(Editor’s note) With this post I am resuming the chapter-by-chapter posting of the remarkable book “Opium And The Opium Appetite” by Alonzo Calkins, MD. This long and challenging book, published in 1870, allows us to hold a mirror up to our current “Opioid Crisis” and see it for what it really is – not a crisis of our times, but an ongoing theme in American life.
In this chapter Dr. Calkins discusses the many cases that he experienced personally, and that he gathered from other physicians and elsewhere, regarding extreme cases of Opium/Morphine consumption. Extremes of consumption were not always tied to addiction, as he points out, and the stories in this chapter ought to make us think twice about the “one dose and you’re hooked” meme that is so popular with those who make a living from ensuring that there is always a plentiful supply of souls in dire need of “rehabilitation” and “recovery”.
Many people born since the 1990’s don’t understand the history of the “Opioid Crisis” because they were not yet born when previous “crises” were being manufactured and sold to the public by breathless media acting as the propaganda mouthpiece of the State. Consider, to take one of the worst examples of social disinformation, the “Crack Epidemic” of the 1980’s that sent tens of thousands of mostly young Black men to prison, creating an entire generation of fatherless Black children and fueling the next act in America’s “drug wars”.
While the “fake news” epithet may seem to be quite contemporary, the fact is that much of the “news” has always been fake, and never so much as when drugs are the topic. For all of his faults, Dr. Alonzo Calkins wrote what he saw and what he believed, and left us a record of what was true 150 years ago and remains true today – we don’t have an Opioid Crisis; we have a permanent crisis of the American soul.
“Opium And The Opium Appetite” by Alonzo Calkins, MD
Chapter XVI: The Posology (Dosage) Of Opium
“Exempla – quorum me turba fatigat.” — Ovid
“Let me have a drachm of poison. Sweet draught! Sweet, quotha? O fool! that now as luscious as locusts, shall shortly be in thy mouth as bitter as coloquintida!” — Romeo and Juliet
By those who have studied the “Ars nihili credendi” many of the statements recorded in this chapter will be transferred to the column of the incredibilia; but there is ample authentication behind nevertheless. Van Swieten refers to a dose of 16 grains as something extraordinary; Garcias (Morewood) knew a woman in Turkey, of good intelligence and of a conversational turn, who informed him her daily consumption was 10 drachms (!). Hufeland mentions a 30-gramme dose, one ounce less half a drachm. As a measure of effect, however, it should be understood the apothecary’s scales are but a very insufficient criterion.
Initial doses vary from a fraction of a grain upward; but amateurs start more boldly, as in the instance of a Chicago youth, who began upon 3 grains of morphine, and ran his course proportionably fast. Surgeon Smith names 5 grains of the chandoo for the neophyte; 290 grains he has known in the case of the veteran. Libermann, in the Chronique Medicale, has given a tabulated summary of a thousand smokers, of whom he kept a record while he was in China engaged in the imperial service, as here classified:
Of the thousand, 646 vary between 1 and 8 grammes, 250 between 10 and 20, and the remaining 104 range from 30 to 100 grammes. (The higher extreme seems scarcely credible, and perhaps the text should read grains.)
The Theriakis of Eupatoria not unfrequently go to 100 grains; the Hamals (porters) of Constantinople not seldom use an entire ounce.
The “big doses” are restricted by no lines of longitude. Dr. Hawkins was informed by a druggist of an eastern county in England concerning a farmer there, who one day came into the shop, asking for an ounce and a half of laudanum. This having been swallowed was after a brief time followed by a second draught, and again by a third, and several ounces besides were purchased for taking home. This “operator” was plainly of the new-school progressives.
But in bold practice New York City and the rest may safely challenge Birmingham, or Paris, or Canton. A woman of Atlanta (a buyer for a considerable time, and if she ain’t gone she lives there still) sends her daughter with the two-ounce vial for laudanum three times a day regularly (Redwine). The cause thereunto moving had been a proclivity to “spiritual liquor.” Wayne gives an instance of 6 ounces; Eimer of the same quantity daily repeated.
