Observations on the use of opium in removing symptoms supposed to be owing to morbid irritability: By Alexander Grant, ...
IMMEDIATELY upon my return to this country, I ſhould have communicated the following Obſervations on the Uſe of Opium; but one opportunity ſoon offering of exhibiting it in a ſimilar caſe to thoſe in which I had found it ſucceſsful; and ſince [Page iv] that three or four others, the laſt of which was a very bad ulcerated Throat; I thought it was better to wait the event of theſe caſes, than too haſtily to adopt an opinion, which, from its novelty and importance, demanded the moſt guarded circumſpection.
As the experienced ſalutary Effects of Opium in a Diſeaſe, in which its Effects have hitherto been little known, aroſe in moſt inſtances from circumſtances in the conſtitution, owing to irregularities incident to a Military Life, I have endeavoured, as far as my experience would lead me, preciſely to determine what theſe circumſtances are.[Page v]
And as it is to you, Sir, I am indebted for the ſituation which afforded me theſe Obſervations, I think it my duty to addreſs them to you; and I am extremely happy in this opportunity of expreſſing my Gratitude, and of aſſuring you, that I am always, with eſteem and truth, Sir,
Your moſt obedient, And moſt obliged humble Servant, ALEXANDER GRANT.St. Alban's Street, Jan. 21, 1785.
IN the year 1779 I had an opportunity of obſerving, in his Majeſty's General Hoſpital at New York, the good Effects of OPIUM, in a variety of caſes, originally Venereal, in which Mercurial preparations appeared to be of no efficacy.
It happened that a great number of ſoldiers fell under my care at the ſame time, who laboured under evident ſymptoms of Morbid Irritability, which might be owing to different cauſes; but all theſe Patients were undergoing, or had undergone, a courſe of mercury.
Theſe ſymptoms, in all their variety of appearances and changes, at firſt ariſing from the venereal virus, and terminating [Page 8] in what has ſince, upon reaſoning and reflexion, appeared to me to have been brought on by Morbid Irritability, were all relieved, and finally the cure compleated, by alleviating pain, and procuring reſt.
And here I may remark, that ſoldiers in general are cured of the Venereal Diſeaſe with more difficulty than any other Patients, owing to their ignorance and inattention, or to their deſire of protracting the diſeaſe, and fruſtrating the uſual modes of relief.
The ſtate of the diſeaſe in which (as far as I am able to judge from the trials I have made) our expectations are likely to be anſwered from the uſe of Opium, is when the ulcers are ſpreading, or continue much the ſame, with a foul appearance, bad diſcharge, and much pain, the patient having little or no reſt, and all local applications ſeeming to be of no ſervice: to theſe ſymptoms [Page 9] may be added a quick pulſe, which is an invariable attendant, being, in general above an hundred, ſometimes an hundred and twenty, and ſometimes more, in a minute.
When I firſt adminiſtered Opium in caſes of this ſort, I had the ſatisfaction to find, that I gained two material points, viz. Eaſe and Reſt; with ſome in the firſt twenty-four hours, and in general within two days; afterwards, from theſe good conſequences, I was induced to continue the uſe of it, increaſing or diminiſhing the quantity as occaſion required, and entirely omitting at the ſame time the uſe of mercurial applications, either externally or internally.
Without entering into a diſquiſition on Opium, I take the liberty of concluding, that it will be ſufficient if I am enabled to [Page 10] ſtate facts, and mention the uſeful effects of this medicine in a diſeaſe, which is one of the moſt violent that the human body can be afflicted with.
