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The Canada Lancet
- Vol. 17 - 1884 pp101
A CASE OF DOUBLE NARCOTIC ADDICTION.---OPIUM AND
ALCOHOL.---IMBECILITY---RECOVERY.
Recovery
With Indian Hemp
BY
J. B. MATTISON, M.D., BROOKLYN, N.Y.
Through the courtesy
of Drs. T. Gaillard Thomas, of New York, and Wm. Bayard, of St. John, N.B.,
there came under the writer's care last year a case of combined opinm and
alcohol taking, presenting a history and result of such importance as probably
to render its recital one of interest to the readers of the LANCET.
Mrs.
----, of Canada, aet. 34, in the summer of 1881, passed through her second
accouchement during the eighth month of gestation. Her recovery was tedious, involving four to five months,
during which she had much discomfort from alvine torpor, and also underwent an
operation for the relief of fistula in ano.
The latter was attended by severe pain, to relieve which her medical
adviser gave morphia hypodermically, and supplying her with a syringe instructed
her and the attendant in its use. This
was in July, and the initial dose of the morphia was 1/8 of a grain, repeated
three or more times daily, when the pain was severe.
She made a fair recovery from this illness, except that the power of her
lower limbs was largely lost, due, it was thought, to the morphia---which she
had steadily taken---and a lack of active exercise.
She had now become a confirmed habitue and during the next two years used
her opiate in increasing quantity and frequency, often repeating it every three
or four hours.
During
the autumn of 1883 she came under the care of a medical gentleman who was called
to relieve her of severe abdominal pain and nervous derangement.
Prior to this time no attempt had been made to abandon the morphia.
Her new medical adviser, appreciating the situation, strongly urged an
effort in that direction, but without success.
Her condition had steadily grown worse, aggravated as it was by an
inordinate use of brandy, of which she took at times from I2 to 16 ounces daily.
From October, 1883, her mental and physical decline was marked, the most
prominent symptoms being anorexia, insomnia, nausea, incessant thirst, subsultus,
loss of memory, delirium, hallucinations and partial imbecility.
Her physician now insisted on stopping her stimulants, and succeeded with
the brandy, while the morphia, which had been increased to several grains, three
to five per diem, was reduced to one or two injections daily. Despite this treatment her mental and physical status
steadily deteriorated until she became completely imbecilic, and in this
condition, on December 21, 1883, she came under the writer's care.
So
weak was she prior to leaving home that some of her friends deemed it hazardous
to make the effort, fearing she would not survive the journey, but under the
watchful care of Dr. Bayard, it was safely effected. Her physical debility on arriving was so great that she was
carried from her carriage. Mentally
she was a wreck. Delusions were
prominent, and hallucinations of sight, sound and touch almost constant, that of
touch being especially marked, patient fancying bugs and reptiles crawling over
her. Her expression was idiotic;
she was utterly unable to converse intelligibly, and her voice in speaking
speedily sank to a whisper and was lost. In
fact such mental ravages from opium we never met.
Physically, she was partially prostrated, pulse frequent and feeble,
marked anorexia, furred tongue and alvine torpor ; in fine, all the symptoms
before noted except delirium and subsultus.
During her coming, in order to maintain her strength, she had taken milk
punch freely, and was given one or two half grain injections of morpbia daily.
Such was her status oh arrival. There
was no history of hereditary insanity. The
case seemed clearly one of profoundly pernicious results from her double
addictions, aggravated by a laudable effort to remove the cause. This being our belief, the prognosis, was favorable, an
opinion endorsed by Dr. John C. Shaw, Superintendent of the King's Co. Insane
Asylum, who was called in consultation, and verified by the result, as the
further record of the case will show.
As a
prelude to active treatment the patient was given a mild mercurial which acted
well. No alcohol was allowed from
the outset, and at the end. of a week the morphia-which previously had been
given in small doses by mouth at bed-time-was quite abandoned, and reliance
placed on large doses of Indian hemp to secure sleep.
As tonics she was given daily seances of electricity, with syr. of the
hypophosphites of iron, strychnia and quinine, in two drachm doses, ter die, and
full feeding. The good effect of
this regime soon declared itself, for in less than a fortnight, signs of
improvement presented. The earliest
of these were mental. The delusions
lessened and the hallucinations departed, the last to leave being those of touch
which persisted for some time after the patient was able to realize that they
were only the vagaries of her disordered brain.
With this amendment came a better brain status in other ways.
The imbecilic look gave place to one of increasing intelligence ; the
power to converse rapidly returned, and within six weeks all mental aberration
had vanished. Meantime, the
physical condition gradually improved, though not so speedily as the mental.
The appetite was slow in returning, but her muscular strength, especially
in the lower limbs, the loss of which for two and a half years, had prevented
exercise, increased steadily, so that at the end of eight weeks she was able to
take walks, drives, go shopping, attend church, etc., in fact, more out of door
exercise than she had enjoyed for years. Her
improvement in every way was notable and persisted with little interruption
until March 4---nearly eleven weeks from the date of her coming---when she left
our care. Tidings, direct and
indirect, of late received, report her doing well.
