The Opium Habit

by Horace B. Day

It is therefore always proper that the opium-eater should find in his physician a confidant who will not violate his secret even to parent or wife. The closer the relation and the dearer the love, the greater will be the likelihood that the optum-eater has shrunk from revealing the full extent of his burden to the friend in question, and the greater will be the temptation to deceive the doctor unless the patient be made to feel that his revelation is as sacred as the secrets of the bridal-chamber.

I solicit from the friend who accompanied Mr. Edgerton the thoroughest statement which he can give me of the case, ab extra. Such a statement is of great value—for the inroads which the habit has made upon the system are often visible to an outsider only. Furthermore, a friend may give me many circumstances connected with the inception of the case: family predispositions and inherited tendencies; causes contributing to the formation of the habit, such as domestic or business misfortune, prior bad habits of other kinds, illnesses suffered, and a variety of other agencies concerning which the patient might hesitate or forget to speak for himself. Then I make Mr. Edgerton the proffer of that inviolable confidence which I have mentioned, and having won his perfect faith in me, obtain the very fullest history of his case which can be elicited by searching, but most kindly and sympathizing cross-examination. The two statements I collate and enter for my future guidance in a private record.

Let us suppose an average hopeful case.

I find that my patient is about thirty years of age—of the energetic yet at the same time delicate and sensitive nervous organization which is peculiarly susceptible to the effects of opium, from which it draws the vast majority of its victims, and in which it makes its most relentless havoc; with a front brain considerably beyond the average in size and development. My patient's general health, apart from the inevitable disturbances of the drug, has always been fair, and his constitufion, under the same limitations, is a vigorous one. His habit, as in nine cases out of every ten, dates from the medical prescription of opium for the relief of violent pain or the cure of obstinate illness. He was not aware of the drug then administered to him, or at any rate of the peril attending its use, and his malady was so long protracted that opium had established itself as a necessary condition of comfortable existence before he realized that it possessed the slightest hold upon him. When the prescription was discontinued he suffered so much distress that he voluntarily resumed it, without consulting his physician, or, if he did consult him, receiving no further warning as to his danger than that "he had better leave off as soon as practicable." Or else, on leaving off his use of opium, the symptoms for which it had originally been administered returned with more or less severity, and under the idea that they indicated a relapse instead of being one of the characteristic actions of the drug itself, he resumed the dose. It gradually lost its power; little by little he was compelled to increase it; and having begun with 1/3 grain powders of which he took three per diem, he is now taking 18 grains of morphia per diem at the end of five years from his first dose.

If I find him tolerably vigorous on his arrival, as will be the case when he has come to Lord's Island after calm deliberation and the conviction not that he must, but on all accounts had better abandon the habit, I leave him to recover from the fatigues of his journey and get acquainted with his surroundings before I begin any treatment of his case. If, however, as sometimes occurs, he reaches us in desperate plight, having been so far injured by his habit as to show unequivocal signs of an opium-poisoning which threatens fatal results; if, as in several cases known to me, he has summoned all his remaining vitality to get to a place of refuge, being overtaken either by that terrible coma which often terminates the case of the opium-eater in the same fashion that persons new to the narcotic are killed by an overdose, or by that only less terrible opium-delirium belonging to the same general class as mania potu—then his case admits of not a moment's delay. Opium-eaters differ so widely—every new case furnishing some marked idiosyncrasy which may demand an entirely different management and list of remedies from those required by the last one—that for any general scheme of treatment a week's study of the patient will be necessary. During that week our attitude will be simply tentative and expectant, and at its close the proper fidelity and vigilance will have authorized us in making out something like a permanent schedule for the patient's upward march, though even then we must be prepared, like skillful generals, to meet new emergencies, take unforeseen steps, even throw overboard old theories, at any stage of his progress. In no disease is there such infinite variety as in that of opio-mania, in none must the interrogation of nature be more humbly deferent and faithfully attentive; in none do slight differences of temperament, previous habits, and circumstances necessitate such wide variation in the remedies to be used. Notice, by way of illustration, the fact that one opium-eater under my care was powerfully affected and greatly benefited by the prescription of one drachm of the fluid extract of cannabis indica, while another, in temperament, history, tendencies, and all but a few apparently trifling particulars almost identical, not only received no benefit but actually experienced no perceptible effect whatever from the absolutely colossal dose of four fluid ounces. [Footnote: I am aware how incredible this statement will seem to those who have never had any extensive experience of the behavior of this remarkably variable drug, and get their notion of its action from the absurd directions on the label of every pound vial I have seen sent forth by our manufacturing pharmaceutists. "Ten to twenty drops at a dose," they say, "cautiously increased." Cannabis should always be used with caution, but ten or even twenty drops must be inert in all but the rarest cases, and I have given an ounce per diem with beneficial effect. But four ounces of the best extract (Hance & Griffith's) producing literally no effect of any kind on an entirely fresh subject, is a phenomenon that I must have needed eye-witness to imagine possible.] I may add that in the latter case, bromide of potassium was administered with the happiest result—in fact as nearly approaching in its efficiency the character of a succedaneum as any remedy I ever used to alleviate the tortures of opium, while in the former no result attended its administration salutary or otherwise. The vast diversity of operation exhibited in different patients by the drug scutellaria is still another illustration of the careful study of idiosyncrasies requisite for a successful treatment of the opium disease. But when the case comes into our hands at a desperate period there are many means of instant alleviation which may anticipate without interfering with future treatment based on study.

