Drugs that enslave

Limited space forbids my illustrating each modification of treatment with pertinent cases, and I content myself with discussing the various drugs and agents used, and the indications calling for their employment. In this way, too, the reader will become acquainted with the various symptoms that arise in the course of rapid deprivation.

BATHS.

Baths of various kinds are the mainstay in the treatment of most cases of this kind. They are used for four purposes: (a) To allay excitement. (b) To relieve pain. (c) To equalize the circulation, and (d) To procure sleep. They succeed when drugs fail.

On the third or fourth day of treatment it is usual to have, especially in very nervous persons, considerable excitement, reflex nervous irritability, not so great, however, as when the drug is suddenly taken away. The violent delirium tremens spoken of by Levenstein I have never seen, save in one case, which I treated according to his method. When delirium occurs at all, it is usually of a low, muttering, harmless kind. For its treatment and that of the severe nervous irritability and restlessness sometimes seen, the hot bath, followed by the cold douche, is an excellent remedy. If the patient is strong I let him remain in it for twenty minutes; if weak, from five to fifteen minutes. A good reaction is had and the quieting powers of the bath enhanced by pouring one or two pails of cold water over the patient’s head and shoulders, or directing upon him for a moment a number of fine jets of cold water, with considerable force. The nozzle should be so arranged that from twenty to forty jets may play at the same time. After this the body should be thoroughly rubbed with a hair glove, until the surface is in a glow, and the patient then be put to bed, where gentle perspiration usually follows, with considerable relief to the pain in the limbs, shivering and sneezing; oftentimes a quiet sleep, lasting from thirty minutes to two hours, follows.

A rapid hot bath, followed by the douche or spray, and that by thorough rubbing, I find an excellent measure in the after-treatment of these cases, it hastening the breaking down of old and stimulating the growth of new tissues, as also the different secretions.

The temperature of the bath should never be below 112° Fahr.

In some neuralgic patients, the cold douche sometimes causes pain afterward. In these cases it should be omitted, the hair glove being used freely in its stead.

Several baths may be given in the course of a day, but I rarely find it necessary to give more than two or three in the worst cases.

The bath, too long continued or too often given, will sometimes greatly weaken the patient. In debilitated subjects and those suffering from pelvic pains I find the hot sitz bath, followed by thorough rubbing and kneading of the whole body, often gives great relief.

For persistent insomnia I find the cold pack a most serviceable agent. The patient is wholly undressed, a sheet is wrung out of cold water, and he is wholly enveloped in it up to the chin. The sheet should be folded under the feet and tucked in evenly and closely about the neck. He is then closely wrapped in from four to six blankets, and in the majority of instances will soon fall asleep, a gentle perspiration breaking out all over him. He may be allowed to remain in this an hour or even two hours.

Excitement and nervousness are calmed by it, the restlessness and pain disappear, and the sufferer often remarks how much good it is doing him.

In removing it, the whole matter should be done rapidly, under cover of a heavy blanket, and the body be thoroughly rubbed with a sponge dipped in whiskey and water.

ELECTRICITY.

This is also a valuable agent in the treatment of the pains, that are usually distressing. Sometimes the interrupted, sometimes the continuous current acts the best. As a rule, however, a powerful continued current (from ten to forty cells) is the most serviceable. The electrodes should be kept continuously moving up and down the limbs, and the current be occasionally reversed.

Dr. William F. Hutchinson relates the following interesting case[41] of cure by electricity: “About the first of January of the present year, I was requested by Dr. O. C. Wiggin, of this city, to see with him a lady supposed to be suffering with cerebral congestion in an advanced stage.

“A visit to Mrs. S. revealed the following history: Age thirty-nine; married; one child, aged six; and has had one miscarriage; weight about 150 pounds; and general appearance of contour and skin good. Patient kept up a low moaning, answering most of my questions intelligently, then relapsing into a semi-unconscious condition. Pulse 100, compressible; temperature 99°; no loss of control of evacuations; conjunctivæ congested and pupils contracted closely; perspiration starts upon the smallest exertion, which also causes pain in abdomen and excites vomiting, which has lately become persistent, accompanied with intense thirst. Hands and feet cold, with shriveled palms and plantar surfaces. No difference in temperature of head and axilla.

