Outlines of the Opium-Cure
Apr 25, 1868
from 'The Opium Habit', by Horace Day
Citation: Ludlow FH. "Outlines of the Opium-Cure" The Opium Habit. Ed. H Day. Harper & Brothers. 1868.
No. I Livingston Place,MY DEAR SIR :- In accordance with your request, I sketch the brief outline of my plan for the treatment of opium-eaters, premising that it pretends much less to novelty than to such value as belongs to generalizations made from large experience by sincere interest and careful study in the light of science and common sense.
April 25, 1868.
April 25, 1868.
That experience having shown me how impracticable in the large majority of cases is any cure of a long-established opium habit while the patient continues his daily avocations and remains at home,1 I shall simplify my sketch by supposing that one great object of my life is already attained, and that an institution for the treatment of the disease is already in successful operation. Starting at this fictitious datum, I shall carry from his arrival under our care until his discharge a healthy, happy, and useful member of society, a gentleman whom for convenience we will name Mr. Edgerton.
Our institution is called not an "Asylum," nor a "Retreat," nor by any of those names which savor of restraint and espionage -- not even a "Home," as spelled with a capital H -- but simply by the name of the spot upon which it is erected -- to wit, "Lord's Island."
It is erected on an island because in the more serious cases a certain degree of watchfulness will always be necessary. On the main-land this watchfulness must be exercised by attendants with the aid of fences, bolts, and bars. On an island the patient whose case has gone beyond self control will be under the Divine Vigilance, with more or less miles of deep water as the barrier between him and the poison by which he is imperilled. For this reason, and because whatever good is accomplished on it for a class which beyond all other sufferers claim heavenly mercy will be directly of the Lord himself, our island is called "Lord's Island." Here our patient will feel none of the irksome tutelage which in an asylum meets him at every step -- thrusting itself before his eyes beyond any power of repulsion, and challenging him to efforts for its evasion which are noxious whether they succeed or not; defeating the purpose of his salvation when they do, irritating him when they do not, and keeping his mind in a state of perpetual morbid concentration upon his exceptional condition among mankind in either case. Here he has all the liberty which is enjoyed by the doctors and nurses -- save that he can not get at the medicine-chest. Mr. Edgerton arrives at Lord's Island at 2 P.M. of a summer's day, having crossed by our half-hourly sail-boat, row-boat, or tug, from the railroad station on the main-land. If he is much debilitated, either by disease or fatigue, he has full opportunity to rest and refresh himself before a word is spoken to him professionally. If a friend accompanies him, he is invited to remain until Mr. Edgerton feels himself thoroughly at home in his new quarters.
After becoming fully rested, Mr. Edgerton is invited to state his case. The head physician must be particular to assure him that every word he utters will be regarded as in the solemnest professional confidence. Mr. Edgerton is made to feel that no syllable of his disclosures will ever be repeated, under any circumstances, even to the most intimate of his friends or the most nearly related of his family. This conviction upon his part is in the highest degree essential. Opium makes the best memory treacherous and, sad as it may be to confess it, the most truthful nature, in matters relating to the habit at least, untrustworthy. Often, I am satisfied, the opium-eater, during periods of protracted effort or great excitement, takes doses of the drug which he does not recollect an hour afterward, and may, practically without knowing it, overrun his supposed weekly dose twenty-five per cent. I often meet persons addicted to the habit who, I have every reason to believe, honestly think they are using twelve grains of morphia daily, yet are found on close watching to take eighteen or twenty. Again, the opium-eater who by nature would scorn a lie as profoundly as the boy Washington, is some times so thoroughly changed by his habit that the truth seems a matter of the most trifling consequence to him, and his assertion upon any subject whatever becomes quite valueless. Occasionally this arises from an entire bouleversement of the veracious sense -- similar to certain perversions of the insane mind, and then other faculties of his nature are liable to share in the alteration. If the man was previously to the highest degree merciful and sympathizing, he may become stolid to human suffering as any infant who laughs at its mother's funeral, not from wickedness of disposition but absence of the faculty which appreciates woe, and I doubt not that this change goes far to explain the ghastly unfeelingness of many a Turkish and Chinese despot whose ingeniously cruel tortures we shudder to read of scarcely more than the placidity with which he sees them inflicted. If he was originally so sensitive to the boundaries between Meum and Tuum that the least invasion of another's property hurt him more than any loss of his own, this delicate sense may become blunted until he commits larceny as shamelessly as a goat would browse through a gardener's pickets, or a child of two years old help himself to a neighbor's sugar-plums. This, too, quite innocently, and with the excuse of as true a Kleptomania as was ever established in the records of medical jurisprudence. I knew a man who had denied himself all but the bare necessaries of life to discharge debts into which another's fraud had plunged him, and whose sense of honor was so keen that when afflicted with chronic dyspepsia the morbid conscientiousness which is not an unusual mental symptom of that malady took the form of hunting up the owner of every pin he picked up from the floor, nor could he shake off a sense of criminality till he had found somebody who had lost one and restored it to him -- yet on being prescribed opium for his complaint, his nature, under its operation, suffered such an entire inversion that the libraries, and on several occasions even the pocket-books of his friends were not safe from him, his larcenies comprising some of the most valuable volumes on the shelf and sums varying between two and twenty dollars in the porte-monnaie. "The Book-Hunter" writing of De Quincey, as you will recollect, under the sobriquet of "Papaverius," describes the perfectly childlike absence of all proprietary distinctions which prevailed in that wonderful man's mind during his later years as regarded the books of his acquaintance, and the innocent way in which he abstracted any volume which he wanted or tore out and carried away with him the particular leaves he wished for reference.
In many cases where the moral sense has suffered no such general bouleversement, the tendency which opium superinduces to look at every thing from the most sanguine point of view -- the vague, dreamy habit of thought and the inability to deal with hard facts or fixed quantities -- make it necessary to take an opium-eater's assertions upon any subject with a certain degree of allowance -- to translate them, as it were, into the accurate expressions of literal life; but even where this necessity does not exist, in cases sometimes though rarely met with, where opium has been long used without tinging any of life's common facts with uncertainty, an opium-eater can scarcely even be relied on for the exact truth concerning his own habit. He may be trusted without hesitation upon every other subject, but on this he almost always speaks evasively, and though about any thing else he would cut his hand off rather than say the thing that is not, will sometimes tell a downright falsehood. In most cases he has been led to this course by witnessing the agony or suffering the reproach with which the knowledge of his habit is received by his friends. He lies either in mercy to them or because the pangs which their rebuke inflicts would become still more intolerable if they knew the extent of his error.
It is therefore always proper that the opium-eater should find in his physician a confidant who will not violate his secret even to parent or wife. The closer the relation and the dearer the love, the greater will be the likelihood that the opium-eater has shrunk from revealing the full extent of his burden to the friend in question, and the greater will be the temptation to deceive the doctor unless the patient be made to feel that his revelation is as sacred as the secrets of the bridal-chamber.
