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

by Unknown

The first symptoms of the withdrawal of the drug show themselves in delicate individuals at the end of three or four hours, and in robust persons about fifteen hours, after the last dose. These symptoms consist of malaise, restlessness, a sense of muscular tension, chilly sensations, and the like, but do not demand treatment. As soon as shivering commences the patient must be put to bed—a measure to which, as a rule, he readily assents on account of the sense of muscular fatigue now experienced. For the relief of the headache, which is rarely absent, applications of cold water or of ice or ether-douches to the forehead may be employed. For the distressing gastralgia compresses moistened with chloroform may be applied to the epigastrium. The colic, which is often distressing, may be treated by sinapisms or hot compresses. The nausea and vomiting and epigastric distress, which are apt to continue for several days, may be treated by a solution of bicarbonate of sodium with tincture of nux vomica and essence of mint. If the vomiting be excessive, recurring twenty or thirty times in the course of twenty-four hours, small doses of morphine by the mouth must be given. If by reason of the continued vomiting and inability to retain nourishment dangerous exhaustion develops, nutritive enemata must be administered. The diarrhœa requires little treatment during the early days. If, however, it be excessive and persists beyond the third or fourth day, large enemata of warm water of a temperature of 98° F., repeated two or three times during the day, are attended by excellent results. The insomnia, which constitutes a most distressing symptom, defies every kind of treatment during the first three or four days. During this time prolonged baths are not well borne, and even when they are employed they scarcely produce more than half an hour or an hour of sleep. Chloral is also, under these circumstances, inadmissible, whether administered by the stomach or by the rectum. It does not induce sleep, and its employment is very often followed by a high degree of excitement. After the fourth day it is well borne by many persons, and manifests its usual hypnotic property. Warm baths of five minutes, followed by cold affusions, exert an excellent influence upon the general debility and mental depression of the first days. The objections of patients to these baths cease after they have experienced the excellent results which follow their use. During the bath stimulants, such as champagne, port, and hot bouillon, may be given. Care must be paid to the alimentation from the very beginning of the treatment. During the first days liquid nourishment should be given, and abundance of wine and other alcoholic beverages according to the previous habits of the patient. Some nourishment is to be given every hour or every two hours. Many patients experience an intense craving for alcoholic drinks; others, on the other hand, are unable to take them. To the former wine, beer, etc. may be given freely during the first three or four days; to the latter a restricted milk diet may be given, one to two quarts in the course of twenty-four hours. Such is the method of Levinstein, to which he adds, however, important modifications for those—and their number is large—who are unable to bear the abrupt withdrawal of the drug.

This method is attended in all cases by indescribable sufferings, and in many by serious dangers. Among the last, collapse and delirium tremens demand special consideration. The collapse which occurs in a certain proportion of the cases requires prompt and energetic treatment. The pulse becomes feeble, small, gradually or suddenly diminishes in frequency; the countenance is pale; the previous agitation gives place to an ominous calm; there is a tendency to syncope, accompanied by persistent somnolence and slowing of the respiration. Inhalations of ammonia and the administration of aromatic spirits of ammonia, champagne, brandy, or hot coffee, with frictions of the surface and cold applications to the head, may occasionally produce reaction. As a rule, however, it is necessary to administer a hypodermic injection of morphine. This condition of collapse, once having shown itself, is apt to recur upon the same or the following day. The treatment of the delirium tremens consists in isolation, the administration of abundant nourishment, the use of the bromides, chloral, or paraldehyde, with alcoholic stimulants. As this complication is unattended by danger to life, and usually disappears in the course of a few days, the administration of morphine is not required.

The modifications of this method suggested by Levinstein for those who are unable to bear the abrupt suppression of the drug are as follows: The patient is isolated and guarded; for two or three days his habitual dose is administered, this duty being performed by the physician himself. The drug is then abruptly discontinued. At the end of twenty-four hours the phenomena of abstinence are manifested; the pulse loses its regularity, distressing diarrhœa and vomiting occur, etc. These symptoms are controlled by the injection of morphine, the dose being much smaller than that to which the patient has been accustomed. By this means the sufferings of the patient are ameliorated, and the dangers attendant upon the rapid suppression of the drug are averted. At the end of twenty-four hours it becomes necessary to again administer the drug, but in diminished dose. After a time it is discontinued altogether.

b. The Gradual Diminution of the Dose.—This method is now generally employed. It consists in isolation of the patient with proper attendants and the progressive diminution of the dose. The drug should always be administered by the physician himself. The rapidity with which it is suppressed will be determined by the circumstances of the individual case. The time occupied should not exceed ten days. In the majority of cases it will be much shorter than this. If the administration of morphine to correct urgent symptoms be at all required after this time, it will be at most on one or two occasions at intervals of twenty-four or forty-eight hours. When the process of reducing the dose is too greatly prolonged, the sufferings of the patient are unnecessarily aggravated. As the diminution progresses the relief produced by each dose is followed by distressing reaction. The anticipation of smaller doses from time to time or from day to day is a matter of great distress to patients. After a while their courage and endurance fail them, and they seek by every possible means to secure at least one good dose of the coveted drug.