“Ophthalmoscopic examination gave retinal and choroidal congestion, with venous enlargement, slight optic neuritis and choked disk.

“There was constant pain, and sense of fullness in frontal region.

“The only family history that could be obtained bearing upon the case was the death of one sister, a year ago, from acute brain inflammation, the remainder of the immediate family being still living and in good health; and the present condition appeared to be the culmination of six years of almost constant pain and general nerve exhaustion, following the birth of a child, and aggravated by a subsequent miscarriage.

“At this visit no suspicion was entertained by me of any opium habit, and the case was diagnosed as passive cerebral congestion, dependent upon general neurasthenia.

“The next day Dr. Wiggin called and gave me the following additional items, which at once placed the case in its proper light and gave the key to many of the symptoms before cited. After her confinement, which was a long and painful one, she suffered severely from wandering pains in back and hips, for which her attending physician at the time ordered tincture of opium applied externally, giving at the same time ten drops by the mouth, and the ground was broken for the building of the habit. The dose steadily increased until she came under the charge of Dr. Wiggin, some six months previous to my seeing her, when she was taking four ounces of laudanum daily, internally, besides continuing external applications as before. Attempts were made to stop the pernicious habit, but it was too late for wise counsel to avail, and the usual cunning of opium eaters procured for her the drug in spite of every effort of both husband and physician.

“All forms of concurrent medication had been faithfully tried, but nothing was of use except the opium, to which it became absolutely necessary to resort occasionally, as without it the poor lady would arouse the neighborhood with agonizing screams and cries.

“At this juncture, as a forlorn hope, it was decided to essay galvanism, hoping that its great vitalizing power might aid in restoring tone to the exhausted nerve centres. At my suggestion, Collis Brown’s chlorodyne was given in place of laudanum, and produced the same effect with an ounce per diem that the four ounces of the former had done.

“Central galvanism was applied, with a twenty-four cell Bartlett battery, using six cells from the cilio-spinal centre to the forehead, with a downward current; then from the cervical vertebræ to the solar plexus, with an ascending current, each lasting six minutes, or until the skin was thoroughly reddened under the negative carbon point. For the first few days applications were made morning and night. In a week the vomiting had ceased and consciousness returned, and the evening sitting was omitted. After a month the dose of anodyne was gradually decreased, but with every diminution the nausea returned, and nothing but a return to the old dose would avail. But her condition was very much improved. She slept better, the eyes were normal as to color and the palms were no longer dry. At the close of the second month she was able to sit up, and the dose of anodyne was steadily cut down without the patient’s knowledge, by adding to the chlorodyne a sufficient quantity of flavored treacle to replace each dose taken, until at that time an ounce would last three days.

“Her general condition was greatly improved, and she began to take interest in her surroundings. In two months more she commenced to go out, and came to my office for treatment, when I changed the current to the Siemens and Halske cabinet cell, which, with its low tension and perfect capability of control, I regard as the ideal battery for central galvanism. There was no further trouble, and to-day, June 21st, the lady is quite well, attending to all her household duties, not having tasted opium in any form for seven weeks, and expressing unbounded delight at being free from the terrible habit which had so long been her master.

“The rationale of the action of galvanism in this case is difficult to understand. When the circuit was closed over the superior sympathetic ganglion, Dr. Wiggin and myself distinctly observed a sudden wave-like contraction of the distended retinal veins, which resumed their size in a few moments after the stimulus was removed. But, after some weeks’ treatment, these veins became normal, and the intraocular congestion had disappeared pari passu with the cerebral symptom, and having repeatedly witnessed the same phenomenon in other cases, I am led to believe that the galvanic current has a direct tonic influence upon the vaso-motor system, which accounts for the occasional surprising results obtained in cases of cerebral congestion. With the advent of increased nerve circulation came an absolute horror for the drug, and it is not easy to know to what to attribute the increase of strength of will up to the point of totally dispensing with it of her own accord, unless it be to some change in mental power, due to increased nerve tone, the direct result of what I have before termed the vitalizing power of the galvanic current. Faradism was not at any time employed.

