The behavior of patients undergoing the suffering attendant upon the abrupt, or even the gradual, withdrawal of the drug is variable. It depends upon the mental and physical organization of the different individuals and upon their ability to endure pain. Some rest quietly in bed, enduring with fortitude suffering from which there is no escape; others, silent, uncomplaining, and apathetic, present theappearance of utter despair; a few, more fortunate than their fellows, lapse into a condition of almost continuous drowsiness. In the greater number of cases, however, these states of repose are but momentary or absent altogether. Restlessness is continuous, and very often intense; the patients are with difficulty kept in bed; if left to themselves they move frantically about the room, moaning, bewailing their condition, and begging the attendants for that which alone is capable of relieving their distress. This condition gradually subsides, giving way to a state of the most profound exhaustion. The exhaustion due to the reaction of the nervous system deprived of the stimulus of the drug is, on the one hand, favored by pre-existent derangement of the nutritive processes, and on the other increased by the pain, wakefulness, diarrhœa, and vomiting which accompany it. The appearance of the patient is now most pitiable; the countenance is blanched and pinched, the body occasionally drenched with sweat; the heart's action is feeble, and the pulse thready and irregular. This condition of collapse is usually of short duration, disappearing in favorable cases under the influence of appropriate nourishment administered in small quantities and with regularity. Where, however, the gastric irritability is unmanageable, an increasing tendency to collapse may threaten life. In rare cases suddenly-developed fatal collapse has occurred at a later period in the treatment, even after the patient has become able to take and retain food. The restlessness does not, however, always subside in this manner. In a considerable proportion of cases it increases. Hallucinations and delusions occur, and a condition of delirium tremens, scarcely differing from the delirium tremens of chronic alcoholism, is established. Tremor is a constant phenomenon of this condition. Sometimes the gravest symptoms of the suppression of the drug are developed with great rapidity. Jouet relates a case of a patient at the Salpêtrière who during a temporary absence from the hospital forgot her syringe and solution; her return being delayed from some cause, she, notwithstanding her struggles against the symptoms caused by the want of her habitual dose, suddenly fell in the street, her countenance haggard and anxious, her hands shrivelled, and her whole body bathed in drenching sweat. She immediately became maniacal, and demolished the glass and lamps of the coupé in which she was taken to the hospital. No sooner had she received her ordinary hypodermic dose than she recovered her usual quietude. This patient was neither hysterical nor had she previously suffered from nervous paroxysms. She was, however, accustomed to administer to herself at four o'clock every day a large hypodermic dose of morphine, and it was at a few minutes past four that the above-described seizure occurred.
DIAGNOSIS.—The diagnosis of the opium habit is in many cases attended with considerable difficulty. Many habitués, it is true, do not hesitate to admit the real cause of their symptoms; others, while seeking to conceal it, do so in such an indifferent manner that detection is not difficult; but the greater number for a long time sedulously conceal their passion, not only from their friends, but also from the physician whom they consult voluntarily or at the solicitation of those interested in them. If inquiries be made upon the subject, they deny the habit altogether, often with vehement protestations. If forced to admit it, they are very apt to misstate the amount employed or the frequency of the repetition of the dose. As a rule—to which there are, however, not infrequentexceptions—emaciation is marked, appetite is diminished and variable, the pulse is small, the circulation feeble, the respiration shallow and occasionally interrupted by long-drawn sighs, the pupils are as a rule contracted, constipation is present, often alternating with diarrhœa. When to these conditions, for which no cause can be found upon careful examination, there are added marked change in disposition, periods of unaccountable dulness and apathy alternating with unusual vivacity and brightness, especially when insomnia alternates with periods of prolonged and heavy sleep, the abuse of morphia may be suspected. If the hypodermic syringe be used the wounds made by the needle confirm the diagnosis. These punctures are usually found in groups upon the thighs, legs, arms, and abdomen. Close inquiry into the habits of the patient, who either goes himself or sends at short intervals for unusual quantities of opium or morphia to some neighboring apothecary, is sometimes necessary to confirm the diagnosis. Finally, the presence of morphine in the urine10renders the diagnosis positive, notwithstanding the most vehement assertions of the patient as regards his innocence of the habit and the extreme cunning with which it is concealed.
