m ■ ... . ■;;-'.'^;,, ffiOgi&SStiSmm ■■■ Cornell Untueraitg Sabrarg Stljara, 2fw» Quick CHARLES WILLIAM WASON COLLECTION CHINA AND THE CHINESE THE GIFT OF CHARLES WILLIAM WASON CLASS OF 1876 1918 Cornell University Library RC 369.K16 Drugs that enslave :the opium morphine. 3 1924 024 009 890 111 Cornell University Library The original of this book is in the Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924024009890 1 ^^^ 1%-W |L \ / . ^ ; - : -^M ? *J F— &^ L « y 11 fl SflRL«. — - — LAOL'DON. Clamorcs simul horrendos ad sidera lullil." !7c.'//, sEncid, Lit>. 11. The knotted coils lie strains to tear apart, Filling the air and heaven with horrid cries Drugs That Enslave. the OPIUM, MORPHINE, CHLORAL AND HASHISCH HABITS. BY H. H. KANE, M. D., NEW YORK CITY. " They are drunken, but not with wine ; they stagger, but not with strong drink." — Isaiah. '* What warre so cruelle, and what siege so sore, To bring the sowle into captivitie, As that fierce appetite doth fain supplie !" PHILADELPHIA: PRESLEY BLAKISTON, 1012 WALNUT STREET. l88l. Entered, according to Act of Congress, in the year 1881, by PRESLEY BLAKISTON, n the office of the Librarian of Congress, at Washington, D. C. To §x. ^Isxm&tx f. (!!,. $fe*>«, Professor of the Medical and Surgical Diseases of Women and the Diseases of Children, in the Long Island College Hospital, Brooklyn, N. Y., THIS LITTLE WORK IS DEDICATED, as a mark of the high esteem, both as regards his scientific attainments, untiring energy, and the largeness of his heart, in which he is held by his old pupil and sincere admirer, THE AUTHOR. PREFACE. The idea of writing this little work was first suggested to me by the numerous letters received from physicians at home and abroad, asking for information on various points connected with the symptomatology, prognosis and treat- ment of the various "habits." While manifesting an earnest desire to become acquainted with the main features of the conditions in question, many presented a lamentable ignorance of the simple facts relating to them. These facts I have endeavored to present in as compre- hensive, yet concise, a form as possible. But little space has been devoted to the study of the hashisch habit, owing to its rarity in this country. The statements as to the dangers and peculiarities of these conditions, aside from what I have myself observed, are based upon the literature of the subject, and the letters of nearly a thousand correspondents in various parts of the world, to whom I take this occasion for returning my hearty thanks. igi West Tenth Street, New York City. " After my death I earnestly entreat that a full and unqualified narrative of my wretchedness, and of its guilty cause, may be made public, that at least some little good may be effected by the direful example." — Coleridge. A curse that is daily spreading, that is daily rejoicing in an increased number of victims, that entangles in its hideous meshes such great men as Coleridge, De Quincey, William Blair, Robert Hall, John Randolph, and William Wilberforce, besides thousands of others whose vice is unknown, should demand of us a searching and scientific examination. As an illustration of the enormous increase of the use of opium and morphia in the United States, the following statis- tics have a painful interest, and it must be remembered that this is no exceptional case. In one of our large cities, contain- ing, twenty-five years ago, a population of 57,000, the sales of opium and morphia reached 350 pounds and 375 ounces, respectively, or about 43 grains of opium and 3 grains of mor- phia yearly for each individual, if the consumption was averaged. The population is now 91,000, and 3500 pounds of opium and 5500 ounces of morphia are sold annually. While the population has increased 59 per cent., the sale of opium has increased 900 per cent., and morphia 1100, or an average of 206 grains of opium and 24 grains of morphia to every in- habitant. But there are additional sales of from 400,000 to 500,000 pills of morphia, which would give us 170 ounces more of the drug. One-fourth of the opium sold is consumed in its natural state, and three-fourths are made into opiates, the principal one being laudanum. The following is official from the New York Custom House : — Imports of opium into the United States for ten fiscal years. iding June 30th : — • 1871, 315,121 lbs. $ 1, 926,9 1 5 1872, 416,864 " 2,107,341 1873, 3'9. I 34 " 1,978,502 1874, 395,909 " 2,540,228 1875, 132,541 " 939,553 1876, 388,311 " 1,805,906 1877, 349. 22 3 " 1.788,347 1878, 43 .95o " 1,874,815 1879, 405.957 " 1,809,696 1880. 533.451 " 2,786,606 Facts like these must, we think, arouse attention. They show a fearful drift. There is a worse form of intemperance than that which comes from bad liquor, although the choice would seem to be between the devil and the deep sea : " And in the lowest depth, a lower deep, Still threatening to devour us, opens wide." CONTENTS. CHAPTER I. page The Opium and Morphine Habits. Formation ; General Symptoms .' 17-26 CHAPTER II. Preparations Employed. Manner of Using 27-33 CHAPTER III. General Symptoms Analyzed and Classified 34-45 CHAPTER IV. General Symptoms Analyzed and Classified — Concluded. 46-70 • CHAPTER V. Accidents Incident to the Subcutaneous Use of Mor- phia 71-105 CHAPTER VI. The Treatment of the Opium and Morphia Habits. General Considerations 106-129 CHAPTER VII. Agents Used in the Treatment of the Opium and Mor- phia Habits 130-148 CHAPTER VIII. The Continued Use of Chloral 149-164 CHAPTER IX. Effects of Chloral on the Different Systems and Appa- ratuses 165-179 7 o CONTENTS. CHAPTER X. page Effects of Chloral on the Different Systems and Appa- ratuses—Concluded 180-199 CHAPTER XI. Symptoms of Abstinence from Chloral — Treatment 200-205 CHAPTER XII. The Hashisch Habit 206-218 CHAPTER XIII. Conclusion 219-221 THE OPIUM AND MORPHINE HABITS. CHAPTER I. THEIR PATHOLOGY. A higher degree of civilization, bringing with it in- creased mental development among all classes, increased cares, duties and shocks, seems to have caused the habitual use of narcotics, once a comparatively rare vice among Christian nations, to have become alarmingly common. Increase in mental strain, hot-house development of the passions, lessened physical labor and increased mental work, have been gradually giving us bodies in which the nervous element largely preponderates. Persons who may be classed under the head of ' ' nervous temperament ' ' are daily on the increase. Diseases are to-day as different from diseases of a century ago as is their treatment. While the average individual now does more mental work in an hour than did our an- cestors in six hours, we are not one-sixth as well able to bear the intellectual strain as they were. Nine-tenths of us neither eat, sleep, exercise, bathe, or procreate in a proper way. It is all hurry and turmoil ; little rest and much care. Generation by generation our physical natures are changing, and in the children of each succeeding generation we see the preponderance of the 17 18 THE OPIUM HABIT. nervous element ; a gradual evolution of that or those peculiarities most prominently brought forth by the exi- gencies of the individual and national life of a people. Finding .pain, "nervousness" and hysteria constantly claiming his attention, and that nothing relieves them so well as opium, or its alkaloid morphia, which is six times the parent strength, the physician resorts to their use more and more freely, expecting as soon as the more distressing symptoms pass away to pursue another and more perman- ent plan of treatment. The patient, however, having once experienced relief, insists upon the further use of the drug, sometimes feigns illness, in order to procure it, finally obtains some herself, and in guilty secrecy drifts rapidly into the habit. Some physicians are weak enough to place the means of gratifying this morbid appetite directly in the hands of the patient. This is more especially the case since the hypo- dermic use of the drug has become common. So magical is the effect of this mode of administration, so rapid and forcible the action of the drug, that many persons will not rest content until they possess and are using the instrument. As the affections for which opium and morphine are most commonly used are chiefly found in neurasthenic patients, and as these patients are ever ready to indulge in excesses, in both stimulants and narcotics, it is not surprising that the number of victims to this slavery is daily on the increase, both in town and country. Moreover, nervous affections are on the increase : pain without any very apparent cause, nervousness from the most trivial things. Neuralgias are more common. Insanity also. Suicide is daily more frequent. Those not acquainted with the truth in this matter will be surprised to learn that there are to-day thousands of ITS PATHOLOGY. 19 educated and respectable people in all countries and\ among all classes, confirmed habitues; slaves to a habit that is more exacting than the hardest taskmaster, that they loathe beyond all else, and yet that binds them in chains that they are wholly unable to break. Everything must give way to this vice. Business is neglected or but imperfectly performed ; family ties are sundered ; hope, ambition, happiness, self-respect are meaningless words ; the one thing that fills the mind is the gratification of this passion, which they loathe, but from which they cannot break. Thus from day to day, week to week, year to year, they go on ; not living — simply existing. Each day, each hour, each minute binds them more firmly, until at last they feel their own inability to cope with the demon that has overpowered them, and abandon themselves, hope- lessly, listlessly, to the vice. Repentance comes too late. The momentary pleasure, the short period of excitement, the hour of vivacity bears fruit a thousand-fold ; fruit, the bitter taste of which must last them a lifetime. That which at first gave them pleasure has now become the veriest tyrant, enforcing long hours of pain and anguish, gloom and despondency. They do not continue its use because it gives them pleasure, but simply because it is the only thing that, in increasing doses, can save them from the torment it has itself imposed ; because without it they are sunk into a. living hell. The mind is incapable of healthy action, the temper is decidedly aggravated, the person taking offence at and scolding furiously about things that in health, or while under the influence of opium, would excite no comment. /They suffer from terrible nightmares. They are constantly on the edge of imagi- nary precipices, or falling, falling down dizzy heights. 20 THE OPIUM HABIT. Sleep, if had at all, is broken, unsatisfactory and fraught with the most frightful and torturing dreams, into the warp and woof of which are constantly woven the most horrible sights. Now they are the victims of some terrible accident, again, they are hurried on by some malignant persecution. /They fancy that they are drowning, that they are being burned at the stake, inhaling the sickening odor of their own burning flesh, feeling it peel from their aching bones. Then comes the awakening with a start or scream. The gradual realization that these things are not real ; the cold sweat ; the trembling of the limbs ; the sense of utter ex- haustion from which they sink into sleep once more, to live again the agonizing scenes of their diseased imagination | waking and sleeping and counting the minutes as days, the hours as years, until morning finally comes. Nor are the torments of day much less than those of the night. The stomach rebels ; nausea is persistent and distressing ; saliva gathers in the mouth ; there is sinking at the pit of the stomach ; severe cramps of the intestines ; the lips and throat are dry and parched ; the tongue swollen. A dry, irritating cough sets in. Pains girdle the body and shoot with agonizing intensity down the limbs and into the face. The muscular system fails ; locomotion is attended with difficulty ; the sufferer staggers like a drunkard ; the muscles of the face and eyelids twitch ; the hands shake so that a glass falls from them, and it is im- possible to pick up a small object. The circulation is affected ; flushing and chilliness alternate ; the eyes are dry, and feel as though filled with sand. The mind wan- ders ; delirium supervenes ; dtawh coa and voffl rt»g-set-4ft, and sometimes collapse, and a more pitiable object can nowhere be found. It is at this time that the sufferer, tortured beyond all ITS PATHOLOGY. 21 power of endurance, would sell body, soul, anything, to obtain that drug which, while it gives no fresh pleasure, removes these ill effects, as if by magic. A dose is taken. A pleasant sense of warmth pervades the body ; the mind clears, the hands become steady, the gait natural, the pains vanish, the nausea and diau 4wea cease? and existence becomes again bearable./ Each dose must be a little larger than the preceding, in order to obtain the desired effect. In some cases the in- crease is very slow, but these are rare exceptions. Rarer still are those instances where no increase is necessary. I have here portrayed the suffering of one who has been using, the drug for a considerable time, or for a shorter time in large doses. The chains, though not at first galling, are nevertheless there, and each succeeding dose rivets them tighter. There are certain rare cases where opium seems, instead of doing harm, to be of positive benefit to the person using it. Dr. Joseph Parrish, a veteran observer of these cases, wrote me that he had known of several. One is related by Dr. Golding Bird.* A lady, probably hysterical, took morphia for the relief of paroxysmal pain in the loins. She had been taking it for several years. For the past two years she had increased the dose to ten grains, taken three times daily. There were no obvious ill effects ; functions were properly carried on, the appetite was good, and there was no known organic disease. The therapeutics of any epoch is strictly in conformity with the most prominent disease or symptom of the people upon whom the physicians practice. This is true of whole countries and sections of countries as well as of times. Formerly, when it was common for physicians to pre- * Practitioner, Vol. vi, p. 149. 22 THE OPIUM HABIT. scribe opium, it was this drug that the people ate. As morphine came into fashion, it was prescribed largely by the profession and the persons forming the habit at that time, as a rule, ate morphine. Habitues of the opium epoch also resorted to it, finding it so much more powerful than the crude drug, so much less bulky, and it did away with the necessity for calling forth a response to opium from the shattered system by resort to alcoholic stimulants. At the time in which De Quincey, Coleridge, and Southey lived, the people and the profession knew little of the opium habit, save among foreign nations; the habitues were few in number, and, as a consequence, when De Quincey' s article appeared, it created a most decided impression on the public mind ; an impression not yet effaced, and one which bore with it an incalculable amount of harm. Men and women who had never heard of such a thing, stimulated by curios- ity, their minds filled with the vivid pictures of a state of dreamy bliss, a feeling of full content with the world and all about, tried the experiment, gradually wound them- selves in the silken meshes of the fascinating net, which only too soon proved too strong to admit of breaking. There is no question in my mind that, in writing his " Confessions," De Quincey left a large debit on the side of truth, and handed down to succeeding generations a mass of ingenious lies ; more pleasantly the fiction, vapor- izing from a laudanum- soaked brain. He must needs seek some justification for his life of willful misery, for the blasted hopes, ambitions and prospects of what might have been a noble career, and he offered the dream life, the fuller development of benevolence, and the many pleasures so fantastically portrayed, as a justification, in part at least, for his sin. Nor does the final confession of the intense pain, the ITS PATHOLOGY. 23 abject misery, the tottering of the mind, the crumbling of the reasoning and will power, and the ever attendant and impenetrable gloom of a living hell, serve to fully counter- act the baneful effects of the portrayal of the pleasures of opium. The reader, confident of his ability to stop short of the ever-shifting line that divides the happiness from the misery, is in no wise deterred from trying the danger-fraught experiment. I know of several patients who began the use of opium simply from reading this most pernicious book. Upon persons living in temperate and cold climates this drug does not have any such effect, with reference to the subject matter of dreams, as upon Orientals. Indolent, over-fed, and by reason of their mode of life, religious associations and habits of thought, fancifully imaginative, it is not surprising that they should enjoy, while under the influence of the drug, grotesque, and to them, pleasant, dreams. Did the opium cause dreams foreign to the pic- ture daily conjured by their fertile imaginations, it would indeed be more surprising. That it does not produce suth effects on our plain, work^a-day people is not to be won- dered at. As I have already said, the preparation of the drug used and the manner of using it in any epoch has been exactly in consonance with the practice of physicians at that time. Of late years physicians are becoming more and more addicted to the subcutaneous use of morphine, and as a consequence, the number of persons who habitually use the drug in this way is daily on the increase. Eight- tenths of those from whom I hear and of those who come to me for treatment are using the drug subcutaneously. Dr. Charles Warrington Earle, of Chicago, in a very able 24 ' THE OPIUM HABIT. and well written little pamphlet,* is of the opinion that the majority of habitues do not use the drug in this way. In reply I can only reassert my opinion just expressed, and must say that the tendency of these patients to falsify, and their delicacy in disclosing their manner of using the drug to the druggists from whom they obtain their supply, must be taken into consideration. Dr. Earle bases his conclu- sions on 235 cases, the histories of which have chiefly been obtained from druggists. Be it understood, however, that I do not maintain that the majority of opium and morphine takers use the latter drug by the hypodermic syringe. I simply say that in my experience this manner of using the drug is largely on the increase among habitues, and will go on increasing from year to year, in the same manner that morphine is rapidly replacing opium in the practice of physicians. This is well shown by one of Dr. Earle's carefully prepared tables : — KIND OF NARCOTIC. Morphia was used in 120 cases. Tincture of opium Paregoric McMunn's elixir was it a used in tt tt 3° " S " 2 " Gum opium Dover's powders Unknown a 1 1 a a a • 5° " 1 " 27 " 2 35 The age at which this habit is most common is from thirty to forty, both in males and females. The following table, which, as Dr. Earle states, is only approximative, is of interest in this connection : — * " The Opium Habit; " reprint from the Chicago Medical Review, October and November 5th, 1880. ITS PATHOLOGY. 