“Dr. Wiggin gives full credit to the special treatment for the cure of the case.”

DRUGS.

The bromides I have found to be very valuable, especially where there is a hysterical tendency. The bromide of sodium is said to disorder the stomach less than any of the others. To be of any service they must be given in large doses. Dr. J. B. Mattison gives sixty grains, three times a day. I have given as high as three hundred and thirty grains in one hour and a half, and often in one hundred grain doses, and have never yet seen the least harm result, but very decided good. Wyeth’s elixir of the bromide of potassium is an elegant preparation. Its strength may be increased at will. Where there is too decided irritation of the stomach I give the drug by the rectum, in milk. Occasionally a large dose of the bromide will quiet persistent nausea. It certainly modifies the excitement and reflex irritability, as also the headache and salivation.

Coca I have tried in several cases, but cannot agree with Prof. Palmer as to its peculiar adaptability to these cases. As a nerve tonic it is a valuable adjunct to other treatment, but beyond that nothing.

Strychnia, capsicum and belladonna I use in large doses, or small doses often repeated. They are all heart stimulants, and the two former decided nerve tonics, aside from their action on the stomach. I vary the quantity of each ingredient to suit each case. The use of capsicum was first suggested by its successful employment in delirium tremens. A nervous tonic may at the same time be a sedative to nervous irritability. I gradually increase the dose as the symptoms are wont to increase, during three or four days, and the drugs thus given seem to have a better effect.

If the nervous irritability is extreme, especially if there are hysterical symptoms or twitching of muscles, or spasm of the rectal or vesical sphincter, I add lobelia and stramonium, which, besides relieving these symptoms, are excellent in allaying the nausea and vomiting.

Cannabis indica is an excellent agent to cause tranquillity and destroy hallucinations. It seems to take the place of the morphine to a certain extent. It, too, must be given in large doses.

Hyoscyamus and hyoscyamia I have tried, and never derived much advantage from them. The former usually increases or produces diarrhœa. My failure to obtain good results has not been due to using too small doses.

Chloral, except in small doses, is a dangerous remedy, and one with which, if a good effect is had, the patient is apt to fall in love. It is not of much service as a sleep producer, save in dangerously large doses. Levenstein found that in some cases it produced violent excitement. I have seen a ten-grain dose produce urticaria that tormented the patient for several days.

Hydrocyanic acid was first recommended in the treatment of this affection by W. C. Blalock.[42] He claims that it supplies the place of morphine or opium. It does not do so. His formula reads as follows—

Sig.—A teaspoonful at 7 A.M., 12 and 8 P.M.

As a quieter of gastric irritation and nausea, and as a nerve stimulant, it is an excellent adjuvant in certain cases.

Lupulin and Lactucarium. I have not had sufficient opportunity to test these drugs fully, but in one case, which I have under treatment now, they seem to take the place of morphine with excellent results, the patient going twenty-four hours with but a small amount of discomfort on a minimum amount of morphine and large amounts of these drugs. In three days I have been enabled, by their use, to reduce the amount of morphine from twelve grains to half a grain, in the twenty-four hours, the patient being up and about. Whether the effect will hold, and whether these drugs can be easily abandoned, remains to be seen. It is in drugs of this class that we must look for a substitute for opium and its alkaloid. With other treatment we merely combat the symptoms that arise.

The fluid extract of lupulin may be used in from one to four drachm doses, by the mouth, or from thirty to sixty drops hypodermically. Lactucarium is best given in powder, in half drachm doses.

I have also used the extract of lettuce (English) in ten-grain doses, every two hours.

DIET AND STIMULANTS.

In the management of these cases diet is as important as medication. With the plan which I am now pursuing I rarely have nausea lasting longer than a few hours, a very important point, both as regards the comfort of the patient and the possibility of full nutrition. Diarrhœa, too, so common in Levenstein’s plan, rarely proves troublesome, is often entirely absent, and I am occasionally obliged to use laxative medicine. If there is any tendency to relaxation of the bowels I interdict the use of fruit, of which these patients are very fond, and give subnitrate of bismuth, in large doses.

