Morphinism: Morphinism in the Young. A Tale of the Poppy and its Moral. Morphinism in the Old; Cases at Three Score and Ten; Recovery. Morphinism in Women. BY J. B. Mattison, M. D., BROOKLYN, N. Y. Medical Director, Brooklyn Home for Narcotic Inebriates; Member American Medical Association; American Association for the Cure of Inebriety; New York Academy of Medicine; New York Medico-Legal Society; Brooklyn Neurological Society; Medical Society of the County of Kings. Read Before the New York Academy of Medicine, io, ii, 15 and 24, Oct., 1895. Reprinted from the Atlantic Medical Weekly for March 14, April 11, June 6 and June 20, 1896. [Reprinted from the Atlantic Medical Weekly for March 14, 1896.] MORPHINISM IN THE YOUNG. By J. B. MATTISON, M. D.,* Brooklyn, N. Y. Medical Director, Brooklyn Home for Habitues ; Mem- ber American Medical Association ; American Asso- ciation for the Cure of Inebriety ; New York Academy of Medicine; New York Medico-Legal Society; Brooklyn Neurological Society; Medical Society of the County of Kings. Morphinism in the young is rare. This statement refers to recorded cases. Obersteiner, Zambaco, Jennings and others, abroad, who have had experi- ence with the morphine disease, told me they had not met it. My own ex- perience, compassing the care of many hundred cases of morphinism, has not covered one in a child. The literature of the subject is meagre. I have con- sulted dozens of books on diseases of children to find only a single reference to it-that, Meadows' work; and careful search through medical journals, at *Read before the Section on Pediatrics, New York Academy of Medicine, October io, 1895. 2 home and abroad-per Index Mediczis and elsewhere-disclosed only five pa- pers,-Carson, 1885; Amabile, 1886; Earle, 1887; Kiernan; 1891; Fischer, 1894. Calkins, Hubbard and Erlen- meyer refer to it mainly, hereditary cases. Morphinism in children may be con- genital or acquired. The latter is more often noted, because many cases of the former are overlooked, not being recog- nized by the doctor, who, unaware of morphinism in the mother, fails to ap- preciate the import of certain symptoms in the babe soon after birth, and the sup- ply of narcotic nutriment (so to speak), as well as other nourishment-for the lacteal secretion is usually suspended- being cut off, the child speedily falls in- to fatal collapse. One of the most notable cases of this kind ever cited was by Dr. Frank B. Earle, before the Chicago Medical Society, in December, 1887. In the pre- ceding October he attended at the birth of a ten pound girl, whose mother-a morphinist-seemed specially solicitous 3 regarding- her babe. Inquiry revealed the fact that three children died soon after birth, the first in two-and-a-half days, the second in three days and the third in four days. In this case, on the third day, the child became sleepless, pale and prostrate. Twelve hours after, was found pulseless and cyanotic; five minutes later, died. The mother had taken eight to fourteen grains of mor- phia, daily, commencing soon after mar- riage. Most cases of acquired morphinism in children are met with in general practice, being noted by the family doc- tor, and by him often treated with suc- cess. Those presented in this paper-now first published-are from that source, and to the medical men who have given them to me I tender my thankful ap- preciation. Case I.-Dr. R. E. Howard. Twins, three months old; healthy, save being fretful and restless at night. By medical advice they were given Papine, in four drop doses. Papine is the product of a western drug house and con- tains one-eighth of a grain of morphia to the 4 drachm. One month after, each child was getting one drachm-one-eighth of a grain of morphine-at 5 p. m., daily. Four weekslater I was consulted and advised abrupt withdrawal. This was done, but for seven days and nights they were the most nervous little creatures I ever saw, did not sleep more than ten minutes at a time, and cried almost incessantly. At the end of a week they went to sleep from sheer exhaustion, and later did well. Case II.-Dr. I. H. Cuffman. Infant, three weeks old, was given two drops laudanum, three times daily for relief of colic. Two weeks later dose was increased to three drops, four times a day. This increase was continued till at the age of seven weeks babe was getting six drops of laudanum six times a day. Ordered it decreased one drop daily and gave chloral and bromide of sodium when needed, and in seven weeks quit the opiate. The child steadily improved and regained perfect health. Case III--Dr. F. I. Given. Boy, twelve years, was given ten drops of tincture of opium to ease the pain from an injured scalp. When the wound healed the opiate need had become fixed, and during one year the amount increased to twenty-five drops each night. Without it he became restless, sleepless and hard to control. The boy is pale and frail, has the facial look of an old man, is listless, with little care for play. Owing to a structural cardiac lesion no treatment of his opium disease has been given. 5 Case IV.