25 Males — From 20 to 30 years ..... 5 From 30 to 40 years 19 From 40 to 50 years 11 From 50 to 60 years ..... 7 From 60 to 70 years .... 1 From 70 to 80 years . . . . 1 Unknown age ....... 22 Total 66 Females — From 10 to 20 years ..... 2 From 20 to 30 years ..... 18 From 30 to 40 years 39 From 40 to 50 years 22 From 50 to 60 years . . . . .14 From 60 to 70 years ..... 4 One-third entire number prostitutes, probably from 15 to 50 . . . . . -56 Unknown age ...... 14 Total . . . . . . .169 Females are more frequent victims than males, in the proportion of three to one. This is undoubtedly due to the fact that women more often than men are afflicted with diseases of a nervous character, in which narcotic remedies are used sometimes for a long period, and also to the fact that in some instances it is used by them in place of alco- holic stimulants, its effects being less noticeable and degrading, although none the less intoxicating. Both males and females are usually of the higher orders, in point of intellect and culture. In some cases business failure or family trouble has been the incentive for a resort to the use of the drug. In some instances the fact that opium eating had ruined the mental powers of the victim, 26 THE OPIUM HABIT. or caused him to be careless or negligent of his home rela- tions, has led to the business failure, or the sundering of family ties. The majority of patients come from the middle classes, those people who are continually toiling and worrying in the almost ceaseless endeavor to " keep up appearances." The fact that most opium eaters are married, widow or widower, is probably explainable on the ground that in the majority of instances, the patients among whom it is most common are at just the age when marriage has taken place. In some the habit is contracted before, in others after marriage. I knew of one example where the wife, a young woman of eighteen, contracted the habit of using the drug subcu- taneously, through the carelessness of her physician. The husband began then to use it himself, and to-day the two are separated, the wife partially insane, the husband a con- firmed habituS and also an alcoholic drunkard. One who sees much of this disease meets with some very sad cases. PREPARATIONS EMPLOYED. 27 CHAPTER II. PREPARATIONS EMPLOYED. MANNER OF USING. The following are the various preparations used by opium and morphia takers— Crude Opium. — Variable in strength. Tincture of Opium, Laudanum. — i grain of opium to every 25 drops, or i grain of opium to every 13 measured drops, minims. Tincture of opium, Camphorated (Paregoric). — 1 grain to the ounce, or 480 drops. McMunn's Elixir. — Same strength as laudanum. Dover's Powder. — 1 grain of opium and 1 grain of ipe- cac to every 10 grains of the powder. Sulphate of Morphia. ) Salts of opium 1 grain of either Acetate of Morphia. \ h f n «. e 1 ual to about 6 S rains J of opium. Laudanum was De Quincey's favorite. He avers that he has taken as high as 8000 drops in the course of twenty- four hours. Coleridge is credited with haying taken more. A patient, a lady, whom I saw in consultation with Dr. Brennan, of this city, took a half pint every morning. Without it she was totally unfit to converse or to be seen. Many of the old fashioned habitues use the gum opium, but few, paregoric, and a less number still, Dover's pow- der. In order to get a sufficient amount of opium for the average user, from Dover's powder, the ipecac, which is present in equal amount, would produce nausea, and offer a further bar to its employment. Pulverized opium and extract of opium have been used in the form of supposito- ries. This was the case with one of my patients, a gentle- 28 THE OPIUM HABIT. man suffering from chronic inflammation of the bladder ; after a time he abandoned the opium, using in its stead morphia, in gradually increasing doses. I have already given Dr. Earle's table as to the relative frequency with which the different preparations are used. I here " append his table of quantities. Of this and the preparation sold, druggists from whom he obtained his statistics would be able to judge with a reasonable degree of accuracy. QUANTITY. Morphia — 21 persons use from i to 3 grains each day. 17 " 3 to 6 12 " 6 to 10 " " 10 " " 10 to 15 12 " " is to 20 " " 7 y^ a drachm ft tt 6 1 drachm tt a 20 " 1 bottle per week. 5 2 a 1 " 1 1 bottles each month. Tr. Opium— 15 persons use 1 drachm each day. 4 3 n 7 4 a 12 " 1 ounce a 4 2 " a 1 3 " ti 1 " 4 " it Gum Opium 3 persons use 10 grains each day. 5 20 " a 9 y 2 drachm a 12 " i " 1 1 4 2 " it 2 3 1 1 1 4 it METHOD OF USING. 29 Morphia is used either by the mouth, rectum or hypo- dermically. I know of a curious case, to be detailed more fully at a subsequent time, where the patient, a young lady, took morphine first subcutaneously, then by the rectum, and finally by the mouth. I am of the opinion that morphia, when continuously used, works more harm when taken by the mouth than when taken subcutaneously. Moreover, that the habit is more difficult to break, and relapses more prone to occur, in the former than in the latter class of cases. Opium or morphine by the mouth, after a time, exercises a directly paralyzing and anaesthetic effect upon the mucous membrane of the alimentary canal, and gives rise to hepatic derange- ment and sometimes serious disease. The subcutaneous injection of morphia undoubtedly exercises a baneful effect upon the same surfaces and organs, but not so directly as when taken by the mouth. Among the Eastern nations opium is used chiefly by smoking. As this is rarely seen in this country, save among people from those countries, it does not especially concern us. Moreover, a full account of these practices may be found in books of travel and other treatises upon that special branch of the subject. To Dr. Alexander Wood, of Edinburgh, belongs the credit of first discovering and practically applying the hypodermic syringe to the treatment of painful affections, more especially neuralgias. Drs. Isaac E. Taylor and Washington, of this city, claim to have used it in this country in 1839, while Wood's discovery was made in 1843, and his first article appeared in 1855. Wood's in- strument was first brought to this country in 1856, by Prof. Fordyce Barker, of this city. Then comparatively unknown, it is now in the possession of almost every physician in the 30 THE OPIUM HABIT. world. In my work upon the hypodermic use of morphia* I made, in the preface, the following statement, the belief in which has since been strengthened : " There is no pro- ceeding in medicine that has become so rapidly popular ; no method of allaying pain so prompt in its action and permanent in its effect ; no plan of medication that has been so carelessly used and thoroughly abused ; and no therapeutic discovery that has been so great a blessing and so great a curse to mankind, as the hypodermic injection of morphia. ' ' The danger of forming the habit from the use of the drug in this way is undoubted. Correspondents, physi- cians from all parts of this country, England and France, assert this and detail cases. Levensteinf gives many in- stances in Germany, and Dr. Loose, of Bremen, sends me the report of an able paper read by him before a medical society, wherein he cites cases, deplores the rapid spread of the practice, and advises special legislation upon the subject. He remarks for that country what Dr. J. B. Mattison, myself and others have noted in the United States, i. e., that many of the victims are members of the medical profession, in good standing. One hundred and thirty-one physicians report to me one hundred and eighty- four cases of the morphia habit, in all of which it was contracted by the use of the hypodermic syringe. The largest amount taken in the twenty-four hours by this method is reported to me by Dr. W. F. McAllister, of the Quarantine Office, San Francisco, California: "A physician, resident in this city, contracted dysentery in Shanghai, China, in the summer of 1873. Morphia was used hypodermically, and he drifted into the habit of using * " The Hypodermic Injection of Morphia. Its History, Advantages and Dangers." N. Y., 1880. t" Morbid Craving for Morphia," London, 1878. METHOD OF USING. Fig. i. 31 Fig. i. — Hypodermic Syringe. Glass cylinder with metal casing. Indexed on glass. Ffr. *■ M «fl Fig. 2. — Plain Glass Syringe, with needle. Index on stem. Fig. 3- Fig. 3. — Plain Metal Syringe, graduated on stem. Fig. 4. Fig. 4. — Plain Metallic Syringe, graduated on stem, with a cap for securely closing needle end of barrel, and a device by which needle can be carried in hollow stem. This is an excellent instrument. All those here shown were made by Codman & Shurtleff, of Boston, and are durable, accurate and easily cleaned. THE OPIUM HABIT. the drug in this way himself; the habit resulting in his death in 1878. I was called to see him professionally in 1875. He was at that time residing in Hong Kong, China. He was consuming each day seventy-two grains of the sulphate of morphia in three doses : twenty-four grains to the dose. This he continued to do until the day of his death. ' ' Prof. T. Gaillard Thomas, of this city, relates to me two fatal cases, in young persons, death being due to extreme exhaustion, dependent on imperfect nutrition and a grad- ual depression of the nervous and circulatory systems. In consequence of the skepticism evinced by some phy- sicians as to the danger of contracting the habit in this way, I feel myself called upon to urge upon them -the utmost care in the use of this instrument, especially in the case of neurasthenic patients. I have had so many de- plorable cases of this kind brought to my notice, either as patients or through correspondence, that I cannot help but feel that this matter is one of great importance, and worthy of more attention and care than is usually given it. I have already spoken of the two ways in which the opium or morphia habit is formed. A patient of a nervous temperament, suffering from some painful or spasmodic disease, is attended by a physician, who administers one of these drugs, by the mouth, rectum, or subcutaneously. The relief to suffering is magical, and persists so long as the effect of the drug lasts. With a return of the pain comes the natural desire to have it relieved, and as the narcotics just spoken of have been found especially efficacious the patient desires its repetition. This may go on for weeks and months, until the disease, of which the pain was but a symp- tom, is cured, or it may never be cured. At any rate, the patient awakes to the knowledge that he must have his nar- cotic. Life without it is unbearable, and instead of METHOD OF USING. 33 putting forth an extreme effort of the will, as is done by some, and then and there abandoning its use, the majority- allow themselves to drift into this habit of daily intoxica- tion with opium. The majority of habitu&s first use the drug for the relief of pain, and then find themselves unable to break loose from it. Some seem to be so constituted that a single or a few doses of drugs of this nature light up in them an irresistible desire to continue their use. There seems to be a morbid craving for something, exactly what is not known, until the narcotic is tried, when this mor- bid appetite is satisfied and fixed, and becomes the typical "morbid craving for morphia." It will be dipsomania, morphia-mania, chloral-mania, hasheesh-mania, according as the one or other drug is presented to the patient in the condition of craving. Some persons are undoubtedly born with, and some acquire, this craving for some narcotic or stimulant. A person knowing this fact can readily see how like putting a match to gunpowder it is to give these people opium or morphine in any form, and how inevitably the reading such a book as that of De Quincey's would create a longing and open the way to a road that has a certain ending in a life's bondage. Such as these are to be pitied, and deserve the kindest treatment and the most judicious care. They are like a person who has lost a limb, or is suffer- ing from a cancer. In the one instance they lack a certain something that should be there, and which is necessary to the free, full and proper enjoyment of life; in the other case — the acquired tendency or craving — they have a pernicious addition to the system that threatens them with death. Pity, then, rather than blame, at the same time using every legitimate means to break up both the habit and the tendency. 34 THE OPIUM HABIT. CHAPTER III. GENERAL SYMPTOMS CLASSIFIED AND ANALYZED. I am of the opinion that a clearer and consequently more thorough understanding of this part of the subject can be obtained by classing the various effects of the con- tinued use of morphine or opium under the headings of the different systems and apparatuses, and have, therefore, adopted this method of presenting these matters to the reader. THE DIGESTIVE APPARATUS. [Stomach, Liver and Bowels.) The first eff ect of opiu m or its alkaloid morphia on the stomach is, in the majbrity of instances, to increase the appetite arid cause a pleasant sensation of warmth and a feeling of general contentment. After a time, however, especially if the drug is taken by the mouth, the appetite is materially impaired, the bowels become constipated, there is a sensation of sinking at the pit of the stomach, the circulation through the liver is interfered with, a catarrhal inflammation of the small intestine and stomach supervenes, the opening of the bile duct is partially ob- structed by the swollen mucous membrane, and the result is a more or less decided staining of the skin with the biliary coloring matter. This is due, in part, to interfer- ence with the cells in the proper performance of their functions, undoubtedly through the medium of the nerves passing to them. At the same time, the gastric juice is diminished in amount and lessened in strength, as is also the case regarding the intestinal and pancreatic secretions, the GENERAL SYMPTOMS ANALYZED. 35 digestion of food is imperfectly performed, and in -conse- quence, a condition of malnutrition results, showing itself in wasting of the muscles and loss of the fatty tissue be- neath the skin, especially of the face, breast and abdomen. As the gastric catarrh increases, nausea and finally vomit- ing ensue, still further debilitating the patient. Derange- ments of the" stomach, liver and bowels are much more common among those who use the drug by the mouth. I have, however, seen patients who, while using morphia hypodermically, have suffered intensely with jaundice, catarrh of the stomach, nausea and vomiting. When these disorders do arise in the course of the subcutaneous use of morphia they are prone to be very acute in character. A gentleman, aged about 32, came under my notice some months ago, suffering from dropsy of both legs, which, from the middle of the leg to and about the ankles, were covered with collections of minute red spots, evidently points at which the capillary blood vessels had ruptured. An examination of his urine discovered thirty per cent, of albumen and some tube casts from the kidneys. Also a decided amount of morphine, and considerable blood. He was put upon tonic remedies ; the legs, previously dressed with sulphate of iron ointment, were tightly ban- daged. After about two weeks the dropsy lessened, the spots disappeared and the general health improved suffici- ently to allow of a business trip to the West. No sooner had he neared his destination, however, than the dropsy of the legs again appeared, and the old trouble came back in full force. In addition, he became somewhat jaundiced, water made its appearance in the abdomen, and a most distressing nausea harassed him day and night. During all this time he managed to do an unusual amount of liter- ary work, that required both knowledge and tact. On his 36 THE OPIUM HABIT. return -to New York, he was in a very weak and debilitated condition. The stomach rebelled at almost every kind of food, the belly was distended with water, the nausea intense, the vomiting frequent, and urine high colored, bloody and containing about sixty per cent, of albumen. While in the West an attempt was made to gradually diminish the amount of morphia, but owing to severe ill- ness, was abandoned. Nor did I think it advisable to try again until the general health was better. Upon iron, in different forms (dialyzed, Bland's pills, and muriated tincture), strychnia, phosphorus and gentian, he gradually improved, and is now just commencing the treatment by gradual reduction. He consumes daily about ten grains, using it subcutaneously. He contracted the habit some five years ago, through its being administered to him hypodermically, during a severe attack of acute articular rheumatism. Two years ago he was broken of the habit by a physician in this city, who pursued the plan of sudden deprivation, with the result of nearly killing the patient. While traveling in Germany, for the purpose of reporting certain facts for his paper, he was suddenly taken with congestion of the brain, accompanied by intense pain and a state of semi-consciousness. A German physician who was called in, not knowing the man's previous history, gave him a subcutaneous injection of morphia, with the result of re-establishing the habit. Fluid in the abdomen is not a common complication, and when it does occur, crowds the stomach upward, in- terferes with the circulation of blood in the viscera in the abdominal cavity and renders the nausea and vomiting still more troublesome. The stools voided by morphia-maniacs are sometimes clay-colored, being devoid of biliary coloring-matter. The GENERAL SYMPTOMS ANALYZED. 