This
case presents several points worthy of detail.
Its origin affords added proof in support of views expressed in "The
Genesis of Opium Addiction," Detroit Lancet, Jan. 1884.
But it must also be said that, in our judgment, the course of the medical
gentlemen in supplying this patient with a hypodermic syringe and solution of
morphia, with instructions for self-taking, unless absolutely unavoidable,
was-to put it mildly---exceedingly indiscreet.
Such action and advice are almost certain to end in addiction; the
effect, even under professional attention, is, too often, disastrous, and the
chance of escaping, when left to caprice of the patient, is small indeed.
We believe that patients should never be allowed to give themselves
injections, if at all possible to avoid it.
When
her initial illness ended, this patient was an opium habitue.
A much more limited time than that will often suffice.
We have repeatedly known as many weeks to beget addiction, and the most
marked examples of this were among those in whom it might be supposed the least
likely to occur-physicians. Increased
experience serves only to strengthen the writer's opinion, as expressed in a
paper on "Opium Addiction among Medical Men," that "any physician
using morphia, daily or oftener---especially hypodermically---for four weeks
incurs great risk of becoming an habitue; indeed we think a still shorter usage
might, with some, prove a snare." This
case adds another to the instances in which addiction to one narcotic tends to
excess in another. While these are
infrequent as compared with those in which one is used, they are sometimes quite
notable. We recall that of a
Canadian gentleman who some time ago consulted us, who had taken for several
years 10 to 20 grains of morphia subcutaneously, 60 to 90 grains of chloral, and
1 to 2 pints of whiskey, daily. Physical
examination disclosed organic heart lesion, and care of his case was declined.
As a rule, the ruinous results exceed those of a single addiction, while
the prospect of permanent cure is always less hopeful.
In our patient the pernicious effect on the brain was notable-more so
than we have ever seen. While
deviations from normal cerebral action are sometimes observed in cases of
confirmed opium taking, it is rare that they are so pronounced as in this
instance. Doubtless they were
aggravated by the alcohol, yet morphia was the main factor.
And it is of interest to note that the attempt at renouncing the
narcotics intensified the mental disorder.
Obersteiner---Brain, Oct.,'82--- demurring to Levinstein's statement that
the Psychical disturbances caused by morphia cease within a few hours, affirms
that " mental diseases arising in the course of morphinism are of the most
intractable kind when once fully developed.
Not only do they not disappear on depriving the patient of morphia, but
they then usually get worse."
This
case tends to prove the latter part of his statement. As one medical gentleman informed us-" The condition in
which you saw her was the result of the addictions aggravated by the attempt to
quit them." But the mental disorder was not of the "most intractable
kind," for improvement was prompt and progressive, much more so than
anticipated, as it was thought several months rather than weeks would be needed
to repair the damaged brain.
Regarding
alienation caused by opium, Obersteiner thinks it frequent, asserting that
"a man who consumes large quantities of morphia during a number of years
will display many nervous symptoms, and that the continued intoxication attacks
the Psychical much more constantly than the somatic life." He further
states: "The degree of mental
aberration arising from protracted use of the drug is very variable.
There may, indeed, be individuals who retain their power of mind in spite
of it, but the number is much greater of those who betray a marked alteration of
their intellectual and moral life; and in not a few cases finally the point of
distinct aberration is reached. This
usually consists of a depressed state, with suicidal tendencies, occasionally
with violent excitement and hallucinations;" and he sums up his views with
the statement that "In most cases the protracted use of morphia in large
doses is followed by Psychical alterations of a lasting nature, which may amount
to decided insanity."
With these opinions we are not in full accord.
Our experience has been much more favorable.
We have observed many cases of opium addiction, among them those who had
taken morphia in large amounts for several years, yet the number with marked
mental derangement has been small. Depression
has been common; so, too, irritability of temper; but we recall only one
instance in which suicidal or homicidal tendency existed, and but a single case
that we deemed "decided insanity."
Far oftener physical symptoms presented.
In some form, these have been almost constant, so that, on this score
also, our observation has been at variance with Obersteiner.
Regarding treatment, one point
deserves special mention---that is, the effect of Indian hemp in large doses.
In this instance it quite maintained the power ascribed to it by Moreau
of removing hallucinations. Again
and again, often by the patient, was this noted.
Its hypnotic action also was very satisfactory.
As a soporific, in ex-opium habitues, cannabis
indica is of great value. They
may be peculiarly susceptible to its good effect, but certain it is we know of
nothing equalling it, and employ it almost exclusively.
For details regarding its use, vide "The Treatment of Opium
Addiction," Courier of Medicine, Dec., 1884.
Finally, the history of this case is of value as warranting hope of
entire recovery under conditions that, seemingly, offer little promise of
success.
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