On the Use of Opium in the Treatment of Insanity. By DANIEL NOBLE, M.D.

Of all the available resources of the Materia Medica, opium, in its beneficial efficacy, is probably surpassed by none. It calms irritability, it soothes pain, it assuages spasm, and restores sleep. And when, in the course of disease, these indications have to be fulfilled, there is no drug like opium upon which we can place such uniform reliance. It is no wonder, then, that its advantages have been solicited, and realised, in the practice of psychological medicine.

In the premonitory and incipient stages of certain forms of emotional insanity, especially those of the melancholic type, the good effects of the salts of morphia, administered from time to time in small doses as first advised, I believe, by Dr. Seymour, appear to be amply demonstrated; and, occasionally, in some of the more acute varieties-those in which maniacal excitement is conspicuous, beneficial results from employment of the preparations of opium have undoubtedly been obtained. I apprehend that, thus far, I only affirm the familiar conclusions of experience. But, of course, opium in the treatment of insanity, like every other remedy in any of the forms of disease, is liable to abuse; and some of the circumstances of this abuse I propose to illustrate in this paper, circumstances which have arisen within my own experience, and in the responsibility of which I may in some degree have participated. If I appear to admit errors of practice, I must frankly own that I see no humiliation in doing so, at least if the errors in question have not had origin in culpable ignorance or in wilful inattention. Indeed, I have often thought that if medical men would be as communicative of their errors as of their sound judgmentsof their misses as of their hits, results much more conducive to practical good would in this way ensue, than by publishing unvarying records of real or supposed sagacity.

What are the conditions in mental maladies indicating, and what those contra indicating, the preparations of opium? This question does not altogether admit of a categorical answer. Administered in moderate quantities two or three times a day, in the earlier stages of those cases of emotional insanity which are characterised by restless irri

tability and an intolerable malaise, opium sometimes relieves, apparently by communicating such a temporary calm to the feelings, as to furnish opportunity for employment of those hygienic and other measures which are fitted to accomplish permanent good. And, again, in some instances of incoherent wandering and maniacal excitement, wherein sleep is rendered impracticable, the somniferous properties of opium would seem to exert a beneficial influence very much after the manner in which the remedy relieves in delirium tremens-procuring for the patient, on awaking from the induced sleep, a decided remission of all the more violent symptoms.

Yet it frequently happens that, at the outset of very decided cases of insanity, the employment of opium seems to produce mischievous effects. Patients become inmates of asylums from time to time who, having been largely treated with this medicine, appear to have become more excited in consequence, more incoherent, less tractable; and who, on ceasing to take narcotic drugs of any kind, progressively improve and in a very short time become tranquil and lucid. Can we by symptomatic phenomena discriminate between the two classes of cases,-those in which opium may be administered with reasonable expectations of benefit, and those in which it may be likely to exercise a prejudicial influence?

I think it will be generally conceded that few points of medical practice involve greater difficulty, and that no very complete elucidation of this inquiry can be given. I apprehend that, for the present at least, we must attempt a solution of the problem rather by citation of additional facts of experience, than by appeals to formal or recognised rules of practice. As a contribution in aid, I will relate the particulars of two cases in which, I fear, the unseasonable employment of the acetate of morphia hastened, if it were not the efficient cause of, a fatal termination.

Upwards of three years ago, I was requested to visit an elderly lady dwelling in the country, some miles distant from my own residence. She had for some months been the subject of melancholic depression of spirits, which had gradually ensued almost immediately upon the death of her husband. A few days prior to my seeing her, she had begun to exhibit all the symptoms of acute mania, unaccompanied, however, by any violence of disposition; an unceasing babble-a veritable diarrhea of words, and an absence for some days of all sleep, constituted the prominent features of

her malady. For some time, she had taken very little food; and this fact, with loss of rest and a long-continued depression of the morale, must have greatly lowered the vital tone-a circumstance not very obvious on the surface of things, owing to the very great excitability which she manifested. I found that the surgeon in attendance was administering the acetate of morphia, with a view to obtain sleep, but in doses which under the circumstances were very inadequate; I think the quantity was the fourth of a grain, twice a day. In the consultation which succeeded my own examination of the patient's condition, I stated that I considered sleep to be most desirable, and that if this were not procured, the lady must die exhausted; that larger than ordinary doses, however, were required in these abnormal states of the brain and nervous system; that, in fact, I would give at least a grain of morphia at once; and that, if this did not produce the desired result in about two hours, I would increase the dose, and, indeed, go on progressively, just as we sometimes did successfully in delirium tremens. I omitted to place any limit to the dose, in this recommendation; and my suggestions were acted upon to the letter. It was not intended, on account of the distance, that I should visit the case again; so I requested the medical attendant to apprise me of the future course of the malady, simply as a matter of scientific interest. In a few days afterwards, he informed me by letter that the patient was dead; that he had gradually elevated the doses of morphia, until sleep was at length obtained; that many grains had been taken-how many I do not remember, but the quantity was certainly enormous, that about fourteen hours had expired before the patient slept, and that the sleep so procured was one from which she never thoroughly awoke. A few hours

before the fatal event, it appeared, there had been some partial restoration to consciousness, and, upon this occasion, a little nutrition was administered; but very soon she dozed off once more, and finally expired, in about forty-eight hours from the period of my visit.