-Dr. C. H. Dove well. In the spring of 1872 I was called to see a sick child and found this case. Babe, about seven months old, wrinkled and shriveled like a person of ninety, with a strange solemn manner and stare. Inquiry elicited the fact that it was a first-born, normal in size and appearance at birth, grew fat and seemed in perfect health till it was four months old, when it began to reject food and to fret and cry. To quiet this, paregoric was given, but it soon needed so much that laudanum was used, and this increased to an average of a tea- spoonful every three hours,so that at time of my call this little seven months creature was getting an ounce of laudanum each day. It weighed about seven pounds, had a big belly, with arms and legs that were a wonderful sight,-simply bone covered loosely by skin that would form a sort of " fringe " when the limb was extended. The head was of usual size, though it seemed much larger, but the neck muscles were so slight they would not support it. Nursing limited to one-eighth of usual amount, every third hour, stopped the vomiting. The laud- anum was reduced one drop each dose, with directions not to give till certain symptoms ensued. No medicine was given. Food was retained, the skin filled out, and at the end of a month the babe was plump and happy. The o'piate was entirely and permanently ended, and the babe developed into a robust boy-now a voter. 6 In reviewing cases of morphinism in children, one cannot fail to note with surprise the facility with which the disease is created, and its rapid growth as shown by an increase of the opiate daily given. As regards the latter point, my experience amonghundreds of opium habitues presents no such notable case as the one last cited, when a child seven months old was getting at the end of three months six grains of morphine a day! That case is unique. Incident to the rise and progress of this disease in children, one point of in- terest and importance presents. There are those in the profession who think that the main genetic factor in morphin- ism is mere moral obliquity on the part of the patient; simply a vicious desire for the pleasure, so-called, of the poppy. I have long held and still hold, increas- ingly so, (see two papers, " The Ethics of Opium Habitues," reprint, if de- sired) that this opinion, as related to most habitues of the better class, is a mistaken one; that these patients do not take opium from an innate propen- 7 sity to evil, but because of a physical necessity. What becomes of the opposite argument in cases such as we have cited? And what more needed to prove it unsound? Surely this sort of "vicious desire" does not obtain among babies! Surely " evil propensity " along this line does not play a part in patients six months old! No, no, a physical need creates, and-made greater by the narcotic, for it grows by what it feeds on-a physical need continues. In the immense major- ity of cases, among young and old, this may be accepted as an etiological fact. So much as to the cause of morphin- ism in the young. What the conse- quence? Speedy decline and death. This the rule; exceptions noted. Details need not detain us. Nutrition centres bear the brunt of opiate excess, which tends to marasmic decay. En passant, it may be noted that the symptoms of this disease in the young, when the opiate is withheld or withdrawn, prove, beyond questio , its somatic status, and that psychic factors have no place either in 8 causation or continuance. Th ey furnish, too, still further disproof of its "vice" origin, for, obviously, neither weak or perverted will to cause, nor strong voli- tion to cure, which, according to some -crassly ignorant of facts-is all that is needed, can, in infantile cases, pos- sibly obtain. The prognosis of morphinism in the young is good. Every case, if uncon- nected with structrual lesion, or if nutrition be not too greatly damaged, and if given proper care, can be cured. The treatment should be slow opiate withdrawal with such roborant regime as will best tend to pristine health. Un- der no condition, save very limited tak- ing, or some other, quite beyond con- trol, should the opium quitting be abruptly complete. The latter plan in the adult-a method monstrous, brutal, mentioned only to be denozmced-not infrequently causes fatal collapse; a peril much more likely in the delicate organism of the young. Mr. Chairman, in closing this paper I cannot refrain from expressing my 9 conviction that morphinism in children is far more prevalent than the paucity of recorded cases implies, and has a much larger influence on infantile mor- tality than vital statistics attest. In the lax condition of things now existing as to supervision of the manufacture and sale of the many nostrums lauded for relief of the painful, spasmodic diseases of child-life; in the certainty that most, if not all, of these mixtures contain opium in some form; in the fact that mothers and nurses, ignorant or care- less or culpable,give, all too often, these insidious disturbers of infantile health; and in the facility with which the dis- ease can be begun, is to be found the reason for my belief in a wide-spread prevalence of morphinism among the young. As