The Opium Habit

by Horace B. Day

"Oh!" I have heard the patient say, "would to God this made me tired! healthily tired, so that I could fall into a minute's doze!"

The apparatus I have just been describing meets this want. Sometimes while the leather and iron fists are pegging away and pummelling him at their hardest, he falls asleep on the machine! It has done for him all that he had not the strength to do for himself—tired him healthily.

The remedies I have mentioned are capable of indefinite combinations. The head of an institution like Lord's Island will want them all, although any one given case may not require all of them. In the hands of a thoroughly scientific, skillful man, they form an armory of means with which such an amount of good can be done as beggars our imagination. Combined with the most faithful attention to the patient's diet—the establishment of healthful nutrition, so that as fast as those abnormal matters which have been clogging the system get cleared away by Nature's relentless processes of decomposition, fresh material may be soundly built up into the system to replace the strength which the fatal stimulant feigned—combined with vigilant, tender, patient nursing—the means described are probably, in many cases, adequate of themselves to restore any opium-eater who is salvable at all. Still, brief as this sketch is, and so far from making any pretensions to be an exhaustive treatise for the guidance of the profession, I should fail of presenting even a fair outline of the treatment which an unusually wide experience with opium-eaters has convinced me to be the true one, did I not add to the above a few words regarding the medicinal agents which are of value during the month of peculiar trial through which Mr. Edgerton is now passing.

It is scarcely necessary to premise that no such thing as a succedaneum for opium is comprehended in the list of these agents. Any drug which would so nearly accomplish for the opium-eater what opium accomplishes that he would not miss the latter, must be nowise preferable to opium itself. Such a drug must be able to prevent the decompositions which cause the suffering; to continue that semi-paralysis of the organic functions in which opium's greatest fascination exists, a paralysis leaving the cerebral man free to exhaust all the vitality of the system in pleasant feelings, lofty imaginings, and aerial dreams, without a protest from the gauglionic man who lies a mere stupefied beggar without any share in the funds of the partnership wherewith to carry on the business of the stomach and bowels and heart, the kidneys and lungs and liver. It must be a drug that can prevent the re-awakening ol the nutritive and excretory processes—for it is these whose waking, seeing how late in the day it is, clamoring at the confusion in which they find affairs and at the immense quantity of behind-hand work suddenly thrown on them, together with that re-sharpening of long-dulled sensation by which the clamor comes into consciousness loud as the world must be to a totally deaf man suddenly presented with his hearing, which constitute the series of phenomena which we call pain. No! there is no such thing as a substitute for opium, save—more opium or death. And I do not know that I need say "or."

Still, there are many alleviatives by which the suffering may be rendered more endurable—by which now and then our patient may be helped to catch a few moments of that heavenly unconsciousness which makes the nervous system stronger to fight the battle out to its blessed end—by which processes of Nature may be slowed when they get too fiery-forceful for human courage to endure, or accelerated when the pull seems likely to be such a long one as to kill or drive mad through sheer exhaustion. I have spoken of bromide of potassium. This in connection with the pack may in many cases wisely be continued throughout the whole progress of the case, and often hastens the restoration of general nervous equilibrium by many days, removing to a very pereptible degree that hyperaesthesia, that exaggerated sensation of all the natural processes normally unconscious, which continues to rob the sufferer of sleep long after acute pain is lulled. The greatest variety of opinions prevails upon the subject of cannabis and scutellaria. The principal objection to the cannabis lies in two facts. First, it is very difficult to obtain any two consecutive specimens of the same strength, even from the same manufacturer. Second, in its gum state it is exceedingly slow of digestion, and unlike opium not seeming to affect the system at all by direct absorption through the walls of the stomach, it is very slow in its action; the dose you give at 4 P.M. may not manifest itself till 9 or even midnight, and even then may still move so sluggishly that you get from it only a prolonged, dull, unpleasant effect instead of a rapid, favorable, and well-defined one. If it is given in the form of a fluid extract or tincture, its operation can be more definitely measured and counted on, but the amount of alcohol required to dissolve it is sufficient often to complicate its effects very prejudicially, while in any case the immense proportion of inert rubbish, gum, green extractive, woody fibre, and earthy residuum is so great as to be a severe tax on the digestive apparatus—often seriously to derange the stomach of the well man who uses it, and much more the exquisitely sensitive organ of the opium-eater, I might add a third objection-the fact that its effects vary so wonderfully in different people—but the physician can soon get over that by making his patient's constitution in the course of a few experiments with the drug the subject of his careful study. Both its lack of uniformity and its difficulty of exhibition may be nullified by using the active principle. It has been one of the opprobria medicinæ that in a drug known to possess such wonderful properties so little advance has been made toward the isolation of the alkaloid or resinoid on which it depends for its potency. I have for years been endeavoring to interest some of our great manufacturing pharmaceutists in the attainment of a form—condensed, uniform, and portable—which should stand to cannabis in the same relation which morphia bears to opium. I believe that, in collaboration with my friend Dr. Frank A. Schlitz (a young German chemist of remarkable ability and with a brilliant professional career before him), I have at last attained this desideratum. I have no room or right here to dwell upon this interesting discovery further than to say that we have obtained a substance we suppose to bear the analogy desired and to deserve the title of Cannabin. If further examination shall establish our result, we have in the form of grayish-white acicular crystals a substance which stands to cannabis in nearly the same proportional relation of potency as niorphia to opium, and this most powerful remedy can be given as easily and certainly as any in the pharmacopoeia. If we are successful we shall ere long present it to the medical profession. With all the objections that prejudice cannabis now, I have still witnessed repeated proofs of its great value in lulling pain and procuring sleep, when all other means had failed with the reforming opium-eater, in doses of from one drachm to five of fluid extract or tincture (in some rare cases even larger), administered twice a day. Like opium it is only secondarily a soporific, and to produce this effect it should be given three or four hours before the intended bed-time. Then the earliest effect will be a cerebral stimulus, sufficient to divert the mind from the body's sufferings during day-light, and the reaction will come on in time to produce slumber of a more peaceful and refreshing character—more nearly like normal sleep in a strong, energetic constitution fatigued by healthy exertion, than that invoked by any drug I know of.