Now, considering that for some months this patient had been under the distressing influence of melancholia, and that the sources of re-invigoration--sleep and food-had for a long time been but little available, there must have obtained a considerable waste of nervous energy; and it is most probable that, owing to lowered vitality, irrespective of all treatment, fatal exhaustion would sooner or later have terminated the maniacal outbreak. But yet I cannot help

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thinking that the sleep-compelling extent to which the morphia was given involved an error in practice, and that the issue was at least accelerated by excessive employment of the narcotic drug.

I may here observe, that notwithstanding that I have for years been most hesitating in the use of opium in psychological practice, I have yet so often seen benefit follow its careful administration, that I cannot bring myself to discontinue it in all cases, either of mania or melancholia; although it is probable that, with all imaginable circumspection, we may occasionally encounter disappointment, and even disaster, in its employment.

I will now record a second case, which teaches the same practical lesson as the foregoing one :

A lady, upwards of forty years of age, apparently approaching the so-called "change of life," became melancholic; and having continued so, more or less, for some months, she at length exhibited herself violently maniacal. She was attended by a surgeon of eminent ability and of high-standing, and it became a question, whether it would not be right to send her to an asylum. Before a decision was taken upon this point, it was agreed that I should be consulted. This was done. The case itself presented no unusual features. The patient had slept badly for months, and scarcely at all for several nights prior to my visit; and, as often happens in such forms of disease, very little food had for some time been taken. In the estimation of the medical attendant, sleep was the prominent requirement; and, in fulfilment of this indication, he was giving very full doses of the acetate of morphia, but without any perceptible effect. I concurred in the view which was taken, very generally; and recommended, moreover, that wine, milk, and other nutrient drinks should be administered, whenever it was practicable to do so. I stated also, that in my opinion, if there was no material abatement of the symptoms after sleep had been experienced, removal to an asylum would become indispensable. I do not remember the precise dose of morphia to which, by gradual elevation, my associate in the case had already attained; but he now proposed that so large a quantity as three grains should be given, to be repeated in three hours if sleep did not ensue, a proposal to which I assented, suggesting at the same time, that before the administration of a second dose he should again see the patient. The medicine, in the quantity agreed upon, was given; and when the surgeon again saw her at the hour

fixed, not the slightest narcotic or even sedative effect was discoverable. Accordingly, he himself administered the second dose, by which, in about half an hour, I believe, she was fairly overpowered. Although, after some hours' heavy sleep, she was capable of being sufficiently roused to take a glass of wine, the sleep itself, barely interrupted for a minute or two, terminated only in that other sleep-the sleep of death!

The foregoing examples of an apparently disastrous issue following the employment of opium in the treatment of insanity, are not taken from amongst numbers; they are quite exceptional in my own experience, and indeed exhaust it; yet still I think them sufficiently striking to suggest the necessity of all possible care in dealing with this medicine under any similar circumstances. The great point of interest in the question is, whether we have any means of determining beforehand the particular cases in which an intolerance of large doses of opium may be reasonably inferred, and of distinguishing them from those wherein we may fearlessly push the remedy? Upon this topic I cannot state anything very definite or decisive. I will venture, nevertheless, to offer a few reflections upon this matter, as they have occurred to myself whilst revolving in mind the facts. just related.

When Dr. Monro states that insanity is an affection consequent upon decreased vitality, manifesting itself peculiarly and specifically in the cerebral masses, he undoubtedly expresses a very general, if not, as he himself supposes, the universal fact. And from this circumstance, some might be disposed to rush at once to the conclusion, that powerful sedatives must inevitably operate prejudicially upon the functions of structure already exhibiting conditions of depressed vitality. But then much experience would negative so absolute a conclusion. Various forms of morbid action, characterised by depressed vitality, not only tolerate, but are unquestionably benefited by such medicines as opium.

Certain cases of anæmia, of delirium tremens, and of adynamic fever, as well as occasional instances of insanity, certainly shew remarkable tolerance of opium and other such drugs. The quantity, indeed, that is sometimes advantageously taken in delirium tremens, and in cases of exhaustion by loss of blood, is, a priori, almost incredible. How shall we reconcile this apparent anomaly ?

I will here premise a few general observations; and in the first instance express my conviction, that hereafter a