a factor in the death-rate, I believe many cases are overlooked by the doctor, because, no thought being given to the use of opium in parent or child, no query is made of the mother or nurse regarding it; and the signs of morphinism being masked by-or mis- taken for-other symptoms, and the 10 needful opiate being unwittingly with- held, the little patient, deprived of a vital support, falls into fatal collapse, or be- comes an easier victim to other disease. If my belief along these lines be well founded, certain preventive measures to better this situation are suggested. They are (i) instruction by the doctor to mothers and nurses of the risk in giving any form of opium to the young; (2) na- tional or state control of all proprietary medicines, compelling their makers to place the formula on every box or bottle, so that "he who runs may read"; (3) careful inquiry, when called to a sick child, as to opium taking in any form, by the mother, before or after the birth of her babe, and as to its giving, in any guise, to the child. Prudent forethought, with proper care, will go far to lessen this one of the ills to which infant life is heir. Prospect Place, near Prospect Park. [Reprinted from the Atlantic Medical Weekly for April xx, 1896.] A TALE OF THE POPPY AND ITS MORAL. By J. B. MATTISON, M. D.,* Brooklyn, N. Y. Medical Director, Brooklyn Home for Habitues ; Mem- ber American Medical Association ; American Asso- ciation for the Cure of Inebriety ; New York Academy of Medicine; New York Medico-Legal Society; Brooklyn Neurological Society ; Medical Society of the County of Kings. History repeats itself so often and with such unerring certainty along ge- netic lines, as regards morphinism and other narcotic ills, that the tale told in this paper will be neither novel nor new; but if the moral that adorns it shall carry the conviction its importance de- serves, we can-by virtue of the fact that prevention does greater good than cure-hope that the sum total of this phase of human ail may be lessened; and, if this wished-for result be accom- *Read before the Section on Neurology, New York Academy pf Medicine, October u, 1895. < 2 plished-be the measure thereof only small-I shall be content. In a paper, "The Etiology of Nar- cotic Inebriety," read before the Brook- lyn Neurological Society, December 14, 1892-reprint at command-it was as- serted that my experience, compassing the history of many hundred cases, had brought a belief-the truth of which no mere theorizing or exonerative desire towards professional confreres can les- sen in the least-that in the great ma- jority of the better class cases of this disease, the largest share of responsi- bility in causation-even granting that it may, in many, be non-active or small -must be laid at the door of the doctor. In asserting this, the fact was not lost sight of that various antecedent or con- curring causes played a part; but quite aside from all these, there stood out in bold relief such a measure of personal responsibility, either active or passive, on the part of the attending medical man as could neither be doubted nor denied. The cases cited to-night add force to this fact, and emphasize ^still more 3 strongly the truth and value of certain deductions, and the ever-present, ever- urgent need of that caution and care in the use of our most common narcotic, which a prudent forethought undoubt- edly demands. Four years ago there came to my care a woman who, for ten years, had been taking morphia, part of the time in large amount, reaching an acme of thirty grs. a day. From a maternal ancestry tainted along neurotic lines there had come to her the heritage of that bane bf Ameri- can women,-headache. As so often occurs, unless rightly treated, this painful condition was met by her medi- cal adviser with morphia in quarter grain doses, whenever needed; without knowledge on her part as to its nature; with no warning as to possible ill; indeed, quite the reverse, for assurance was given that no solicitude need be felt on that score. And so, soon the old story, which, freighted with more of sorrow than the world will ever know, has come to me so often,-growing by 4 what it fed on, the soothing but snare- ful drug became part and parcel of her daily need-need, I say, not desire, vicious desire, as some mistakenly put it-for I hold that under such condi- tions any charge of mere moral obli- quity that so often is made against this hapless folk is quite without war- rant, because no larger measure of per- sonal responsibility in causation obtains than in many other departures from physical health. Of the half-score years of poppy bond- age we need not now detail. Enough to say they made up the same gruesome story of ill health of body and ardent, sorrowful longings for "a freedom-like life made new. " At last the wished-for time arrived, but so strongy trenched was the opiate enemy that nearly a six months' seige was needed before the victory was complete. And it has con- tinued, for the woman is well to-day. Two weeks after the date I deemed it safe to dismiss this patient, a sister, four years the junior, presented herself with