I solicit from the friend who accompanied Mr. Edgerton the thoroughest statement which he can give me of the case, ab extra. Such a statement is of great value -- for the inroads which the habit has made upon the system are often visible to an outsider only. Furthermore, a friend may give me many circumstances connected with the inception of the case: family predispositions and inherited tendencies; causes contributing to the formation of the habit, such as domestic or business misfortune, prior bad habits of other kinds, illnesses suffered, and a variety of other agencies concerning which the patient might hesitate or forget to speak for himself. Then I make Mr. Edgerton the proffer of that inviolable confidence which I have mentioned, and having won his perfect faith in me, obtain the very fullest history of his case which can be elicited by searching, but most kindly and sympathizing cross-examination. The two statements I collate and enter for my future guidance in a private record.
Let us suppose an average hopeful case.
I find that my patient is about thirty years of age -- of the energetic yet at the same time delicate and sensitive nervous organization which is peculiarly susceptible to the effects of opium, from which it draws the vast majority of its victims, and in which it makes its most relentless havoc; with a front brain considerably beyond the average in size and development. My patient's general health, apart from the inevitable disturbances of the drug, has always been fair, and his constitution, under the same limitations, is a vigorous one. His habit, as in nine cases out of every ten, dates from the medical prescription of opium for the relief of violent pain or the cure of obstinate illness. He was not aware of the drug then administered to him, or at any rate of the peril attending its use, and his malady was so long protracted that opium had established itself as a necessary condition of comfortable existence before he realized that it possessed the slightest hold upon him. When the prescription was discontinued he suffered so much distress that he voluntarily resumed it, without consulting his physician, or, if he did consult him, receiving no further warning as to his danger than that "he had better leave off as soon as practicable." Or else, on leaving off his use of opium, the symptoms for which it had originally been administered returned with more or less severity, and under the idea that they indicated a relapse instead of being one of the characteristic actions of the drug itself, he resumed the dose. It gradually lost its power; little by little he was compelled to increase it; and having begun with 1/3 grain powders of which he took three per diem, he is now taking 18 grains of morphia per diem at the end of five years from his first dose.
If I find him tolerably vigorous on his arrival, as will be the case when he has come to Lord's Island after calm deliberation and the conviction not that he must, but on all accounts had better abandon the habit, I leave him to recover from the fatigues of his journey and get acquainted with his surroundings before I begin any treatment of his case. If, however, as sometimes occurs, he reaches us in desperate plight, having been so far injured by his habit as to show unequivocal signs of an opium-poisoning which threatens fatal results; if, as in several cases known to me, he has summoned all his remaining vitality to get to a place of refuge, being overtaken either by that terrible coma which often terminates the case of the opium-eater in the same fashion that persons new to the narcotic are killed by an overdose, or by that only less terrible opium-delirium belonging to the same general class as mania potu -- then his case admits of not a moment's delay. Opium-eaters differ so widely -- every new case furnishing some marked idiosyncrasy which may demand an entirely different management and list of remedies from those required by the last one -- that for any general scheme of treatment a week's study of the patient will be necessary. During that week our attitude will be simply tentative and expectant, and at its close the proper fidelity and vigilance will have authorized us in making out something like a permanent schedule for the patient's upward march, though even then we must be prepared, like skillful generals, to meet new emergencies, take unforeseen steps, even throw overboard old theories, at any stage of his progress. In no disease is there such infinite variety as in that of opio-mania, in none must the interrogation of nature be more humbly deferent and faithfully attentive; in none do slight differences of temperament, previous habits, and circumstances necessitate such wide variation in the remedies to be used. Notice, by way of illustration, the fact that one opium-eater under my care was powerfully affected and greatly benefited by the prescription of one drachm of the fluid extract of cannabis indica, while another, in temperament, history, tendencies, and all but a few apparently trifling particulars almost identical, not only received no benefit but actually experienced no perceptible effect whatever from the absolutely colossal dose of four fluid ounces.2 I may add that in the latter case, bromide of potassium was administered with the happiest result -- in fact as nearly approaching in its efficiency the character of a succedaneum as any remedy I ever used to alleviate the tortures of opium, while in the former no result attended its administration salutary or otherwise. The vast diversity of operation exhibited in different patients by the drug scutellaria is still another illustration of the careful study of idiosyncrasies requisite for a successful treatment of the opium disease. But when the case comes into our hands at a desperate period there are many means of instant alleviation which may anticipate without interfering with future treatment based on study.
Mr. Edgerton, though by no means a man of ruined constitution, has brought himself temporarily into a critical place by the fatigues and anxieties of harassing business, by exceptional overwork which kept him at his desk or in his shop until inordinately late hours; even, let me say, by going for entire nights without sleep and neglecting his regular meals day after day for a period of several weeks; performing and enduring all this by the support of extra doses of opium. Perhaps, finding the stimulus to which he has become accustomed too slow in its operation, he has violated his usual custom of abstinence from alcoholic drinks and reinforced his opium with more or less frequent potations of whisky. This is no fancy sketch. Our overtasked commercial men frequently go on what might with propriety be called "a business spree" in which for a month at a time, whether using stimulants or not, they plunge into as mad a vortex with as thorough a recklessness as those of the periodical inebriate; finding out in the long run that the fascinations of speculation, and the spring and fall trade, bring as dire destruction to soul and body as those of the bowl and the laudanum vial. During times of great financial pressure or under the screws of preparation for some great professional effort, the moderate opium-eater finds that he must inevitably increase his dose. When he adds liquor to it (and this addition to an old opium-eater is often as necessary as liquor alone would have been before he used opium at all) he is indeed burning his candle at both ends. Mr. Edgerton reached the commencement of his period of extra exertion with as sound a constitution -- in as comfortable condition of general health -- as is enjoyed by any man habituated to opium for four or five years; and such cases are frequently found among men who appear to enjoy life pretty well, attend to their business with as much regularity as ever, and show no trace of the ravages wrought by their insidious foe to any but the expert student. After six weeks of exciting labor and solicitude, during which his sleep and his rations were always delayed till exhaustion overpowered him, and then cut down below half the normal standard, he wakes one morning from a slumber heavy as death into a state of the most awful vigilance his mind can conceive of. He even doubts for some moments whether he shall ever sleep again, and in the agony of that strange, wild suspicion, a cold sweat breaks out over him from head to foot. Waking from the most utter unconsciousness possible to a wide-awake state like having the top of one's skull suddenly lifted off by some surgeon Asmodeus, and the noonday sun poured into every cranny of his brain, he suffers a shock compared with which any galvanic battery, not fatal, gives but a gentle tap. The suddenness of the transition -- no gentle fading out of half-remembered dreams, no slow lifting of lids, no pleasant uncertainty of time and place gradually replacing itself by dawning outlines of familiar chair and window frame and cornice -- the leap from absolute nonentity into a glaring, staring world -- for a moment almost unsettles Mr. Edgerton's reason. Then the fear for his sanity passes and a strange horror of approaching death takes its room. His pulse at the instant of waking throbs like a trip-hammer; an instant more and it intermits. Then it begins again at the old pace. He snatches up his watch from the bureau with a trembling hand and counts -- the beat is 130 a minute. Again it stops; again it begins; but now little by little growing faster and threadier until it runs so swiftly yet so thinly as to feel under his finger like some continuous strand of gossamer drawn through the artery. His feet and hands grow deadly cold. He seems to feel his blood trickling feebly back to his heart from every portion of his body. He catches a hurried look at the glass -- he sees a dreadful spectre with bistre rings around the eyelids, an ashen face, leaden lips, and great, mournful, hollow, desolate eyes. Then his pulse stops altogether; his lungs cease their involuntary action; and with a sense of inconceivable terror paralyzing the very effort he now feels it vital to make, he puts them under voluntary control and makes each separate inspiration by an effort as conscious as working a bellows. I doubt not that many men have died just at this place through absolute lack of will to continue such effort. Then the metaphorical paralysis of fear is seconded by the simulation of a literal one, extending through the limbs of one side or both; the sufferer reels, feeling one foot fail him -- tries to revolve one arm like a windmill, that he may restore his circulation, and that arm for some instants hangs powerless. Presently, with one tremendous concentration of will, his brain shouts down an order to the rebellious member -- it stirs with sullen reluctance -- it moves an inch -- and then it breaks from the prison of its waking nightmare. Summoning his entire array of vital forces, our patient leaps, and smites his breast, kicks, whirls his arms, and little by little feels his heart tick again. By the time a feeble and sickly but regular pulse is re-established he has gone through enough agony to punish the worst enemy, my dear Sir, that you or I ever had. The vague, overpowering fear of death which during such an attack afflicts even the man who by grace or nature is at all other times most exempt from it is one of this period's most terrible symptoms. This passes with the return of breath and circulation.