Paregoric and McMunn come in for their share in the awarding of honors. Besides the quart-measure are pint cases in plenty by Shedden, Lee, S. Smith, and others. McMunn also talks loud. Dr. Lente knows a woman at Cold Spring, who buys for the week three dozens of bottles. A gentleman who was making a purchase on Union Square one day, declared of himself that he used up, one day with another, 12 bottles. Dr. L. had seen and prescribed for a youth (as he then was), who, having become habituated to strong drink provided by injudicious friends for a lingering diarrhoea of his, had found in this elixir a present quietive for symptoms threatening delirium tremens. On a certain day he was known positively to have taken six bottles. This case, however, is thrown into shade altogether by a record at Binghamton, that of a lawyer, a detenu at the Asylum there half a dozen years since, whose totality was by his own record 3200 bottles, and for a certain day one and two-thirds dozens, the equivalent of a pint of laudanum within one ounce.
Morphine demands a separate section. MacGillivray’s patient has been noted already (chap. xii.). Dr. Gill of London had on his hands one time a professor of vegetarianism (50 years old actually, but, judged by his attenuated limbs and parchment skin 20 years ahead of that mark), whose stated supply was 55 grains. The allowance having been cut down flesh was substituted for porridge and cabbage, and in no long space Mr. Witherskin was able to make a much-improved show in the outer man. A third drachm case is from Redwine, that of “a brother fallen from his high estate,” who had pioneered upon whiskey. A fourth case is of a German woman lately in the hands of Naumann, who by a gradual progression through several years had finally reached one drachm precisely, at which mark she stood a considerable time. This person cured herself by pursuing, at the suggestion of Mr. N. (a very intelligent druggist), the gradative course. The weekly diminutions were made by grain and two-grain reductions in alternation.
A fifth case is communicated by Mr. Leys of Brooklyn, and the detail is a precise transcript of the record. A woman, thirty-five years old at the time of her death, wife and mother both, had been a regular purchaser for the six years precedent to her demise, though a consumer for several years earlier. Of medium embonpoint and with a fair countenance, she would scarcely have attracted casual attention otherwise than by the half-averted but lustrous eye. In regard to constipation hers was an exceptional case, nor was the final sickness (which was of the acute type) obviously traceable to her morbid habit. The dose for the first month of the six years was 16 grains (in the form of Magendie’s solution), which quantity had doubled by six months and quadrupled by the time a year had run. This 16 grains per month had grown by the end of the fourth year to 16 grains per day, and in another year to 20 grains. For the first half of the sixth year the progress was from 20 up to 30 grains; during the final six months one drachm was the measure, regularly called for as the morning came.
Number six is Mr. B., a prominent druggist in the metropolis, age 49, the subject of a severe chronic diarrhoea for half a dozen years. Morphine, which, like Choroebus penetrating the Grecian phalanx now within Ilion’s towers after assuming the helmet of the slain Androgeos, a pretended friend while an enemy in disguise, was early employed for its supposed curative efficacy (and indeed always to the present mitigation of symptoms, for “without it his bowels would run away from him”), but the benefit derived has ever been of ephemeral continuance only. No notable emaciation is observable as yet, nor has the general health become materially impaired. Magendie’s solution (16 grains to the ounce) is the form, and this is taken, an ounce for the time, in very precise measure, to the extent perhaps of four times that in the day, or again a pint may last the week through. He has been known to have his ounce four times in the day, and an additional one at his private office, i.e. 80 grains of the salt. In the general way, morphine to the amount of 15 grains is no uncommon dose; 30 to 36 grains is with rare exceptions the limit.