It may sometimes be necessary, when the pain has become so maddening and been so protracted, to save the brain from the delirium of exhaustion (or even as I have known to happen, death) by procuring sleep for half an hour at any cost save that of a return. The most interesting patient and noble man whose sufferings compose the text and prompted the writing of my Harper's Magazine article, died just as it was going to press through the exhaustion of a brain that had no true sleep for months. To avoid such a termination, sleep must be had at any cost, and even the danger attending chloroform or ether must be risked, though I need not point out the necessity of pre-eminent wisdom, and the constant personal presence and watchfulness of symptoms, in the physician during the time that the anaesthetic is inhaled. Of ether as much as three or four ounces may be inhaled during a single evening without much danger, if the precaution of alternating the inspirations from a saturated handkerchief with those of pure atmospheric air be carefully attended to. Chloroform is much more risky, and almost always tends to derange the stomach for several days after its use, still its action is certain in some cases where ether fails even to obscure sensation, and must be resorted to. A single ounce per evening, inhaled with rather longer intervals between whiffs, need not be a perilous dose, and in my experience has often conferred magical relief. Nitrous oxide is too transient to be of much use, but to the extent of twenty or thirty gallons may be used with pleasant effect and about five minutes of alleviation.

Very different from these powerful agents is the humble, much-neglected scutellaria. It has been repeatedly pronounced inert, but is beyond all question a minor sedative of charmingly soothing properties, giving sleep, as I have sometimes witnessed, out of the very midst of intolerable rythmical neuralgic suffering—in one case the first sleep the patient had enjoyed since leaving off opium. It may be given with impunity in much larger doses, but on those constitutions with which it has any effect at all a table-spoonful is usually efficacious about ten minutes after its exhibition in the form of fluid extract. Lupulin, valerian, valerianate of zinc, and hyoscyamus (or with a much less tendency to derange the stomach, hyoscyamin in 1/10 grain doses) all have their value in the less violent cases or toward the close of the struggle. Capsicum, in the five grain doses earlier mentioned, may often be relied on to counteract the tendency to frightful dreams arising from the exquisitely irritable state of the stomach in which the opium-habit leaves its victims.