But the clammy sweat continues -- pouring from every point of the surface -- saturating the garments next the skin as if they had been dipped in a tub of water. Presently our patient begins to suffer an intolerable thirst, and runs to the ice-pitcher to quench it. In vain. He can not retain a mouthful. The instant it is swallowed it seems to strike a trap and is rejected with one jerk. He seeks the sedative which up to this hour has allayed his worst gastric irritations. Now, if never before, opium in every form produces nausea. Laudanum instantly follows the example of the water, and even a dry dose of morphia swallowed with no moisture but saliva, casts itself back after agonizing retchings. To liquor his rebellious stomach proves yet more intolerant -- food is almost as irritating as liquor. In a horror he discovers that even pounded ice will not stay down -- and he is parching like Dives. His anguish becomes nearly suicidal as the fact stares him in the face that he has come to the place where he can not take opium any more -- though to be without it is hell -- that food, drink, medicine, are all denied him.
A merciful, death-like apathy ensues. He lies down, and with his brain full of delirious visions, appalling, grotesque, meaningless, beautiful, torturing by turns, still manages to catch an occasional minute of unconsciousness. He hears his name called -- tries to rise and answer -- but his voice faints in his throat and he falls back upon his bed. Friends enter his bed-chamber -- in an agony of alarm rouse him -- lift him to his feet -- but he has not the strength of an infant, and he falls again. In this condition he may continue for a day or two, then sink into absolute coma, and die of nervous exhaustion, or his constitution may rally as the effects of the last overdose pass off, and the man, after a fortnight's utter prostration, come gradually back to such a state of tolerable health and comfort as he enjoyed before he overtaxed himself.
Mr. Edgerton is brought to Lord's Island in the condition I have described, living near enough to be transported on mattresses in carriage and boat. A few hurried questions put to his friends reveal that although his condition is alarming it is by no means necessarily fatal; being one of those in which the habit is of such comparatively short standing, and the constitution still so vigorous, that even at home he might come up again by natural reactions.
He is immediately undressed and put to bed, with hot bricks and blankets at the extremities, and the galvanic battery is judiciously administered by placing both feet in contact with a copper plate constituting the negative electrode, while the operator grasps the positive in one hand, and having wetted the fingers of the other, follows the spine downward, exerting gentle pressure with them as he goes. "Judiciously," I say, because there is a vast deal of injudicious use of the battery. In many cases for instance, a powerful and spasmodic current is used to the absolute injury of the patient, where the greatest benefit might be secured by an even one so light as scarcely to be perceptible. But I can only mention the battery. Its application is by itself a science, and demands a book. The practitioner who treats opium patients needs that science as much as any one interested in whatsoever branch of nervous therapeutics. The battery in the hands of a scientific man is one of our most powerful adjuncts throughout every stage of treatment, both of opium-eating and its sequelae. Paralysis following the habit, and persistent long after its abandonment, I have cured by it when all other means failed. Here, however, we have only room to indicate the weapons in our armory.
If Mr. Edgerton's digestive apparatus is still as intolerant as at the commencement of the attack which hurried him to Lord's Island, we may hope for a marked mitigation of this symptom, in the use of the battery by passing a mild current transversely through him in the region of the solar plexus. As soon as it is possible for his stomach to retain any thing we administer a bolus of capsicum, compounded of five grains of the powder with any simple addition like mucilage and liquorice to make it a coherent mass. The remaining nausea and irritability will in great likelihood be speedily relieved as by magic, and with these will disappear some of the most distressing cerebral symptoms -- the horror and frenzy or comatose apathy among them. In few cases will a patient reach the Island in time for the advantageous use of belladonna. That is a direct antidote -- exerting its function in antagonism to the earlier toxical effects of the opium. In cases where a single overdose has worked the difficulty and produced the coma which Mr. Edgerton's now resembles, it may be given to an old habitué of the drug with as good advantage as to a person whose overdose is his first experience of opium. It is of especial value where the absorbents have carried the excess beyond the reach of an emetic, any time, indeed, within fifteen or twenty hours after the overdose, when sulphate of zinc and the stomach-pump have failed to bring the poison. If our patient on the Island has taken his overdose so recently, and it seems still worth while to act by antidote, we shall be obliged to get over the difficulty presented by his stomach's lack of retention by administering our belladonna in the form of atropin in solution as a hypodermic injection. The many eminent researches of late made in this interesting method of administering remedies, and the practitioner's own judgment, must guide him as to the proportions of his dose -- whether one-fortieth grain, one-twentieth, or larger. Of this operation, with opium-eaters, I have seen several most successful instances.
In all probability, however, there will be a better field in such cases as Mr. Edgerton's for the use of nux vomica than of belladonna. Where the prostration is so great as to call for the most immediate action to avoid a syncope from which there shall be no rallying, it will be unwise to await the soothing action of the battery, capsicum, or any other means preparatory to giving nux vomica by the mouth. Strychnia in solution (it is needless to say with what caution) must be administered like the atropin, subcutaneously, or else nux vomica tincture in the form of the ordinary enema per rectum in about the same dose as it would be given by the mouth. The former method in wise hands is the better, both as the speedier, and, considering the opiate torpidity of the intestines, by far the more certain. In cases where the stomach tolerates fluid, as our ability to await the action of the battery and capsicum have now enabled us to find Mr. Edgerton's, we may give from fifteen to twenty drops of the ordinary pharmaceutical tincture of nux vomica in a table-spoonful of water.