37 absence of bile in the intestinal canal allows of decompo- sition of the food, with the production of ill-smelling gases which regurgitate through the stomach, or pass by the bowels. Constipation is the rule. Sometimes it alternates with severe diarrhoea. In one patient whom I saw, the faeces collected day by day in the bowels, until impaction resulted and the mass was removed, with the greatest diffi- culty, by means of large enemata and the handle of a spoon. This lady had been using the drug, crude opium, for only eight months. This constipation from hardened condition of the faeces produces irritation, intestinal catarrh, and often hemorrhoids accompanied by an eczematous eruption about the anus. Heartburn, not from an excess of gastric juice, as is so often supposed, but from an acid fermentation of the food, is not an uncommon symptom. Some patients go on for years with no disturbance of the bowels, liver and stomach, beyond a slight catarrh and some jaundice, but these troubles are sure to come sooner or later. In many instances as the appetite for food decreases the appetite for alcoholic stimulants replaces it. A young lady, of twenty, formerly a patient of mine, after using the drug subcutaneously for three years, lost her appetite and subsisted for nearly eight months upon lager beer, a few crackers and a little toast. She would consume about one gallon of beer a day. During this time she somewhat diminished the amount of morphine used (eight grains, dropped to six grains, in twenty-four hours) and gained in weight and health. At the end of this time, however, severe gastric disturbance supervened, and she lay for months in a precarious condition. She is now cured of the habit. 38 THE OPIUM HABIT. Alcoholic stimulants are used by some habitues to in- crease the effect of the morphia, which it does to a certain extent. They delude themselves into the belief that they will be enabled to thus reduce the amount of morphia used, but in the majority of cases this is a fallacy. Those who prefer laudanum and paregoric to opium or morphine often do so on account of the amount of alcohol contained in these preparations. I knew a gentleman, some years ago, now dead, an Episcopalian minister, who became addicted to the use of alcoholic stimulants. His excesses were so frequent and so degrading that it was found neces- sary to expel him from the church. Sobered by the blow, yet unwilling to entirely abandon his habit, he seized upon the expedient of using large quantities of laudanum, thus getting the effect of both opium and alcohol. He died some two years after, from taking an overdose, at the end of a spree, the first and last one in the two years. His tombstone is a monument to blasted hopes, unsat- isfied ambition, a life ill-spent, and points a very pregnant moral to those who knew him. Let a man count well the cost before he takes service with a master who is only satisfied with a blasted life, here and hereafter. THE CUTANEOUS SURFACE. The effects of these drugs upon the skin may be divided into those relating to color, sensation and nutrition. The sallow, cadaveric hue so often seen in advanced cases is partly due to discoloration by the biliary matters, which are not properly excreted by the liver, and partly to a condition of malnutrition, so often seen in persons suffering from cancerous disease. In case there is serious interference with the working of the kidneys, the sallow color becomes less distinct, diluted expresses it well, and GENERAL SYMPTOMS ANALYZED. 39 it has an appearance more like that of old white marble. In this case the tissue feels doughy and "soggy," and at points a pit made in the skin by the pressure of the finger remains. There is also puffiness under the eyelids and the eyes are bleared and watery. When there is no dropsy the skin is usually dry and harsh, although at times bathed with a cold, exhausting perspiration, the odor of which is oftentimes very Offensive. A morphia or opium taker, previously ill-nourished, sometimes seems to improve, taking on flesh rapidly. The appearance, often best seen in the face, is very deceptive, and is, in the majority of instances, due to slight dropsy. It is sometimes seen a few weeks after these patients commence to use alcoholic stimulants, especially beer. It soon passes away, leaving them looking thinner and more miserable than before. In those cases where the habit has not progressed very far, the skin is usually made redder and coarser than , natural, and is dotted here and there with pustules. In one case that I have recently had under my care, that of a young lady who had never used stimulants and who had only used morphia, and that subcutaneously, for seventeen months, a swollen and reddened condition of the nose, exactly like that seen in old drunkards, was pre- sent. Two weeks after the morphine was stopped the nose began to lessen in size and the color to disappear, and the condition was entirely cured at the end of three weeks. No local applications were used. Loss of elasticity of the skin is a common change. That nutrition is seriously interfered with is seen by this altera- tion, the loss of adipose tissue, the ill-balanced circulation, giving at one time coldness and paleness, at another flush- ing and undue warmth, and the variable secretion. A plump and well nourished person who commences the use 40 THE OPIUM HABIT. of morphia loses those outlines of health caused by the proper development of the muscular system and normal distribution of fat beneath the skin. Face and form are both changed, and certainly for the worse. These changes are undoubtedly due to a double action of morphine ; that on the alimentary canal preventing the proper digestion and assimilation of food, and that upon the nerves regulating the supply of blood that passes to the skin. Eruptions after a time appear upon various parts of the body, more especially the face, chest and back. They are usually pustular, with hard, indurated bases ; sometimes papular. Herpes zoster or "shingles" is occasionally pro- duced, and is attended by most intolerable itching; less often purpura hemorrhagica. In the case of the literary gentleman already spoken of this was present, as was also bleeding from the kidneys. When it does occur the system must be in a greatly exhausted and the blood in a very poor condition, a condition which it usually takes a long time or large doses of the drug to produce. Another symptom dependent on disordered nutrition of the skin is the rapid or slow falling of the hair that occurs in some patients. However much hair restorers and scalp tonics may be used in these cases, the hair, once having commenced to fall, will continue to do so until the general health improves. When the drug has been stopped a free falling out of the hair occurs, followed by a new and luxuriant growth. Indeed, sweeping out and rebuilding seems to be the rule in every tissue. Change in . color of the hair has been noted in some cases. Those affections of the skin due to the use of dirty solu- tions and unclean needles when the drug is given subcu- taneously will be spoken of fully presently. GENERAL SYMPTOMS ANALYZED. 41 Sensation is variously altered. Sometimes there is a condition of hyperesthesia, the least touch being intensely painful, the contact of the clothing causing decided irrita- tion. Occasionally a whole limb or part of a limb or portions of the trunk or face will feel "numb or dead." Sometimes there are a series of pricking or tickling sensa- tions that are very aggravating, as they and the numbness are often looked upon by patients as precursors of paraly- sis. Sensitiveness to cold is often extreme. This and the very hard clay-colored stools are also seen in saccharine diabetes, and in every case where I have noted them sugar was found in greater or less quantity in the urine of the patient. What the connection is I cannot say, but it is worthy of further study. THE SEXUAL ORGANS. The continued use of opium or morphine has a decided effect upon the sexual apparatus. One of the first changes to be noticed in women is scantiness, then irregularity, and finally, total cessation of menstruation. In some cases an occasional period is observed, but as a rule, the stopping is decided and permanent until the habit is abandoned. Occasionally menstruation occurs when a change is made from one preparation to another, or from one mode of administering to another. In one of my patients, not under treatment for that, but still an habituS, menstruation showed itself, after a three years' cessation, on changing from the use of laudanum by the mouth to morphine by the skin. It occurred, however, but the once. In the case of the young married lady already referred to, when a change was made from subcutaneous to rectal injections the flow was re-established and showed itself, although irregularly, for nearly a year. 42 THE OPIUM HABIT. Levenstein, who has made some interesting and valuable researches and experiments upon this matter, believes that this abnormal menopause is due to the inactivity of the ovaries. He says : — "According to Pflueger's theory, in cases of amenorrhcea due to morbid craving for morphia, the growth of the ovarian cells would be stopped from one monthly period to another, and consequently there would be a want of stimulus on the ovarian nerves, causing on the one hand the rupture of Graaf's follicles, and producing, on the other hand, a congested state of the generative organs by reflex action. Hence, the morphia would act in the same man- ner on the ovaries as on other secreting glands, *'. control. In October following she had improved so far as to pass from the immediate charge of her physician. Soon after this he ascertained she was using hypodermic injections of morphia, to relieve pain in her limbs and different parts of her body. I quote from his letter: — I was informed that she was using it (morphia) to a consider- able extent, and called immediately to explain to her the effects and danger attending the practice. I believe every effort was made that could be to prevail upon her to desist, but all to no purpose. She was 'cunning and artful, and would almost al- ways study out some plan to get the morphia. She has used as much as two drachms in a week, in one or two well-authen- ticated instances. The usual amount was one drachm per week. She used but little, if any, for three or four months before she was sent to the asylum, for it was very difficult for her to get it. She has acted very strangely ever since her first sickness. She has been truly a mystery, which no one could solve. Her mother says : — That for years she has complained of pain, and pressed her hand on either side of her head, with the exclamation, "Oh, mother, mother, I shall die ! " That for six years she has com- plained of such soreness of the head that when she passed her hand over it, in smoothing her daughter's hair, she would cry out: "Oh, mother, don't ; it hurts me so!" That five years 56 THE OPIUM HABIT. ago, in 1867, she was obliged to call in help, as the patient threatened and intended to take her own life. That both be- fore and after she began the use of morphia, her conduct was peculiar and erratic ; that she was emotional and easily dis- turbed by trifles. That after the morphia habit was known, her conduct for many years preceding was wrongly attributed to this cause. A few weeks before she was sent to the asylum she passed into an acutely maniacal condition, in which she was sleepless, ate little and irregularly, lost flesh and strength rapidly, and became' quite feeble. She was de- structive of clothing, pulled her hair out, was noisy, inco- herent and violent ; opposed care, wandered about, and was with difficulty controlled. In this condition she was admitted to the institution, on the fifth of May, 187 1. She was carried to the ward and placed in bed. Examina- tion revealed scars and ecchymosed spots, covering nearly the whole of the body which could be reached by her own hand. She asserted that she had employed the hypodermic injections for three and one-half years, once, and much of the time twice, a day, making in all about two thousand injections ; that during the last few months of its continu- ance she had used a drachm and one-half of morphia per week ; that she inserted the needle perpendicularly to the surface, and often carried its full length into the tissues. For two days she was sleepless and retained no nourish- ment. Chloral, in thirty-grain doses, was then admin- istered, which was tolerated by the stomach, and secured sleep. The vomiting gradually became less frequent and soon ceased. She ate well, gained flesh and strength, all maniacal symptoms subsided, and in twenty days she was up and about the ward. Menstruation, as she said, had been suppressed for two years. As she complained of pain GENERAL SYMPTOMS ANALYZED. 57 in the back and other symptoms which usually preceded it, she was placed on the use of capsules of apiol, and on the 24th of June began to menstruate, but the flow was scanty, and accompanied by much pain. During the month following she steadily gained in men- tal strength, and became quite stout. At time of next menstrual period the right breast swelled to an extraordi- nary size, so that we were obliged to suspend it with adhesive straps. It was hard and extremely sensitive to the touch. This condition of swelling and tenderness extended in a narrow ridge to the spine. The state of the breast was at first supposed to be owing to the sympathetic action of the organ with the renewed activity of the menstrual function. For two weeks applications were employed, without suc- cess, to relieve the pain and tension. At this time, on the 13th of August, the patient, in rubbing her hand over the breast, discovered an elevated point just under the skin, which, on pressure, gave a pricking sensation. This was cut down upon, and a broken needle extracted. On the 15th another needle was removed. The breast was now inflamed and extremely sensitive. August 28th, another needle was taken out. August 29th, menstruation began again. The flow was profuse, and she became at once delirious. Was talkative, restless, profane and obscene, and pulled her hair out. She continued in this condition some twelve hours, and, as she stated the next day, was entirely unconscious of what had occurred. From this time till September 28th, from one to five needles were removed daily from the breast. Menstrua- tion then occurred again, and was characterized as before by a similar attack of mental disturbance. After this, during the months of October and November, needles were taken from various parts of the body ; from the left 58 THE OPIUM HABIT. breast, the abdominal parietes, the mons veneris, the labia, and vagina. Of these latter, some passed across the urethra and rendered urination difficult and painful ; others across the vagina, either end being imbedded in opposite sides. Some were removed from the thighs, from the leg, down to the ankle, from the buttocks, from about the anus, from the back as high up as between the shoul- ders. The largest number extracted in any one day was twelve. Oh one occasion ether was administered, but the diffi- culty experienced in bringing her under its influence, and the mental disturbance produced by it were so great that it was not again resorted to. During the whole period, to her final illness, she retained her flesh, though she ate and slept irregularly, under use of tonics and sedatives. She was in a variable mental state, at times irritable, petulant, fault-finding, attempting to create ill-feeling between attendants, and demanding unnecessary care and waiting upon. At other times she was abnormally cheerful, gay, pleasant, and fulsome of praise of all around her. For the first two months but comparatively little pain was felt in the extraction of the needles. The skin was thickened, harsh and dry, and almost insensible, from the prolonged and distributed use of the injections. After- ward, she suffered acutely, and often begged, with tears, that their removal might be postponed from day to day. About a month before death she had an attack of localized pneumonia, affecting the lower portion of right lung. This was accompanied by stridulous breathing, spasm of the glottis, globus hystericus, crying, and other hysterical manifestations. It was followed by an attack resembling muscular rheumatism, characterized by "great pain and hyperesthesia of surface. The right arm was swelled, hot GENERAL SYMPTOMS ANALYZED. 59 and extremely sensitive. It was supported on a pillow and kept bathed in anodyne lotions. She lost appetite and sleep, became much depressed, and gave up all hope of recovery. Her tongue became dry and brown, pulse rapid, secretions offensive, and mind very feeble. A diarrhoea supervened and the evacuations of bowels and bladder were involuntary. She became unconscious, and finally coma- tose, and died on the 25 th of December, 1871. No needles were removed during the last two weeks ; 286 were taken from her body during life; 11 were found in the tissues after death ; 3 were passed from the rectum during sickness ; making a total of 300 needles and pieces. Of this number, 246 were whole, and 54 were parts of needles. One was a No. 7 sewing machine needle, and several were bent. They varied in size from No. 4 to No. 12. As regards position in the body, they were distributed about as follows : in right breast 150 ; left breast, 20 ; ab- domen, 60 ; genitals, 20 ; thighs and legs, 30 ; back, 20. Of those removed after death, 5 were found in the right and 3 in the left breast ; one in a small abscess in the epi- gastric, and one in the right iliac region, the point im- pigning upon the peritoneum, which was discolored with rust ; and one in the upper part of lower lobe of left lung. The presence and position of the needles were indicated to the patient by the pricking sensation occasioned by mus- cular movements. They were removed in a few instances at first, by cutting down upon them. This proved to be a painful, and, from the movements of the needles in the tissues, a difficult process. Hemorrhage from the small vessels, at • times, gave some trouble. Afterwards, by manipulation, the ends of the needles were engaged be- tween the thumb and forefinger, and the points, forced through the skin, were seized and the needles extracted 60 THE OPIUM HABIT. with forceps. Sometimes much force was required to withdraw them. They changed position quite readily, and frequently moved from one to two inches in a day. They produced little local irritation or trouble beyond the pricking sensation, and did not seem to have contributed in any notable degree toward producing the fatal result. In regard to the presence of this large number of needles in the system, no information could be obtained. The pa- tient repeatedly and persistently denied any knowledge of having introduced them, either by the stomach or through the skin. Her mother, who visited the Asylum, could throw no light upon the subject, and was entirely ignorant of the fact until informed by us. She, however, recalled the circumstance that the patient purchased, at one time, ten papers of needles, and could account for only two of them. They were not obtained or introduced while in the Asylum. She was under strict surveillance, and had no means of obtaining any number of needles, and those removed were all rusted and bore evidence of having been a long time in the body. The stomach was closely exam- ined after death, and was in a perfectly healthy condition, with no evidence of any previous inflammatory action. The only theory which seems to us at all tenable, is that they were introduced through the skin while she was under the influence of morphia, hypodermically admin- istered, and while suffering from hysteria. That some were found in positions where they could not have been inserted by the patient, can be accounted for by their movements in the tissues, which were observed so often during the life of the patient. , The diseased condition of the brain and its membranes was a cause sufficient to account for the abnormal mental action and conduct of her who had been " truly a mystery GENERAL SYMPTOMS ANALYZED. 