Gravity of action may be as disproportioned to quantity as is the case of alcoholics. An instance of idiosyncrasy referable to this section is given by Dr. Barnes. The occasion was an existing diarrhoea. With the approbation of a doctor opium had been used daily for three weeks, by the end of which time, “although the flux was subdued the opium was not subdued.” The medicine acted strangely, kindling Then up a fire in the stomach as it seemed, so that for another three weeks nothing swallowed would lie, rice water excepted, and all the vital powers seemed to be flagging. A year having proceeded in this manner, a change to the right-about was resolved on. Agonies and horrors followed upon the breaking up, to abate only by littles, but success was secured at last. For a time from the first, but for a brief period only, a sort of ideal tranquility, a visionary happiness followed each dose, but the subsequent experience was the reverse of all this. The recollection of the sufferings had survived as vividly twenty-five years after as if they had been of yesterday. The dose (the gum was used) had at no time exceeded four grains.
The caprices of single doses taken for a special occasion are even more variant and strange than the operations under continued use. Of minimum doses of fatality there have been noted (as already mentioned) 3 grains of the gum (Grisolle), a grain of morphia, and half an ounce of laudanum, and there have been even less than these. Maximum doses of tolerance are the very antipodes of such. Recovery has followed upon the ingestion of 30 and 60 grains of the gum, and once after 20 drachms had been swallowed. Instances of like result are recorded of morphia in doses of 30, 55, 60, and even 75 grains, and after laudanum, as in two cases, where 5 ounces had been taken, and in a third where the quantity was 6 ounces.
The records of practice in disease are yet more astounding. Doses fearlessly used at this day for various forms of organic derangement would only a half-century since have staggered the boldest. For instance, Pinel allowed a woman at La Charite, far gone with cancer uteri, 120 grains of solid opium for the twenty-four hours, and greatly to the alleviation of symptoms. M. Marc, in the Gazette de Paris, gives a similar case. His patient on one of the days took 62 grains of morphine. Monges and La Roche of Philadelphia had such a patient, whose allowance her last three months was 3 pints of laudanum for a day and a night, with some pure opium extra. For a urethral malformation a woman under Zaviani consumed in the progress of thirty-four years 200 pounds of the solid and above. On some days 200 grains was her mark. Dr. Knight of New Haven once had a patient with uterine cancer, who used daily and for a very considerable time, and without prejudice also, a drachm of morphine at least, and from that even up to 3 drachms. Bellevue Hospital records make a show ahead even of these. In a case of puerperal peritonitis occurring in 1862, Dr. Clark administered in the course of seven days various preparations, equivalent altogether to 200 ounces of opium proper, and on one of the days 472 grains, an ounce to within a fraction.
Rev. G. Smith, an English missionary, made a tour of observation one day around Amoy, having Lim-pai, a reformed opium eater, for cicerone, with the following results. Upon questioning ten persons as met indiscriminately and at random, he found their average to be 1 mace or 60 grains. The general average he ascertained to be 3 candareens (= 17% grains) of the chandoo (Allen). The mean for Aleppo Russell puts at 3 drachms; a high figure certainly, even for the maw of a Turk. Dr. Garrod, however, knew of a Turkish gentleman, a mere youth, who used one drachm in the morning and the same repeated at night, besides the laudanum he took in the intervals, an ounce or more.
At the Pauper-house, Singapore, Dr. Little ascertained that of fifteen persons, smokers for periods varying from 3 to 20 and averaging 11 years, the medium dose was 32 grains. At the Mount Hope Asylum 2 to 4 ounces of laudanum is nothing uncommon (Dr. Stokes). Specific quantities are a drachm of the gum, 1 to 2 drachms of the salt, and a pint of the tincture, so much per week (Moore, Skey). The dose varies much with the pecuniary ability. A purchaser at Giles’s (such is a specimen-case) would get from time to time an ounce of laudanum only, it might be, and again twice or thrice that. Equability and moderation in dose is what is oftentimes but very capriciously respected. A gentleman called one day at Tarrant’s for a scruple of morphine; this, having dropped into a tumbler of water, he swallowed forthwith, with the intent, as was for the moment suspected, of poisoning himself. All anxiety was soon removed, however, by the stranger’s explanation that “such was his way.”
“The small quantity of Opium,” observes Dr. Little, “soon loses its effect, and to produce the requisite excitement the little pea must be doubled and again increased, until, as I have known, the original has got multiplied a hundredfold.”