In the course of ten minutes we find a decided improvement in the pulse of the patient; he experiences great relief from his feelings of apprehension and distress about the epigastrium; and the most powerful tonic known to science begins dispatching its irresistible behests to every fibre of the organic life. That painful as well as agitating subsultus -- that involuntary twitching and cramp in the muscles of the limbs and abdomen which often characterizes this form of the opium malady, by degrees gets lulled as under a charm, and it may not even be necessary to repeat the dose in two and a half hours to remove it so entirely that the patient gets ten or fifteen minutes of refreshing sleep.
The earliest symptoms of this species of attack sometimes indicate such prostration as make any bath of the ordinary kind unsafe; yet rare indeed are the cases (not one in a hundred I should say) where there is any danger of further depressing the nervous system (of course the great thing to guard against) by putting a patient like Mr. Edgerton into a Russian bath. I need not enlarge upon the value of this most admirable appliance -- all the most enlightened men of the medical profession know it and esteem it as it deserves, though its use in rheumatic affections and cutaneous diseases has hitherto received more study than in the class of maladies where its employment is perhaps the most beneficial of all -- the nervous. Pre-eminently valuable is it in the treatment of delirium tremens and in every stage of the opio-mania.
As your book is for the purpose of the public rather than professional men, I may perhaps properly say a few words about this bath by way of description. We have one, as a matter of course, at Lord's Island.
A room forty-five feet long and twenty broad, with a vaulted ceiling twenty feet high at the crown, is provided along each of its two longer sides with a series of marble slabs rising in three tiers from eighteen inches above the floor to a couple of feet below the ceiling. The idea may be gained more accurately by supposing three steps of a giant staircase mounting from an aisle three feet wide through the middle of the room, back and upward to the parallel cornice. The level surface of each of these steps is sufficiently wide to accommodate a man stretched on his back, and the upright portion of each step is an iron grating. Under the series of steps on both sides runs a system of sinuous iron pipes pierced with minute holes, and connected by stopcocks with a boiler out of sight.
The steps occupy in length twenty-five feet of the room, and its entire breadth except the narrow aisle between the two series. The remaining twenty feet square of the room is occupied by a tank sunk beneath the floor, sixteen feet square by four and a half deep, filled with water kept throughout the year at a uniform temperature of about 70 degrees F., and by the gallery which runs round the railing of the tank on the floor level. About the sides of the gallery are arranged hot and cold water-pipes with faucets and hose connections, the hose being terminated by a spray apparatus similar to the nose of a watering-pot. Opening off the gallery at the end furthest from the steps is a small closet fitted up with ascending, descending, and horizontal shower apparatus, by means of perforated plates connecting with the water-pipes by faucets set in floor, walls, and ceiling.
After the battery, the capsicum, and the nux, if Mr. Edgerton can retain it, we feed him by slow tea-spoonfuls from one-half to a whole cup of the most concentrated beef-tea -- prepared after Liebig's recipe or another which I have usually found better relished, and as that, where food must be administered to fastidious stomachs, is half the battle, which I prefer. (I will give it hereafter.) Should his stomach reject it thus administered, it must be given as an enema. Its place in the plan of all enlightened medical treatment is too lofty to need my insisting on. We must rely on it at Lord's Island every step of our way. It will not have been within our patient's system five minutes before the pulse shows it, nor ten before he feels from head to foot as if he had taken some powerful and generous stimulant. It is always wise to give beer-tea, even just before a bath of any kind, and it is never well to enter the Russian bath on an empty stomach.
Having taken his beef-tea, Mr. Edgerton is carried or propelled in a wheel-chair by attendants to the Russian bath-room. Having stripped in an anteroom; upon entering the vaulted chamber he finds himself in an atmosphere of steam at 120 degrees F., which fills the apartment, even obscures the sky-lights, yet to his surprise does not impede his respiration or produce any unpleasant sense of fullness in the head. He is now stretched on his back upon one of the lowest slabs, where the atmosphere is coolest and the vapor least dense; a large wet sponge is put under his occiput for a pillow, and another sponge in a pail of cool water placed by his side with which he, or in case of too extreme debility his attendants, may from time to time bathe and cool the rest of his head. As soon as he has become accustomed to the heat and moisture, a sensation of pleasant languor steals over him; all remains of his nausea and other gastric distress vanish; his nervous system grows more and more placid; his clammy skin is bedewed by a profuse and warm natural perspiration. Perhaps, as in cases of extreme debility and where the nerves have suffered tension from protracted pain, he even falls into a pleasant sleep. He is allowed to lie quietly on this lower slab for about fifteen minutes. An attendant then lathers him from head to foot with a perfumed cake of soap and gives him a gentle but thorough scrubbing with an oval brush like that in use among hostlers -- finishing the operation by vigorously shampooing, Oriental fashion, each separate joint of his whole body, with a result of exquisite relief not exaggerated by Eastern travellers as applicable to well people and quite beyond expression when its subject is the poor, long-tortured frame of a sick opium-eater. This process over, the patient is taken to the gallery and stood up before the hose apparatus above-mentioned. One hand of the attendant directs over his body a fine spray of steam and the other follows it up and down with a spray of cool water (either of which by combining and graduating appropriate faucets may be made as warm as you like), producing a fine glow and reaction of the whole surface. The up, down, and lateral showers are then administered, after which the patient is sent to plunge into the tank, and if able to swim, a stroke or two. Emerging, rosy as Aphrodité, and with a sense of vigor he can hardly believe, he again lies down on the slab -- this time taking the next higher tier, and in about ten minutes more, mounting, if so disposed, to the highest, where the perspiration rolls from him in rivulets, and with it such an amount of poison seems discharged from his veins as makes him feel like a new being. Finally, in about an hour from the time he entered the bath-room he is treated to one last plunge in the tank and carried back to the anteroom. The thermometer there marks but 70 degrees F., or half a hundred degrees cooler than the steam from which he has just emerged; still his blood has been set in such healthful circulation, and during the last hour he has absorbed such an amount of caloric, that the change seems a very pleasant one, and his skin has been so toned that he runs not the slightest risk (even were he the frailest person with pulmonary disease) of catching cold. Singular as it may seem, the first case of such a result has yet to be recorded.
This is all the more remarkable when we consider that instead of being immediately wrapped up after his vigorous drying with furzy bath-towels, he is kept naked for five minutes longer during a further process of hand-rubbing and shampooing by an attendant. The shampooing takes place as he lies prostrate on a couch and thus gives his debility all the advantage of rest and passive exercise at the same time. Whether we explain it upon the yet unsettled hypotheses of animal magnetism or upon simple principles of mechanical friction, the suppling which the patient gets in this part of the process from the hands of a strong, faithful, cheerful-minded and hale-bodied servant is one of the most valuable means which can be relied upon for the relief of opium suffering at any stage whatever. After coming from the ante-room our patient who entered more dead than alive may feel in possession of such a new capital of nervous and muscular vigor that he would like to give his recovered powers play in walking back to his room, but it is best not to humor him by letting him draw on his first deposit. He should be tenderly wheeled back as he came -- put to bed, and if it does not revolt his appetite, fed slowly as before another cup of beef-tea. After that he will probably fall into a refreshing slumber from which he is on no account to be roused, but suffered to wake himself. On his waking another cup of beef-tea should be given him, and no other medicine, unless his pulse becomes alarming and he shows signs of return to the original sinking condition in which we found him -- when the nux may be repeated.