With regard to the action of Opium on the body in this diſeaſe, I have to obſerve, that in ſome patients its effects were ſudden, in others gradual; in general the circulation of the blood was very much decreaſed by it, and ſometimes the pulſe was rendered ſo ſlow as to beat only fifty and forty times in a minute; but this effect is not always neceſſary to the cure, as a good deal will depend upon the patient's diſpoſition to Irritability, which is the principal thing I attend to—for I have conſtantly obſerved, that as ſoon as that has been leſſened, ſome ſalutary change has been produced on the ſurface of the ulcer.[Page 11]
Its effects, in a few of the caſes, were almoſt inſtantaneous; amongſt theſe was that of a young man, twenty-two years of age, who had two Buboes (one in each Groin), which were opened and treated in the uſual way, but continued in an ulcerated ſtate for five months, during which time he rubbed in three ounces and a half of ſtrong mercurial ointment, which ſeemed ſufficiently to affect the conſtitution: a proper diet was uſed, and every thing elſe directed which was thought neceſſary at the time. No change being perceived, he was ordered to waſh out, and take purging phyſick, which he did ſeveral times. Three weeks elapſed, and at this period he was not in the leaſt emaciated, but remained in full ſtrength and good habit of body. At this time the ulcers were foul, with thick edges, and the diſcharge from them ichorous, [Page 12] with conſiderable pain; and the patient had little or no reſt. I then began with Opium, and gave him the firſt night one grain and a half only, directed a low diet, and dreſſed the ulcers in the moſt ſimple manner; the next day there was no alteration: I increaſed the doſe of the medicine, half a grain in that day; the following day he was much the ſame; but the day afterwards, which was the fourth, a favourable change was obſerved; and, from that time to the expiration of three weeks, gradual changes took place, and both ulcers perfectly healed, without his having had occaſion to increaſe the doſe, or to make uſe of any other medicine. And here I will beg leave to remark, that with every patient I have avoided as much as poſſible ſuch applications as ſeemed to make the parts in any way uneaſy. A ſoft well-made [Page 13] bread and milk poultice will anſwer in the early part of the treatment, and afterwards dry lint and cerate; but, if a fungus exiſts, I prefer a ſolution of thebaic extract in an oatmeal poultice, applied cold in contact with the ſore, to any thing elſe.
The manner in which the alteration takes place is both curious and ſingular; the firſt favourable ſymptoms are eaſe and reſt; the next, if I may be allowed the expreſſion, is an unfolding or looſening of the texture of the ſurface of the ulcer after the irritability is leſſened, which effect ſoon takes place, the parts are in a ſtate of relaxation, owing to the ſtricture on the ſurface being relieved, and finally the cure is aſſiſted by the ſkin corrugating, or contracting to the center of the ulcer, unaided by ſtimulating applications, and, [Page 14] frequently, with very little aſſiſtance, by the uſual way of a new ſkin.
In ſeveral caſes I have obſerved the cure go on extremely well, without the ſurface of the ulcer appearing florid at any one time, as is uſual in healthy-looking ſores. I am very happy in this part, in having Mr. Wier's, Surgeon of his Majeſty's Military Hoſpitals, permiſſion to ſay, that he has obſerved all the above facts that I mention. And ſince that, having communicated my ideas to Mr. Forſter, who is likewiſe Surgeon of his Majeſty's Military Hoſpitals, and whoſe abilities I reſpect, I have much ſatisfaction in being able to add his opinion in corroborating the above facts; Mr. Forſter having obſerved the ſame appearances, and changes, that I have endeavoured to deſcribe.[Page 15]
The doſe that I have in general begun with in this diſeaſe, has been about one grain and a half the firſt night, which I have increaſed night and morning, until I found it anſwered the intended purpoſes. With a view of keeping the patient quiet, and leſs diſpoſed to move, I always divided the time, and therefore gave it night and morning; and what is very extraordinary, the patient in the day-time never appeared to me more drowſy than if he were not making uſe of the medicine; but with ſome an indolency took place, and continued, or diſcontinued, either as the conſtitution became uſed to the medicine, or to the variation of the doſe. I confeſs myſelf, I was always happy when [Page 16] it appeared; as I never knew any harm accrue from it: and, beſides its own action internally, Opium diſpoſes a reſtleſs temper of mind, to obſerve a proper regimen, and to obey any directions that may be thought neceſſary at the time. I have always obſerved, that it is beſt to keep the patient ignorant of the medicine whilſt he is uſing it.
A tremor, which ſometimes came on, never obliged me to decreaſe the doſe, or to pay any particular attention to this ſymptom, unleſs the bowels were diſpoſed to be coſtive; and then a purge readily relieved it in a great meaſure.
The preparation that I invariably gave my patients was Extractum Thebaicum; if any objection aroſe to its being uſed in a ſolid ſtate, I preferred diſſolving the doſe [Page 17] in plain water to the tincture, or any other form.