Mr. Edgerton, though by no means a man of ruined constitution, has brought himself temporarily into a critical place by the fatigues and anxieties of harassing business, by exceptional overwork which kept him at his desk or in his shop until inordinately late hours; even, let me say, by going for entire nights without sleep and neglecting his regular meals day after day for a period of several weeks; performing and enduring all this by the support of extra doses of opium. Perhaps, finding the stimulus to which he has become accustomed too slow in its operation, he has violated his usual custom of abstinence from alcoholic drinks and reinforced his opium with more or less frequent potations of whisky. This is no fancy sketch, Our overtasked commercial men frequently go on what might with propriety be called "a business spree," in which for a month at a time, whether using stimulants or not, they plunge into as mad a vortex with as thorough a recklessness as those of the periodical inebriate; finding out in the long run that the fascinations of speculation, and the spring and fall trade, bring as dire destruction to soul and body as those of the bowl and the laudanum vial. During times of great financial pressure or under the screws of preparation for some great professional effort, the moderate opium-eater finds that he must inevitably increase his dose. When he adds liquor to it (and this addition to an old opium-eater is often as necessary as liquor alone would have been before he used opium at all) he is indeed burning his candle at both ends. Mr. Edgerton reached the commencement of his period of extra exertion with as sound a constitution—in as comfortable condition of general health—as is enjoyed by any man habituated to opium for four or five years; and such cases are frequently found among men who appear to enjoy life pretty well, attend to their business with as much regularity as ever, and show no trace of the ravages wrought by their insidious foe to any but the expert student. After six weeks of exciting labor and solicitude, during which his sleep and his rations were always delayed till exhaustion overpowered him, and then cut down below half the normal standard, he wakes one morning from a slumber heavy as death into a state of the most awful vigilance his mind can conceive of. He even doubts for some moments whether he shall ever sleep again, and in the agony of that strange, wild suspicion, a cold sweat breaks out over him from head to foot. Waking from the most utter unconsciousness possible to a wide-awake state like having the top of one's skull suddenly lifted off by some surgeon Asmodeus, and the noonday sun poured into every cranny of his brain, he suffers a shock compared with which any galvanic battery, not fatal, gives but a gentle tap. The suddenness of the transition—no gentle fading out of half-remembered dreams, no slow lifting of lids, no pleasant uncertainty of time and place gradually replacing itself by dawning outlines of familiar chair and window frame and cornice—the leap from absolute nonentity into a glaring, staring world—for a moment almost unsettles Mr. Edgerton's reason. Then the fear for his sanity passes and a strange horror of approaching death takes its room. His pulse at the instant of waking throbs like a trip-hammer; an instant more and it intermits. Then it begins again at the old pace. He snatches up his watch from the bureau with a trembling hand and counts—the beat is 130 a minute. Again it stops; again it begins; but now little by little growing faster and threadier until it runs so swiftly yet so thinly as to feel under his finger like some continuous strand of gossamer drawn through the artery. His feet and hands grow deadly cold. He seems to feel his blood trickling feebly back to his heart from every portion of his body. He catches a hurried look at the glass—he sees a dreadful spectre with bistre rings around the eyelids, an ashen face, leaden lips, and great, mournful, hollow, desolate eyes. Then his pulse stops altogether; his lungs cease their involuntary action; and with a sense of inconceivable terror paralyzing the very effort he now feels it vital to make, he puts them under voluntary control and makes each separate inspiration by an effort as conscious as working a bellows. I doubt not that many men have died just at this place through absolute lack of will to continue such effort. Then the metaphorical paralysis of fear is seconded by the simulation of a literal one, extending through the limbs of one side or both; the sufferer reels, feeling one foot fail him—tries to revolve one arm like a windmill, that he may restore his circulation, and that arm for some instants hangs powerless. Presently, with one tremendous concentration of will, his brain shouts down an order to the rebellious member—it stirs with sullen reluctance—it moves an inch—and then it breaks from the prison of its waking nightmare. Summoning his entire array of vital forces, our patient leaps, and smites his breast, kicks, whirls his arms, and little by little feels his heart tick again. By the time a feeble and sickly but regular pulse is re-established he has gone through enough agony to punish the worst enemy, my dear Sir, that you or I ever had. The vague, overpowering fear of death which during such an attack afflicts even the man who by grace or nature is at all other times most exempt from it is one of this period's most terrible symptoms. This passes with the return of breath and circulation.