precisely the same story of mor- 5 phia taking as to cause, duration and amount. Such a double history, so similar in essential details, is, in tny experience, unique; and a peculiar fea- ture in each case was that the initial form of the opiate-using-quarter grain granules-was continued, so that these women came to take more than a hun- dred morphia granules daily, year after year. Treatment, in this case, was a failure. The woman, despite her lesser years, seemed to have been made in a differ- ent mould, and the pernicious effect of the poppy, particularly in a damaged morale, was much more marked. Per- sistent curative effort was of no lasting avail. After a few months' re-use of the drug-this time the opiate tincture -on urgent request, a second attempt at cure was made, but without success. The case proving one in which the only hope of permanent recovery was in co- ercive care long continued, and con- ditions being such that this was not at command, treatment ended. The woman is given a daily stipend of opium, and, 6 most likely, will live atid die under the poppy spell. In January of last year, through the courtesy of Dr. John A. McCorkle, Mrs. A., widow, aet. fifty-two, consulted me regarding herself and told this story. Ten years before, for relief of a dis- turbed cardiac condition, her medical adviser gave: R Spts. Eth. Comp. Spts. Lavand. Syr. Simp aa 3iij Sol. Morph. Magendie. Eld. Ext. Convallar aa 3ss Aq. Camphorse aa § ij M.S. One drachm every half hour till relieved. Each dose had one-sixteenth gr. mor- phia. It served a good purpose in im- proving heart action, but ere many moons waned it had made itself increas- ingly needful, and at time of coming to me she was taking the mixture in ounce doses several times a day. Repeated self-effort to quit was without success. Under treatment she made a good re- covery, and has remained well. So much for the tale. What the moral? This-Caution in all cases where mor- phia may seem called for, and a watch- 7 ful care, if it be given, lest the outcome of its taking be that of the cases we have cited. In those of the sisters, the ancestral record was such as should have prompt- ed the doctor, before giving, to weigh well the chance of such an untoward result and by after watch and ward avert it. In migraine of women, treated with morphia, there is special risk that the interim between doses will steadily and speedily lessen till the opiate tak- ing is continuous. In no other condition is the risk so large, not even in the often painful periods incident to their sex. That being so, the importance of special care is obvious, and must be given, if the future good of the patient is to be conserved. In the third Case, with a dose so small, the chance of an ill ending seemed slight, yet morphinism became a fact. The wisdom of its giving in this case seems to me open to question, for it is not unfair to presume that a non-opiate regime would have effected'the desired result. Had the impaired heart status 8 been structural, there might have been less cause for criticism, for there are certain organic departures from cardiac health when opium in some form is of sovereign value. The small initial taking in this case- less than two minims of magendie- doubly emphasizes the poppy peril, for it proved large enough to do harm. I have been told of a teacher in a leading medical school who was wont to com- mend for relief from the fatigue of his overworked calling, i minim magendie subcutan. If such were true, I am bound to say the advice was pernicious, for many a doctor, following such coun- sel, would find it cause for life-long re- gret. This tale again brings us face to face with the fact that in neurotic dis- eases treated with narcotics the doc- tor is, in a special sense, his brother's keeper, and it becomes him to take full cognizance of all conditions, past and present, on which, unless rightly appre- ciated, the danger of creating a drug disease so largely depends. To give relief from one ill only to make a 9 greater, is a sorry ending to a well meant endeavor; but such an ending is almost certain if there be neglect of those precautions to which we have referred. Regarding the increase of morphin- ism in America, I am optimistic. In my opinion, the disease is on the wane; and the most hopeful feature of this devoutly-to-be-wished-for decline is that its greatest factor is found in the very field that once was so largely given over to the growth of this disease,-that is, in the profession. Wish it as we will, excuse it as we may, it is a fact, neither to be gainsaid noi' set aside, that the main measure of responsibility, direct or indirect, for the rise-rise, I say, not progress-of morphinism rests on med- cal men, and it is cause- for profound gratulation that, in steadily increasing number, they are coming to realize this fact, and, as much as in them lies, are striving to make amends for the mis- chief already made, by a less frequent counseling and less lavish giving of this snareful drug. 10 I believe this bettered state of things more largely obtains among the senior members of the profession, but quite as much is my