A married woman turned of 50, who began upon two ounces of laudanum for a week, has now, after a considerable term, attained to the pint-mark (Leys). A spinster of 55 was several years in getting as high as 6 ounces per week. Dr. Palmer reports two cases where the weekly consumption was 2 drachms of morphine, and four others in which the quantity was half that Among his opium-cases was Mrs. O’G., addicted to the drug about forty years, .who by very slow advances had reached at last two drachms for the week, with the addition of a little whiskey taken as a priming. Another instance was Mrs. T., 50 years old at her death, who had been a consumer for nigh upon half of this term. She even in her latter years had not exceeded a drachm for the week to the very last year, but here the quantity was doubled. An extra interest attaches to this last case, in connection with the question of degeneracy. Of the two children born subsequently to the confirmation of the habit, the elder, a son always feeble and sickly, died at fifteen; the daughter, contrarily to what might be expected, now eleven years old, has a robust and thriving aspect. The patient died a year ago of pneumonia.
A lady of Ontario county with whom the writer has conferred, Mrs. S., age 60 or above, mother now of several grown-up children, became an invalid ere she had completed her maiden life; whereupon, with the concurrence of a physician, she sought relief in morphine. From the beginning through the entire period the advances have been very gradual to a drachm for three weeks (the present limit), or if for any special exigency this amount has been at all exceeded, she has ever been careful to recover the lost ground, returning again to the fixed standard. No other medicine has been found upon trial to answer her needs by way of substitution. Those common sufferings, such as constipation, agrypnia and ugly dreams, have not been among her experiences, nor is there during the day any marked exhilaration, or indeed any very definitely-pronounced characteristic, with the exception of the peculiar skin-hue and a somewhat toddling gait. A discontinuance was not advised.
Periodic augmentations in a ratio constantly increasing are according to the normal course; but then there are stages also of what may be called a “satisfied craving,” lasting for months or even years. Formiggini had a patient with a facial neuralgia that had come of caries of the maxilla, who used one gramme of morphine daily. This kept her system at the saturation point; but this precise quantity the lady must have, no less, no more; any excess she could not (or would not) tolerate, and if put on reduced allowance she became desperate (Revue de Paris).
The Lancet, 1832, contains a case not dissimilar. In this instance hysteria was the objective malady. A woman, now of the respectable age of 50, used for her measure 20 grains of the gum, so much precisely, day after day. (These hysterial cases require a good deal of humoring, particularly when spinsters are concerned who have arrived at a “certain age,” that age of all ages the most uncertain.) Dr. S. S. sends the case of a woman twenty-five years old and married, who made a beginning upon laudanum in her 20th year. Lately she has kept herself strictly to 4 ounces for the twenty-four hours; but “this much she will have at all events, even if she must beg for it or steal for it.”
Jones had for a reputed customer an elderly lady of the Hudson River border somewhere along, who purchased her supply of him for several years, sending a granddaughter (her deputy in the transaction) once a month for the pint of laudanum. Like the rest she ceased by-and-by to make report representatively or otherwise. “They come and go,” as Dr. Guion says.
A woman of mature age, an attendant at Eimer’s for fifteen years continuously there was, whose weekly purchase was what would make an average of half a drachm for a day. There was also a teacher attached to one of the public schools in Brooklyn, who was so careful of her ways, that she was at the pains of crossing East River about every four days, to get as many ounces of laudanum from a doctor at the West End (Mr. L.). Her general aspect all this time gave no indication of any progressing deterioration, nor was there so much as constipation complained of. This person all at once ceased to reappear; whether it was that she had opened a new account with another doctor, or whether she had gone to settle an old account with death, did not transpire.
Moderation in quantity and steadiness of dose are oftener observable perhaps in case of congenital infirmity or traumatic lesion; for instance, when spinal irritation or an ununited fracture is the coexisting evil.