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, paints 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, it 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 cut off short was one where the patient used 32 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 any body would pronounce exceptional, though even that did not save him from 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 shall 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 majority 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 characeristic 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.3 We may therefore find it necessary to carry on our reformatory process upon 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:
Morph. Sulph. . . . . . . . grs. xvi.
Aqua Destill. . . . . . . . . oz. i.
Vitrioli . . . . . . . . . . . . . quant. suff.
Mr. Edgerton has used 18 grains of morphia per diem. His equivalent in Magendie's Solution will be 9 fluid drachms.
This amount I divide into three equal doses -- one to be administered after each meal. By administering them after meals I give nutrition the start of narcotism, prevent the violent action possessed by stimulants and opiates on the naked stomach, and secure a slower, more uniform distribution of the effects throughout the day. The position of the third dose after the 6 o'clock meal of the day is particularly counselled by the fact that opium is only secondarily a narcotic, its sedative effects following as a reaction upon its stimulant, and the third dose accordingly begins to act soporifically just about bed-time, when this action is especially required.
I keep a glass for each of my patients, upon which their "high-water mark" is indicated by a slip of paper gummed on the outside. When Mr. Edgerton, pursuant to our stipulation, comes to me for his dose, I drop into the glass before his eyes a shot about the size of a small pea -- then fill the glass with Magendie's Solution up to the mark indicated. (This shot varies in each case with the rapidity of diminution I think safe to adopt. In some cases it is a buckshot or a small pistol bullet.) Every day a new shot goes in -- and if he bears that rate of progress I may even drop one into the glass with each alternate dose.
Midway between the doses of morphia I give Mr. E. a powder of bromide of potassium, amounting to 30 or even 40 grains at a time, and an average of about 100 grains per day. The value of this remedy has been a matter of much controversy -- some practitioners lauding it to the skies as one of the most powerful agents of control in all disorders of the nervous system, others pronouncing it entirely inert. Where it has proved the latter it has probably been given in too small doses or not persevered in for a sufficient length of time. (The timidity with which it is often prescribed may be seen in the fact that one of the principal druggists on Broadway lately warned a person to whom I had given a prescription for 30 grain doses that he was running a very dangerous risk in taking such a quantity) Its operation is so entirely different from that of the vegetable narcotics that people looking for their instantaneous sedative effect can not fail to be disappointed. It is very slowly cumulative in its action, seeming to act upon the nervous system by a gradual constitutional change rather than any special impetus in a given direction. Because that is its modus operandi, I begin to give it thus early; and it is of peculiar value now, not only as making the daily diminution of the opium more tolerable, but as preparing the system for the time when the drug is to be abandoned altogether and the hardest part of the tug comes.
In Mr. Edgerton's case the gradual descent to a grain per diem, when we leave off the opium entirely, consumes let us say a period of one month. It is not to be expected that this period will pass without considerable discomfort and some absolute suffering, for the nervous system can not be dealt with artfully enough to hide from it the fact that it is losing its main support. It is the nature of that system not even to rest content with the continuation of the same dose. It grows daily less susceptible to opium and more clamorous of increase. When the dose does not even remain in status quo but suffers steady diminutions however small, the nerves can not fail to begin revenging themselves. Still, this period may be made very tolerable by keeping the mind diverted in every pleasant occupation possible, such as I shall presently refer to as abounding on our Island. Our physical treatment for the month is especially directed to the establishment of such healthy nutrition and circulation as shall provide the nervous system with a liberal capital to draw on during the exhausting struggles which are to ensue for at least the first ten days or fortnight after the complete abandonment of opium. The patient's digestion must be carefully attended to, and kept as vigorous as is consistent with the still continued use of the drug. Beef-tea, lamb-broth with rice, all the more concentrated forms of nutriment, are to be given him, in small quantities at a time, as frequently as his appetite will permit; and if progressive gastric irritability does not develop itself as the diminution of the narcotic proceeds, he is to have generous diet of all kinds. We must pay particular attention to the excretory functions -- getting them as nearly as possible in complete working order for the extra task they have presently to fulfill when the barriers are entirely withdrawn and the long pent-up effete matters of the body come rushing forth at every channel. The bowels must be trained to perfect regularity, and the skin roused to the greatest activity of which it is capable. Exercise, carried to the extent of healthy fatigue, but rigorously kept short of exhaustion, may be secured in our bowling-alley, gymnasium, and that system of light gymnastics perfected by Dio Lewis -- a system combining amusement with improvement to a remarkable degree, as being a regular drill in which at certain regular hours all those patients, both ladies and gentlemen, who are able to leave their rooms, join under the command of a skillful leader to the sound of music. This system has an advantage, even for well people, over the ordinary exercises of the old-fashioned gymnasium, with its bars, poles, ropes, dumb-bells, etc., inasmuch as it secures the uniform development, on sound anatomical and physiological principles, of every muscle in the human body, instead of aiming at the hypertrophy of an isolated set. I do not mean by this to deny the value of the old style gymnasium, our Island will possess as good a one as any athlete could desire. Horseback riding will form another admirable means of effecting our purpose, especially where the patient suffers from more than the usual opiate torpidity of the liver. We shall have room enough if not for an extended ride at least for a mile track around the Island, and a stud, however unlikely to set John Hunter looking to his laurels, capable of affording choice between a trotter and a cantering animal. During the summer there will be ample opportunity for those who love horticulture to take exercise in the flower and vegetable garden attached to the institution, and such as wished might be assigned little plots of ground whose management and produce should exclusively belong to them. Looking for a moment from the therapeutics to the economics of the matter, I can see no reason why the house might not rely largely upon itself for at least its summer vegetables and its fruit -- if the poorer patients were permitted to pay part of their dues, when they so elected and the exertion was not too much for them, by taking care of the grounds. Another admirable means of exercise will be found in rowing. Our Island must have a good substantial boat-house, containing a good-sized barge for excursions and several pleasure-boats pulling two or three pair of sculls each; perhaps, eventually, a pair of racing-boats for such of our guests as were well enough to manage a club. Bath-houses for the convenience of those who love a plunge or a swim will be indispensable -- affording facilities for a species of summer exercise which nothing can replace.
In winter and summer the bath must be our principal reliance for promoting that vigorous action of the excretory system which with healthy nutrition is our great aim in treating the patient.