61 which no one could solve." We close this remarkable case with a transcript of the post-mortem examination. Autopsy. — Rigor present ; body well nourished ; anterior surface thickly studded with small cicatrices; abdomen covered with thick layer of fat. A small abscess in abdom- inal wall, two inches above umbilicus, three inches by one and one-half, was filled with pus and contained one needle. A second abscess, two inches above and to the right of the symphysis pubis, immediately under Poupart's ligament, contained another needle. This pressed upon the perito- neum, which, though discolored by rust, was not inflamed. From the right breast, one whole and four broken needles, and from the left one whole and two broken needles, were removed. Head. — Arachnoid opaque and thickened over right hemisphere. The left hemisphere was covered by a thin layer of pus, contained in the sub-arachnoid space. Marked depression of convolutions at vertex of both hemispheres. The brain substance was firmer than normal. The ven- tricles were empty, and the choroid plexus contained numer- ous small cysts upon its surface, filled with serum. TTwrax. — The lower lobe of the right lung was hepat- ized. A whole needle was found in the upper part of the lower lobe of the left lung. Abdomen. — The liver was soft and fatty, and the spleen enlarged ; kidneys were normal. The stomach was sub- jected to a critical examination. It was found normal, and there was no evidence that the needles were introduced into the system through that organ. The vascular system, through the agency of the nerves-, is profoundly affected, as already shown. Spasm of the muscles of the bladder and rectum is some- 62 THE OPIUM HABIT. times present, and in some cases is distressing and lasts for a considerable time. Symptoms resembling those produced by malaria are occasionally found. Levenstein, who was the first to call attention to this, says : "Intermittent fever, in consequence of a morbid craving for morphia, seems to be due to a cer- tain neuropathic disposition, as it does not show itself with many patients, although they have taken large doses of the drug, and for years together. It was, however, impossible to fix on any other cause for the development of intermit- tent fever but the use of morphia, as the respective patients lived in regions free from malaria, and as none of the other members of the family living under the same con- ditions showed any similar symptoms. " We may distinguish a light and a severe type of inter- mittent fever, when brought on by a morbid craving for morphia. Both forms resemble real malarial fever, inas- much as the first paroxysms, occurring at regular intervals, seemed to disappear after the use of quinine, returning, however, very soon, although the febrifuge was continually given ; that, furthermore, they were improved by change of air, but came on again from the simplest causes, such as boating, errors of diet, etc. ' ' The characteristic symptoms of this fever are the same as those caused by malaria: chilly feeling, up to regular shivering, headache, oppression, heat and perspiration. They differ from one another in this respect, that immedi- ately the morphia is discontinued, the attacks disappear without any treatment, although they may have existed a long time. "In some cases the intermittent fever sets in in an erratic manner. The patient, at irregular times, experiences an attack of fever, with chill, heat and sweating. These GENERAL SYMPTOMS ANALYZED. 63 attacks occur from three to six times, at long intervals, not showing themselves hereafter any more at all, or only after a great lapse of time. In most cases the attacks of inter- mittent fever, in morbid craving for morphia, shows a tertian, rarely a quotidian, type. They are sometimes ante-, sometimes post-ponent. The attacks last from four to ten hours, and are followed by a normal condition. "The paroxysms disappear only in exceptional cases, without the morphia being stopped. In this case the patients complain of experiencing an uncomfortable sen- sation, principally of an exhausting character, at the usual time of the attacks. "The feverish attacks are accompanied by neuralgic affections of the different nerves, principally in the region of the supra-orbital, intercostal and cardiac nerves. The temperature is increased in all cases, varying from 38. 5 ° C. to 40 C. (101.3 F. to 104 F.). The spleen is gener- ally enlarged. The attack is followed by sediments in the urine. In the severest forms of intermittents the patients get delirious when the fever has reached its maximum, cannot be kept in bed and may become maniacal. Both forms cause great weakness and exhaustion, which last during the intervals." I have seen but two cases that could at all be classed as such. In one there was no fever, and the chill came every morning at daybreak, for three mornings, missed one morn- ing and occurred again the next. It was followed by pro- fuse sweating, that lasted the whole day. In the other case, that of the lady who had used the drug by the mouth for sixteen years, there was fever and some intercostal neuralgia, occurring every other day, for ten days, but not followed by perspiration. A few doses of quinine broke it up. It was for this that I was first called to attend her, B4 THE OPIUM HABIT. her husband believing her to be suffering from malarial fever. In neither of these cases was there any enlargement of the spleen. I then discovered that she was a morphine habitue, much to her chagrin and her husband's surprise, he never having suspected it. The two following cases are those given as examples by Levenstein : — CASE I. INTERMITTENT FEVER IN CONSEQUENCE OF MORBID CRAVING FOR MORPHIA. M. H., law student, 24 years old, sent to the Institution by Dr. Ewald in 1874, was suffering from acute articular rheumatism when the first injection of morphia was admin- istered. After his recovery, although not compelled to do so through pain, he continued the injections several times in the day, increasing the doses, for the sole reason that he felt elated by them. The principal symptoms that resulted therefrom were loss of appetite, progressive emaciation, loss of strength, and increased perspiration, which fre- quently caused the patient to become wet all over while in a cold room and quite quiet. Before his admission into the Maison de SantS he was troubled with feverish attacks, which came on every two or four days, at different times in the day, in the following manner: first there was a chilly feeling for half an hour, followed by heat and profuse sweating. The latter was accompanied by the general symptoms of every feverish attack, enlargement of the spleen also being present. Present State. — Patient is a tall, muscular man ; the ex- amination of the internal organs shows no abnormal con- dition, excepting an enlarged spleen. Pupils of middle size, equal, reacting well. On December 10, 1875, m the afternoon, patient received the last injection of morphia. GENERAL SYMPTOMS ANALYZED. 65 December 12. Patient slept in the night. In the course of the day he only feels a little sleepy. The face is red, the skin moist. Toward the evening there is nausea, pressure in the epigastrium, great restlessness, and stomach- ache. Pajient moves about in bed, complains of headache, cannot get to sleep. Three relaxed motions. December 22. Patient has had no sleep during the night, three relaxed motions, vomited once. He com- plains of giddiness, restlessness and palpitation of the heart. In the morning there is a chill followed by heat and profuse sweating. Vomiting, diarrhoea. Until the afternoon he felt very prostrate and exhausted. Between 3 and 5 p.m. he got up. Soon, however, the symptoms of the morning returned again, and pain in the knees, exhaus- tion and restlessness compel him to go to bed. December 23. Has slept from 2 to 5 a.m. with inter- ruptions. Profuse perspiration, nausea, intense craving for morphia, frequent paroxysms of sneezing. The sickness stopped in the course of the day. At 8 p.m. 30 grains of chloral were given. December 24. Only three hours' rest. Feels knocked up. One relaxed motion. Much sneezing; craving for morphia. At 9 p.m. 45 grains of chloral were given, but were immediately brought up again. December 25. Patient has had hardly any rest. One relaxed motion. Has been sneezing frequently. Emission of semen. Great prostration, _even in the horizontal posture ; red cheeks ; craving for morphia continues for the whole of the day. Appetite small. At 10 p.m. 45 grains of chloral. December 26. He has slept well during the night, only woke up two or three times. Pressure in the stomach, headache and palpitation of the heart come on now and 66 THE OPIUM HABIT. then in the course of the day. At n p.m. 40 grains of chloral were given. December 27. Restless sleep, much interrupted. Pa- tient went about the room on waking up-. During the day he complained of heavy pressure in the head^ December 28. Patient has slept for about three hours. Sneezing. The red color of the face of the past days was still present to-day. Although tired he could get no rest. Two relaxed motions. In the morning a warm bath with cold douche was given. December 29. Patient has slept for nearly eight hours. Head not well yet. Severe sneezing. He feels better in himself. Toward the evening, however, an uneasy feeling came on in the legs. Three relaxed motions. January 1, 1876. Except the sleep being restless, patient feels well. January 3. Slept only from 3.A.M. ; ran about in a rest- less manner previously. Three relaxed motions. In the afternoon warm bath with cold douche. January 13. The bodily functions are all in a normal condition. General health good. There have been no further attacks of fever. January 14. Patient left the Institution. He has had no relapse. Urine. — The specific gravity varied from 1.012 to 1.020. Reduction of oxide of copper was noticed. CASE II INTERMITTENT FEVER IN CONSEQUENCE OF MOR- BID CRAVING FOR MORPHIA. (IMPOTENCE. DISORDERED SPEECH. ALBUMINURIA.) Captain B., sent to the Institution by Staff-Surgeon Dr. Peltzer, had been using injections of morphia in conse- quence of severe pains from a gunshot wound in 1871. GENERAL SYMPTOMS ANALYZED. 67 For a time his medical attendant diminished the drug, but soon, by the advice of the latter, he purchased a syringe and bought the morphia, first at a chemist's, and afterward at a shop where they sold chemicals ; he injected gradually as much as twenty-four grains per day. Several times his wife tried to stop the injections or at least to diminish' the dose, but this was followed by vomiting, diarrhoea and loss of sleep, so that the doctor again recommended its further use. The principal complaints of the patient, on account of which he, on December 20, 1875, sought admission into the ' Maison de SanteV were: The appetite is bad, the bowels are so much constipated that they are sometimes not relieved for eight days. From time to time patient suffers from disordered micturition, having to strain rather long before the water passes. Very frequently there was congestion to the head, and during sleep quivering of the muscles of the face and extremities. Now and then he suffered from giddiness and headache. He feels unwell, principally in the morning. Impotent for three years. He was obliged to resort to alcoholic beverages as stimu- lants, but he was no drunkard. From September 12 until the end of October, 1874, the patient had had a shivering lasting two hours daily, followed by half an hour's heat and two or three hours' profuse perspiration. Large doses of quinine taken daily for a period of three weeks are said to have cured the fever ; it is worthy of notice that the patient stopped the use of the morphia during the latter period of the feverish attacks. Taking to it again, there was the same characteristic attack every week or fortnight at first ; gradually, however, the free intervals became shorter l and at the time of his admission into the Institu- tion the intermittent had again returned to the quotidian 68 THE OPIUM HABIT. type. A treatment with large doses of quinine for several months, resorted to by his medical attendant, proved of no avail. Patient is pretty tall ; muscles and subcutaneous areolar tissue very well developed. Face red. Eyes bright. Tremor of hands, slight degree of difficulty in speaking. Patient shows great vivacity in talking ; his features move quickly ; his movements are brisk. The physical examination of the thoracic and abdominal organs shows no abnormal condition, except a considerable en- largement of the spleen. The morphia was at once withheld. December 21. Patient had a restless night, feels ex- hausted and knocked up ; yawns, comglains of cold, loss of appetite, severe headache on moving the head, and pains in the back ) this is followed by nausea and at night by vomiting. Profuse perspiration. December 22. Patient was very restless in the night; got out of bed, ran about, laid down again, perspired freely, asked for morphia. The abundant perspiration lasted till midday and was accompanied by determination of blood to the head. Patient suffered from giddiness and felt greatly tired. Appetite poor. Frequent retching, but no vomiting. December 23. Patient has slept little. Three relaxed motions in the morning. Symptoms the same as on the previous day. New symptoms : twitchings in the extremi- ties, excitement, sensitiveness to the light, and epigastric pains. To remove the latter symptom sinapisms to the stomach, hot poultices and cupping (four times) were attended with success. Frequent vomiting. December 24. Patient has only slept for a few hours. A great deal of sneezing; eight relaxed motions. In the course of the day he felt well. GENERAL SYMPTOMS ANALYZED. 69 December 25. The pains and pressure in the region of the stomach have returned and he had also palpitation of the heart, was very much exhausted and suffered from tenesmus. Two seminal emissions. December 26. Four relaxed motions, shivering, feels uncomfortable. December 28. Patient has only had two hours' rest. Hands and feet burning hot. Eight motions ; during the day he felt weak, complains of formication in the hands and feet. December 29. Uncomfortable feeling continuing the whole of the day. Patient's face was of a dark red hue ; he complained of hyperaesthesia in the feet and of cold. While reading a letter from his wife he began to cry, although the contents showed no reason for his doing so. Appetite good. Two relaxed motions. December 30. Slept from 3 to 7 a.m. Two relaxed motions. A great deal of sneezing, pressure in the epigastrium, appetite small. January 3, 1876. Slept from 12 to 4 a.m., after running about in a restless manner. Formication in hands and feet. January 6. General condition satisfactory. Appetite increased. January 14. The patient has continued to recover his strength. Bodily functions normal. Sexual power has returned. Urine. — During the first weeks of abstinence from mor- phia the urine contained albumen. Patient left the Institution on January 22, in perfect health. He has not had a relapse. Neuralgia of one-half of the face, in all respects like malarial hemicrania, I have seen in two cases. In neither 70 THE OPIUM HABIT. were there other symptoms of malarial trouble. Both cases yielded to quinine and arsenic. ^ Super-sensitiveness of the skin, sometimes of the whole body, more often of a limb, or a feeling of numbness, is not uncommon. A fact that I had noticed before I commenced the special study of this subject is, that those opium eaters who live past middle age usually die from paralysis. In four instances I have seen this. In all four cases the persons took laudanum. SUBCUTANEOUS INJECTION. 71 CHAPTER V. ACCIDENTS INCIDENT TO THE SUBCUTANEOUS INJECTION OF MORPHIA. There are certain dangers attending the temporary or continued use of morphia by the hypodermic syringe that deserve careful attention, in order that, if possible, they may be remedied. The first is the production of abscess and inflammation. The majority of those who use morphia in this way are badly scarred. The skin is thickened, reddened and covered with bluish and reddish discolorations. Abscesses just forming, formed, or commencing to heal, are found here and there. Ulcers and sloughs are sometimes seen. Cysts are occasionally met with. Isolated patches of ery- sipelatous inflammation and gangrene are found in some instances. In the accompanying cut (p. 73) is shown the condition of the skin in a male nurse at Bellevue Hospital, who was an habitue. The photograph from which the cut was made was taken but a short time before death. I have now other patients who are quite as badly scarred. In the case of a young married lady, the skin, everywhere that the dress covered the body in front, and the limbs all aver, was scarred, contracted and discolored, as though she had been badly burned and then pricked all over with India ink. Dujardin Beaumetz (quoted by Barfholow*) relates a case where these injuries resulted in death. These abscesses are due, in the majority of instances, to (a) carelessness in injecting, (<5) unclean needles or syringe, * " Hypodermic Medication," p. 96. Philadelphia, 1879. 