Opium Use in The Medical Casebook

 

Effects Of Opium Use:-

“Effects of repeated subcutaneous opium injection.” [20]

This Week

We’ll conclude our travels through Victorian addictions this week by taking a look at Opium Use. Opium, morphine and heroin are essentially the same drug [albeit with different levels of refinement].

 

Sherlock Holmes And The Adventure Of The Ordered Occupations

Another story to accompany publication of The Medical Casebook Of Sherlock Holmes And Dr John Watson.

Dr Watson attends a hansom cab accident on Kensington High Street, in which a fellow general practitioner is seriously injured. Acting as a locum for his colleague, Watson is called to a mysterious death. Sherlock Holmes is asked for help, and discovers another similar death. Unravelling the mystery makes full use of Watson’s medical knowledge, but can our heroes prevent further deaths?

Available from the Amazon Kindle Store.

Opium Use

Opium Use + Sherlock

We are going to start our chapter on opium and morphine with the two stories that feature opium misuse.

Our main references are in “The Man With The Twisted Lip”. Dr Watson is looking for the husband of a friend of his wife, Mary, who is missing.

Isa Whitney, brother of the late Elias Whitney, DD, Principal of the Theological College of St George’s, was much addicted to opium. The habit grew upon him, as I understand, from some foolish freak when he was at college; for having read Dr Quincey’s description of his dreams and sensations, he had drenched his tobacco with laudanum in an attempt to produce the same effects. He found, as so many more have done, that the practice is easier to attain than to get rid of, and for many years he continued to be a slave to the drug, an object of mingled horror and pity to his friends and relatives. I can see him now, with yellow, pasty face, drooping lids, and pin-point pupils, all huddled in a chair, the wreck and ruin of a noble man.

Mary’s friend, Kate Whitney, provides more information about her husband’s addiction.

She had the surest information that of late he had, when the fit was on him, made use of an opium den in the farthest east of the City. Hitherto his orgies had always been confined to one day, and he had come back, twitching and shattered, in the evening. But now the spell had been upon him eight-and-forty hours, and he lay there, doubtless among the dregs of the docks, breathing in the poison or sleeping off the effects. There he was to be found, she was sure of it, at the Bar of Gold, in Upper Swandam Lane. 

Watson heads to the opium den, convinces Isa Whitney to head home, but then makes a surprising further discovery.

I walked down the narrow passage between the double row of sleepers, holding my breath to keep out the vile, stupefying fumes of the drug, and looking about for the manager. As I passed the tall man who sat by the brazier I felt a sudden pluck at my skirt, and a low voice whispered, “Walk past me, and then look back at me.” The words fell quite distinctly upon my ear. I glanced down. They could only have come from the old man at my side, and yet he sat now as absorbed as ever, very thin, very wrinkled, bent with age, an opium pipe dangling down from between his knees, as though it had dropped in sheer lassitude from his fingers. I took two steps forward and looked back. It took all my self-control to prevent me from breaking out into a cry of astonishment. He had turned his back so that none could see him but I. His form filled out, his wrinkles were gone, the dull eyes had regained their fire, and there, sitting by the fire and grinning at my surprise, was none other than Sherlock Holmes.

Holmes is working undercover to find another missing man, Neville St Clair, who it transpires, rather unbelievably, is a journalist by day, but moonlights as a beggar at night, as the latter profession brings in much more money.

We get one brief reference to self-inflicted acute opium poisoning in “The Sign Of Four”.

For myself, I used to stand outside the gateway, looking down on the broad, winding river, and on the twinkling lights of the great city. The beating of drums, the rattle of tomtoms, and the yells and howls of the rebels, drunk with opium and with bang, were enough to remind us all night of our dangerous neighbours across the stream.

There are then four references to opium or morphine being used as a medical treatment.

In “The Adventure Of The Illustrious Client”, Watson, having found out that Holmes has been attacked, races back to Baker Street.

I found Sir Leslie Oakshott, the famous surgeon, in the hall and his brougham waiting at the curb.