With regard to the quantity that may be given, I will not determine; I think for the moſt part the diſeaſe yielded to about four or ſix grains a day; I have in two or three caſes given eight grains, and in one extraordinary caſe of a cancerous lip, of near three years ſtanding, I increaſed the quantity to twenty-four grains in a day, divided in three doſes; the patient was a man about fifty years of age, and I was ſix weeks in bringing him to this doſe, which I continued for a few days, and finding that it did not do any material ſervice in the progreſs of the cure, I diſcontinued it; yet now and then a favourable change ſeemed to appear, for two ſinuſes that I had occaſion to lay open digeſted [Page 18] well, and cloſed; no ill effects were produced by the medicine, excepting ſometimes a giddineſs, which was always relieved by a gentle purge; previous to his making uſe of Opium, he had always a quick pulſe; but it afterwards decreaſed to between forty and fifty ſtrokes in a minute, and continued ſo for ſome time. And I cannot help being very much of opinion, that had Opium been properly given in the earlier ſtate of the diſeaſe, a cure might have been obtained: and in this opinion I am confirmed by a caſe I have lately attended; which was an ulcer in the mouth of three months ſtanding, with all the characteriſtic marks and ſymptoms of an Incipient Cancer, which was compleatly cured by Opium and Cicuta joined. This patient (Major Sinclair) Dr. Garthſhore [Page 19] attended with me; the firſt time we ſaw him we agreed in opinion with reſpect to the means to be purſued for his cure, and never had occaſion to deviate from the plan. Before he began the uſe of theſe medicines, he was almoſt in a ſtate of diſtraction from pain, and his pulſe beat an hundred and twenty ſtrokes in a minute. This quickneſs of pulſe was diminiſhed on the third day, and about the tenth the ulcers changed for the better; and in a month afterwards he was quite well*.
Gentle Purges frequently become neceſſary in the early part of uſing the medicine, though in a ſmall doſe, eſpecially where the body is diſpoſed to be [Page 20] coſtive; and I have generally found that a little glauber ſalts anſwered the purpoſe, as this operated without my being obliged to delay the uſe of Opium; on the ſecond or third day with ſome a head-ach came on in conſequence of the bowels being conſtipated; but this always readily gave way to a gentle purge, and I have always found, that as the conſtitution became uſed to the medicine the pain of the head was no longer an attendant, and in general the body became regular; nay, with ſome a Diarrhoea has been produced, which has continued for two or three days, and that without ſeeming to do any harm.
An increaſed ſecretion of ſaliva is not uncommon, as well as of urine; it does not depend upon taking a large quantity, for it will happen ſometimes in the firſt [Page 21] ſix days; but neither one, nor the other, ſeems at any time to be injurious, nor does it appear neceſſary to forward the cure, as patients who have experienced neither of thoſe effects have obtained it in as ſhort a ſpace of time.
One remark further I muſt add, with regard to diet, viz. that until I procured eaſe and reſt, I continued the patient on a low diet, which I in general began with; and as circumſtances changed afterwards, ſo I made ſuch alterations as the conſtitution ſeemed to require; ſometimes adding meat, and ſometimes either a gill of rum in the day, or wine in proportion.
From the above obſervations it will appear, that I am inclined to confine the good effects of Opium (which are indeed very conſiderable) to an advanced ſtage of [Page 22] the diſeaſe, or what, in my humble opinion, may more properly be termed Morbid Irritability ſimply, in which ſtate, mercury has either loſt its efficacy, or ſeems to do miſchief; and this irritability may, I apprehend, probably ariſe from different cauſes, as it certainly may be a queſtion, whether there was any Virus of a Venereal Nature, remaining in the caſes in which I gave Opium: however that may be, the good effects of the medicine were unqueſtionable; and it will appear that I do not truſt to Opium as a ſpecific in recent caſes, or where any part of the Venereal Virus might ſeem to remain; for the laſt caſe I had under my care being of ſo complicated a nature, I joined Mercury with the Opium for the laſt three weeks, but not till I had fully and effectually [Page 23] relieved the ſymptoms of Morbid Irritability.