10“According to Bouchardat, morphine, when taken in the free state or under the form of opium, speedily appears in the urine, and may be detected by the liquid yielding a reddish-brown precipitate with a solution of iodine in iodide of potassium. Since, however, as we have already seen, this reagent also produces similar precipitates with most of the other alkalies and with certain other organic substances, this reaction in itself could by no means be regarded as direct proof of the presence of the alkaloid. Moreover, we find that the reagent not unfrequently throws down a precipitate from what may be regarded as normal urine, while, on the other hand, it sometimes fails to produce a precipitate even when comparatively large quantities of the alkaloid have been purposely added to the liquid” (Wormley,Micro-chemistry of Poisons).
The presence of meconic acid or morphine in the urine can only be positively determined by elaborate chemical analysis. In cases of doubt the urine should be submitted to a competent analyst. To make sure that opium or its derivatives are not being taken, the feces must also be examined.
PROGNOSIS.—The prognosis is favorable as regards the discontinuance of the habit for a time, doubtful as regards a permanent cure. Relapses are apt to occur. They are more common in men than in women, in the aged than in middle life, and in persons of feeble physical and mental organization than in those who are possessed of bodily and mental vigor. Relapses also occur more frequently in those individuals addicted to alcohol, and in those who are habitually subjected to temptation by reason of their avocation, such as doctors, nurses, and apothecaries, than in others. The danger of relapse is greater where the habit has been formed in consequence of chronic painful affections than where it has been rapidly developed in the course of acute illnesses. Of 82 men treated by Levinstein, relapses occurred in 61; of 28 women, in 10; of 38 physicians, in 26. The danger of relapse diminishes with the lapse of time; nevertheless, a single dose of morphine or a hypodermic injection may, after an abstinence of months, precipitate a relapse. Indeed, the return of the habit is in the majority of instances caused by the thoughtlessness of medical men in prescribing in these cases opiates for maladies which are often in themselves insignificant.
The prediction made by B. W. Richardson, within two years of Liebreich's announcement of the medicinal properties of chloral, that itsabuse would become widespread, has been abundantly fulfilled. The consumption of this substance as a narcotic has reached an extent in certain classes of society which raises it, after alcohol and opium, to the third place among such agents.
SYNONYMS.—The Chloral habit, Chloralism.
ETIOLOGY.—A. Predisposing Influences.—Age exerts but little predisposing influence. Cases occur almost exclusively in adults, and the greater proportion of these are in middle life. The abuse of chloral is relatively somewhat more common among males than among females. Individuals addicted to this habit usually belong to the refined and educated classes of society; the fascinations of chloral remain thus far unknown to the great mass of the people. Professional men and those engaged in literary work form a very considerable proportion of the cases. Chloral is occasionally used by hospital nurses, and very frequently by prostitutes. Chronic alcoholism is an important predisposing element in the formation of the chloral habit; in fact, morbid conditions attended by insomnia from whatever cause tend to the formation of this habit.
B. The Exciting Cause.—Chloral is a powerful hypnotic, usually without unpleasant after-effects. In full doses it is a depressant to the nerve-centres at the base of the brain and to the spinal cord. It enfeebles the action of the heart, depresses respiration, and lessens reflex activity. It has no action on the secretions except that of the kidneys, which it frequently augments.
The habit has in some few instances been developed in consequence of the indulgence in a morbid desire to experience the effects of the drug. In a majority of instances it is due to the continuance of the medicine indefinitely after the sickness in which it was originally prescribed has ceased. I have known apothecaries to renew prescriptions of chloral often enough to supply a daily dose of from forty to sixty grains for years—in one instance for more than four years.