Inconsiderable advances upon the existing dose are seldom hazardous, where a large stride might prove critical. An inquest at Bradford, England, brought out the following facts: a woman with chronic asthma (one of those maladies that contraindicate opium absolutely) had taken a dose considerably exceeding the usual one, causing her death only a few hours after. A second case to be adduced comes from Binghamton. A patient there was, who, having strayed off to town one evening, felt disposed to have a fresh sip of an old friend; and so, having purchased two ounces of laudanum he swallowed the whole at once, a quantity he had never ventured on before. Dr. Day reached him, but not immediately, nor until the comatose stage had set in. The battery with other appropriate helps was put to expeditious use, but to no purpose, for death had his victim the very same night.
There was a New York lady, now of middle age, a custom-visitor at Bedford’s for years together, who for the alleviation of an existing intra-pelvic tumor had used morphine a long time, but in very definite and exactly-measured doses always. Her usage was to have the 48 grains (her amount for the day) divided into three-grain packets, so that the times of recurrence should come with the expiration of every hour and a half. One morning it appears, but for some reason not cleared up, she had put four of the divisions together for a single dose, thus having swallowed 12 grains instead of the 4. The stimulative action proper was overwhelmed by the predominant toxic force, and a fatal coma set in.
The rule of progressive cumulation reversed is among the rarest of the rare, and asseverations made to fortify such pretensions must ever be taken cum grano salis, i.e. at a very considerable discount.
There used to present herself very regularly at Goodall’s a young woman with her four-ounce laudanum vial. That she used twice four ounces every day was manifest from a circumstance she did not appear herself to have thought of, the extra label that had been superadded at another shop. There was a merchant who had broken down upon McMunn’s, an irregular visitor at Gates’s, who whenever he called would drink off a vial of the elixir, and take away several of the same sort, for occasional use only as he pretended, when doubtless he did the same thing at other druggeries. A Frenchman, known to Naumann for nineteen years, who all this time and even before had been familiar with laudanum, had a two-thirds ounce vial, which he was very particular to have filled once a day. The double labelling it was that exposed him. Long and freely as this monsieur had been addicted to his stimulus, he showed no distinctive indication of the habit other than in the peculiar sallowness of complexion.
Devices intended for disguising the extent if not the fact of the enslavement are as ingenious and varied as the contrivers are numerous. Two considerations act as prompters to such course; the supposed power of exerting a certain self-control over the paroxysmal excitement, and the apprehension of encountering a frowning public opinion in case the deception is unmasked.
Miss P., a spinster of thirty summers (and who was liable to continue such for as many winters), had purchased of Loines in the course of two years (so the ledger showed) 13 gallons of McMunn’s solution, without enumerating the additional supplies she had certainly procured in the interims from other establishments. This course it appears had been followed up so clandestinely all the while, that outside of her own family not a surmise of the existing habit had found place even among the naturally credulous. Opium eaters, if they cannot obviate suspicion altogether, may by the exercise of a dextrous ingenuity often put this same suspicion on its good behavior. A nibble from the mass, a pinch from the packet or a sip from the vial may create no more wonder, than the brandy flask slyly drawn from the pocket, or the delicate thumbing of the rappee box by the suaviter-faced tourist in the linen overall.
Reductions upon established doses, palpable in quantity if not of permanent continuance too, are to be reckoned among the actualities as well as the possibilities. De Quincey once fell back from his professed maximum of 8000 drops to 1000, and without experiencing any considerable discomfort either. Mr. B. of the Hospital calculated upon personal trials, that for real working service half an ounce of the gum or half a drachm of the alkaloid is as good as twice that. In the occasional use, amidst the daily avocations of business, it is possible to exercise much “prudence and discretion,” what is in accordance with the views of Dr. Pitcher (who appears to have a sharp eye for observation), and also of Dr. Lee. The merchant, for instance, who feels the need of an extra stimulus of some sort, by substituting a pill of opium in place of the half-gill of whiskey, is better able to work himself out of the perplexities of the hour without attracting the notice of some censorious neighbor, who is ever quick in discerning the mote in a brother’s eye though unaware all the time of the beam in his own eye.