Quackery has to so great an extent monopolized the therapeutic use of water, and so much arrant nonsense has been talked in that pure element's name, that we are in danger of overlooking its wonderful value as a curative means. It is one of the most powerful agents at the command of the practitioner, and should no more be trifled with than arsenic or opium. Used by a blundering, shallow-pated empiric it may be worse than useless -- may do as in many cases it has done, incalculable mischief to a patient. In the hands of a clear-sighted, experienced, scientific man, who administers it according to well-known laws of physiology and therapeutics, it is an inestimable remedy, often capable of accomplishing cures without the assistance of any other medicine, and, indeed, where all other has failed. Many of the forms in which it is applied at water-cures well deserve adoption by the more scientific practitioner. Among these the pack occupies a front rank. During Mr. Edgerton's month of diminution we use this with him daily. Its sedative effect, when given about three and a half P.M. just after the second dose of bromide of potassium, is exceedingly happy -- seeming, as I have heard a patient remark, "to smooth all the fur down the right way" -- removing entirely the excessive nervous irritability of the opium-craving, and often affording the patient his only hour of unbroken sleep during the twenty-four. Its tendency to promote perspiration makes it a most effective means for restoring the activity of the opium eater's skin, and this benefit will be still further increased if it be followed by sponging down the body with strong brine at a temperature as low as the patient can healthily react from, concluding the operation with a vigorous hand-rubbing administered by the attendant until the skin shines. This same salt sponge is a most invigorating bath to be taken immediately on rising. Another excellent bath in use at water-cures, of value both for its tonic and sedative properties, is "the dripping sheet," in which a sheet like that used in the pack, of strong muslin and ample size, is immersed in a pail of fresh water at about 70 degrees F., and, without wringing, spread around the standing patient so as to envelop him from neck to feet, the attendant rubbing him energetically with hands outside it for several minutes till he is all aglow. In cases where great oppression is felt at the epigastrium -- that corded sensation so much complained of by opium-eaters during their earlier period of abandonment, and that peculiar self-consciousness of the stomach which follows in the track of awakening organic vitality -- the greatest relief may be expected from "hot fomentations." This is the well-known "hot and wet external application" of the regular practice, and consists of a many-folded square of flannel wrung out of water as hot as the skin can bear, and laid over the pit of the stomach, with renewals as often as the temperature perceptibly falls.
The symptom of cerebral congestion -- a chronic sense of fullness in the head -- is often very simply alleviated by placing the patient in "a sitz" or hip-bath, with the water varying from 70 to 90 degrees F. Enemata will constantly be found of service where the torpidity of the bowels is extreme. Not only so, but in cases where the liver is beginning to re-assert itself, and its tremendous overaction sends down such a supply of bile as to provoke inversion of the pylorus, an enema may often act sympathetically beyond that portion of the intestine actually reached by it, and change the direction of the intestinal movement, so as to convert the deadly nausea excited by the presence of bile in the stomach into a harmless diarrhea which at once removes the cause of the suffering. Of the value of foot-baths I need not speak, and to the hot full-bath I must now make reference as the most indispensable agent in ameliorating the sufferings of one who has completely abandoned the drug.
When Mr. Edgerton's dose has reached as low an ebb as 1 grain of morphia he abandons the drug entirely. In my Harper's Magazine article I have fully depicted the sufferings which now ensue -- as fully, at least, as they can be depicted on paper though that at the best must be a mere bird's-eye view. During the period of diminution he has endured considerable uneasiness and distress, but these have been trifling to compare with the suffering which he must endure for the first few days and nights, at least, after total abandonment. Universal experience testifies that although the previous period of diminution greatly shortens and softens the sufferings to be endured after giving up opium altogether, the descent from 1/2 grain of morphia to none at all must involve a few days at least of severe suffering, which nothing borne during the diminution at all foreshadows.
In my Harper's article I have said:
"An employment of the hot bath in what would ordinarily be excess is absolutely necessary as a sedative throughout the first week of the struggle. I have had several patients whom during this period I plunged into water at4 110 degrees F. as often as fifteen times in a single day -- each bath lasting as long as the patient experienced relief."
Science and experience have thus far revealed no other way of making tolerable the agonizing pain which Mr. Edgerton now endures. This pain is quite inconceivable by the ordinary mind. It can not be described, and the only hint by which an outsider can be let into something like an inkling of it is the supposition (which I have elsewhere used) that pain has become fluidized, and is throbbing through the arteries like a column of quicksilver undergoing rhythmical movement. If the arteries were rigid glass tubes, and the pain quicksilver indeed, there could not be a more striking impression of ebb and flow every second against some stout elastic diaphragm whose percussion seems the pain which is felt. This is especially the case along the course of the sciatic nerve and all its branches, where the pulse of pain is so agonizing that the sufferer can not keep his legs still for an instant. There is occasionally severe pain of this kind in the arms also, but this is very rare. The suffering which usually accompanies that of the legs is a maddening frontal headache, and a dull perpetual ache through the region of the kidneys, described as a sensation of "breaking in two at the waist;" nausea, burning, and constriction about the epigastrium, and intense sensitiveness of the liver -- besides general nervous and mental distress which has neither representative nor parallel.
All these symptoms are instantaneously met and for the time being counteracted by the hot-bath. When the patient gets tired of it, and it temporarily loses its efficiency from this cause, great advantage may be gained by substituting either the Russian bath or the common box vapor-bath, with an aperture in the top to stick the head out of, and a close-fitting collar of soft rubber to prevent the escape of the steam.
I must here refer to another means of alleviation, concerning which I can not hear the witness of personal experience, but which has been highly recommended to me. Even this brief sketch of treatment would be imperfect without at least a mention of it, and if it possesses all the value claimed for it by persons of judgment who have reported it to me, it will form an indispensable part of our apparatus on Lord's Island. This is an air-tight iron box of strongly-riveted boiler plates, with a bottom and top fifteen feet square and sides ten feet high; thick plate-glass bull's-eyes in each side sufficiently large to light the interior as clearly as an ordinary room; and a cast-iron door, six feet in height, shutting with a rubber-lined flange, so that all its joints are as air-tight as the rest of the box. Inside of the box, in the centre, stands a table, suitable for reading, writing, draughts, cards, chess, or games of any similar kind, with comfortable chairs arranged around it corresponding in number to the people who for an hour or two could comfortably occupy the room. In one side of the box is a circular aperture connecting with an iron tube, which in its turn is joined to a powerful condensing air-pump outside, and on the other side is a pressure gauge with its index inside the box. Sufferers from severe neuralgic pain being admitted, the air-tight door is shut; they seat themselves, and the condensing pump is set in motion by an engine until the gauge within indicates a pressure of any amount desired. I am told that the severest cases of neuralgia have found instantaneous and thorough relief by the addition of six or eight atmospheres to the usual pressure of air upon the surface of the body. There is no reason why the condensation might not be continued to twenty or more, the increased density causing no uneasiness to those within the box, the same equilibrium between internal and outward pressure that exists everywhere in the air being maintained here. Persons who have made trial of this apparatus speak of the cessation of their pain as something magical; say they can feel it leaving them with every stroke of the pump; and although as yet we may not be able to offer a scientific explanation of the relief afforded, we can not fail to see its applicability to the case of the reforming opium-eater. If it does all that is claimed for it, it probably acts both mechanically and chemically -- the pressure, even though imperceptible from its even distribution, affecting the body like the shampooing, kneading action of an attendant's hand, and the vastly increased volume of oxygen which it affords to the lungs and pores accelerating those processes of vital decomposition by which the causes of many a pain, but especially that of our patient, are to be removed.