“No immediate danger,” was his report. “Two lacerated scalp wounds and some considerable bruises. Several stitches have been necessary. Morphine has been injected and quiet is essential, but an interview of a few minutes would not be absolutely forbidden.”

Later in the same story, Watson administers treatment to Baron Gruner, after Kitty Winter throws vitriol at him.

I bathed his face in oil, put cotton wadding on the raw surfaces, and administered a hypodermic of morphia. All suspicion of me had passed from his mind in the presence of this shock, and he clung to my hands as if I might have the power even yet to clear those dead-fish eyes which gazed up at me. I could have wept over the ruin had I not remembered very clearly the vile life which had led up to so hideous a change.

In “The Adventure Of The Creeping Man”, which we will look at more fully in our Lumbago chapter, Watson treats Professor Prestbury after he is mauled by his own wolfhound.

The hound was secured, and together we carried the professor up to his room, where Bennett, who had a medical degree, helped me to dress his torn throat. The sharp teeth had passed dangerously near the carotid artery, and the haemorrhage was serious. In half an hour the danger was past, I had given the patient an injection of morphia, and he had sunk into deep sleep.

To finish our treatment section, in “The Adventure Of The Lion’s Mane”, Ian Murdoch begs for treatment after his encounter with the fearful jellyfish. Though on this occasion, Watson is not present, so Holmes resorts to an alternative treatment.

“For God’s sake, oil, opium, morphia!” he  cried. “Anything to ease this infernal agony!”

The inspector and I cried out at the sight. There, crisscrossed upon the man’s naked shoulder, was the same strange reticulated pattern of red, inflamed lines which had been the death-mark of Fitzroy McPherson.

The pain was evidently terrible and was more than local, for the sufferer’s breathing would stop for a time, his face would turn black, and then with loud gasps he would clap his hand to his heart, while his brow dropped beads of sweat. At any moment he might die. More and more brandy was poured down his throat, each fresh dose bringing him back to life. Pads of cotton-wool soaked in salad-oil seemed to take the agony from the strange wounds. 

I’m going to add a note here that “Silver Blaze” and “The Adventure Of Wisteria Lodge” feature characters being drugged by opium, but I have opted not to fully discuss poisoning by others in my review of Sherlockian medical cases.

We know that Holmes was an expert on poisons, including opium. Although it doesn’t refer to opium in the context of a disease, the following excerpt from “A Study In Scarlet” is so wonderful I feel I must include it. Watson’s summary of the attributes of Sherlock Holmes just brilliantly draws you into the character of the eccentric master detective.

I enumerated in my own mind all the various points upon which he had shown me that he was exceptionally well-informed. I even took a pencil and jotted them down. I could not help smiling at the document when I had completed it. It ran in this way:

Sherlock Holmes—his limits.

1. Knowledge of Literature.—Nil.

2. Philosophy.—Nil.

3. Astronomy.—Nil.

4. Politics.—Feeble.

5. Botany.—Variable. Well up in belladonna, opium, and poisons generally. Knows nothing of practical gardening.

6. Geology.—Practical, but limited. Tells at a glance different soils from each other. After walks has shown me splashes upon his trousers, and told me by their colour and consistence in what part of London he had received them.

7. Chemistry.—Profound.

8. Anatomy.—Accurate, but unsystematic.

9. Sensational Literature.—Immense. He appears to know every detail of every horror perpetrated in the century.

10. Plays the violin well.

11. Is an expert singlestick player, boxer, and swordsman.

12. Has a good practical knowledge of British law.

  

Opium Use In Victorian Times

Opium was an extremely widely used drug in Victorian times. The list of conditions it’s use was recommended for was pretty well anything – pain, fever, diarrhoea, rectal bleeding, agitation, insomnia, itching, cough, colic, and for many specific diseases. Our Fenwick text on medical treatment contains 110 references to the use of opium [6].

But there was also clear recognition that opium caused problems, though interestingly only in some of the textbooks.

Firstly let us have a look at acute opium poisoning. 