belief that this wise pre- cept and practice of the fathers of our fraternity will, at no distant day, be followed by the sons. Speed that good time, for when it comes, the millenium will be nearer than now. Prospect Place, near Prospect Park. [Reprinted from the Atlantic Medical Weekly for June 6, 1896.] MORPHINISM IN THE OLD ; CASES AT THREE SCORE AND TEN; RECOVERY. By J. B. MATTISON, M. D.,* Brooklyn, N. Y. Medical Director, Brooklyn Home for Habitues ; Mem- ber American Medical Association ; American Asso- ciation for the Cure of Inebriety ; New York Academy of Medicine; New York Medico-Legal Society; Brooklyn Neurological Society ; Medical Society of the County of Kings. Morphinism in the old is rare. Most cases of this neurosis are noted be- tween thirty and forty, and the disease steadily declines in frequency during later decades. In a paper -"Morphinism in the Young"-attention was called to the rarity of this disorder in children, as evidenced by reported cases, but the be- lief was expressed, and proof presented, that it prevails much more largely ♦Read before the Section on General Medicine, New York Academy of Medicine, October 15, 1895. 2 than clinical records or mortality tables attest. This toxic factor in the ill-health of old age is, for reason soon given, much more patent than in the earlier days of life. In the latter, many cases are the unsuspected heritage of a maternal an- cestry tainted along narcotic lines; and most of these, I believe, being unrecog- nized, and not given proper care, flash, so to say, flicker and go out, death usually coming before the fourth day; and of acquired cases, the outcome of ignorant or indiscreet poppy giving by mothers or nurses, not a few are masked by symptoms of other disease, but, in the old, no such ignorance of causation, or the true narcotic status obtains. Some-not all-of the genetic factors of morphinism in middle life play a part in the old, but lack of the most common cause-pain-may, I think, be safely set down as the main reason for its infrequency in senile life. Neuralgia is, in my experience, the most prolific cause of morphinism, but neuralgia is, essentially, a disease of the 3 first four decades, and if the fifty year period be passed without it, the chance of its coming steadily lessens, unless it be from structural lesion or morbid growth. Pain, of brawn or brain, has been the cause of every case of mor- phinism after the age of fifty that has come to my care. Of those cited in this paper, one was due to sciatica, the other to-what might be termed mental pain -melancholia. Both were laymen; one was seventy, the other seventy-two. In the former, the disease had persisted four years; the opiate was laudanum,and sometimes rum, taken to excess. The latter had used morphia twenty years, but reaching only four grs. daily, sub- cutan. His physical status was much impaired; the other's physique had not been greatly disturbed, but his mental darkness persisted, despite the opiate. The hypodermic user was under care eleven weeks; the other, twelve. De- tails of treatment need not detain us. Each recovered. The elder patient, who took morphia, lived fifteen months -"a complete cure," his physician re- 4 ported-and died of albuminuria. The other survived four years, free from opium, and died of old age. Genetic details of morphinism in the old being largely like those of middle life, call for no special comment. Regarding results, they are, as a rule, less disastrous than in earlier years. Two things tend mainly to this. One is a less lavish use of the drug. Old folks seldom take it to excess. The lessened work and care of later life make no such demand for its stimulant effect -which comes to be a factor in con- tinued taking, quite apart from its pain easing power-as among patients of middle life. Again, and this I take to be the most important factor of all, it is my belief that in a certain proportion of cases- and that proportion not small-the moderate use of opium after the age of three score and five, is salutary, dis- tinctly conducive to length of days. Quite apart from its supportive effect at this time of life, when vital force is on the wane, it unquestionably has a pro- 5 tective, prophylactic power against in- flammatory disease. En passant, it may be noted that this preventive action ob- tains among opium habitues in earlier life, and the reverse when the habitual opiate is withdrawn, they being exposed to special, but steadily decreasing, risk along this line during the early absti- nence time. A striking case of this sort, showing the conservative effect of opium, oc- curred in my own social circle. A dear friend was gathered to her fathers at the age of eighty-six. She suffered from sciatica, and for several years prior to her death took, by my counsel, daily- sometimes semi-daily-opium, in the form of Squibb's deodorized tincture, in doses seldom exceeding ten or twelve drops. It worked well, gave her more sleepful nights, more painless days. That case may have been exceptional, inasmuch as so small a dose-for it never exceeded fifteen drops, and, con- trary to the rule in earlier life, did not "grow by what it fed on "-served her so well. Be that as it may, there is not 6 the slightest doubt on my part that it prolonged her life,-years; and not only did she live longer, but she lived in much more comfort. The wear of her neuralgic pain was well met by the anodyne-soporific-tonic good of the opi- ate. It was of sovereign value. The prognosis of morphinism in the old, among cases eligible for treatment, is good. The proportion of perma- nent recoveries in patients above sixty, under my care, has been larger than in those below that age. The main rea- son for this is the larger liability to re- curring causes in ex-morphinists of middle life, and the fact that sufficient time is not taken by the latter for such prolonged post-active treatment as will make certain of a continued good get- ting on,-vide paper, " The Post-Active Treatment of Narcotic Habitues." Es- pecially is this so with medical men, who form seventy per cent, of those who honor me with their care. With the coming of improved health, when the opium incubus is removed, comes the danger of a premature return to 7 professional work. This, in my experi- ence, has been the most frequent cause of a recurring of this disease. The re- mote future, much more than the im- mediate, of my patients gives me most concern. Despite the fact of their be- ing physicians, too many of them do not realize this peril; do not appreciate the fact that, in many cases, months, and even years, of hygienic care and favora- ble environment, after active treatment is ended, are absolutely essential for a lasting cure. After what has been said of the beneficent effect of opium, often- times, in the old, it will be inferred that some such cases of morphinism are not eligible for treatment. That is true. Under such conditions, the best plan is to give that form of opiate tending least to untoward effect-and that, in my opinion, is the crude drug, or deo- dorized tincture, morphia subcutan. be- ing the most disastrous-and in the most limited amount that will serve the end desired. In cases where it is deemed best to entirely withdraw the opiate, treatment 8 must be adapted to the special need of each case. The patient, as well as his disease, should be treated. In proper cases, the Mattison method, which it is a pleasure to commend, because I know its value, may be used with full promise of good. In others, a more gradual opiate de- crease is best, taking months, and with it a full, roborant regime. Under no conditions, save those of very limited using, both as to time and amount, or others peculiar and be- yond control, should the quitting be abruptly complete. This method, monstrous, brutal, mentioned only to be denounced, sometimes causes fatal col- lapse in the vigor of middle life, a peril much more likely in the weakened or- ganism of the old. Prospect Place, near Prospect Park. [Reprinted from the Atlantic Medical Weekly for June 20, 1896.] MORPHINISM IN WOMEN. By J. B. MATTISON, M. D. ,* Brooklyn, N. Y. Medical Director, Brooklyn Home for Habitues ; Mem- ber American Medical Association ; American Asso- ciation for the Cure of Inebriety ; New York Academy of Medicine; New York Medico-Legal Society; Brooklyn Neurological Society ; Medical Society of the County of Kings. Morphinism in women is not rare. The assertion has been made, and that opinion somewhat obtains, that it is less often noted among men; but my expe- rience is not in keeping with that belief. Inference is not fact, and I am unaware of any proof that it prevails more largely among the gentler sex. The genesis of morphinism in women pre- sents no special variation from that re- lating to men. A physical necessity- not "vicious desire," not innate propen- sity to wrong, as some mistakenly put *Read before the Section on Gynecology, New York Acad- emy of Medicine, October 24, 1895. 2 it-stands out strongly along causation lines in almost every case among the better class. Even those departures from physical health, peculiar to their sex, which lead up to this toxic neuro- sis, have as the one great factor, pain. The diagnosis of morphinism in wo- men need never be difficult. Often, however, it is. Usually a consensus of symptoms, the import of which is dis- tinctive, though details need not detain us, mark the disease, even to the non- expert. But there are cases-and not a few-where the lack of somatic signs, combined with denial of the drug tak- ing-a denial due to the desire,common to most habitues, to protect herself from unkind and unjust judgment (the out- come of ignorance as to the true ethics of these cases), which prompts her to conceal the opiate using-make it not easy to determine the true condition. There is a largely held opinion that all morphinists have a set of symptoms which leave little doubt as to diagnosis. That is not true. Many of them, ob- jective as well as subjective, pertain to 3 other diseases. Some morphinists use the drug years with little departure from mind and body health. I recall a strik- ing case: New England physician who had taken morphia fifteen years, by mouth, reaching a six grains daily using, in whom I noted no evidence