72 THE "OPIUM HABIT. (V) a dirty or over-acid solution, and (d) a low condition of the general system, predisposing to inflammation and suppuration on slight irritation. I have never seen but one habitue who had a clear solu- tion of morphia, and he made it up fresh each day. Abundant testimony as to the production of inflammation and abscess from the above mentioned causes can be found in my little work on " Morphia Hypodermically. " Those patients who exercise great care in regard to cleanliness and manner of injecting are rarely troubled with abscess. Thus one patient of mine had used morphia subcutaneously in large amount, for over six years, inject- ing every time, and that several times daily, into a spot upon one thigh, that could be covered by a small tea- saucer, and has never yet had either inflammation or abscess. Indeed, some persons who exercise no care whatever to keep syringe or solution clean, are free from this trouble- some complication. Such a case is related by Dr. Roberts Bartholow, as follows: "One of the most inveterate sub- jects I have ever encountered was a man living in the wilds of Texas, who used a glass hypodermic syringe, that had been broken many times, and mended with successive deposits of sealing wax, until only the rusty old needle remained in view, and yet he escaped all accidents." Magendie's solution is that most commonly used. It is of the strength of sixteen grains of sulphate of morphia to the ounce of water, a few drops of acid being added to dissolve the drug. The solution made after the plan of Dr. H. M. Keyes is excellent. It will keep for a long time unchanged. He writes as follows : " Some years ago, while attached to the Roosevelt Hospital, in New York city, after repeated experiments with various tests and anti-ferments, I became SUBCUTANEOUS INJECTION. 73 74 THE OPIUM HABIT. convinced of the practicability of making a solution of the sulphate of morphia, of the strength of Magendie's, with- out the aid of acid, except salicylic, and that not as a solvent, but as a preventive of decomposition, making a solution that, when properly prepared, gave perfect satis- faction after years of use, never causing abscesses, as is frequently the case when the mineral acids are used, and when carried in the pocket for months being in as perfect condition for use as when freshly prepared. "The following directions, if followed, will give the desired result : — Sulphate of morphia, 256 grains Salicylic acid, 8 grains Distilled water, 16 fluid ounces. " Heat the water in a porcelain capsule, over a spirit lamp, until the boiling point is reached ; add the powders and stir with a glass rod, until they are dissolved. Filter through coarse filtering paper, while hot, and keep in a glass-stoppered bottle ol green glass." Some physicians use carbolic acid, some chloral hydrate, some benzoic acid, and some chloroform, as preservative agents. Any of these substances, present in sufficient amount to prevent decomposition and clouding of the solution with minute vegetable growths, are apt to be irri- tating. In my first work on morphia, a full list of the solutions used in this and other countries will be found. Erysipelas sometimes results from the subcutaneous use of morphia. * The syringe needles are sometimes broken off in the flesh. This is, however, a rare occurrence. The method of making an injection, undoubtedly, has something to do with the occurrence of abscess. The usual plan is to pinch up a fold of skin and pushing the SUBCUTANEOUS INJECTION. 75 needle in quickly, inject the solution slowly, beneath it. Some persons prefer to plunge the needle deep into the muscular tissue. It is claimed for this plan that abscess seldom occurs, and there is certainly less liability of wound- ing a vein. The following is taken from my book on ' ' Morphia Hypodermically," and illustrates very fully another danger sometimes attending the use of the drug in this way : — Articles have, from time to time, appeared in various medical journals, at home and abroad, detailing certain alarming symptoms following immediately upon the in- jection, subcutaneously, of moderate doses of morphia. Such accidents have been ascribed by most authors, to the entrance of a needle into a vein, with the consequent sud- den passage of the drug into the circulation ; by some, to the injection of a bubble of air into the vein ; by others, to fright attendant upon the dread of the operation and the prick of the needle ; and by still others to the rapid absorption of the remedy when a vein is not punctured. Which of these hypotheses is the correct one it is at pres- ent difficult to decide ; perhaps each may have proved a factor at certain times or in certain cases. The weight of opinion would seem to favor the idea of sudden entrance of the drug into the circulation by puncture of a vein. By a careful study of some of these cases we may be able to come to a" definite conclusion. Dr. M. E. Woodling, of North Branch, Minn., writes: — ' ' My first case in which the hypodermic injection of morphia was tried, resulted as follows : Patient large, strong and ro- bust-looking man. Complained of pain in the course of the sciatic nerve, and of lumbago. Injection given back of the trochanter major, patient sitting; given slowly. I 76 THE OPIUM HABIT. turned to lay the syringe on the table, when the patient appeared unsteady, straightened rather rapidly and persist- ently, and slipped from the chair, falling full length, supine, upon the floor, pale and with absent respiration. He was now perfectly limp. No response to shaking or questions. Spoke the word 'breathe,' loudly, in his ear. This he obeyed. Repeated this for about a minute, and in another he was able to sit up, but was very sleepy and unsteady, requiring assistance. In about five minutes he was able to stand, and I took him out on the street and walked around with him for an hour. I then took him home, still sleepy, but improving. The next morning he was all right, but the pain was only partially relieved. Other injections were given, with no bad consequences. ' ' Dr. A. Atkinson, Professor Materia Medica, College of Physicians and Surgeons, Baltimore, in reply to my fifth query, writes : " Never had death to result, and but one accident, and that was apparent suspension of animation for about fifteen minutes, in a young lady, very anaemic, in whose case I injected one-eighth of a grain of the sul- phate of morphia (the regular Magendie's solution) into the rectus muscle of the abdomen, at the repeated and urgent entreaties of the patient, to relieve an obstinate uterine neuralgia. She recovered from the neuralgia and from the effects of the morphia in three-quarters of an hour. I had, a year before, injected one-fourth of a grain into the arm of this same patient, for cardiac neural- gia, with complete relief of the pain in one hour, and with no bad effects. ' ' Dr. E. Jones, of Cincinnati, has kindly written me and inclosed an article* of his, bearing directly upon this sub- * " Some Observations on the Deep Injection of Morphia." Cincinnati Lancet and Clinic t August ioth, 1878. SUBCUTANEOUS INJECTION. 77 ject. In it he says : " Did the needle enter an abdominal vein ? Several times. The first time I became somewhat alarmed ; the patient at once threw up her arms, com- plained of suffocation, giddiness, excessive fatigue, a severe tingling sensation following the course of the circulation. The countenance was at first livid, then flushed ; the eyes became unusually brilliant; slight muscular twitchings, profuse sweating, with cold extremities, and in a few mo- ments complete relaxation was followed by deep sleep, which lasted only four hours, when she awakened, feeling, as she expressed it, ' ever so much better. ' " The same accident occurred three times, the symp- toms much milder, with the exception of a burning sensa- tion of both eyelids of either eye and both lips, which at one time became painfully intense. The above symptoms were produced by an injection of five grains of sulphate of morphia into an abdominal vein. " Being unable to see her for a day or two, I requested my friend, Dr. Geo. E. Walton, who had watched the case with a good deal of interest, to call and give her an injection of two grains, when she put both hands to her head and gave a cry of excruciating agony. A sharp pain darted through her head, which lasted ten or fifteen min- utes ; also complained of an intense itching of nose and lips, finally passing off, leaving no deleterious effects. The same accident occurred to myself, only in a less degree. These injections were also made in the abdomen." The patient was a German woman, aged thirty-seven, and weighing about 135 lbs. The case was presumably one of fecal accumulation in the colon, with severe abdom- inal pains. Dr. W. A. Neal, of Dayton, Michigan, writes in this connection as follows: " No deaths ; the only accidents 78 THE OPIUM HABIT. were where a vein was punctured. This produced dysp- noea, great distress, and was usually followed by a chill and the reaction by fever ; but in every instance there has been but one chill, and fever once, lasting three or four hours. ' ' Edward T. Wilson, m.b., Oxon., f.r.c.p., Lond., who has a valuable and interesting article on the subcutaneous injection of morphine, in the St. George's Hospital Re- ports, for 1869, writes me as follows: "Never either death or accident. Nothing beyond a temporary feeling of faintness, and on two occasions a temporary outburst of urticaria, which soon passed away. ' ' I hardly think these phenomena were due to injection into a vein ; indeed, the writer does not endeavor to account for them on this ground. They partake more of the nature of rapid absorption with some idiosyncrasy. Dr. E. C. Seguin makes mention, in the New York Medical Record, of a lady thus affected (urticaria) by any preparation of opium taken by the mouth. Arthur R. Graham, m.d., etc., of Weybridge, England, sends me the following interesting and conclusive case : " No deaths; but one alarming accident worth recording : I had injected a large dose (probably three-quarters of a grain) into the right forearm of a woman whom I was in the habit of injecting daily. Almost immediately she started up, and holding up her left hand and looking at it, exclaimed, ' O, how funny my fingers feel ! ' and fell back in a dead faint, with blanched lips. I immediately bound a tape tightly around the arm, above the puncture, and then gave brandy and asafoetida injections, but she re- mained unconscious, I think, for more than half an hour. After she was sufficiently recovered to talk rationally I loosened the tape, when she immediately fainted again. SUBCUTANEOUS INJECTION. 79 Of course, I at once tightened the ligature and kept it so for some hours. The second swoon was less alarming than the first. In the first no pulse could be felt, nqr could the heart sounds be heard, excepting with great difficulty. My impression at that time was that, had I not applied the ligature at once I should have had a fatal result to chron- icle. It was the impulse of the moment to tie on the tape, and had I had time to reason I should have rejected the idea as an entirely useless one ; but in any similar emergency I should now recommend any one to try it." Dr. E. Fletcher Ingalls*, who has devoted much atten- tion to the hypodermic injection of morphia, reports the following case : "I have often used hypodermic injections of morphia, and always with good results, until a few weeks since, when I obtained alarming results from the adminis- tration, by this method, of one-fourth of a grain of mor- phia. " The patient, in consequence of continuous watching with sick children, had become debilitated, and, as a result, suffered at times from severe pains of a neuralgic character. I was called in the night to see her in one of these attacks. The pain had commenced about twelve hours previously, and with frequent exacerbations, had steadily increased in severity until it had become unbear- able. "I dissolved one-fourth of a grain of morphia in pure water, and administered it under the integument on the outer side of the arm. Within a few seconds the breath- ing became stertorous, the pulse failed, the lips and coun- tenance became livid, and the eyes were set ; respiration ceased, the radial and cardiac pulsations were lost, and the heart sounds could not be distinguished. The woman * Chicago Medical Journal and Examiner, Aug. 1877. 80 THE OPIUM HABIT. was to all appearances dead. How long this condition continued I cannot tell ; it seemed an age, but was prob- ably only ten or fifteen seconds, for by prompt means I succeeded in resuscitating my patient. "After a few minutes she expressed herself as much relieved. I remained with her some time, and then left careful directions with the husband in case any other unfavorable symptoms should occur. During the next few hours the patient fainted twice, but she was restored by dashes of cold water in the face. ' ' Dr. H. L. Harrington, of Little York, 111., refers me to the report of a case* of his, which reads as follows : " Was called a short time since to treat W. S. , male, aged sixty- two, for acute dyspepsia (bilious attack) accompanied by very severe pain. Administered hypodermically, in the hypogastric region, morphia? sulph. 0.02 gram. Before the syringe was emptied alarming syncope supervened, and occurred twice, at intervals of ten or fifteen minutes. Stimulants administered freely, artificial respiration and the use of electricity were successful in reviving the patient. Neither narcotism nor coma were in any degree present. Is it possible to attribute the syncope to the ef- fects of the drug ? Not over fifteen seconds were occupied in the operation." I think this an excellent example of the puncture of a vein with entrance of the drug directly into the circulation. Dr. Aug. M. Tupper, of Rockport, Mass., published the following interesting case :f "On the morning of the 2 2d ult. I was called to see Mr. G., who was stopping at one of our hotels. I found a healthy-looking young man, about thirty years old, suffer- * Chicago Med. Journal and Examiner, April, 1879. f Boston Medical and Surgical Journal, October 30th, 1879. SUBCUTANEOUS INJECTION. 81 ing from lumbago, confined to his bed, and in consider- able pain, aggravated very much by movement. Applica- tions of mustard and an anodyne liniment were prescribed. In the evening I called again, and as the relief was slight, decided to inject some morphia directly over the seat of pain, a method I have found very efficacious in similar cases. Ac- cordingly I injected nine drops of a solution of sulphate of morphia, one grain to a drachm of water, into a spot mid- way between the spine and crest of the ilium. As is my custom, the solution contained one drop of carbolic acid, which I added in order to keep it. In five minutes he expressed himself as feeling relieved, and sat up in bed to show us the improvement. I told him to lie down and keep still awhile, and he did so. We chatted pleasantly for perhaps five minutes longer, when, turning toward his wife, he said, ' I think I am going to vomit,' and turned to the side of the bed. I noticed that he looked a little pale, and before Mrs. G., could get the basin, he grew deadly pale, his eyes rolled up in his head so that only the whites were visible, the jaws were clenched, the head was drawn back, and the whole body stiffened, respiration ceasing also. I immediately went to him, dashed cold water in his face, and took the wrist to feel his pulse, which, to my horror, was not to be felt. He was in this state for perhaps a minute. I then raised him up, and looking into his eyes, which were staring wide open, saw that the pupils were widely dilated. Very soon the color began to return to his face, he was drenched with perspi- ration, and recovered consciousness. I laid him back on the bed, and he looked up, smiled, and said, ' I'm all right now. 1 The pulse was quite full at sixty, but inclined to be irregular. I gave him brandy freely, and he had no further trouble, but the pulse remained at sixty for the 82 THE OPIUM HABIT. next twenty-four hours ; he said it was usually about eighty. I cannot verify that, for he left town the following day. "That was certainly a very unusual effect from such a dose, a little over one-eighth of a grain. The question arose in my mind whether the acid could have had any- thing to do with it ; but I have given the same mixture a great many times without the slightest trouble. I may add that the solution was prepared that morning, and I injected the same dose into the same part of the body, for neural- gia, in a female patient, that very same day, previous to using it on this patient. I should not care to repeat this operation on Mr. G., and advised him never to have it done again. I would also state that it relieved his lumbago, for the next afternoon he was dressed and down at his meals. ' ' After seeing the report of this case I wrote Dr. Tupper, who has courteously furnished me with the following ad- ditional facts: "My patient, I should say, was of a phleg- matic temperament. He had taken no medicines by the mouth before I saw him, nor while under my care. He had never taken any narcotic in his life, he says. The pupils were natural very soon after the effects of the dose ceased. He writes me that his pulse remained at sixty for a week, but that he felt first rate. Pulse rate since then has been seventy-six. It seems to me that it must have been a peculiar susceptibility to this drug in his case, else it would not have had such a lasting effect upon the pulse. I do not think it was due to the mode of administration. He related to me afterward, that a cousin (I think that was the relation) had very peculiar and even dangerous symptoms from a dose of Dover's powder, some time ago, and that the physician in attendance was detained all night in consequence. This would go to show an idiosyn- crasy in the family." SUBCUTANEOUS INJECTION. 