Chapter 25

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.

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° 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 1/2 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 he 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 at [Footnote: On some occasions, by repealed 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° 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.] 110° 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 bear 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 similiar 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 if [Footnote: 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.] 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 we 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 haby 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.