The dose taken by victims of the chloral habit varies greatly. Thirty or forty grains daily is a moderate amount. Not rarely this quantity is repeated twice or oftener within the space of twenty-four hours. The tolerance after a time exhibited by the organism for enormous doses of alcohol and opium is not established, as a rule, in regard to chloral. The victim of the latter after a little time discovers the average dose required to produce narcotic effects, and, while he may vary it within limits, he is liable to acute toxic effects if it be greatly exceeded. Death from such excesses is not uncommon.
SYMPTOMATOLOGY.—I. Symptoms Due to Habitual Excesses.—The habitual use of chloral, notwithstanding its ruinous consequences in a certain proportion of the cases, is less dangerous than that of opium or morphine. Many individuals take chloral in considerable doses for years without obvious ill effect. The craving for it is much less intense than that for opium or morphine, and is readily satisfied by other drugs. In point of fact, persons addicted to chloral very frequently exchange it for other narcotics. For these reasons the chloral habit is more easily cured.
Derangements of the digestive system are common, but by no means constant. They are (1) primary, and due to the direct irritant action of the drug upon the mucous tissues of the month and stomach; and (2) secondary, due to its effects upon the nervous system and the circulation.Irritation of the mucous membranes is very common. This not rarely amounts to gastro-duodenal catarrh with its characteristic symptoms. Jaundice is common, sometimes intense. A sense of fulness with pain and tenderness in the hepatic region is frequent. Constipation, with clay-colored stools, is the rule. It occasionally alternates with diarrhœa. The tongue is often coated and the breath foul. On the other hand, in a fair proportion of the cases the digestive organs are not affected. Chloral has been said to occasionally exert even a favorable influence upon appetite and digestion when taken before meals. The recent observations of Fiumi and Favrat11in a man suffering from a gastric fistula and insomnia have shown that chloral hydrate in twenty- or forty-grain doses, administered before or at the beginning of a meal, retarded digestion by increasing the secretion of mucus in the stomach. The acidity of the gastric juice is diminished temporarily. The secretion of pepsin is not changed. Taken two hours after meals, doses not exceeding forty grains caused no derangement of gastric digestion.
11Archives Ital. de Bioloqie, vol. vi. No. 3.
Persons not habituated to chloral usually experience a sense of constriction upon swallowing it, and a disagreeable after-taste.
The circulation is much affected. Chloral weakens, and finally paralyzes, the vaso-motor centre, and thus dilates the vessels; it at the same time weakens the action of the heart. Its habitual use is attended by flushing of the face, congestion of the eyes, and fulness of the head. The heart's action is weak, intermittent, irregular; palpitation occurs; the pulse is full and compressible or small and weak. It is usually slow.
The blood undergoes changes corresponding to the general disturbances of nutrition. What the special changes in its composition may be is not known. Many of the cases, even after the prolonged use of the drug in considerable doses, show few evidences of malnutrition or of anæmia. In the greater number, however, wasting is marked, and the physical signs and rational symptoms of profound anæmia are present. Deterioration in the composition of the blood is further indicated by petechiæ, hemorrhage from mucous surfaces, sponginess of the gums, and serous effusions.
The respiration is not permanently affected, save in grave cases. It is then slow, irregular, and shallow. Dyspnœa is common and easily provoked. It is usually accompanied by cough and abundant frothy expectoration. These symptoms vanish upon the discontinuance of the drug. In a fatal case of chloral-poisoning seen by the writer, in which the daily use of the narcotic in non-poisonous amounts had been for a long time varied at intervals of five or six weeks by doses sufficient to induce prolonged coma, death was preceded by Cheyne-Stokes respiration. This patient was a retired dentist, and kept the solution of chloral in a large unlabelled bottle. The actual doses taken were not ascertained.
The muscular system shares in the general malnutrition. The muscles become flabby and wasted. Persons addicted to chloral are very frequently of nervous organization and sedentary habits, and hence of poor muscular development prior to the use of the drug.