The caſe I allude to was, that of a bad ſore throat, which came under my care about ſix months ago: the patient was a gentleman about three or four and thirty years of age, and of a thin habit.—At the time I firſt ſaw him he was rather in an emaciated ſtate: he was purſuing a courſe of mercury, which he had began about two months before. I found upon examination ſeveral ulcers in the Fauces, and a large one on the left tonſil; a ſevere pain on the forepart of one leg, with the Perioſteum thickned—an eruption on his breaſt, his pulſe beating an hundred and thirty ſtrokes in a minute; a moſt reſtleſs diſpoſition—great anxiety—and he had not had any ſleep for ſome weeks: [Page 24] I omitted entirely the whole of the plan he was then upon, and did not give him any thing till bed-time, when he took one grain and a half of Opium, with directions to repeat one grain the morning following. Upon ſeeing him the next day, before I aſked him a queſtion, he cried out, "I am a well man to what I was; I have had no pain ſince laſt night, and ſlept well." This formed the foundation of his cure. I increaſed the doſe, till he took three grains at night, and two in the morning.
On the third day the ulcers ſeemed to appear cleaner, and every day afterwards [Page 25] he gradually grew better, till the twenty-fourth day, when all the parts were healed.—On the fifth day I obſerved that his pulſe was in a natural ſtate, and it continued ſo the whole time of his recovery.
The eighth day after uſing the Opium a ſpitting came on, and continued eleven days. For a few days he ſpit about a pint each day. This did not weaken him in the leaſt—from being confined to his bed, he was able to walk about, and every day gained ſtrength. Juſt at this time I directed a quart of very ſtrong decoction of Sarſaparilla to be taken every day, which produced a gentle diaphoreſis; and I continued this plan for ſix weeks, and, for the ſake of ſecurity, for the laſt three weeks I joined to the Opium at bed-time [Page 26] half a grain of Mercurius Calcinatus. In the courſe of the firſt fortnight the eruption diſappeared, and the thickened Perioſteum gave way to a bliſter.
And from the 24th to the 42d day, when I left it off, conſidering him as perfectly cured, I only gave one grain in the twenty-four hours—He had occaſion to make uſe of purging medicines at different times, owing to a coſtive habit of body; but theſe never interfered with the Opium.
William Rockett, of the detachment of Guards that was in America during the late war, thirty-ſeven years of age, had [Page 27] ulcers on each tonſil, and almoſt the whole of the fauces, with violent pains in his bones. Theſe complaints were of three months ſtanding; mercurials, and other medicines, had been adminiſtered during the whole of that time.
On the eighth day, he appeared weak, and his throat in general relaxed. I [Page 28] omitted the Opium, and began with the Peruvian Bark, in as large doſes as the patient's ſtomach would bear, and ordered him to make uſe of an aſtringent gargle.
On the twelfth day, as he was much the ſame, I increaſed the doſe, one grain in the morning, and continued this plan to the fifty-ſecond day, without varying the doſe; when every thing ſeemed to go on ſo extremely well, and the pains of the bones having left him, I omitted the two grains in the morning.[Page 29]
In a week afterwards all the ulcers were healed; and he was gaining ſtrength daily. I continued one grain at night for a fortnight longer, and diſcharged him from the hoſpital perfectly cured. It was near a fortnight before the pulſe returned to its natural ſtate; and afterwards it was frequently under ſixty.—This caſe happened among the firſt in the year 1779; and Mr. Ruſh, Surgeon to the Second Troop of Horſe Grenadier Guards, and late Surgeon to the Brigade of Guards in North America, was witneſs to the whole of the treatment.
Thomas Wells, thirty-ſix years of age, of a ſtrong plethorick habit of body, with rather a full pulſe, had ſmall ulcers on the tonſils and fauces, and an ophthalmia, for which he had been ſalivated without the leaſt benefit. I directed for him a low diet, [Page 30] and began with giving him one grain of Opium night and morning.[Page 31]
April 7th, 1782, I was deſired to ſee John Blewers, a ſailor, twenty-eight years of age, of a plethorick habit of body, with ulcers on the glans penis, a phymoſis, the praeputium in a gangrenous ſtate, and ſuffering moſt excruciating pain; his pulſe beat an hundred and twenty-ſtrokes in a minute, and appeared to be increaſing in quickneſs. He had rubbed enough of the mercurial ointment to affect his mouth twice.[Page 32] [Page 33]
Beſides the above, I had the ſatisfaction of effectually relieving, with the ſame manner of treatment, ten other patients; of whom, ſix had either obſtinate or ſpreading ulcers in the groin; one an ulcerated glans penis; and three ulcerations of the tonſils and fauces.