of his dis- ease. Another notable instance was that of Mrs. A., wife of a New York doctor, whose case, in 1888, figured largely in the courts, during a suit for divorce. Charge was made that she was a morphinist. It was denied. She was examined by two physicians, who declared her free from the disease. They were mistaken. She had been an habitue six years. She came under my care, made a good recovery, and has remained well. The mistaken opinion as to the patent signs of morphinism has led to legal error. The most notable of recent years was in the case of Carlyle Har- ris. You will remember that applica- tion was made for a new trial on the ground of evidence that his wife had been a morphinist. The application 4 was denied, and in anopinion accompa- nying, the presiding judge laid much stress-most stress, if I mistake not-on his belief that had Mrs. Harris been an habitue, it would have been known to her husband, for whom, in a former trial, no such extenuating plea had been presented. I have known again and again mor- phinism in the wife concealed from her husband for years. In view of this fact, I have no hesitation in saying that the opinion of Recorder Smyth, refusing a new trial on that ground, was a grave judicial error. The detection of morphinism in wo- men need never be difficult. We have infallible means to decide it. Two tests place the diagnosis beyond doubt. One is urinary analysis; the other, enforced abstinence. The latter is the better. The former is best made by the Bartley process,-Dr. E. H. Bartley, Professor of Chemistry, L. I. College Hospital. There are other methods, but they are complex. This is simple and sure. It is: Make suspected urine alkaline with 5 carbonate of soda. To this add one- fourth of its volume of chloroform or amylic alcohol. Shake well, allow to settle, draw off the chloroform and add small amount of iodic acid. If morphia be present, a violet tinge will be noted. The other test suggests itself. Forced abstinence from morphia for forty-eight hours will surely give rise to reflex symptoms due to opiate need, and settle habitual taking beyond dispute. The length of opiate using in cases under my care has been from six months to twenty-two years. The for- mer took morphia subcutan., recovered in five weeks, and has been in good health several years. The other used 14 5 laudanum daily, and was not cured. The daily amount of poppy taken has varied from nine-tenths of a gr. to forty grs. morphia subcutan. Both were women. The former had been given the drug ten years, and it seems scarcely credible that the daily giving was so small. In that, the case was unique. All tests to prove larger using failed. The secret of the unprecedentedly small 6 amount was found in the fact that it was never self-taken. Patient was dismissed in five weeks cured,in the winter of 1892, and has continued well. The case of forty grains daily subcutan. taking was a brilliant literary woman. The first treatment was a success, which continu- ed three years. The disease has recurred several times. Treatment has not been, probably will not be, of lasting avail. Three women, each taking thirty grains morphia per day,by mouth, have been noted. Two were sisters, each ten years' takers, the other seventeen years. The latter and one of the sisters recov- ered four years ago. The disease has not returned. Morphinism in women is, as in men, disastrous. You need not be told it in detail. The most important feature of it concerns functions peculiar to their sex,-ovulation, fecundation. The for- mer is almost always disturbed, often very irregular, sometimes long sus- pended. This condition is non-struct- ural, and on removal of the cause rights itself. As a sequence of this status, 7 most women morphinists are sterile. Marked exceptions, however, have been noted. The most notable case of the kind known to me, and emphasizing the need of special post-partum care to these miniature morphinists lest they die in collapse, was reported by Dr. Frank B. Earle, of Chicago, in Decem- ber, 1887. The preceding October, he attended at the birth of a ten pound girl, whose mother, a morphinist, seemed specially solicitous regarding her babe. Inquiry revealed the fact that three children died soon after birth,-the first in two and a half days, the second in three days, and the third on the fourth day. In this case, on the third day, the child became sleepless, pale and prostrate. Twelve hours after was found pulseless and cyanotic; five minutes later, died. Themother had taken eight to fourteen grains of morphia daily, commencing soon after marriage. The sterility of morphinism ends soon after the removal of drug. My clini- cal records show quite a colony of post- poppy babies. 