The symptoms produced by the suppression of the drug speedily show themselves, increasing in intensity as the dose diminishes. Temporary amelioration is, however, produced by each of the successively diminishing doses of the drug. Whatever may have been the method followed by the patient, the hypodermic injection of morphine is to be preferred in the treatment. The disturbances of the digestive system which speedily appear require but little special medication. The danger of inanition which attends the complete loss of appetite, the inability to take ordinary food, and the frequent often uncontrollable vomiting, are best met by the systematic administration of easily assimilable liquid diet, consisting of lime-water and milk, milk and Vichy water, pancreatized milk, koumiss, concentrated broths, the expressed juice of fresh partly-cooked beef, and the various commercial foods used in the artificial feeding of infants. Vomiting rarely occurs immediately after the ingestion of articles of this kind. If it takes place in the course of an hour, some degree of digestion and absorption will have taken place. Should, however, all food be rejected by the stomach, efforts at rectal alimentation must be attempted. Efforts to control the vomiting by medicines other than the administration of opium or morphine in some way are not usually attended by success. The diarrhœa is usually frequent, the stools being liquid, sometimes small, often copious, and amounting in number from eight or ten to thirty or more in the course of twenty-four hours. They are not usually attended by pain. Some relief to this symptom follows the administration for a time of large doses of bismuth subnitrate (grs. xx to xxx) every second, third, or fourth hour. The sinking feeling at the pit of the stomach and the epigastric pain are to some extent alleviated by external applications. Hot fomentations or compresses containing a few drops of chloroform or turpentine are also useful.

The derangement of the respiratory system, which consists usually in a certain amount of bronchitis with more or less cough and some dyspnœa aggravated by exertion and movement, does not usually require special treatment.

Disturbances of the circulation constitute a very important group of symptoms, and require close watching always, active interference frequently. For the relief of the phenomena due to flagging action of the heart the recumbent posture, external warmth, friction of the extremities, the application of turpentine stupes or mustard to the præcordial and epigastric regions, the inhalation of ammonia or the administration of preparations of ammonia, and sometimes digitalis, which may be given either by the mouth or hypodermically, will be required. Alcohol, however, will prove in the greater number of cases a most useful remedy—in many an indispensable one. It may be given in the form of milk-punch, hot toddy, or of port, champagne, etc., according to the requirements of the case. Failure of the circulation may, notwithstanding every effort to control it, reach such a degree as to jeopardize the patient's life. Under such circumstances the treatment must be interrupted by the immediate administration of small but efficient doses of morphine, which, if necessary, must be repeated. As diarrhœa increases the quantity of urine excreted rapidly diminishes. It may not exceed eight or ten fluidounces in the course of twenty-four hours. After the third or fourth day of the treatment the urine in a considerable proportion of cases contains albumen and occasionally casts. The oliguresia is largely due to the excessive loss of fluid by the bowel, and does not require treatment. Nor, indeed, is active treatment demanded by the albuminuria, which usually spontaneously subsides in the course of a few days, although it sometimes persists for some weeks or months. Persistent albuminuria requires appropriate treatment.

The nervous symptoms, which constitute a most important group, are favorably influenced by methodical alimentation and the free use of alcoholics. Care must be taken to reduce the amount of alcohol administered as convalescence progresses. With the re-establishment of the normal functions of the body, the disappearance of insomnia, and improved nutrition, alcohol may in the majority of cases be rapidly diminished or wholly withdrawn. This course, favored by the regular life which the patient should be obliged to lead on becoming convalescent, and the feeling of general bienaise which is gradually developed as the cure progresses, is rendered especially important by the fact that a considerable proportion of opium-habitués are individuals of unstable nervous organization, which in itself constitutes a powerful predisposing influence to alcoholism.

It seems hardly necessary to describe in detail the treatment demanded for the relief of the varied disturbances of the nervous system. The use of coca in the form of a good preparation of the wine or fluid extract in appropriate doses, to which may be added tincture of cannabis indica, exerts a favorable influence. The administration of cocaine by the mouth and hypodermically has in some instances seemed to me to be followed by favorable results. It is not, however, to be adopted as a routine practice, by reason of its occasional depressing effect and the possible danger of replacing the opium habit by a craving for cocaine. Lupulin, and in particular an ethereal extract of lupulin, exerts a favorable but not very powerful influence in tranquillizing the nervous system. With the view of controlling to some extent the insomnia, the hypodermic injections should, during the early part of the treatment, be so timed that the period of sleep or drowsiness which they produce should occur during the night. As soon as the number of injections is reduced to one daily, that one should be administered at the latest convenient hour before midnight. For twenty-four or forty-eight hours after the final discontinuance of morphine but little effect may be expected from ordinary doses of other sleep-inducing drugs. Chloral in single large doses (grs. xx to xxx), either alone or associated with a corresponding large dose (grs. xl to lx) of one of the bromides, administered on the second or third night after total suppression, is very often followed by prolonged, tranquil, and refreshing sleep. Caution must be observed, however, in administering chloral so long as the indications of feeble circulation persist. Paraldehyde, although less certain, is a less dangerous hypnotic under such circumstances. Massage, hot baths, and the cold pack are all useful adjuvants to the treatment. The sweating when copious and distressing is favorably influenced by sponging with hot alcohol.