83 I think that the doctor is right with reference to idio- syncrasy, but I think, also, that the method of administer- ing the drug had much to do with it. As I have said before, where an idiosyncrasy, be it to narcotism or any other peculiar manifestation, exists, the sudden entrance of the drug into the system is certain to aggravate those symptoms; may, indeed, call forth an idiosyncrasy that the drug given by the stomach would, possibly, never have revealed. The fact that some ten minutes elapsed between the time of the injection and the first appearance of the alarming symptoms seems to preclude the idea of the needle having entered a vein. The symptoms are, how- ever, exactly those that are seen when a vein is punctured. As will be seen from the results of experiments soon to be recorded, and from the conclusions arrived at by the Committee of the Medico-Chirurgical Society* of Eng- land, five minutes is abundant time for enough of the drug to be absorbed to produce its characteristic, and, there- fore, its unusual effects, where*idiosyncrasy exists. Prof. H. C. Wood,f states that he has seen deep coma produced in three minutes by a hypodermic injection of morphia. This may have been due to unusual rapidity of absorption from the cellular tissue, or to direct injection into a vein. Here is a somewhat similar case J : A lady, aged twenty- four, who has been a sufferer from neuralgia every day for months, was given a hypodermic injection of one-fourth of a grain of the hydrochlorate of morphia in the subcuta- neous tissue of the leg. Alarming syncope and extreme prostration came on within five minutes after the injection was made. The patient was not out of danger for four *" Medico-Chirurgical Society Trans.," vol. L. f " Materia Medica and Therapeutics," Phila., 1877, P- 2 °5- % "Medico-Chirurgical Transactions," vol. L. 84 THE OPIUM HABIT. hours after, and was too ill to leave her bed for two weeks. The neuralgia did not return for some months. Dr. Francis H. Miller, of East New York, formerly House Surgeon of St. Peter's Hospital, Brooklyn, writes me : " Several times, when I suppose my fluid entered some small vein, the patients complained of sudden weak- ness, faintness and dizziness, and almost syncope." Dr. Samuel W. Francis, of Newport, R. I., writes me: "I have heard of two or three cases where extreme syn- cope set in, the patients being restored only with great difficulty." Dr. J. S. Jewell, Professor of Nervous and Mental Dis- eases, Chicago Medical College, writes me: "I have never had any serious consequences follow morphia injec- tion, but have seen temporary unpleasant symptoms (vaso- motor disturbances), vertigo, mental confusion, etc., a few times." Dr. Geo. R. Fowler,* of Brooklyn, states that he has twice had alarming symptoms from puncturing a vein. He believes that this may be avoided by making the skin of the part to be punctured tense, and introducing the needle at a right angle to the axis of the limb. Prof Nussbaum,f of Munich, has published an interest- ing account of an accident that happened to himself. He had made use of the hypodermic method of giving mor- phine to himself, as often as 2000 times, using sometimes as much as five grains of morphia at an injection. One day he accidentally injected two grains of the acetate of morphia into a vein, and did not recover from the dan- gerous effects for two hours. He has seen the same symp- toms, in a less degree, in two of his patients. He advises * N. Y. Medical Record, Aug. 15th, 1874. t Medical Times and Gazette, Sept. 23d, 1865. SUBCUTANEOUS INJECTION. 85 slow injecting, and withdrawal of the piston if a vein is punctured. The following interesting remarks are clipped from an English journal,* and bear directly on the question in hand : — " ' Observer ' remarks that ' Spectator,' in the Journal, of April 1 2th, very accurately described what always happened when a vein has been pierced and morphia in- jected into it, although he might have added (as no doubt it occurred) that the person injected also experienced a strong taste of morphia ; and probably, also, an unusually. large quantity of blood flowed from the puncture. It is a very serious accident to inject morphia into a vein, but it need never happen, if the operator, thrusting the instru- ment under the skin, will draw up the piston, when, if the point be in a vein, blood will be drawn into the syringe. ' Observer ' knows a gentleman who for years has been in the habit of injecting himself with morphia, three and four times a day, to whom the accident has frequently occurred, accompanied by the symptoms described by ' Spectator. ' He is much alarmed at the time, and is after- ward careful to draw up his piston, but in three or four months he begins to be less cautious, until he gets another reminder. As to the necessity of drawing up the piston, there cannot be two opinions ; for besides the symptoms certain to follow the introduction of morphia directly into a vein, there is the danger of air entering as well, should care not be taken to prevent it. ' Observer has known an habitual morphia taker by injection to contract albumin- uria. The albumen would greatly diminish on the daily quantity of the injection being lessened, and entirely dis- appear in forty-eight hours, when the morphia was wholly discontinued. * British Medical yournal, May, 1879. 86 THE OPIUM HABIT. " ' Injector ' was, until very lately, for nearly two years, one of the victims of morphia, and during that time he five times thoroughly, and twice partially, experienced more or less of the horrible symptoms sketched by ' Spec- tator ' in the Journal of April 1 2th. The sensations were as follows: i. A dull, gnawing pain in some decayed teeth, accompanied by a metallic taste in the mouth. 2. A pricking and tingling of the forehead and cheeks, somewhat like prickly heat; but this soon increased, spreading to the ears, neck, arms and chest (but not below the waist, although the morphia was injected into the calf of the leg). This pain soon became almost unbearable, but it was entirely eclipsed by what ' Spectator ' calls 'throbbing,' but which 'Injector' says would be better represented by imagining twenty blacksmiths confined in his head, with each an India-rubber-headed sledge ham- mer, and each trying to make the best of his way out. Imagine, at the same time, that you are suffering from the first mentioned broiled feeling ; that your skin feels as if about to burst ; your eyes as if already started from their sockets ; your lips as if they did not belong to you — then you may have a faint idea of what ' Spectator' wishes to describe, and what I, who have five times felt it, yet feel powerless to lay before you as I ought. ' ' He had always thought that this condition was caused by : 1, too rapid injection ; 2, too much at once ; 3, the solution being too strong ; and 4, by its being injected directly into a toler- ably large vein. When the symptoms have occurred, he has always noticed that injection has taken place at one of two spots — probably into the same vein each time in each leg — one on each leg. Again, it only occurred when he had to inject a large quantity in a short time ; and he always used a very strong solution of acetate of morphia SUBCUTANEOUS INJECTION. 87 (forty grains to the half-ounce of water). He advises that when one feels any of the symptoms coming, he should walk about as rapidly as he can. He has relieved his worst attacks in this way, and has warded off others by violent exercise in his room, as soon as he felt the pain in his teeth, or the metallic taste or the "prickly heat." He thinks that corroboration of his belief as to the cause of the symptoms is afforded by Dr. Pepper's description of the results of injecting milk into the veins of anaemic patients. The case referred to by "Observer" reads as follows:* " Scarcely has the fluid left the syringe when the most in- tense feeling of irritation and pricking is felt in the skin, spreading from the puncture rapidly all over the body. At the same time the skin becomes suffused with a. bright blush. The heart's action then becomes greatly quickened, and there is a throbbing, rushing feeling through the head. The hands are somewhat swollen and the lips get a glazed appearance. In one case that I had, the patient became suddenly unconscious, as if knocked down by the sudden shock ; and in all the cases where these symptoms have appeared the general disturbance has been very great and the attack of a severe character. The symptoms generally subside gradually, leaving behind great pain in the head. This gentleman gives these as the main symptoms of several such accidents that have occurred in his • practice, and characterizes their occurrence as something novel and important. Dr. J. A. Houtz,f of Logansville, Pa., who is a staunch advocate of the hypodermic method, says : " The greatest danger is in injecting into a vein sufficiently large to carry the whole dose at once into the circulation. That can be * British Medical Journal, April 12th, 1879. t Philadelphia Med. and Surg. Reporter, Oct. 18th, 1879. 88 THE OPIUM HABIT. avoided by selecting a place where the large veins are least numerous, and by injecting, say a third of a dose, and then waiting eight or ten seconds, when, if in a vein, the symptoms will sh©w themselves. The first symptoms are a feeling of great fullness of the head and intense flushing of the face, coming on within a few seconds after the operation. Such, at least, was the case in a patient of mine." A case of syncope and prostration is reported by Dr. E. Wenger, of Gilman, 111. The amount of morphia used is not stated. F. Woodhouse Braine, f.r.c.s., etc., publishes the fol- lowing case:* "Mrs. H. C, aged thirty-five, in good health otherwise, had been kept awake seventy-two hours by intense neuralgic pain on left side of head, face and neck, arising from a carious molar tooth on the left side of lower jaw. She was injected with one-third of a grain of acetate of morphia. At i a.m., on June 28th last, the morphia, dissolved in about four drops of water, was intro- duced under the skin of the left arm, just over the inser- tion of the deltoid. No blood appeared at the puncture. In about fifteen seconds tightness of the chest and diffi- culty in breathing was complained of, and the patient asked to. be raised, saying she felt as if she was dying. Her face and lips now became pale ; speech became indistinct (not inaudible) ; pulse irregular ; some spasm of the facial muscles took place, and she fell, to all appearance, dead. Cold water was freely dashed over her face and chest, and as she was unable to swallow, her tongue was rubbed over with sal volatile, and ammonia applied to her nose, artifi- cial respiration being kept up at the same time. During this time her face was blanched, pulse not to be felt, and * Med. Times and Gazette, Jan. 4th, 1868, p. 8. SUBCUTANEOUS INJECTION. 89 respiration not to be perceived. Insensibility continued for about three minutes ; then, happily, one or two feeble beats of the pulse, and a shallow inspiration or two, showed returning animation. She then became conscious ; pulse feeble but regular; respiration slow; fingers remained numb and both thumbs were firmly drawn into the palms of the hands. This passed off in about six minutes, leav- ing her feeling very ill, but free from the neuralgic pain, which did not return. There was no feeling of nausea, and no attempt at vomiting during any part of the time. ' ' Mr. Arthur Roberts* publishes the following cases : — " Sir: — The case described by Mr. Braine, in your last week's journal, of an unusual effect of subcutaneous injec- tion, is what I have seen in two instances, but nothing like to such an alarming extent. One was in a gentleman whom I had injected several times previously, the other in a lady. I have also partly noticed it when I have injected myself. In the first case, a few minutes after the opera- tion, the face became intensely flushed ; this was followed by vomiting, and then a dead faint and struggling for breath, the pulse scarcely perceptible. These cases, and the effect on myself, taught me, when injecting a patient for the first time, never to give more than the sixth of a grain — wait a quarter of an hour longer, and then give the remainder of the dose, after ascertaining how the first injection was taking effect. Women, I have found, are generally bad subjects for subcutaneous treatment ; for they get frightened and nervous — in fact, one woman told me that though the morphia taken by the skin did her more good than by the mouth, yet she preferred the latter, for the instrument frightened her. I have used my needle over three hundred times, and I have always noticed one * Medical Times and Gazette, Jan. nth, 1868, p. 53. 90 THE OPIUM HABIT. fact, that if the wound bleeds after the operation the mor- phine enters the system much more powerfully and rapidly ; and I always know when it is going to. bleed, by the opera- tion giving a good deal of pain. When this is the case I withdraw the instrument, to see if the puncture bleeds ; if it does, I try a fresh place. ' ' Bartholow,* in his useful and able little work, calls at- tention to this danger in these words : "In practicing the hypodermic injection it is important to avoid puncturing a vein. Serious depression of the powers of life, fainting and sudden and profound narcotism have been produced by injecting a solution of morphia directly into a vein. Fatal collapse might be induced by injecting air into a large vein, along with the solution." Syncope, etc., as we have seen, from this cause, is com- mon ; narcotism rare, the drug seeming to exhaust itself in its initial action, or to produce a condition of the system in which narcotism is wholly or partially impossible. Dr. Coronaf ( Giornale di Medicina Militaire), summing up the results of his experiments on animals, says : " The injection of the two poisons (morphia and atropia) into the veins showed that a much smaller dose was sufficie nt to produce rapid and grave poisoning, but even then the morphia produced its action instantaneously, and its action always superseded that of atropia. ' ' J. Pennock Sleightholme, l.r.c.p., Lond.,J reports the following case : "A young man of sound constitution and good health, who had never before taken morphia hypo- dermically, partly as an experiment and partly with the hope of relieving some slight restlessness, injected himself, at about 3 a.m., with one-sixth of a grain of morphia. * " The Hypodermic Method," Philadelphia, 1879, p. 32. t Edin. Med. Journal, Dec. 1876. Practitioner, 1877, p. 132. I Practitioner, July, 1871, p. 25. SUBCUTANEOUS INJECTION. 91 Immediately after the injection he fell down on the floor in a state of syncope, and had slight convulsive movements on one side of the body; consciousness did not entirely leave him, and after lying still for about ten minutes he was sufficiently recovered to be able to go to the next room and help himself to a couple of glasses of sherry. After this the feeling of faintness gradually passed off, and he slept for about two hours, but on rising, at eight o'clock in the morning, the same feeling of faintness returned, accom- panied with great pallor. These symptoms were relieved by a dose of brandy, but did not entirely cease until noon the same day." A physician in the South, who is a slave to this habit, writes me : " Several times I have been unfortunate enough to puncture a vein, and to introduce some of the solution directly into it. Immediately I feel a peculiar tingling all over me, from the tips of my fingers to the ends of my toes. The skin of my head feels as if a myriad of pins were penetrating it. This feeling passes off in from three to five seconds. Sometimes it has been followed by a tur- gescence of the vessels of the brain, causing a great fullness and throbbing, with slight headache following." In a most interesting and instructive letter from Dr. Wm. W. Cable, of Pittsburg, Pa., I find the following: " I have spoken of minor accidents which sometimes oc- curred. In all that I have seen they were caused by the injection of the morphia directly into a vein. A series of phenomena instantly take place. The patient describes the first sensations as the stinging of bees all over the body, with difficulty of respiration, and intense congestion and swelling of the face and body. In one case that I saw the face was so swollen that in five minutes all traces of the natural features were lost. This condition of affairs calls 92 THE OPIUM HABIT. for prompt action. If possible, the patient must be kept in motion and applications of cold water be made to the face and spine. If the patient falls the limbs must be raised, and all methods used to keep the heart acting, for if you can bridge over ten or twelve minutes the patient is safe. To prevent being ' struck,' as he calls it, one patient of mine carries a cord, which he throws over the arm, and if an unfavorable symptom occurs, he uses it as a tourni- quet, and in a moment the result is apparent in the extra- vasation of the blood and the morphia from the wounded vessel. This is a safe condition, as afterward no rapid absorption can occur." This is a companion case to that reported by Graham, where ligation of the limb proved to be of great practical importance. An interesting series of experiments, bearing directly upon the use of the ligature in such cases, were made by Mr. Georges,* at the Paris Society of Practical Medicine, some of which were conducted for this gentleman by M. Claude Bernard. These experiments consisted in "in- jecting poisonous substances into the cellular tissue, with the view of showing the far greater safety and cer- tainty of the hypodermic method as a means of administer- ing, medicinally, highly-poisonous substances. He in- jected quantities of codeine, atropine and especially strych- nine, which would surely cause death in the absence of precautions for preventing the too rapid introduction of the poisons. These injections were practiced without dan- ger in the dog's paw, the passage of the poison into the veins being checked by the forcible application of a liga- ture around the paw. To render the experiment still more striking, he resolved to employ injections of the most dan- * Medical Times and Gazette, June 14th, 1865, P- 4 2 - SUBCUTANEOUS INJECTION. 