The whole group of poisons classed as narcotics produce coma or unconsciousness. Of these the commonest and most important is opium. This may cause coma in certain cases when administered even in medicinal doses, especially in renal disease. Extreme contraction of the pupils is an important indication of opium poisoning, although found in other forms of coma due to cerebral disease. [15]

Opium is by far the most important of narcotic poisons. It induces giddiness, stupor, and lethargic sleep, from which, however, the patient can at first be roused, if sharply spoken to. Subsequently this sleep deepens into coma and cannot be broken; the skin is relaxed and perspiring; the face is usually pale; the pupils are contracted and insensible to light; erections of the penis are common. A more or less evident odor of opium may often be perceived about the person or on the breath. No distinction can be drawn between the effects of different forms of this poison; the stronger the preparation, however, the more marked and the more rapid will be the progress of the case. Morphia, codeia, narcotine, and the other alkaloids give rise to similar symptoms, but the smell of opium is, of course, absent; convulsions are most likely to occur from narcotine, papaverine and thebaine. [3]

Opium use is very ancient – piles of poppy seeds found in a cave in Spain were carbon-dated to 4200 BC.  Opiates, which include morphine and codeine, are all derived from the opium poppy, Papaver somniferum.

We also get detailed sections on chronic opium addiction.

The narcotics, taken in the same manner, act upon the vasomotor nerves and the cerebro-spinal system, and through this upon the alimentary canal, so deranging digestion and nutrition as even indirectly to cause death. Opium is the most important of the articles thus used; it is often administered to infants for the purpose of quieting their cries, and the frequent repetition of the dose induced a series of phenomena closely allied to those observed in the adult. With the effects, on the mind, of opium taken persistently for the sake of intoxication, the reading world is familiar through the published experiences of De Quincey and of Coleridge. [3]

The habit is here and in Europe generally acquired only by persons who have begun the practice for the relief of some painful affection; in the East, opium is used much more commonly, and, in many Oriental countries, to smoke it is a favorite amusement. Those who employ it constantly are pale, or have a sallow, haggard countenance and a dull eye. They lose the power of will and their energy, and are troubled by loss of appetite, giddiness, anomalous neuralgic pains, sleeplessness, and low spirits, which they remove by resorting to the opiate. Though, in spite of the pernicious custom, the general health may remain for many years good, yet sooner or later it gives way, and the opium-eater dies worn out; or death may be the consequence of disease of the liver, of palsy, or of inveterate diarrhoea, produced by long addiction to the vice. Persons who consume large quantities of opium are apt to have, from time to time, attacks of extreme nervous prostration, attended, perhaps, with violent headache, and requiring free stimulation for their relief. The employment of morphia hypodermically is becoming an alarmingly frequent form of the opium habit, especially among members of the medical profession. [3] 

There is nothing at all in the texts regarding management of chronic opiate use. 

I thought it would be of interest to provide a brief summary of GP involvement with opiate addiction in the modern day.

We see opiate addiction in two contexts. Firstly via the use of illegal drugs, typically heroin. I don’t have any great expertise in this area, and it doesn’t greatly affect my day to day practice. Rural areas generally have far lower prevalence of such addiction than urban areas. At present, my practice of 8000 patients has less than 10 patients being managed for heroin dependence. Most GP’s don’t get involved with managing opiate addiction. We might be involved in first identifying the problem, but then refer the patients on to specialist drugs and alcohol services to manage the necessary prescribing [typically methadone or buprenorphine maintenance prescribing, to replace the illegal opiates].

A far bigger issue for us is prescribed opiate addiction. Over the past few decades the medical profession has been guilty of over-use of opiates in the management of chronic pain. Thankfully it has now been recognised that this is poor practice, and there has been a radical rethink of our use of opiates in just the last few years. The National Institute for Health and Care Excellence [NICE] produced revolutionary guidance in 2021, which essentially says that opiate use for chronic pain, particularly when there is no clear diagnosis, has no clinical evidence base at all, and should be completely avoided. 

 

Next Week

Next week we’ll start a couple of weeks looking at heart disease. Our first area will be heart failure, often called dropsy in Victorian times.

 

Buying The Book 

The Medical Casebook of Sherlock Holmes and Dr John Watson is available from all good bookstores including Amazon USA, Barnes and Noble, Amazon UK and additional formats like Kindle.