Beefsteak, beef broth, chicken soup, mutton broth, wine jelly, eggs and plenty of milk are called for. With the milk a little lime water should be used. If the digestion is slow and labored, from ten to twenty grains of pepsine should be given after each meal. If there seems to be decided gastric catarrh nothing acts so well as pills composed of—

One, one hour before meals.

If there are symptoms of collapse, although this is unusual, wine should be given freely, or whiskey hypodermically, three or four syringefuls at a time. Milk punch is an excellent stimulant and food, and egg-nog good, when well borne by the stomach, which is not always the case.

The best wine for these patients is sherry, and it should be better than that found in drug stores and bar rooms. Port is usually largely adulterated. Claret causes acidity. As a rapid stimulant the best champagne is excellent. There comes a little apparatus that can be screwed through the cork of the bottle, and by turning a faucet as much or as little can be drawn as is wanted. It saves wine and keeps it from staling.

Bottled beer is of service in some cases. The purest only should be used. It may be kept from staling in the same manner as the champagne.

Alcoholic stimulants should be continued only so long as is absolutely necessary, which is never more than ten days. This is very important, for it must be borne in mind that these patients are prone to go to excess with stimulants, as well as narcotics.

AFTER TREATMENT.

The thorough cure of an opium or morphine habituè does not consist alone in stopping the use of the drug. This is certainly a very important step, but there yet remains much to be done, especially in those cases where the person became habituated to the use of the drug through its employment in some extremely painful neuralgic affection. This disease may still persist or return in full force on the withdrawal of the drug.

The use of the drug being discontinued, attention should be at once directed to the treatment of the original affection or of any disease that may lead the patient to again return to the use of the drug.

There are, too, certain troublesome symptoms, about some of which I have already spoken, that come on a few days after the opium or morphine is stopped. The most troublesome of these is “soreness of the throat,” consisting in congestion of the pharynx, tonsils, larynx and vocal cords. There is a sensation of tickling and a short, dry, annoying cough, that comes on in paroxysms and is especially troublesome at night. It is best treated by the local application of nitrate of silver (twenty to forty grs. to the ounce) and five-drop doses of benzoic acid given several times daily.

The insomnia is usually relieved by exercise better than by drugs, although I have often found bromide of potassium and hyoscyamus of service. On no account use chloral hydrate, or give stimulants at bedtime. Exercise is by far the best remedy. Walking, running, making garden, etc., sufficient to tire the patient out thoroughly, is an almost certain sleep producer, appetizer and hastener of tissue metamorphosis. The cold pack or a hot bath at bedtime often proves of service.

The appetite usually needs no stimulation by drugs. It is, as a rule, ravenous for the first few weeks after the morphine is stopped, so much so that ten-grain doses of pepsine will often be found necessary after each meal, the patients usually over eating. As a rule, I give the following mixture, as much for its effect on the nervous system as for the appetite:—

Sig.—One drachm half an hour before meals.

If anæmic, nothing acts so well as the muriated tincture of iron, which usually contains a trifle of arsenic, in from fifteen to forty-drop doses, three times a day, after meals. It should be given in half a goblet of water. Cod-liver oil is also of great benefit, especially if there is combined with it minute doses of the iodide of arsenic.

Seminal emissions and priapism in males will right themselves.

Females who suffered from leucorrhœa before they commenced using opium or morphine, and who stopped during the time they were taking it, as, also, those who have never had such a discharge, are usually troubled with a white, ropy matter passing away from them in large amount. This is sometimes accompanied by severe, labor-like pains. Vaginal injections of a strong infusion of white oak bark are called for, to be followed by the use of the following on the top of pads made of borated or absorbent cotton:—

These pads are made a little larger than a lemon, with a pedicle twisted with fine cord. They are medicated on the top, the sides smeared with vaseline, and are then pushed up against the mouth of the womb. A small piece of cord is left hanging, so that they can be easily removed. They are to be introduced in the morning, and removed at night.