But the clammy sweat continues—pouring from every point of the surface—saturating the garments next the skin as if they had been dipped in a tub of water. Presently our patient begins to suffer an intolerable thirst, and runs to the ice-pitcher to quench it. In vain. He can not retain a mouthful. The instant it is swallowed it seems to strike a trap and is rejected with one jerk. He seeks the sedative which up to this hour has allayed his worst gastric irritations. Now, if never before, opium in every form produces nausea. Laudanum instantly follows the example of the water, and even a dry dose of morphia, swallowed with no moisture but saliva, casts itself back after agonizing retchings. To liquor his rebellious stomach proves yet more intolerant—food is almost as irritating as liquor. In a horror he discovers that even pounded ice will not stay down—and he is parching like Dives. His anguish becomes nearly suicidal as the fact stares him in the face that he has come to the place where he can not take opium any more—though to be without it is hell—that food, drink, medicine, are all denied him.

A merciful, death-like apathy ensues. He lies down, and with his brain full of delirious visions, appalling, grotesque, meaningless, beautiful, torturing by turns, still manages to catch an occasional minute of unconsciousness. He hears his name called—tries to rise and answer—but his voice faints in his throat and he falls back upon his bed. Friends enter his bed-chamber—in an agony of alarm rouse him—lift him to his feet—but he has not the strength of an infant, and he falls again. In this condition he may continue for a day or two, then sink into absolute coma, and die of nervous exhaustion, or his constitution may rally as the effects of the last overdose pass off, and the man, after a fortnight's utter prostration, come gradually back to such a state of tolerable health and comfort as he enjoyed before he overtaxed himself.

Mr. Edgerton is brought to Lord's Island in the condition I have described, living near enough to be transported on mattresses in carriage and boat. A few hurried questions put to his friends reveal that although his condition is alarming it is by no means necessarily fatal; being one of those in which the habit is of such comparatively short standing, and the constitution still so vigorous, that even at home he might come up again by natural reactions.

He is immediately undressed and put to bed, with hot bricks and blankets at the extremities, and the galvanic battery is judiciously administered by placing both feet in contact with a copper plate constituting the negative electrode, while the operator grasps the positive in one hand, and having wetted the fingers of the other, follows the spine downward, exerting gentle pressure with them as he goes. "Judiciously," I say, because there is a vast deal of injudicious use of the battery. In many cases, for instance, a powerful and spasmodic current is used to the absolute injury of the patient, where the greatest benefit might be secured by an even one so light as scarcely to be perceptible. But I can only mention the battery. Its application is by itself a science, and demands a book. The practitioner who treats opium patients needs that science as much as any one interested in whatsoever branch of nervous therapeutics. The battery in the hands of a scientific man is one of our most powerful adjuncts throughout every stage of treatment, both of opium-eating and its sequelae. Paralysis following the habit, and persistent long after its abandonment, I have cured by it when all other means failed. Here, however, we have only room to indicate the weapons in our armory.