooms, join under the command of a skillful leader to the sound of
music. This system has an advantage, even for well people, with its
bars, poles, ropes, dumb-bells, etc., inasmuch as it secures the
uniform development, on sound anatomical and physiological principles,
of every muscle in the human body, instead of aiming at the
hypertrophy of an isolated set. I do not mean by this to deny the
value of the old style gymnasium, our Island will possess as good a
one as any athlete could desire. Horseback riding will form another
admirable means of effecting our purpose, especially where the patient
suffers from more than the usual opiate torpidity of the liver. We
shall have room enough if not for an extended ride at least for a mile
track around the Island, and a stud, however unlikely to set John
Hunter looking to his laurels, capable of affording choice between a
trotter and a cantering animal. During the summer there will be ample
opportunity for those who love horticulture to take exercise in the
flower and vegetable garden attached to the institution, and such as
wished might be assigned little plots of ground whose management and
produce should exclusively belong to them. Looking for a moment from
the therapeutics to the economics of the matter, I can see no reason
why the house might not rely largely upon itself for at least its
summer vegetables and its fruit--if the poorer patients were permitted
to pay part of their dues, when they so elected and the exertion was
not too much for them, by taking care of the grounds. Another
admirable means of exercise will be found in rowing. Our Island must
have a good substantial boat-house, containing a good-sized barge for
excursions and several pleasure-boats pulling two or three pair of
sculls each; perhaps, eventually, a pair of racing-boats for such of
our guests as were well enough to manage a club. Bath-houses for the
convenience of those who love a plunge or a swim will be
indispensable--affording facilities for a species of summer exercise
which nothing can replace.
In winter and summer the bath must be our principal reliance for
promoting that vigorous action of the excretory system which with
healthy nutrition is our great aim in treating the patient.
Quackery has to so great an extent monopolized the therapeutic use of
water, and so much arrant nonsense has been talked in that pure
element's name, that we are in danger of overlooking its wonderful
value as a curative means. It is one of the most powerful agents at
the command of the practitioner, and should no more he trifled with
than arsenic or opium. Used by a blundering, shallow-pated empiric it
may be worse than useless--may do, as in many cases it has done,
incalculable mischief to a patient. In the hands of a clear-sighted,
experienced, scientific man, who administers it according to
well-known laws of physiology and therapeutics, it is an inestimable
remedy, often capable of accomplishing cures without the assistance of
any other medicine, and, indeed, where all other has failed. Many of
the forms in which it is applied at water-cures well deserve adoption
by the more scientific practitioner. Among these the pack occupies a
front rank. During Mr. Edgerton's month of diminution we use this with
him daily. Its sedative effect, when given about three and a half
P.M., just after the second dose of bromide of potassium, is
exceedingly happy-seeming, as I have heard a patient remark, "to
smooth all the fur down the right way"--removing entirely the
excessive nervous irritability of the opium-craving, and often
affording the patient his only hour of unbroken sleep during the
twenty-four. Its tendency to promote perspiration makes it a most
effective means for restoring the activity of the opium-eater's skin,
and this benefit will be still further increased if it be followed by
sponging down the body with strong brine at a temperature as low as
the patient can healthily react from, concluding the operation with a
vigorous hand-rubbing administered by the attendant until the skin
shines. This same salt sponge is a most invigorating bath to be taken
immediately on rising. Another excellent bath in use at water-cures,
of value both for its tonic and sedative properties, is "_the
dripping sheet_," in which a sheet like that used in the pack, of
strong muslin and ample size, is immersed in a pail of fresh water at
about 70° F., and, without wringing, spread around the standing
patient so as to envelop him from neck to feet, the attendant rubbing
him energetically with hands outside it for several minutes till he is
all aglow. In cases where great oppression is felt at the
epigastrium--that _corded_ sensation so much complained of by
opium-eaters during their earlier period of abandonment, and that
peculiar self-consciousness of the stomach which follows in the track
of awakening organic vitality--the greatest relief may be expected
from "_hot fomentations_," This is the well-known "hot and wet
external application" of the regular practice, and consists of a
many-folded square of flannel wrung out of water as hot as the skin
can bear, and laid over the pit of the stomach, with renewals as often
as the temperature perceptibly falls.
The symptom of cerebral congestion--a chronic sense of fullness in the
head--is often very simply alleviated by placing the patient in "_a
sitz_" or hip-bath, with the water varying from 70° to 90° F,
_Enemata_ will constantly be found of service where the torpidity
of the bowels is extreme. Not only so, but in cases where the liver is
beginning to re-assert itself, and its tremendous overaction sends
down such a supply of bile as to provoke inversion of the pylorus, an
enema may often act sympathetically beyond that portion of the
intestine actually reached by it, and change the direction of the
intestinal movement, so as to convert the deadly nausea excited by the
presence of bile in the stomach into a harmless diarrhea which at once
removes the cause of the suffering. Of the value of foot-baths I need
not speak, and to the hot full-bath I must now make reference as the
most indispensable agent in ameliorating the sufferings of one who has
completely abandoned the drug.