Neuralgic pains in the limbs and body are best removed by the hot bath and massage.

The menses may come on irregularly, that is to say, not at the period at which they usually came before addiction to the habit caused their suppression. Pain in the pelvic region, fullness of the abdomen, and a general sensation of puffiness, indicate their coming. On the appearance of these symptoms I give the following until the bowels are freely moved, at about which time the menses usually appear:—

In capsule every night or morning, or the pills of Oppolzer.[43]

The period is finally established at its proper time by coming on a few days sooner each month until the normal date is reached, after which there is rarely any change. The second and third menstruation is much more abundant and less painful than the first.

Dyspepsia and “biliousness,” which are sometimes present, are best overcome by pepsine, and the following, every third night, to be followed in the morning by some laxative mineral water:—

It may be made in pill form or be put in a capsule.

Finally, plenty of exercise and fresh air, baths, regular habits of life, and treatment directed to those complaints, real or imaginary, if still existing, for the relief of which the patient first took the drug.

The rapid way in which these patients gain flesh is sometimes astonishing. A gain of fifty pounds in a month’s time is not unusual.

PROGNOSIS.

The prognosis is, in the majority of cases, good. A cure can be effected in any case, provided the directions followed are faithfully carried out, especially in a private institution, where absolute control of patient and nurse is possible, and where the number of patients is limited.

Levenstein says:—

“To treat morbid craving for morphia with success, it is necessary to decide the principal question, namely, whether each individual patient does or does not suffer from pathological complaints or chronic disorders requiring narcotics for their relief. If he does, it is only necessary for the doctor to deprive the patient of the morphia syringe and to inject personally, if his time permits of so doing, a dose which he thinks sufficient, or else to give the narcotic internally.

“Furthermore, we exclude from the treatment all patients weak or exhausted through bodily or mental affliction. It is all the same whether the prostration is caused by night duty, distress, illness, childbed, want of proper food, flooding, etc.; only those conditions of weakness following upon the poisoning with morphia constitute no counter-indication, as they disappear in consequence of the deprivation. Only such individuals, therefore, are suited for the treatment who have continued the injections while in perfect health, the former morbid appearances for which they at first administered them having disappeared.”

From these statements I must heartily dissent. No organic disease, no affection of the general system, save those that are sure to prove fatal, as cancer and the like, justify continuance in this habit. In almost every instance the accompanying ill effects will be found to be due more to the abuse of morphine than to the disease itself. Indeed, its continuance may place the patient in a condition that will preclude the possibility of recovery.

Patients with one foot apparently in the grave, when deprived of their morphine, take a decided turn for the better, and regain fair, if not perfect health. A fatal ending sometimes follows the waiting and attempting to build up the health before commencing the treatment of the habit.

As to the advisability of treating debilitated and exsanguinated patients by the method of sudden deprivation, I fully agree with him, for the trial is as much as a robust and healthy individual can bear. By substitution and gradual deprivation, however, it can be accomplished safely and satisfactorily.

The danger of a return to this habit decreases with each year, each month, each day of abstinence. It is greater in neurasthenic patients and those who have taken large amounts, or who have not received proper after treatment.

Under no circumstances should these people be given opiates in any form or for any complaint, save when life can be saved in no other way, for a relapse is almost certain to occur if this is done. Witness the case of the literary gentleman already referred to. A single dose may undo the work of years.

In conclusion, I feel that I am warranted in again insisting upon the growing evil of indiscriminate and careless use of the hypodermic syringe. The following, from my work upon the hypodermic use of morphia, well expresses my feelings in this matter.