The kidneys show no constant derangement. In a certain proportion of the cases chloral acts as a diuretic, largely increasing the urinary excretion. Albumen is present in a certain proportion of the gravercases, when it is apt to be associated with anæmia, serous effusions, and a tendency to hemorrhages from mucous tracts. The occurrence of casts and the persistence of albuminuria after the discontinuance of chloral suggest an antecedent or coincidently developed nephritis. The reducing substance present in the urine after small doses of chloral is uro-chloralic acid (Mering and Musulus). It gives the reaction of sugar with the copper and bismuth tests, but is levogyrate. Glycosuria is occasionally encountered.
Vesical and urethral irritation occurs in a small proportion of the cases. When these symptoms vanish upon the discontinuance of the drug and recur upon its resumption, it may be fairly assumed that they are due to its action. A great number of morbid phenomena relating to the genito-urinary tract and to the urine, that have been ascribed to the action of chloral in those addicted to its use, are due to associated conditions rather than to the drug itself.
It has been claimed upon evidence that does not appear to the writer adequate that chloral sometimes acts upon the sexual system as an aphrodisiac, sometimes as the reverse. More or less complete impairment of sexual power and appetite is the rule in individuals addicted to great excesses in narcotics of all kinds. Menstruation is not arrested by chloral as by morphine, nor does it necessarily cause sterility in the female.
The skin undergoes nutritive disturbances of a marked kind. As a result of individual peculiarity, single doses or medicinal doses continued for brief periods of time have occasionally caused erythematous, urticarious, papular, vesicular, and pustular eruptions. Of these, the first named is of most frequent occurrence. The habitual abuse of chloral causes in many individuals chronic congestion of the face, neck, and ears. This redness is often very striking. It is increased by the use of alcohol. Erythematous patches upon the chest, in the neighborhood of the larger articulations, and upon the backs of the hands and feet, also occasionally occur. They are often associated with urticaria. General eruptions resembling measles, scarlatina, and even mild variola, are said to have been observed after large doses of chloral. Purpura is by no means rare in old cases, and falling of the hair and atrophy and loss of the nails occur.
The nervous system bears the blunt of the disturbance, and the more significant symptoms relate directly to it.
The hypnotic effect is usually preserved. Hence the chloral habitué is dull, apathetic, somnolent, disposed to neglect his ordinary duties and affairs. He passes much of his time in a state of dreamy lethargy or in deep and prolonged sleep, from which he awakes unrefreshed and in pain. In one of my cases, however, even larger doses than usual at length failed to induce more than fitful slumber, and the insomnia which led to the formation of the habit finally reasserted itself, reinforced by the unutterable miseries of chloralism.
Headache is a frequent symptom. It is usually general, sometimes frontal, often referred to the top of the head. It is commonly severe, not rarely agonizing, and is described as a pressure, weight, or a constricting band. It is associated with injection of the eyes, flushing of the face, confusion of thought, inability to converse intelligently or to articulate distinctly, and other evidences of cerebral congestion. Vertigo is common.
Sensory disturbances are frequently present. They consist in local areas of hyperæsthesia, more frequently of anæsthesia, numbness of the hands and fingers or of the feet, formication of the surface of the body and limbs, and burning or neuralgic pains in the face, chest, and extremities. The pains in the limbs are almost characteristic. They are acute and persistent, neuralgic in character, but not localized to particular nerve-tracts. They are more common in the legs than in the arms, and occupy by preference the calves of the legs and the flexor muscles between the elbows and the wrists. They do not implicate the joints, are not aggravated to any grave extent by movement, and are often temporarily relieved by gentle frictions. The pains of chloralism have been described as like encircling bands above the wrists and ankles.
Sensations of chilliness alternating with flashes of heat are experienced. The temperature is, in the absence of complications, normal. Excessive doses are followed by a reduction of one or more degrees Fahrenheit, lasting several hours.
Among the motor disturbances are the following:
Tremor.—This symptom is not common. It is neither so pronounced nor so distinctly rhythmical as that of alcoholism or the opium habit. It is increased upon voluntary effort. It affects chiefly the hands and arms and the tongue.