HAVING remarked, that in caſes where fungus exiſts I prefer a ſolution of thebaic extract in an oatmeal-poultice, made and applied cold, I beg leave, as proofs of its peculiar efficacy, to add the two following [Page 34] caſes; neither of which, as far as my enquiries went, originated from the Venereal Diſeaſe.
Iſaac Pratt, twenty years of age, had a very large ulcer on the fore part of his right leg, with a fungus at leaſt an inch high on one part, inclining to the inſide of the leg, and of a hard texture.—This ulcer, which came on after a long intermittent fever, began with an inflammation, attended with ſmall white bliſters. It grew worſe and worſe, and when I firſt ſaw him was of thirteen months ſtanding. The Peruvian Bark, and other medicines, were occaſionally made uſe of, as ſeemed neceſſary, as were alſo a variety of external applications (including a tight bandage), [Page 35] without producing any favourable change, though the patient recovered his health in every other reſpect. The diſcharge from the ulcer was ichorous, and at times the pain was very great; but at intervals he was perfectly eaſy; his pulſe was never affected, excepting when he was in pain.—Conjecturing that Morbid Irritability might be the cauſe of the ulcers continuing in the ſame bad ſtate, I left off the uſual dreſſings, and in their ſtead applied to the ſore an oatmeal-poultice, prepared with a ſolution of thebaic extract, in the proportion of three drachms of the latter to eight ounces of cold water. This dreſſing I renewed twice a day; and I likewiſe began with giving him internally one grain of Opium night and morning.—This was on the 25th of February, 1780. [Page 36]
During the five following days the changes for the better, though ſlow, were very evident; and, upon applying my finger to the fungus, I felt that it was not quite ſo hard as before. At this time another purge was thought neceſſary, and the patient continued till the latter end of April, gradually getting better.[Page 37]
The ſame doſe of Opium, viz. three grains, was conſtantly exhibited; and now and then, as occaſion required, a ſmall doſe of ſalts, which always anſwered the purpoſe of procuring ſtools when well diluted.[Page 38]
This caſe, with others that I have had an opportunity of obſerving, together with the remarks of my colleagues Meſſrs. Forſter and Wier, will, I flatter myſelf, be ſufficient to make Surgeons leſs fearful of the probability of a cure being obtained, and leſs deſirous of uſing ſtimulating applications, with a view of producing the change to a florid, or what is commonly termed healthy ſtate of an ulcer; for, as far as I am able to judge, by ſo doing the cure will be protracted.
March 16th, 1780, Abraham Elſtone, forty-one years of age, was received into the General Hoſpital, with an ulceration on [Page 39] the whole ſurface of the chin and left ſide of the lower jaw, with a fungus of nearly the thickneſs of half an inch, irritable to the touch, and extending univerſally over the ulcer, and attended with an ichorous diſcharge. He had been ſix weeks in this ſtate.—He informed me, that at two or three different times, in the early part of his life, he had been ſubject to an enlargement of the maxillary glands, which had always been ſoon relieved.—The Surgeon, whoſe care he was under for the preſent diſeaſe, conſidered the caſe as ſcrophulous, and treated it accordingly, without any ſort of benefit, as the ulcer continued to ſpread, and was rendered exceedingly painful by the growth of the patient's beard.—I directed one grain of Opium to be adminiſtered night and morning, and [Page 40] likewiſe recommended the uſe of an opiate poultice cold, as in the former caſe: this method was perſevered in till the twentieth, but without any alteration, although the doſe of Opium was increaſed to four grains night and morning.
About a fortnight afterwards the ulceration was quite healed, and I laid aſide the poultice; but I did not begin to leſſen the doſes of opium till the 23d of May; after which time I went on gradually diminiſhing them, till the patient omitted them altogether; and on the 12th of June I diſcharged him from the hoſpital perfectly recovered; and eighteen months afterwards I had an opportunity of enquiring after him, and had the pleaſure to find he had continued well.