The shampooing just referred to, and previously mentioned as forming one process in the Russian bath, is another means of relief constantly in use while the patient is going through his terrible struggle. Our attendants upon Lord's Island are picked men. We do not proceed on the principle in such favor among most of our public institutions, asylums, water-cures, and the like, of procuring the very cheapest servants we can get, and thinking it an economical triumph to chuckle over if5 we can manage our patients with the aid of subordinates at twenty dollars a month. We know that in the long run it will pre-eminently pay to engage the best people, and weo pay the wages which such deserve -- wages such as will ensure their quality. Our attendants are selected from the strongest, healthiest, best-tempered, most cheerful-minded, kindest-hearted, most industrious and faithful men and women we can find -- people not afraid of work and indefatigable in it -- people who understand that no office they can perform for the sick is degrading or menial, and who will not object, when the patient needs it, to lift him like a baby and rub him vigorously with their hands for an hour at a time. This rubbing our patient often finds the most heavenly relief, not only right after a bath, but at any hour of the day or night. There is, therefore, no hour of either during which Mr. Edgerton can not procure this means of relief from some servant upon duty. Applied to the back and legs especially, it is a sovereign soother for both the opium-eater's acute pain and that malaise which is only less terrible. In very severe cases it may be necessary to rub the patient for many consecutive hours, and in such cases it may be necessary either to assign an attendant to the patient's sole care, or, better yet, to have several attendants relieve each other in the manual labor. If the patient could afford and desired it, I should approve of his having his own private servant during the worst of the struggle to perform this labor for him, with the distinct understanding however, that he was to be private only in the sense of devoting himself to this patient solely, and to receive all his orders from the head of the institution. The expense of such an arrangement would be trifling compared with the amount and intensity of agony which it would save, and in a case of no longer standing than Mr. Edgerton's need last only through the first fortnight or so after abandoning the drug.
Another most important means of alleviation is the galvanic bath. House's patent is an excellent apparatus for the purpose; convenient in shape and size, comfortable, nor easily deranged, affording a variety of simple and combined currents, adjustable so as to pass the current either through the whole body or along almost any nervous tract where it is especially wanted for the relief of local suffering like that of the opium sciatica, and manageable by any intelligent child who has ever watched attentively while it was getting put into operation. Many a sufferer who seems quite a discouraging subject under the dry method of administering galvanism responds to it at once transmitted through a bath, and in any case this is a no less beneficial than delightful way of using it. The skin is so much better a conductor when wet, and the distribution by water so uniform, that in most cases it may be pronounced the best way.
The Turkish bath I have seen used with excellent result during the earlier days of suffering. It will seem almost incredible to any one who has taken a Turkish bath for other purposes, and knows the tax which it seemed to inflict upon his nervous system for the first few minutes after entering the heated chamber and till profuse perspiration came to his relief, when I say that have seen a man brought to the bath in that almost dying state of prostration some pages back described as belonging to the acute attack of opio-mania, at once subjected to the temperature of 130 degrees F., and in ten minutes after to thirty degrees higher, not only without rapidly sinking into fatal collapse, but with a result of almost immediate and steady improvement. To my own great surprise his pulse began getting fuller, slower, steadier, and in every way more normal from the moment that the attendant laid him down upon his slab. When he came in he was obliged to be carried in the arms of his friends like an infant; his pulse one minute was 140, the next 40-60, or entirely imperceptible, and when fastest alarmingly thready; his countenance was corpse-like, he breathed nine or ten times a minute, and his general prostration so utter that he could scarcely speak even in a whisper. He stayed in the bath an hour and a quarter, in a streaming perspiration for the last forty minutes, and much of the time sleeping sweetly. He came out walking easily without assistance, and in the cool anteroom fell asleep again upon the lounge, not to wake for an hour longer. This one bath entirely broke up the attack. He kept on improving, and with the aid of beef-tea was well enough to go to business in a week. The value of the bath in treating Mr. Edgerton at present will be greatest when he suffers most severely from acute neuralgic pains in the legs and back, especially if the efficiency of the hot full-baths and vapors seem temporarily suspended through frequent use. His own feelings are the best criterion of its worth at any given time. It operates very differently on different people and in different conditions of the system. To some persons it is less debilitating than the use of hot water, and others, myself among the number, find it so excessively disagreeable from the apoplectic sensation it produces in their heads, and the difficulty of breathing which they suffer from it, that nothing but a discovery that it was the only means in their particular case of relieving sufferings like those of opium would induce them to enter it. Many persons profess to like it as well as the Russian (which, singularly enough, in no case have I ever known to produce the disagreeable feeling in head or lungs), and it certainly ranks with the foremost alleviatives of the opium suffering -- the agonizing rythmical neuralgia of which I have spoken usually becoming magically lulled within two minutes from the time of entering the first heated chamber, and ceasing altogether as soon as the perspiration becomes thoroughly established. At Lord's Island our Turkish bath-room will immediately adjoin our Russian, and the temperature being supported by pipes from the same boiler which furnishes vapor to the other, will be no heavy addition to our expense in the way of apparatus. I don't know whether it is necessary to tell any body that the Turkish bath is merely an exposure of the naked body (with a wet turban around the head) to a dry heat varying from 110 degrees F. to a temperature hot enough to cook an egg hard -- followed by ablutions and shampooings somewhat similar to those of the Russian bath.
As it is our aim to cure the opium-eater by bringing to bear upon his most complicated of all difficulties every means which has proved effectual in the treatment of any one of its particulars, however caused in other instances, we ask no questions of any appliance regarding its nativity, but take from the empiric whatever he has stumbled on of value as freely as the worthiest discoveries of the philosopher from him. There have been various attempts to erect into a pathy every one of the applications we have already mentioned, and I shall close this brief outline of our therapeutic apparatus at Lord's Island with one more valuable method of relief and cure whose enthusiastic discoverers (or rather adapters) have outraged etymology worse than the regular practice by trying to build on their one good thing an entire system under the title of "Motorpathy."6 The "Movement Cure" contains some very good ideas which, like many of the Hydropathists', ought to be taken up by Science, in whose hands and their proper place they can do fine service.
As we have found in the case of shampooing, a great deal of the suffering of any part can be taken out by giving it something else to do. A portion of the good done by rubbing an aching leg is no doubt accomplished by setting the nerve at work upon the sensations of pressure and of heat and so diverting it from that of pain, but another portion is probably due to the fact of motions producing changes, in the nature of mechanical and chemical decompositions, in the substance of the tissue; thus by a well known physiological law summoning a concentration of the nervous forces to the particular part. Nature is thus accelerated in her action there, and as that action is always toward cure (so long as life and hope exist), the nerves of the part are reinforced to act sanely. To be weak is to be miserable -- to be strong is to be free from pain -- thus the nerve's returning vigor eliminates its suffering. The fresh blood that is pumped into the part by motion brings about another set of ameliorating changes of more especial importance where the pain is caused by a local lesion instead of rather being sympathetic with the whole systematic debility. Whatever be our theory, the tenet that motion relieves pain, as a tenet, is as old as the "back-straightening" process used in some shires by the British turnip-hoers who on coming to the end of their rows lie down and let the rest of the women in the field walk over their toil-bent spine and cramped dorsal muscles, while as a fact it is as old as pain itself.
On Lord's Island, therefore. we have a room fitted up with apparatus intended to give passive exercise to every part of the body which the pain of abandoning opium is especially likely to attack.