Palsy.—Loss of power in the lower extremities has been observed in a number of instances. It varies in degree from paresis to complete paraplegia. Its occurrence may be gradual or sudden. It passes away upon the discontinuance of the habit. In many respects this condition resembles alcoholic paraplegia.
Impairment of Co-ordinating Power.—Ataxic phenomena are sometimes present. The patient has difficulty in walking in the dark, cannot stand with his eyes closed, has trouble in buttoning his clothes, and the like.
Impairment or Abolition of the Knee-jerk.—In a man aged fifty, who had taken thirty to sixty grains of chloral hydrate at night for eighteen months, the writer observed complete loss of the knee-jerk, which, however, reappeared in the course of a few weeks after the discontinuance of the drug.
In rare cases epileptiform seizures have occurred.
Chloral produces in certain individuals, even as the result of a single dose, congestion and irritation of the conjunctiva. Apart from this idiosyncrasy, its habitual use not infrequently causes conjunctivitis. This affection is occasionally of a severe grade and accompanied by œdema of the eyelids and great photophobia. Retinal congestion has been noted by several observers. Amblyopia, disappearing upon the cessation of the habit, has also been observed.
Psychical Derangements.—The mental and moral perversion caused by immoderate chloral-taking shows itself rapidly. The transient stimulating effects of the dose of opium or morphine in those accustomed to these drugs are seen not at all or to a very slight extent in chloralism. Hence the mental state is characterized by dulness, apathy, confusion, and uncertainty. These conditions alternate with periods of irritability and peevishness. The physical sufferings of the chloral-taker in the daily intervals of abstinence are greater than those of themorphine-taker; his mental depression less. The one is tormented by the agony of pain, the other by the anguish of craving. To the former repetition of the dose brings stupor and sleep, to the latter exhilaration and activity. In certain respects, however, the effects of these drugs upon the mind are similar. They alike produce intellectual enfeeblement, inability to concentrate the mind, habitual timidity, and impairment of memory. In the worse cases of chloralism hallucinations, delusions, and delirium occur. Acute mania may occur, and dementia constitutes a terminal state.
II. Symptoms Due to Abstinence from Chloral.—The symptoms occasioned by the abrupt discontinuance of even large habitual doses of chloral are not, as a rule, severe. In this respect the difference between this drug and opium and its derivatives is very marked. The chloral-taker not infrequently substitutes some other narcotic, as alcohol or opium, for his usual doses without discomfort, and in many instances voluntarily abstains from the drug, without replacing it by others for periods of weeks or months.
The more important of the symptoms induced by sudden discontinuance relate to the nervous system. Insomnia is usual. It is not always readily controlled, and constitutes one of the principal difficulties in the management of these cases. Headache is rarely absent; it is in many cases accompanied by vertigo. Occipital neuralgia frequently occurs, and is often severe. Neuralgias of the fifth pair also occur. Darting pains in the limbs are usual, and the fixed aching pains already described as peculiar to habitual chloral excess are present, and often persist for a long time after the withdrawal of the drug.
Irregular flushes of heat, nervousness, restlessness, inability to fix the attention, formication, burning sensations in various regions of the surface of the body, are unimportant but annoying symptoms.
In a considerable proportion of the cases delirium occurs. It is commonly associated with tremor, great prostration, complete insomnia, sweating, inability to take food, and vomiting, and resembles in every particular the delirium tremens of alcoholic subjects. In the absence of this condition gastric derangements are not of a grave kind. The nausea, vomiting, epigastric pain, and diarrhœa which are induced by the discontinuance of opium are absent, or if present at all only to a slight degree. As a matter of fact, the functions of the digestive system are in a very short time much more perfectly performed than before. Hemorrhage from the stomach, bowel, or urinary tract may also occur.
The conjunctivitis and cutaneous eruptions usually disappear with promptness as soon as the influence of the habitual chloral excesses passes away.
