It is now improbable, after the happy change described has taken place in him, that he will succumb to the acute attack of opium-poisoning which led him to us. Alarming as it appears, it is seldom dangerous or persistent. The patient who has not constitutional strength to rally at once, goes down rapidly and dies in a few days, while he who rallies once gets well, pro hâc vice, without much medical treatment save that which was promptly given at the critical moment, or treatment of any kind but nourishing food, rest, baths, and vigilant, tender nursing. As soon as the chronic appetite calls for its habitual dose, and the stomach receives it without revenging its grudge against the recent excesses, the patient may be considered out of danger as far as the acute attack is concerned.
Here I will be asked (as I am constantly out of the book), why not begin the abandonment of the drug as soon as this acute attack is over? When the terrible and immediate peril has been staved off by such a mere hair's-breadth, why listen again to "the chronic appetite" which "calls for its habitual dose?" Surely, now that the patient has gone for forty-eight hours or more without that dose, would it not be better never to return to it? Must he begin his former career again and afterward have all the same ground to go over?
I answer that he will not have the same ground. That which he has just traversed was the ground separating between an excess and his normal life—and he is in reality in a worse condition to try the experiment of instant abandonment than he was before the struggle. It is a very different thing to cure a man of acute from curing him of chronic opium-poisoning; and my own large experience, together with that of all the most experienced, the soundest and most skillful men that I have ever known as successful practitioners among these cases, points to the unanimous conclusion that it is not safe, either to mind or body, to make the abrupt transition required of an old opium-eater who must give up his drug in toto and at once, especially after such an acute attack as that just described. He would be very likely to die of exhaustion, to endure an amount of agony which would permanently enfeeble his mind, or to commit suicide as his only way of escape from it, if we cut him short from the equivalent of 15 or 20 grains of sulphate of morphia after having used the drug for five years. The most terrible case of opium-eating which I ever saw instantly cu short was one where the patient used 33 grains of morphia per diem, but he had used it for less than a year, and possessed a constitution whose physical grit and mental pluck anybody would pronounce exceptional, though even that did not save him from the tortures which endangered his reason. I am always in favor of a man's "breaking off short" if he can. I believe that the majority of people who have used the drug less than a year can, but the number who are able to do it after that diminish in geometric ratio with every month of habituation.
I therefore permit Mr. Edgerton, as soon as his stomach will bear it, to return to the use of opium.
But before giving him his dose I make the stipulation that from this moment he shall deal as frankly with me as he does with his own consciousness—that we shall have no opium secrets apart.
In advanced cases, where opium has been used long enough to break down the will and the sense of moral accountability, I may feel it wise to ask of the friend who accompanies my patient that he go through the baggage and clothes of the latter before leaving him, and report to me that no form of opium is contained in them. But in most cases I prefer to rely entirely upon the good understanding established between my patient and myself for my guarantee that no opiate is smuggled into the institution, and upon my own daily examination of the patient to determine whether this guarantee is kept inviolate. To an expert reader of opium cases it will soon become apparent whether in any given case a patient is taking more than the amount prescribed—and after total abandonment is resolved upon, the question whether the patient is taking opium at all may be decided by a tyro.
In the case of Mr. Edgerton, who has voluntarily come to ask our help on the way upward, I proceed by a system of complete mutual confidence. I tell him that I am sure he feels even more deeply than myself the necessity of abandoning the drug. I promise him that he shall never be pushed beyond the limits of endurance, and ask only that he will allow any dose he may take to pass through my hands. I request that if he has brought any form of opium with him he will give it to me, and we enter into a stipulation that he will come to me for any opiate or other alleviative which he may desire. I bind myself never to upbraid or censure him—never to reveal to a living soul any confidence soever which he may repose in me—and then I ask him to name me the average dose upon which, before his late acute attack, he has managed to keep comfortable—rather, I should say, before the overwork and consequent opiate excess which brought it on. During his terrible six weeks of high-pressure, he tells me, he reached a per diem as high as 25, on one occasion even 30 grains; but for a year previous he had never taken more than the equivalent of 18 grains of morphia a day. This, then, shall furnish our starting-point.
Whether he has previously adopted the same method or not, I divide this amount into three or more doses to be taken at regular intervals during the day.
I say "the equivalent of 18 grains of morphia," because although the majorify of habitués use that principle of opium as their favorite form, there are some who after many years' use of the drug still adhere to crude gum opium or laudanum. The portability and ease of exhibition which belong to morphia—the fact that it fails to sicken some persons in whom any other opiate produces violent nausea—its usual certainty, rapidity, and uniformity of action, and the ability which it possesses to produce the characteristic effects of the narcotic after other preparations have become comparatively inert, make it the most general form in use among opium-eaters of long standing. Still, bearing in mind the wonderful complexity of opium (vide "What Shall They Do to be Saved?") and the equally marvellous diversity in the manner in which it affects different people, we can not wonder at the fact that some of its victims require for their desired effect either the crude drug or other preparations containing its principles entire. Morphia is by far the most important of these principles, and more nearly than any one stands typical of them all. Still, it is easy to conceive how certain constitutions may respond more sympathetically to the complex agent of Nature's compounding than to any one of its constituents. [Footnote: In some cases, especially of shorter standing, codeia may be used as the form of opiate to diminish on. In any case its employment is worth trying, for it possesses much of the pain-controlling efficiency of opium and morphia, with less of their congestive action upon the brain. Practically it may be treated in such an experiment as the equivalent of opium; not that it at all represents all the drug's operations, but that where crude opium has been the form in use, codeia may be substituted grain for grain. Some patiets find it quite valueless as a substitute, but there is always a chance of its proving adequate. When tried, the best form is a solution similar to Magendie's, but replacing one grain of morphia by six of codeia.] We may therefore find it necessary to carry on our reformatory process upan laudanum or M'Munn's Elixir, but by far the larger number of cases will do better by being put instantly upon a regimen of Magendie's Solution of Morphia. The formula for this preparation is:
Rx
Morph. Sulph. . . . . . . . . . . . grs. xvi.
Aqua Destill. . . . . . . . . . . . ounce j
Elix. Vitrioli. . . . . . . . . . . quant. suff.