93 gerous of poisons — curare — and M. Claude Bernard con- ducted them for him. A solution containing about five centigrams of curare (sufficient to kill more than fifty dogs of the size of the one operated upon), was injected into the paw, and in twenty minutes the animal fell on its side. The paw was now firmly tied, and at the end of about twenty minutes the animal arose. Whenever the ligature was loosened he again fell down, sometimes at the end of ten minutes, and sometimes in a shorter period,* and in this way it became possible to dose with complete certainty, according to the effect desired to be produced, the quantity of poison to be absorbed. The next day the dog was found on his three paws, only suffering from the swelling caused in the fourth by the injections. The ligature was removed and he was soon all right. " The same experiment performed on another dog was followed by the same results, the animal being caused to fall or rise at the end of five, ten, or fifteen minutes, accordingly as the paw was tied or untied. This dog, how- ever, next morning, on the removal of the ligature, fell down again, all the poison not having had time to become eliminated by the urine, so that it was necessary to reapply the ligature. M. Georges points out the superiority of the endermic method, when we have to administer powerful substances, as we may apportion the dose with an exacti- tude, according to the tolerance of the disease and idio- syncrasy of the patient, quite unattainable when admin- istered internally." Dr. Alonzo Clark, Professor of Theory and Practice of Medicine and Clinical Medicine in the College of Physi- cians and Surgeons, New York, kindly gives me the details of the following case : "There was brought into Bellevue * Italics mine. 94 THE OPIUM HABIT. Hospital, some years ago, during his term of service, a young woman, aged about twenty-five, suffering from tris- mus. The jaws were so firmly locked that it was neces- sary to break out a tooth, in order to administer food and medicine. All ordinary medicine failing, on the evening of the second day the house physician determined to treat the case with hypodermic injections of morphia. He gave three injections of fifteen minims of Magendie's solution, with two hours' interval between the doses, and finding that no effects of the morphia were apparent at 2 a.m., he gave an injection of twenty minims. When he returned to the ward, at 4 a.m., the patient was dead. The nurse, on being questioned, stated that the patient was "asleep" before the doctor left the ward. The arm in which the puncture had been made was examined by Dr. Clark and others, and over the point of the last puncture a little discol- oration, as from extravasated blood, was apparent, and which, on careful dissection, was found to mark the track of the needle, which had opened directly into a vein. In this case the patient probably died almost immedi- ately, the action of the morphia being shock-like, and its effect the more intense as one grain and a half had already entered the system by the skin. Prof. Wm. T. Lusk, of this city, writes me of a case of syncope following immediately upon the injection. No blood appeared at the point of puncture. Another case of death from injection into a vein is re- ported to me by Professor Willard Parker. An injection of morphia, to relieve the severe pain of neuralgia, was made into the temporal region of an apparently healthy young man. Death was almost immediate. The case was in the hands of a physician in Connecticut. I have re- peatedly written, asking for full particulars, but cannot get SUBCUTANEOUS INJECTION. 95 them. It is a strange fact that all the cases where injection into the temporal or infra-orbital region is mentioned by correspondents and by some authors, have been attended by either intense narcotism or death. This is, of course, not a uniform occurrence, but it has happened sufficiently often to call our attention to it, and urge caution in its use in this situation. In this connection, and in point of history, the follow- ing quaintly worded extract from a diary, which appears in Pepy' s Journal,* of May 16th, 1664, is of interest. " With Mr. Pierce, the surgeon, to see the experiment of killing a dog by letting opium into its hind leg. He and Dr. Clark did fail mightily in hitting the vein, and in effect did not do the business after many trials ; but with the little they got in, the dog did presently fall asleep and so lay till we cut him up." The different effects produced by the same accident on different persons seems to be due to some peculiarity of constitution with reference to morphine. The drug is thrown so rapidly into the circulation that it carries every- thing before it, seeming to instantly overwhelm the vital powers. The brunt of its action seems to be exerted on the heart, and the key to proper treatment is thereby afforded. To whatever cause due, the effect is essentially the same, the difference being only one of degree. That syncope and vaso-motor disturbances are ever due to the injection of air into a vein with the solution, I very much doubt. In the first place the morphia itself is quite suffi- cient to produce the symptoms, and in the second place not more than a bubble of air is ever left, by carelessness, in a syringe, and this is not sufficient to produce these symptoms. To settle this matter, I purposely injected into * E. P. Wilson, "St. George's Hospital Reports," 1869. 96 THE OPIUM HABIT. the median cephalic vein of my own arm twice as much air as this, with a solution of warm water, and without any bad effects ; in fact, no effect whatever. My arm, above the point of puncture, was protected by a ligature that could have been drawn tight at a moment's notice, had there beeh any untoward symptoms. The following day I injected one-sixteenth of a grain of the sulphate of morphia into another vein, with the effect of producing sudden dizziness, a feeling as if the head would burst, pricking and tingling of the nose, suffusion of the face and eyeballs, dilatation of the pupils, faintness and nausea. The pulse was first greatly accelerated, and then fell to about 65, and remained so all that day. My pulse in health is 74. This was done at 10.30 a.m., and I did not fully recover until about 3 p.m. It may be well to state that morphia, either by the mouth or skin, always has a very unpleasant effect on me, while opium has not. Instead of causing sleep and soothing irritation, the former makes me nervous, " twitchy" and somewhat light-headed. In both cases the needle entered the vein, as it was made prominent by the ligature, and blood appeared at the point of puncture. As soon as the injection was made the ligature was loosened, I being ready to pull it tight at a moment's notice. M. Calvet* presents a physiological research of the action of morphine upon the various functions of the organism. A clinical study of morphine as a therapeutical agent, especially in. the relations of acute to chronic morphinism. In the first he observes that both intravenous as well as subcutaneous injection of the hydrochlorate of morphine accelerates respiratory movements, succeeded by a period of retardation, and produces sometimes a momentary arrest or respiratory syncope. The same relative effects occur * " These de Paris," N. Y. Med. Journal, Sept. 1877. SUBCUTANEOUS INJECTION. 97 with the cardiac movements; at first accelerated, followed by retarded pulsations ; sometimes even by cardiac syncope. During this time animal heat exhibits analogous pheno- mena, namely, the elevated is followed by lowered tem- perature. In fact, the absorption of morphine, whether by intravenous or subcutaneous injection, produces a very marked influence upon the reflex actions. In certain cases the period of exaltation does not occur, but the temperature becomes lowered, and the respiratory and cardiac move- ments are slower. Though he has not finally completed his researches, M. Calvet advances the opinion "that the above phenomena are the dyspnoea, dizziness, etc., some- times seen during the operation of intravenous injection of milk. ' ' A study of these cases* (milk injections) shows us that these phenomena rarely if ever present themselves until a large bulk of fluid (from two to six ounces) has been added to the blood, and that, therefore, the argument does not hold good. An interesting and novel series of careful experiments on man and animals, made by Dr. Gaspar Griswold,f then house physician in Bellevue Hospital, this city, although not made with that end in view, seem to demonstrate very clearly that a powerful and possibly irritant medicine (aq. ammonia dil.) when injected into a vein in quantity does not produce any untoward symptoms, but, on the contrary, were always found to have the happiest, and sometimes a most marvelous effect. Another question arises here: Is it possible for such phenomena as have been ascribed to the injection of morphia into a vein to take place without such puncture ? * Pepper, N. Y. Medical Record, Nov. 16th, 1878. H. H. Smith, Ibid. Joseph H. Howe, aid., Dec. 7 th, 1878, and Jan. 4th, 1879. J. S. Prout, Ibid, May nth, 1878. f " The Intravenous Injection of Ammonia," N. Y. Medical Record, June, 1879. 98 THE OPIUM HABIT. I think so. Some of the cases reported would seem to prove it; notably that by Dr. Tupper, where the symp- toms did not appear until ten minutes after the injection was made. Every insertion of a hypodermic needle, of necessity, cuts across or opens a number of capillary ves- sels, to which is undoubtedly due, to a certain extent, the rapidity of absorption when drugs are given in this manner. The Committee of the Medico- Chirurgical So- ciety* came to the conclusion, from experiments on men and animals, that absorption of a sufficient amount of the remedy to produce decided symptoms took place in from four to ten minutes. " Experiments on a healthy man, aged thirty-two. One- sixth of a grain of acetate of morphia was employed : — Symptoms. Skin. Mouth. Absorption 5 min. 1 10 min. Pulse increased . . 8 beats. None. Pulse lowered 12 " 10 beats. Headache . . 36 hours. 10 hours. Nausea .... 46 " 3 " Pulse, its nat. standard . 22 " 8 " Incapacity to work 7 " None. Total duration of symptoms 46 " 11 hours. I have found that some drugs, notably jaborandi, when used hypodermically, manifest their peculiar symptoms in so short a time as one minute, no vein of any size being punctured. It is to be supposed that one drug is absorbed from the subcutaneous cellular tissue with about the same rapidity as another, but that each drug manifests its presence in thetirculation with a difference in point of time, ac- cording to its peculiar action, or to some idiosyncrasy of the patient. Thus, while morphia may be absorbed as rapidly as pilocarpine or jaborandi, it does not, save in * " Medico-Chirurg. Transactions/' vol. i.. p. 570. SUBCUTANEOUS INJECTION. 99 certain persons or at certain times, give evidence of its presence by recognizable symptoms so early or so decidedly as the latter, unless the patient manifests some idiosyncrasy. From this it would appear possible, in certain cases, for a very rapid absorption to take place, and sudden over- whelming of the heart by the drug to occur without the puncture of a vein. As the needle does not go deeper than the subcutaneous cellular tissues, in a large majority of the cases the immediate treatment would be as effective in one case as in the other. At a recent meeting of the New York Pathological Society,* Dr. Amidon presented some microscopic speci- mens exemplifying the pathology of hypodermic medi- cation. He said that although hypodermic medica- tion had been in vogue twenty-five years, or according to the claims of some, forty years, he was not aware of any accurate investigation of the relations between the hypodermically injected mass and the skin. He had injected Prussian blue (a weak solution) into the skin of moribund subjects, and a portion of skin was excised after death. The hypodermic injection was given in what he considered the best manner, namely, the pinching up a -fold of skin and introducing the needle horizontally. The hypodermic injection was found to occupy a space three and a half centimetres in diameter and one milli- metre in thickness, tapering in shape. The location of the hypodermic injection varied according to the amount of adipose tissues in the subject. In those who had but little adipose tissue the hypodermic injection remained immediately below the skin, while in those who had much, the injection diffused itself. It would be seen in the specimens presented that the hypodermically injected mass * New York Medical Gazette, Jan. 10th, 1880. 100 THE OPIUM HABIT. lay close to the arteries and veins ; sometimes it com- pletely surrounded an artery or vein. This, together with some other experiments, proved that it was by the blood vessels and not by the lymphatics that absorption took place. In order to still further test the mat- ter, he had injected muriate of pilocar- pine into the ankle and into the supra- clavicular region. The physiological effects of the drug (diaphoresis, sali- vation, etc.) were produced in both cases in about the same time, varying in different subjects from one and a half to four minutes ; there was no appreciable difference. If the absorption had been by means of the lymphatics, the injec- tion in the supraclavicular region would have produced its effects much more rapidly than that injected into the ankle. In one of the slides the section had fortu- nately been in the line of the puncture of the needle, and showed that consider- able injury had been done to the tissues. I am firmly convinced that no physician should be held free from blame in case of accident where he has not had a liga- (Agnew.) ture or tape loosely encircling the arm cf 'i£Ti? Ve I in em 7 t M*n above tne point of puncture. At the Vei"n k c C AnteLr^B?anch first mtimat i° n of danger this should be of Bakic Vein ; rf Poster- pulled tight and kept so for several lor Branch of Basilic Vein; ° r e Basilic Van;/, Median hours, being loosened gradually, thus Vein ; g, Median Basilic . . Vein; a, Median Cephalic permitting but a gradual entrance of the Vein; z, Biceps Muscle; j, . ° ° Tourniquet. drug into the general circulation. With SUBCUTANEOUS INJECTION. 101 this precaution it will be seldom necessary to treat such alarming symptoms as are here recorded. A tourniquet for this purpose is here shown. It consists of a strap or heavy tape, at one end of which is sewed a "patent buckle," that will catch and hold at any point. In the absence of this or a skate strap with such a buckle, any cord or tape, so arranged as to be pulled tight at a moment's warning, may be used. The treatment of such condition when al- ready established, is summed up in one word — stimulation. Whiskey and ammonia hypodermically, cold affusion, elec- tricity, when there is a battery at hand, and hot bottles to the prsecordia. In some instances tetanus has followed the use of rusty needles, in one case resulting in the death of the victim, an habituS.* At Southsea, recently, an inquest was held upon the body of Mrs. Frampton, wife of a lieutenant and adjutant in the Royal Marine Light Infantry. The husband of deceased deposed that his wife was twenty- five years old, and that in 1871, previous to giving birth to a child, she suffered greatly from sickness. A surgeon, to alleviate this, used morphia by the hypodermic method, always injecting the solution himself. Some time since deceased assured him she had entirely given up the use of morphia. On the previous Thursday he found the deceased suf- fering from convulsions. She grew worse and died the following morning. Since her death several bottles had been found in her wardrobe, tied up in a parcel and se- creted, together with five or six small cases, each contain- ing a hypodermic syringe. *" The Hypodermic Injection of Morphia; its History, Advantages and Dan- gers." N. Y., 1880. 102 THE OPIUM HABIT. Mr. Cruise, pharmaceutical chemist, said that at first he refused to serve the solution, but on reference to his junior assistant he was informed that Mrs. Frampton had been frequently supplied with the solution. In August, Sep- tember and October, he supplied nine bottles each month, the last being on the 30th ult. Dr. Norman described the state he found deceased in, and stated that when Mr. Norman and Dr. Jackson were called in they discovered on the upper part of both arms a large number of old scars, which they were informed were the result of hypodermic injections five years ago. There were no recent marks about the arms, but upon both thighs there were a large number of similar marks, and also seve- ral marks of recent punctures. Around some of these latter there was a redness of the skin in different stages, and one particularly had the appearance of having been made within twenty-four hours. He was of opinion that Mrs. Frampton died from tetanus, caused by the punctures made in the thighs for the purpose of injecting a solution of morphia. He had been shown three syringes, all of which were in a dirty condition, apparently not having been wiped dry after using. The steel needles were in a very rusty state, which would be likely to set up inflammation. The jury returned a verdict to the effect, "That the deceased died from tetanus, or lockjaw, caused by inflam- mation arising from punctures made by the deceased her- self, for the purpose of subcutaneous injection of a solution of morphia."* The newspaper report of the following case has been kindly sent me by F. W. Barkitt, l.r.c.p., etc., Dublin, Ireland. The extract is from the Irish Times newspaper, October 23d, 1870, giving an account of the coroner's inquest : — * Medical Press and Circular , Nov. 29th, 1876. SUBCUTANEOUS INJECTION. 103 The patient was a governess, single, aged 56, and ad- dicted to the morphine habit, using the drug hypoder- mically. "Dr. Austin Meldon deposed he was called to see the deceased on the morning of the 16th instant. He found her in the spasm of lockjaw. She was actually in the spasm when he entered the room, her body being bent forward. Witness was of opinion the disease commenced late on Sunday night. From examination and inquiry, witness had made up his mind that the disease was caused by a slight wound, inflicted by the needle of a subcuta- neous injection syringe. There were numbers of marks over her body, where she had been in the habit of making these injections. The slight wound to which he had re- ferred was made on the previous Friday. He found she had been in the habit of using these injections for years. That morning she told him she had used twelve grains of morphia in one injection, and showed him the papers which had contained the four powders. That was an enormous quantity, a quarter grain being a full dose. The immense quantity she used that morning showed she had been using it for years. She told him that she was in the habit of using, when affected with neuralgia, twenty grains in twenty-four hours. There was no case on record of so much being used.* * Witness asked her why she had adopted that mode of taking morphia. She said, in order to avoid the tempta- tion of taking more of the drug. There was a case of poisoning from morphia in the same way in London, last year, but the quantity was considerably smaller — the dose taken being only one grain four times a day. After * In my chapter on " The Morphia Habit," I shall show that much larger amounts have been used, and for long periods. 