DIAGNOSIS.—The diagnosis of the chloral habit is attended with much less difficulty than that of the morphine habit. In the first place, there is general and often serious derangement of health without adequate discoverable cause. The appetite is poor and capricious, the digestion imperfect and slowly performed; jaundice of variable intensity, often slight, sometimes severe, occurs in many cases; the bowels are not, as a rule, constipated. Dyspnœa upon slight exertion is, in the absence of pulmonary, cardiac, or renal cause, of diagnostic importance. The circulation is, as a rule, feeble. Disorders of the skin, persistent or easily provoked conjunctivitis, puffiness about the eyelids, and a tendency to hemorrhagefrom mucous surfaces also occur. When with these symptoms, irregularly grouped as they are, we find a tendency to recurring attacks of cerebral congestion, persistent or frequently recurring headaches, and the characteristic pains in the legs, the abuse of chloral must be suspected. This suspicion becomes the more probable if there be a history of protracted painful illness or of prolonged insomnia in the past. The adroitness of these patients in concealing their vice, and the astonishing persistency with which they deny it, are remarkable. In the absence of the characteristic association of pains, conjunctivitis, and affections of the skin the diagnosis is attended with considerable difficulty. It becomes probable from the association of chronic ill-health, not otherwise explicable, with perversion of the moral nature, enfeeblement of the will and of the intellectual forces. It is rendered positive, notwithstanding the denials of the patient, by the discovery of the drug or the prescription by means of which it is procured.
PROGNOSIS.—If the confirmed chloral habitué be left to himself, the prognosis, after excessive doses or the stage of periodical debauches has been reached, is highly unfavorable. The condition of mind and body alike is abject. There is danger of sudden death from cerebral congestion or heart-failure—a mode of termination by no means rare.
On the other hand, the prognosis under treatment may be said to be favorable. The habit is much more readily broken up, and the danger of relapse is far less, than in cases of confirmed opium or morphine addiction. Nevertheless, the underlying vice of organization which impels so many individuals to the abuse of narcotics precludes a permanent cure in a certain proportion of the cases of chloralism. Sooner or later relapse occurs—if not relapse to chloral, relapse to opium, morphine, or alcohol, or into that wretched condition in which any narcotic capable of producing excitement and stupor is taken in excess as occasion permits.
The use of this hypnotic is not unattended with danger. In a single case afterward under the observation of the writer paraldehyde was used in large and increasing doses for the sake of its narcotic properties. The patient, a young married woman whose family history was bad, her mother having died insane, contracted the chloral habit after an acute illness. After some months a cure was effected without great difficulty. She relapsed into chloralism after a second sickness which was attended with distressing insomnia. The habit was again broken up. In consequence of over-exertion in social life during a winter of unusual gayety insomnia recurred. For the relief of this condition paraldehyde was prescribed with success. Notwithstanding its disagreeable and persistent ethereal odor, and the precautions taken by the physician, this lady managed to secure paraldehyde at first in small quantities, afterward in half-pound bottles from a wholesale druggist, and took it in enormous amounts, with the result of producing aggravated nervous and psychical disturbances corresponding to those produced by chloral, but without the disturbances of nutrition attendant upon the abuse of the latter drug. The patient remained well nourished, retained her appetite and digestion, and was freefrom disorders of the skin and the intense neuralgia which had been present during both periods of chloral abuse. She suffered, however, from a persistent binding headache, disturbances of accommodation, phosphenes, and brow-pains. Under the influence of moderate doses she was enabled to take part in social life with some of her old interest and vivacity. The brief intervals of abstinence which occasionally occurred were characterized by distressing indifference to her friends and surroundings and by apathy and depression. At frequently-recurring intervals the indulgence in excessive doses, constituting actual paraldehyde-debauches, was followed at first by maniacal excitement of some hours' duration, later by profound comatose sleep lasting from one to three days. Upon the complete withdrawal of the drug this patient manifested the symptoms produced by complete abstinence in the confirmed morphine habit—yawning, anorexia, epigastric pains, vomiting, diarrhœa, absolute sleeplessness, extending over several days, heart-failure, collapse, colliquative sweating, and finally well-characterized delirium tremens. At the end of a week, under the influence of repeated small doses of codeine, sleep was secured, and within a month convalescence was complete. This person now continues free from addiction to any narcotic, in good health, and able to sleep fairly well, after the lapse of several months since the complete discontinuance of paraldehyde.