When Mr. Edgerton's dose has reached as low an ebb as 1/2 grain of
morphia he abandons the drug entirely. In my _Harper's Magazine_
article I have fully depicted the sufferings which now ensue--as
fully, at least, as they can be depicted on paper--though that at the
best must he a mere bird's-eye view. During the period of diminution
he has endured considerable uneasiness and distress, but these have
been trifling to compare with the suffering which he must endure for
the first few days and nights, at least, after total abandonment.
Universal experience testifies that although the previous period of
diminution greatly shortens and softens the sufferings to be endured
after giving up opium altogether, the descent from 1/2 grain of morphia
to none at all must involve a few days at least of severe suffering,
which nothing borne during the diminution at all foreshadows.
In my _Harper's_ article I have said:
"An employment of the hot bath in what would ordinarily be excess is
absolutely necessary as a sedative throughout the first week of the
struggle. I have had several patients whom during this period I
plunged into water at [Footnote: On some occasions, by repealed
additions from the hot faucet as the temperature of the water in the
bath-tub fell, I have raised the bath as high as 120° F. without
causing any inconvenience to the patient. Most bath-tubs--all in our
own city houses--are too capacious, and too broad for their depth. To
prevent cooling by evaporation the tub should be just the width of a
broad pair of shoulders and about two feet deep.] 110° F. as often as
fifteen times in a single day--each bath lasting as long as the
patient experienced relief."
Science and experience have thus far revealed no other way of making
tolerable the agonizing pain which Mr. Edgerton now endures. This pain
is quite inconceivable by the ordinary mind. It can not be described,
and the only hint by which an outsider can be let into something like
an inkling of it is the supposition (which I have elsewhere used) that
pain has become _fluidized_, and is throbbing through the
arteries like a column of quicksilver undergoing rhythmical
movement. If the arteries were rigid glass tubes, and the pain
quicksilver indeed, there could not be a more striking impression of
ebb and flow every second against some stout elastic diaphragm whose
percussion seems the pain which is felt. This is especially the case
along the course of the sciatic nerve and all its branches, where the
pulse of pain is so agonizing that the sufferer can not keep his legs
still for an instant. There is occasionally severe pain of this kind
in the arms also, but this is very rare. The suffering which usually
accompanies that of the legs is a maddening frontal headache, and a
dull perpetual ache through the region of the kidneys, described as a
sensation of "breaking in two at the waist;" nausea, burning, and
constriction about the epigastrium, and intense sensitiveness of the
liver--besides general nervous and mental distress which has neither
representative nor parallel.
All these symptoms are instantaneously met and for the time being
counteracted by the hot-bath. When the patient gets tired of it, and
it temporarily loses its efficiency from this cause, great advantage
may be gained by substituting either the Russian bath or the common
box vapor-bath, with an aperture in the top to stick the head out of,
and a close-fitting collar of soft rubber to prevent the escape of the
steam.
I must here refer to another means of alleviation, concerning which I
can not bear the witness of personal experience, but which has been
highly recommended to me. Even this brief sketch of treatment would be
imperfect without at least a mention of it, and if it possesses all
the value claimed for it by persons of judgment who have reported it
to me, it will form an indispensable part of our apparatus on Lord's
Island. This is an air-tight iron box of strongly-riveted boiler
plates, with a bottom and top fifteen feet square and sides ten feet
high; thick plate-glass bull's-eyes in each side sufficiently large to
light the interior as clearly as an ordinary room; and a cast-iron
door, six feet in height, shutting with a rubber-lined flange, so that
all its joints are as air-tight as the rest of the box. Inside of the
box, in the centre, stands a table, suitable for reading, writing,
draughts, cards, chess, or games of any similiar kind, with
comfortable chairs arranged around it corresponding in number to the
people who for an hour or two could comfortably occupy the room. In
one side of the box is a circular aperture connecting with an iron
tube, which in its turn is joined to a powerful condensing air-pump
outside, and on the other side is a pressure gauge with its index
inside the box. Sufferers from severe neuralgic pain being admitted,
the air-tight door is shut; they seat themselves, and the condensing
pump is set in motion by an engine until the gauge within indicates a
pressure of any amount desired. I am told that the severest cases of
neuralgia have found instantaneous and thorough relief by the addition
of six or eight atmospheres to the usual pressure of air upon the
surface of the body. There is no reason why the condensation might not
be continued to twenty or more, the increased density causing no
uneasiness to those within the box, the same equilibrium between
internal and outward pressure that exists everywhere in the air being
maintained here. Persons who have made trial of this apparatus speak
of the cessation of their pain as something magical; say they can feel
it leaving them with every stroke of the pump; and although as yet we
may not be able to offer a scientific explanation of the relief
afforded, we can not fail to see its applicability to the case of the
reforming opium-eater. If it does all that is claimed for it, it
probably acts both mechanically and chemically--the pressure, even
though imperceptible from its even distribution, affecting the body
like the shampooing, kneading action of an attendant's hand, and the
vastly increased volume of oxygen which it affords to the lungs and
pores accelerating those processes of vital decomposition by which the
causes of many a pain, but especially that of our patient, are to be
removed.