Our object with Mr. Edgerton during the month of struggle has been to assist Nature in eliminating the obsolete matters of the system by all the excretory passages as preparative to the rebuilding of his system on a healthy plan by new material. During most of the time he has suffered from a profuse and weakening diarrhea, but this we have not checked nor retarded, because it was Nature's indispensable condition precedent to the new man. His perspiration has been profuse, and that we have assisted for the same reason by every means in our power—all our baths and rubbings, our galvanism and medicine so far as used, have favored to the utmost the activity of his skin. Our repeated hot-baths have greatly relaxed him; he may have come to the end of his month so weak that he could not walk a quarter of a mile if his life depended on it. No matter. This, however alarming at first sight, is good practice. The more rapidly he has become relaxed, the further and the further we have banished pain, from whose presence a state of tension is inseparable. We have not injured him. It is astonishing to any one accustomed to dealing only with the prostration of ordinary disease to see to what an extremity the opium-eater will bear to be reduced—what an extent of muscular debility he will even thrive under. If we look at him closely, we will see through all his pallor a healthy texture of skin—in all his languor a soundness of vital operation which stands to his account for more valid strength, than if he could lift all the weights of Dr. Winship. Unless the opium-disease is complicated with some serious organic difficulty it is safe to carry on the process of relaxation as long as it relieves pain until the patient has just enough strength left to lift his eyelids. We have kept him up with the constant, faithful administration of beef-tea—half a tea-cupful, by slow sips, every hour or hour and a half that he was awake during day or night, but never rousing him for any purpose whatever if he showed any inclination to sleep. The nurse who does that when an opium-eater is going through his struggle should be discharged without warning. Sleep for ten minutes any time during this month is worth to nutrition alone more than a week's feeding.

At the end of the month Mr. Edgerton can sleep with tolerable soundness for half an hour—even an hour at a time, and the sum of all his dozes amount to about four hours out of the twenty-four. He is still nervous, though the painful tigerish restlessness is gone. The pangs of his opium-neuralgia are also gone—or re-appear at long intervals, and much mitigated, to stay but a few minutes. He is in every respect on the upward grade. When his sleep becomes decidedly better, so that most of his night, despite frequent wakings, is consumed in it, he enters on an entirely different stage of his treatment. We stop pulling him down. We begin toning him up.

To the description of this process I need devote but little room. It consists in a gradual cooling of the temperature of his baths—a substitution of the more bracing and invigorating for one after another of the relaxing and soothing forms of treatment. The hot full-bath is discontinued almost entirely, and we replace it by the use of a couple of pailfuls of water at 65-75, doused over the patient; or "the flow," in which the water spreads through a fan-shaped faucet like a funnel with its sides smashed flat and falls over his shoulders; or the salt sponge—all followed by vigorous towel and hand-rubbing until the skin is in a healthy glow. The pack we still employ, wringing the sheet out of water as near the natural temperature as he can comfortably and at once react from. It is an admirable means of equalizing the circulation of our patient and soothing his remaining nervous irritability. We encourage his being in the open air and sunshine as much as is compatible with the season and the weather, and favor his taking exercise in every unexhausting way possible. His appetite will by this time take care of his nutrition with-out much nursing, but we must listen to its caprices and provide it with every thing it thinks it would like. Our sedative medicines may in all likelihood be safely discontinued, and very little indeed of any kind be given him save tonics. In my experience, and that of all others to whom I have recommended them, the very best and most universally to be relied on at this stage are quinine, nux vomica tincture, and pyro-phosphate of iron, together with last, but most important of all, our invaluable stand-by, beef-tea. This may be made more palatable to the fastidious palate which has become palled by a steady month or two of it, by a few whole cloves and shreds of onion, but most people relish its delicious meaty flavor quite as well when it is simply made by chopping lean rump into pieces the size of dice, covering them with cold water in the proportion of about three pints to two pounds, letting the whole stand a couple of hours to soak in a saucepan, then drawing it forward upon the range, where it will gently simmer for ten minutes, and salting and pouring it out just as it comes up to a brisk boil. If the meat be just slightly browned on both sides (not broiled through, remember) before being chopped, the flavor of the tea is to many tastes still more exquisite. Beef-tea should be on the range, ready for patients in our house who need it, at all hours of the day and night, and all the year round. The whole cookery of our establishment must be of the very best. There is no greater mistake than that existing in most sanitary institutions— stinting in the larder and the kitchen. The best meats, the most skillful, delicate cookery, the freshest of vegetables and fruit, the ability to tempt the capricious palate by all sorts of savory little made dishes—these should always characterize the table of a place where food has to do so much as with us in replacing the fatal supports of the narcotics and stimuli. It will be noticed that neither here nor in my mention of tonics have I referred to alcoholic stimulants. The omission has been intentional. My entire experience has gone to prove that the use of alcohol in any form with opium-eaters undergoing cure is worse than useless, almost invariably redoubling their suffering from loss of opium, and frequently rendering the craving for a return to their curse an incontrollable agony. I therefore leave it entirely out, alike of my pharmacopia and my bill of fare.