“Some of my correspondents, men of ability and in large practice, express themselves as very skeptical of the truth of the statement that the morphia habit has ever been formed by the use of the drug hypodermically. Testimony from all parts of the civilized world settles this matter beyond question. Bartholow, from whose excellent little work I have so often quoted, says:[44]

“‘The introduction of the hypodermic syringe has placed in the hands of man a means of intoxication more seductive than any which has heretofore contributed to his craving for narcotic stimulation. So common now are the instances of its habitual use, and so enslaving is the habit when indulged in by this mode, that a lover of his kind must regard the future of society with no little apprehension. It may well be questioned whether the world has been the gainer or the loser by the discovery of subcutaneous medication. For every remote village has its slave, and not unfrequently several, to the hypodermic syringe, and in the larger cities, men in business and in the professions, women condemned to a life of constant invalidism, and ladies immersed in the gayeties of social life, are alike bound to a habit which they loathe, but whose bonds they are powerless to break. Lamentable examples are daily encountered, of men and women, regardful only of the morphia intoxication, and indifferent to all the duties and obligations of life, reduced to a state of mental and moral weakness most pitiful to behold.

“‘Usually the habit is formed in consequence of the legitimate use of the hypodermic syringe in the treatment of disease. Employed in chronic painful maladies for a long period, it is discovered, when an attempt is made to discontinue the injections, that the patient cannot or will not bear the disagreeable, even painful, sensations which now occur. More frequently, when the injections are to be used for a long time, the patient is unwisely intrusted with the instrument, and taught all the mysteries of the solutions and the mode of administration.’

“A study of the opinions and cases that I have collected and presented in the preceding chapters furnishes abundant food for thought; the more so, as nearly every physician in the world is using a hypodermic syringe with more or less frequency. Many are unquestionably using this instrument too often; are using it in cases where the same, or other remedies, by the mouth, would be equally efficacious, and certainly safer. Far be it from me to condemn the use of an instrument the employment of which has brought both temporary and permanent relief, sometimes cure, to thousands suffering the most intense agony. Its value in cases especially suited to it cannot be over-estimated; its use in cases unsuited to it, or where other means would answer as well, cannot be too strongly and heartily condemned. Death, syncope, alarming narcotism, and, perhaps, more important than all, that living death—the morphia habit—bids us choose our cases well, and continue its use for only so long a time as is absolutely necessary.

“It would seem, from a study of the cases related under the latter head, and from many of the interesting letters for which I cannot find space, and, therefore, give at second-hand, that so long as the drug is used carefully, and with discrimination, by the physician, the morphia habit is little apt to result, and that it may be broken off when once formed, although the amount of morphia used is large. But, nevertheless, even when these results are attained, persons, especially those of the neurasthenic type, will often procure a hypodermic syringe surreptitiously, and continue, commence or re-commence the practice anew. For this the physician is certainly not to blame, but the fact still stands, and the question arises whether relief by other means, though less prompt and less permanent, would not have been more preferable to the deplorable mental, moral and physical condition that almost uniformly obtains when the habit is once established.

“When Wood first gave his idea to the world, and when that idea was practically developed and extended in point of applicability by Hunter and others, it was thought to be glory enough to have found a weapon sufficiently powerful to cope with severe and obstinate neuralgia and diseases that would not yield to other treatment. To-day, as seen from its journal literature, the subcutaneous method of giving morphine has become almost universal, and it is employed for complaints of the most trivial character. Aside from the immediate and remote danger of thus needlessly extending this practice, there is another reason why this instrument should not be so commonly employed—there is apt to be slurring of diagnosis and a blind treatment of the most prominent symptom. This is especially the case with the younger members of the profession. Having relieved the pain, they fail to study the minor symptoms, to look at patient’s family and personal history, to be observing of skin, and tongue, and pulse. It may be urged that the patient often recovers without any other treatment. True! But many do not, and the lack of study of every point in the successful cases bears its fruit of slovenly diagnosis and unscientific treatment in many succeeding cases.

“Finally, let it be distinctly understood that I consider the hypodermic use of morphia a very decided therapeutic advance, and of incalculable benefit in allaying pain and curing disease in cases where other modes of treatment utterly fail. In calling attention to the dangers sometimes attending the use of the drug in this way, I do it not from a one-sided view of the question, not with a desire to condemn it, simply to point out what may occur, endeavor to show how best to avoid it, and, if possible, restrict its use to those cases in which it is proper.”

The physician should never entrust a syringe or the solution to patients or their friends. He should use it himself.