These drugs are habitually used as narcotic stimulants by a limited number of individuals. Cannabis indica, or Indian hemp, the hashhish of the Arabians, is said to be largely used in India and Egypt. It is occasionally taken by medical students and other youths of an experimental turn of mind, but no case of habitual hashhish addiction has come under the observation of the writer.
The use of ether as a narcotic stimulant is occasionally observed among druggists, nurses, and other hospital attendants, but does not give rise to clinical phenomena sufficiently marked or distinctive to demand extended consideration in this article. The same remark may be made of chloroform, which is also used in the same way to a considerable extent among women suffering from neuralgia and other painful or distressing affections of the nervous system. The fact that individuals are every now and then found dead in bed with an empty chloroform-bottle by their side serves to indicate the extreme danger attending the vicious use of this substance.
Cocaine, within the short time that has elapsed since its introduction into therapeutics, has unquestionably been largely abused, both within the ranks of the profession and among the people. Highly sensational accounts of the disastrous effects resulting from its habitual use in excessive doses have appeared in the newspapers and in certain of the medical journals. No case of this kind has fallen under the observation of the writer, and it would appear premature to formulate definite conclusions concerning the effects of cocaine upon the data thus far available.
The treatment of the opium habit and kindred affections is a subject which derives its importance from the following facts: First, the gravity of the disease, as regards the functions both of the body and of the mind; second, the enormous suffering and misfortune, alike on the part of the patient himself and on the part of those interested in him, which these affections entail; third, the fact that they are not self-limited, and therefore cannot be treated with indifference or upon the expectant plan, but are, on the other hand, progressive and gradually destructive of all that makes life worth living, and at last of life itself; and finally, because they are capable at the hands of skilful and experienced physicians of a cure which in a considerable proportion of the cases may be made permanent.
The treatment of these affections naturally arranges itself under two headings: (a) the prophylactic, (b) the curative treatment.
a. Prophylaxis.—It is impossible to overrate the importance of a true conception of the duty of practitioners of medicine in regard to the prophylaxis of the opium habit and associated affections. In communities constituted as are those in which the physicians practise into whose hands this volume is likely to fall, a large—I may say an enormous—proportion of the cases of habitual vicious narcotism is due to the amiable weakness or thoughtlessness of medical men. A majority of the cases occur either in chronic painful affections attended or not by insomnia, or as a result of acute illness in which narcotics have been employed to relieve pain or induce sleep. The chronic affections constitute two classes: First, those manifestly incurable, as visceral and external cancer, certain cases of advanced phthisis, confirmed saccharine diabetes, and tabes dorsalis. In such cases the use of morphine in large and often-repeated doses, although attended with evils and likely to shorten life, amounts to a positive boon. It is neither practicable, nor would it be desirable, to interfere with it. To this class may be added those cases of grave valvular or degenerative disease of the heart where the patient has become addicted to the habitual use of narcotics. Here, notwithstanding the evils resulting from these habits, among which the likelihood of shortening the period of life must unquestionably be counted, the dangers of the withdrawal of the drug are so great that it must be looked upon as neither desirable nor feasible. Attention must, at this point, be called to the fact that great caution is required in the management of pregnant women addicted to narcotics. Incautious attempts to withdraw the habitual drug are almost certain to be followed by speedy loss of the fœtus; and it is to my mind questionable whether anything more than the most guarded reduction of the daily dose should be attempted while the pregnancy continues.
