Part 22

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 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 vomlca 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 votnica 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 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 opiomania.

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 stop-cocks 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 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° 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 Lieblg'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 beef-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 bathroom. Having stripped in an anteroom, upon entering the vaulted chamber he finds himself in an atmosphere of steam at 120° F., which fills the apartment, even obscures the skylights, 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. The 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 Aphrodite, 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 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° 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 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 anteroom our patient who entered more dead than alive may feel 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, points 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, if 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 cu short was one where the patient used 33 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 anybody would pronounce exceptional, though even that did not save him from the 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 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 majorify 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 characteristic 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. [Footnote: 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 patiets 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.] We may therefore find it necessary to carry on our reformatory process upan 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:

Rx Morph. Sulph. . . . . . . . . . . . grs. xvi. Aqua Destill. . . . . . . . . . . . ounce j Elix. 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 dcse 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 thin 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 1/2 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 statu 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 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, 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 he 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° 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.