8 The prognosis of morphinism in women, in cases eligible for treatment, is good. ^.Based on my experience, it is better th'en in men. The main reason for this is the larger liability to recur- ring causes among the latter. Of those who honor me with their care, seventy per cent, are medical men. With the coming of improved health, when the opium incubus is removed, comes the danger of a premature return to profes- sional work. This is the rock on which the doctors founder. This, with the lack of that prolonged post-active treatment -hygienic care and favoring environ- ment, which, continued through months, or even years, is absolutely essential to a lasting cure-is, I take it, the great factor in a recurrence of morphinism in medical men. Recovery may be secured in some cases where the prospect seems signally unhopeful. My most striking case of this sort was noted in 1884. A Cana- dian lady-a lady by title as well as her accomplishments-was brought to me by her medical and legal advisers, 9 who had accompanied her because her condition was such they deemed it doubt- ful whether she survived the journey. She was the greatest wreck from mor- phia I ever met. Physically she was too weak to walk ; mentally she was im- becilic in look and talk; had various de- lusions; hallucinations of sight and sound, and-the only instance in many hundred cases-hallucinations of touch, not only seeing bugsand reptiles crawl- ing over her, but feeling them as well. A more pitiable case could not well be pictured. She responded promptly to treatment, made an excellent recovery, -her psychical betterment outpacing the somatic-was dismissed, cured, in eleven weeks, and has remained well nearly eleven years,-tidings, by tele- gram, to that effect, reaching me to-day. The treatment of morphinism in women, like that in men, must depend on conditions peculiar to each case. The patient as well as her disease must be treated. Changes incident to her sex must be met and adjusted. In my ex- perience, however, the need in this re- 10 gard has been small. In most cases, nature, freed from poppy fetters, has, unaided, reasserted herself. Along other lines there need be no special thera- peutic departure. Speaking broadly, more prolonged treatment than in men is usually required. The extremes in recoveries under my care have been five weeks, and six months. The latter was a ten years' case, with a daily morphia taking of thirty grs. by mouth. The seige was a long one, but it was a suc- cess. In proper cases, the Mattison method -which it is a pleasure to commend, because I know its value-may be used with full promise of success. Other cases should have a more gradual mor- phia quitting. Not seldom the opiate plays a minor part in the situation,-pro- found neurasthenia or other condition being of larger import. Such a case is now under my care: a brilliant young woman, wife of a physician, weary and wakeful from constant care of her hus- band, who from morphia-cocaine excess will soon reach a graveyard or a mad- 11 house. Three months ago she was given morphia, subcutan., to bring rest and sleep, and-history repeated itself. The drug made special havoc in her case, for from an avoirdupois of 140 she wasted to 70. The tide has turned; she weighs 96; she will recover, but months of active treatment and pro- longed post-active care will be needed, because underlying her toxic neurosis, is a profoundly depressed nerve status that will require long time to restore. Treatment in women enceinte may be effected-by non-abrupt method- without solicitude as to mother or babe, any time before the fourth month. After that the risk to each progressively in- creases. If gestation be completed, special care must be given the child, lest it die in collapse, which so often proves fatal in such cases. Under no conditions, save very lim- ited opiate taking as to time and amount, or others beyond control, should the morphia quitting be abruptly complete. This method-monstrous, brrital, men- tioned only to be denounced-always en- 12 tails needless suffering, and sometimes ends in fatal collapse. Two such cases, both women, one in a Brooklyn hos- pital, the other in a Virginia asylum, are known to me. Never was there so little excuse for it, for never was the humane treatment of the morphine dis- ease so simple, so satisfactory, and so successful as now. Mr. Chairman, in reviewing the sub- ject of morphinism in women, I am profoundly impressed with a belief which has steadily grown stronger, that the largest measure of good work by the profession, in this field, lies not along the line of cure, but prevention. Morphinism has its rise in painful or other disorders, met by morphia. In many cases this must needs be, but in many more it need not be. Morphin- ism is, largely, a preventable disease. This fact, and my belief that the pro- fession is increasingly appreciating it, and by less frequent counseling and less lavish giving of this snareful drug are steadily tending to lessen the growth of the disease, make me optimistic regard- 13 ing morphinism in America. I think it on the wane. To the fathers of our fraternity, in my opinion, much credit for this is due, for, by more care- ful thought, or an experience often un- happy, they have come to realize the danger ever connected with a careless or uncalled for use of morphia; but I believe their wise precept and practice is bound to have a like effect upon the sons, and, at no distant day, redound to the glory of the profession, and the good of human kind. Prospect Place, near Prospect Park.