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

by Unknown

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 are obvious, 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 stages of 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 observers¹² have reported successful cases not only of 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.

¹² See, 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 devoted to 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.