A system of practical medicine. By American authors. Vol. 5

by Unknown

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 free from 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.

Cannabis Indica, Ether, Chloroform, and Cocaine.

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.

Treatment.

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.