The second class of chronic cases includes individuals suffering from diseases which are remediable or capable of decided or prolonged amelioration. Among these affections are painful diseases curable by surgical procedures, such as certain obstinate and intractable localized neuralgias, painful neuromas, irritable cicatrices, pelvic and abdominal tumors, and surgical affections of the joints and extremities. Here, either before or after radical surgical treatment, an effort to relieve the patient from the bondage of habitual narcotism should be made. For reasons that areobvious, measures having this end in view should be instituted by preference subsequently to surgical treatment. To this class also belong certain painful affections occupying the border-region between surgery and medicine. These are floating kidney, renal and hepatic abscess, calculous pyelitis, cystitis, impacted gall-stones, and thoracic and abdominal aneurism. In these cases the possibility of a cure renders it in the highest degree desirable that the opium habit should be stopped. Whether this attempt should be made while the patient is under treatment for the original affection, or deferred until relief has been obtained, is a question to be decided by the circumstances of the particular case under consideration. Finally, we encounter a large group of chronic painful affections coming properly under the care of the physician in which the opium habit is frequently developed. This group includes curable neuralgias of superficial nerves, as the trigeminal, occipital, brachial, intercostal, crural, and sciatic, and visceral neuralgias, as the pain of angina, gastralgia, enteralgia, and the pelvic and reflex neuralgias of women. Here also are to be mentioned the pains of neurasthenia, hypochondriasis, and hysteria. In this group of affections the original disease constitutes no obstacle to the attempt to break up the habit to which it has given rise.
The practice of using narcotics, especially the preparations of opium, in large and increasing doses for the relief of frequently-recurring pains, especially in neurotic individuals, is a dangerous one. When necessary at all, the use of these drugs should be guarded with every possible precaution. In the first place, in so far as is practicable, the patient should be kept in ignorance of the character of the anodyne used and of the dose. In the second place, the physician should personally supervise and control, in so far as is possible, the use of such drugs and the frequency of their administration, taking care that the minimum amount capable of producing the desired effect is employed. In the third place, the occasional alternation of anodyne medicaments is desirable. Fourthly, an effort—which, unfortunately, is too often likely to be unsuccessful—should be made to prevent repeated renewals of the prescription without the direct sanction, or indeed without the written order, of the physician himself. Finally, the danger of yielding to the temptation to allow a merely palliative treatment to assume too great importance in the management of painful affections must be sedulously shunned. Too often these precautions are neglected, and the patient, betrayed by a dangerous knowledge of the drug and the dose by which he may relieve not only physical pain, but also mental depression, and tempted by the facility with which the coveted narcotic may be obtained, falls an easy victim to habitual excesses. The lowered moral tone of convalescence from severe illness and of habitual invalidism increases these dangers. Yet more reprehensible than the neglect of many physicians in these matters is the folly of the few who do not hesitate to fully inform the patient in regard to the medicines given to relieve pain or induce sleep, and to place in his hands designedly the means of procuring them without restriction for an indefinite period of time. Almost criminal is the course of those who entrust to the patient himself or to those in attendance upon him the hypodermic syringe. No trouble or inconvenience on the part of the physician, no reasonable expense in procuring continuous medical attendance on the part of the patient for the sake of relief from pain, can ever offset, save in cases of the final stagesof hopelessly incurable painful affections, the dangers which attend self-administered hypodermic injections.
The uniform and efficient regulation of the sale of narcotic drugs by law would constitute an important prophylaxis against habitual narcotism. Unfortunately, the existing laws relating to this subject are a dead letter. They are neither adequate to control the evil nor is their enforcement practicable. Nostrums containing narcotics, and particularly opium and morphine, in proportions that occasionally produce fatal results are freely dispensed at the shops to all comers. Prescriptions calling for large amounts of opium, morphine, codeia, chloral, cannabis indica, etc. are dispensed to the same individuals at short intervals over the counters of apothecaries for months or years after the illness in which they were originally prescribed is over. Yet more, occasional cases come to light which serve to indicate the appalling frequency with which opium, its tincture, morphine, and solutions of chloral are directly sold to unauthorized individuals. If the evil thus accomplished were better understood, the paltry profit realized from such nefarious trading would rarely tempt men to the commission of the crime which these practices constitute.
Finally, the dissemination of a wholesome knowledge of the methods by 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 observers12have reported successful cases not onlyof 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.
12See, 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 devotedto 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,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 tremensconsists 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 rectalalimentation 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.