Mr. Edgerton is suffering extremely, about the close of the third day after his last 1/2 grain dose of morphia, from the agonizing rythmical neuralgia of which I have spoken, throbbing from the loins to the feet; and although with good effect we have given him galvanism, shampooing, baths of several kinds, and a number of internal remedies, still, wishing to keep each of these appliances fresh in its potency, we make a change this time to the "movement-room," He is stripped to his shirt, dressing-gown, and drawers, and laid on his back along a comfortable stuffed-leather settee, running quite through whose bottom are a number of holes about four by three and a half inches. These holes are occupied by loose-fitting pistons which play vertically up through the cushion -- lying level with it when at rest, and when in motion projecting about two inches above it; at the height of their stroke. Motion is secured to them by crank connection with a light shaft running beneath the settee, revolved by a band-wheel, which in its turn connects by a belt with the small engine outside the building, by which all the drudgery of the house is performed. Mr. Edgerton is adjusted over the holes so that, in coming up, the pistons, which are covered with stuffed leather pads, strike him alternately on each side of the spine, from about the region of the kidneys to just beneath the shoulder-blade. The shifting of a lever throws the machine into gear, and for the next five minutes, or as long as he experiences relief, the artificial fists pummel and knead him at any rate of speed desired, according to the adjustment of a brake. This process over, if he still feels pain in the lower extremities, his foot is buckled upon an iron sole which oscillates in any direction according to its method of connection with the power, from side to side, so as to twist the leg about forty-five degrees each way, up and down, to imitate the trotting of the foot, or with a motion which combines several. A variety of other apparatus gives play to other muscles; but I have said enough to show the idea of its modus operandi. The passive exercise thus afforded is an admirable substitute for that active kind which in his first few days of deprivation the intensity of his agony often incapacitates him from taking. I have seen men at this period almost bent double from mere pain, and hobbling when they attempted to walk like subjects of inflammatory rheumatism. Their debility also is often so great as to prevent exercise, especially when the characteristic diarrhea has been for some days in operation, though different people differ astonishingly in this respect. I knew one case where an opium-eater of three years' habituation to the drug endured in its abandonment every conceivable distress without suffering from debility at all, as may be inferred from the fact that as his only way of making life tolerable he took a walk of twelve miles every morning while going through his trial. The majority, however, suffer not only pain but prostration of the most distressing character -- a combination as terrible as can be conceived, since the former will not let the victim remain in one position for a single minute, and the latter takes away all his own control of his motion, so that he seems a mere helpless, buffeted mass of agony -- an involuntary devil-possessed, devil-driven body. consciousness at its keenest, will at its deepest imbecility -- almost fainting with fatigue, unable to limp across the room on legs which seem dislocated in every joint and broken in a thousand places, yet unable to stop tossing from side to side, and writhing like a trodden worm all night, all day, perhaps for weeks.
"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 of 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 perceptible 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 morphia 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 anæsthetic 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, 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 without 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 pharmacopoeia and my bill of fare.
A few final words about the attractions of the Island. Besides the amusements earlier mentioned, I propose that our perfected scheme shall contain every thing necessary to make the social life in-doors a delightful refuge, to all far enough advanced to take pleasure in society, from the dejection and introversion peculiarly characteristic of opium's revenges. This comprehends a suite of parlors where ladies and gentlemen can meet in the evening on just the same refined and pleasant terms that belong to an elegant home elsewhere; furnished with piano to dance to, play, or sing with; first-class pictures as fast as our own funds aided by donations and bequests, can procure them for us -- but bare wall or handsome paper or fresco rather than any daub to fill a panel; fine engravings in portfolios; cosy open fire-places; unblemished taste in furniture and carpets; in fine, an air of the highest ideal of a private family's handsomest assembling-room. I propose a billiard-room with a couple of tables -- so neatly kept that both ladies and gentlemen can meet there to enjoy the game, a reading room with the best papers and magazines and a good library, both to be enjoyed by guests of either sex; a smoking and card-room for the gentlemen. I propose to have our engine before mentioned do the work of taking our invalids up and down stairs by a lift, like those in use in some of our best hotels, so that the highest rooms may be practically as near the baths, the dining and social apartments, and as eligible as any of the lower ones. And if feasible, I suggest that some at least of the rooms be arranged in small suites or pairs, so as to admit of a well daughter, son, sister, parent, wife, or brother coming to stay with any invalid who needs their loving presence and nursing.
I have thus given as clear an outline as I can of my idea what such an institution as we have so often talked over ought to be, and described a method of treatment which has been successful wherever I have had the opportunity even to approach its realization. For its perfect realization an institution especially devoted to the noble work is a sine qua non. If the publication of this letter shall call to our aid in its establishment, by awakening to a sense of its necessity, any of our vigorous, public-spirited countrymen, I am sure we may live to see it flourishing on a sound basis and doing an incalculable amount of good which shall make mankind wonder how so many generations ever lived without it since opium began to scourge the world. I shall then, too, be even more indebted to you than I am now for the courtesy which has afforded so large a space in your book to.
Fitz Hugh Ludlow.
- In my article upon opium-eating, entitled "What Shall They Do to be Saved?" published in Harper's Magazine for the month of August, 1867, and hereto prefixed, I have referred to this impracticability in fuller detail. It arises from the fact that in his own house a man can not isolate himself from the hourly hearing of matters for which he feels responsible, yet to which he can give no adequate attention without his accustomed stimulus; that his best friends are apt to upbraid him for a weakness which is not crime but disease, and that the control of him by those whom he has habitually directed, however well-judged, seems always an harassment.
- I am aware how incredible this statement will seem to those who have never had any extensive experience of the behavior of this remarkably variable drug, and get their notion of its action from the absurd directions on the label of every pound vial I have seen sent forth by our manufacturing pharmaceutists. "Ten to twenty drops at a dose," they say, "cautiously increased." Cannabis sould always be used with caution, but ten or even twenty drops must be inert in all but the rarest cases, and I have given an ounce per diem with beneficial effect. But four ounces of the best extract (Hance & Griffith's) producing literally no effect of any kind on an entirely fresh subject, is a phenomenon that I must have needed eye-witness to imagine possible.
- 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 patients 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.
- On some occasions, by repeated additions from the hot faucet as the temperature of the water in the bath-tub fell, I have raised the bath as high as 120 degrees F. without causing any inconvenience to the patient. Most bath-tubs -- all in our own city houses -- are too capacious, and too broad for their depth. To prevent cooling by evaporation the tub should be just the width of a broad pair of shoulders and about two feet deep.
- This is all that the "canny" business men who compose the managing boards of some of the first asylums in this country permit the heads of the institutions to offer those who must for twenty-three hours of the twenty-four be responsible for the moral and physical well-being of a class of patients (the insane) who require, above all others, wisdom, tact, benevolence, courage, fidelity, and the highest virtues and capacities in those who attend them.
- I see that some scholar has lately got hold of them and forced them to respect philological canons by kicking the mongrel out of their dictionary and calling themselves Kinesipathists, instead of the other Græco-Latin barbarism.