104 THE OPIUM HABIT. witness saw her, he continued the injections during her spasms, and they relieved her pain, but, of course, the doses he gave were very small, and as the suffering became less, so did the quantity in the injection he administered. He would account for the lockjaw which caused her death by the particular puncture in the skin, as a nerve might have been injured by the entrance of the needle. It was a very hazardous thing for an unprofessional person to use one of those needles. He knew of two cases of lockjaw caused by it. In one of these cases, the patient was very nearly poisoned, for he used when he had no pain a dose which had been ordered him by a medical man when he was in great pain. Witness made a careful post-mortem examination. ' He had never seen a lady of that age whose organs were in a more healthy condition. The reason she used it, I may say, was to relieve facial neuralgia, in the first instance, and the habit grew on her. I found the surface of the body punctured in innumerable places with the needle. She seemed as if she had been tattooed. "Coroner. Is there anything else you think it well to tell us ? Are you certain she died from traumatic tetanus ? ' I am clearly of that opinion, both from the history and condition of the case.' "Corotier. There is one point which I would wish to have cleared up. Several medical men have mentioned to me that it is quite possible she might have obtained, either by mistake or otherwise, strychnia in place of mor- phia. You are satisfied that is not the case ? ' I am per- fectly satisfied. I should say that the symptoms of tetanus and strychnine poisoning are the same while the spasms are on.' After the spasms pass away, the patient becomes SUBCUTANEOUS INJECTION. 105 quite well in strychnine poisoning, but the muscles remain contracted in lockjaw. ' ' ' I have written Dr. Meldon, asking for histories of the two cases of tetanus referred to, but as yet have not had a reply. The British Medical Journal, in commenting on this case, says that it has no knowledge of the case referred to by Dr. Meldon as occurring in London, but refers to three cases of death from traumatic tetanus after the hypo- dermic injection of thesulphate of quinine {Lancet, July 6, 1867), and a case of tetanus after the use of morphia, due, probably, to the use of rusty needles {Lancet, December, 1876, p. 873). 106 THE OPIUM HABIT. CHAPTER VI. THE TREATMENT OF THE OPIUM AND MORPHIA HABITS. So many of our fellow-men have been, in the past, are now, and will be, bound hand and foot in this terrible bondage, from which they seem utterly incapable of re- leasing themselves ; so many illustrious men have offered themselves as living sacrifices to this false deity ; so many lives have been ruined, homes desolated, hopes destroyed, ambitions smothered by it ; so many of those dear to us have fallen beneath the shadow of this sickening evil ; so rapidly is the habit spreading, that the question of its treatment and cure has become one of momentous import- ance. Reading the histories of those cases where a cure was effected some years ago, one's mind is divided between admiration of the great heroism displayed by the unfortu- nates, and pity for the agony which they were allowed to endure. Great advances have been made in the treatment of this affection in the last few years, and to-day, although science is unable to substitute for the accursed drug one that can fully take its place, still she can lend a helping hand, whereby the ascent is made easier and more rapid. The suffering incident to the breaking of the habit can, in a great measure, be relieved. The method strongly advocated and practiced by Leven- stein, of Germany, I consider barbarous in the extreme, and dangerous. The following cases, a type of all, select- ed from those published in his book,* well illustrate this:— * " Morbid Craving for Morphia." London, 1880. TREATMENT. 107 Mr. von X., sent to the Institution by Professor West - phal, had caught cold while on a journey, which brought on rheumatic pains. To relieve him injections of morphia have been administered since 1872, at first by the medical attendant, and afterward by the patient himself, and in increased quantities, the largest daily dose having amounted to sixteen grains. The symptoms showing themselves in consequence of this use were loss of appetite and sleep, excited condition, emaciation, tremor of the hands. On October 9, 1875, patient came into the Institution; he had injected morphia for the last time on the morning of the same day. At 10 p.m. patient went to bed and at once fell asleep. At 3.30 a.m. he was sick, felt very weak and prostrate, suffered from twitching in the lower extrem- ities and diarrhoea. October 10. In the morning patient had five relaxed motions. Frequent vomiting during the whole of the day. Excitement and intense craving for morphia increases hourly. In the afternoon he talks of suicide. October 1 1 . Patient has had no sleep during the night, but has been frequently sick. Severe vomiting continued until 11 a.m., but stopped entirely during the rest of the day. Patient complains of languid pains in the legs, severe pain in the stomach. October 12. At iop.m. patient suddenly started up, andin a frightened manner asked, several times, "Was not the doctor in the room just now ?' ' only the nurse having been present. Until 12 p.m. he laid in bed quietly without speaking; he afterward raised himself up and screamed out, in great excitement, " Who is that big fellow in the next room ? He is so tall that he cannot get through the door ! And now he is getting taller still. . Now there are several of them ; they are ghosts ! ' ' His voice was 108 THE OPIUM HABIT. trembling, his extremities in constant convulsive move- ments. He was quieted,, but only with great difficulty. Again and again he raised himself and anxiously looked at the door. Temperature, 38.5° C. (101.3 F.). In the morning the patient addressed the superintendent, as he entered, as follows: "Ah, good morning, dear Emily. I am very glad you are coming ! ' ' While saying so he was lying down quietly. Now and then he raised his head slightly and looked at the wall for a time, as if observing something, and his lips were moving as if he was talking to somebody. In the course of the day he vomited considerably, several times. Patient feels very weak, the speech is unintelligible, the tremor has increased. He entered into a short conversation, and thinks himself better than yesterday. Although very tired he cannot get to sleep. Pulse was strong throughout fcjp.e day. Auscul- tation and percussion of the lungs and heart showed a normal condition. The bladder was empty and no urine was passed until 5 p.m. Several relaxed motions. October 13. Toward midnight patient suddenly raised himself up, looked around, stretched his hands, as if fright- ened, and called out in a trembling voice, "What do you want ? There is the — the ghost ! ' ' The voice next morn- ing was hoarse, hesitating, unintelligible, devoid of sound. The features looked worn. During the whole of the day there was diarrhoea and vomiting. An injection of food into the bowels was given (after Leube). October 14. Patient has slept for only a quarter of an hour in the night. The other part of the time he was dozing ; vomited four times, and had four relaxed motions. At 5 a.m. he called out to those watching him during the night, "Come along, come along, quick, quick!" He gradually lost consciousness, did not move upon being TREATMENT. 109 called. Pulse 40, very small, hardly to be felt ; respira- tion gasping, slow. Hippocratic face. Injected one- fourth of a grain of morphia. Pulse and respiration soon became regular, and he regained his consciousness. There was no vomiting during the day. The voice is still gone, the features worn. Toward the evening the patient had an injection of food (Leube) of sixteen and a half ounces. Great prostration. Skin moist and hot. October 15. Patient had no sleep, but lay quietly in bed until about 2 a.m., when there was vomiting, oppres- sion, moaning, clonic contractions of the muscles "of the face and extremities. Pulse strong. October 16. He had three relaxed motions, vomiting and bleeding of the nose during the night. During day- time patient felt well. October 17. Batient has had no sleep during the night, but was quiet ; vomiting and diarrhoea. In the day feeling of great weakness. Appetite good. October 18. No sleep, patient feels thoroughly knocked up. In the afternoon he slept for a short time. From this time the patient's condition was satisfactory. He slept at first for three hours, afterward for five hours, at last during the whole of the night ; the appetite increased considerably, the disposition was changed. He left the Institution on November 21st. Urine. — The specific gravity of the urine vacillated be- tween 1. 019 and 1.029. -A- precipitation with alkaline solution of sulphate of copper was noticeable only occa- sionally. The patient, whom I saw six months after his discharge, has had no relapse. Mrs. Jane G., a patient of Dr. B. Frankel, of Berlin, 35 years old, eleven years ago, after having been suffering 110 THE OPIUM HABIT. with typhoid fever, was afflicted with an abdominal com- plaint which caused so much pain that the family doctor had to administer an injection of morphia daily. Ten years ago patient married, and has given birth to two children one five years, the other eight years old now. The confinements were protracted ; both children died soon after their birth. During both pregnancies the use of morphia was discontinued by the doctor, the same taking place during several occasional journeys to bathing- places made by the patient because of her complaint. For five years she has injected morphia herself, the largest dose pro die having been eight grains. While using the drug, a febris intermittens tertiana showed itself, two years ago, lasting, with an interruption of four weeks, until November; 1876. Regularly at 4.30 p.m. she had shiverings, followed by burning heat, and ending in perspiration. Thje repeated use of quinine, even a change of air and a sojourn in the country, were unable to suppress the fever. Dr. B. Frankel, who had only for three months attended Mrs. G., and whom she had never told of her custom of using morphia regularly, made the diagnosis of morbid craving for morphia only through con- sidering the intermittent fever. Apart from the latter, the use of the drug had brought on the following symptoms : sleeplessness, headache, principally in the region of the right occipital nerve, parched mouth, loss of appetite, nau- sea, sickness, constipation, feeling of oppression, mental anxiety, palpitations of the heart. Patient, after having hardly fallen asleep, wakes up with dyspnoea, which in- creases to actual fits of choking ; swimming before the eyes and muscular quivering. - ■Patient is admitted into the Maison de Sant6, and the use of the morphia is stopped forthwith. TREATMENT. Ill October 1 6. Hardly any sleep during the night ; in the morning patient is in a happy temper, makes no complaints. Temperature and pulse normal. In the course of the fore- noon there was much perspiration, and patient complained of headache and nausea. Pupils unequal, the left smaller than the right. Pressure on the stomach, shivering, yawn- ing ; in the afternoon, there is restlessness, stomach-ache, epigastric pain, oppressiveness, much perspiration, shiver- ing. Poultices were applied to the abdomen. Up to the evening she had altogether vomited twelve times and had one relaxed motion. Pupils unequal, the left wider than the right. The excitement, in consequence of the pain in the stomach, increases hourly. Patient moves about in bed and moans aloud. Frequent spasmodic yawning. At 9 p.m., a bath with cold douche of a quarter of an hour's duration is given, after which she became quieter for a short time. October 1 7. Patient has been sick thirteen times during the night ; no sleep ; the pains in the abdomen were very severe? hiring the character of labor pains. Face pale, pulse 64,Tull,'regSfer. Frequent yawning, burning in the throat, and abdominal pains continue during the whole cf the day. Patient looks worn out, is now and then in a half-dozing condition. Left pupil wider than the right. Great prostration, great thirst. In the course of the day vomited nine times, two relaxed motions. October 18. No sleep5ft!ruTg the»night, restless ; com- plains of tearing pains in the legs, and excessive pain in the stomach ; pulse and respiration normal ; vomited four times, one relaxed motion, frequent sneezing during the day ; she is very sensible to every kind of noise. Fre- quent retching ; severe vomiting ten times. Left pupil wider than the right. Patient feels cold. In the afternoon 112 THE OPIUM HABIT. at 5 o'clock patient lisps, becomes of a pale, death-like color, is very much oppressed, and loses consciousness ; sinks back on to the pillows with closed eyes. Pulse 42, small, irregular. A quarter of a grain of morphia was at once given, and repeated after twenty minutes' time. Right pupil wider than the left. After a quarter of an hour patient wakes up, says that she had never felt so well be- fore; takes milk with relish without bringing it up again. Pulse 60, strong and powerful. This favorable condition lasts till 9 p.m., when she again has nausea from time to time. At 10 o'clock a bath, with a cold douche, is given. October 19. Patient has slept only from 10.30 p.m. to 1.30 a.m. At this time retching again occurs, vomiting, prostration, pains in the epigastric region ; hallucinations, illusions set in, followed by collapse accompanied by the symptoms already mentioned, and necessitating the imme- diate injection of half a grain of morphia at 2.20 a.m., followed by a weaker injection of a quarter of a grain of morphia at 4.15 a.m. Afterwards patient again felt quite well. During the forenoon her condition has been good only at times, the principal complaints being great pros- tration, impossibility to sleep, pains in the stomach, great thirst. Left pupil wider than the right. About 10 a.m. the sickness increased to such an extent that an injection of one-fifth of a grain of morphia had to be administered. Feeling well after it, patient partook of a pint of milk and soup. In the afternoon she had some cocoa, which she has not brought up. Towards the evening she felt op- pressed, which, however, subsided after a warm bath, with cold douche. At 9.25 p.m. another injection of a quarter of a grain of morphia had to be given, on account of symp- toms of a collapse showing themselves. Only three-quar- ters of an hour afterwards the good effect was visible. TREATMENT. 113 October 20. Patient has slept altogether for five hours during the night, with many interruptions. During the intervals, besides being restless, there was prostration, craving for morphia, nausea, and frequent vomiting, and pains in the stomach. In the morning sneezing and yawn- ing. During the daytime the condition was comparative- ly good. Left pupil wider than the right, towards the even- ing the contrary taking place. At 8.30 p.m. patient had a bath at 31 R. (87. 8° F.) of half an hour's duration, with cold douche. October 21. Restless during the whole of the night, craving for morphia and increased reflex action. During the daytime the condition of the patient is satisfactory, excepting some yawning, sneezing, and slight prostration. October 22. No sleep during the night, paroxysms of sneezing and yawning. October 23. Patient slept for three hours with interrup- tions. Towards the morning severe sneezing. Appetite good. She had a bath, with cold douche, morning and night. October 24. Patient was very restless in the night, moved about in the bed, and in the morning was much exasperated on account of the bad night. At 9 p.m. 40 grains of chloral were given in gruel, but were immedi- ately brought up again. October 26. Patient slept for two hours with interrup- tions. During the remainder of the night she felt op- pressed and had palpitations of the heart. Sneezing the same as yesterday. October 28. Very restless during the night. Patient had only about one hour's sleep towards the morning, and then felt pains in the lower part of the abdomen. October 29. Has had hardly any sleep during the 114 THE OPIUM HABIT. night. Mental condition nevertheless good ; appetite the same. October 31. During the past nights she slept, on the average, for three hours. Meals are taken regularly. Thirty grains of chloral were given in capsules. Patient in the daytime complains of labor-like pains in the lower abdominal region. November 1 . Patient slept for several hours after having taken 30 grains of chloral. The pains in the hypogastric region are still apparent now and then ; some reddish watery spots show on the linen. November 2. The pains have increased in the morn- ing ; the whole abdominal region is sensitive to the touch. Poultices were applied. In the middle of the day the men- strual discharge shows itself. November 3. The pains have abated. Patient has slept for four hours. November 4. Menstrual discharge still continues. While it is said formerly to have lasted only for a few hours, it has now lasted for forty-eight hours. Toward midday the patient left her bed and remained on the couch for several hours. November 5. Slept from n p.m. till 2.30 a.m. Patient felt oppressed in the night ; there was difficult breathing, and she could not remain in bed. Patient leaves the Institution on November 15 th, all bodily functions having become regular. She has up to the present time had no relapse. In favor of this plan of treatment Levenstein urges the following : " Confidence in the medical adviser is strength- ened in consequence of the short duration of the severe symptoms, and the improvement already experienced after a few days ; the patients take courage, look forward to TREATMENT. 115 their complete recovery, and submit with patience and resignation to the few days of suffering." And again : " The human organization, as we know from our surgery, midwifery, etc, will, in general, submit more easily to sudden and energetic treatment, even when acting power- fully, than to a milder influence. The gradual deprivation requiring a long time, excites the physical and moral powers to a greater extent, because every dose, smaller than the previous days' quantity, will produce new symp- toms of reaction. The constant mental anxiety in which these patients live, while expecting a smaller dose on the following day, makes them fretful and irritable ; their intention of submitting till the end of the cure, and their energy, begin to decline, and they try to evade the treat- ment. They set up intrigues against the officials and nurses; they simulate morbid appearances, in order to excite the pity of their relations and friends ; they lose confidence in themselves and in their doctor, whose full and absolute authority is indispensable for the successful treatment of abstinence. ' ' This is certainly true of those cases where the treatment is by very gradual reduction, not at all so of those where it lasts but from four to seven days ; ten at the most. The latter plan combines all the advantages of Levenstein's method, and escapes the danger and misery of his, and that of the long protracted course. In many instances persons addicted to this habit gradu- ally reduce the quantity they have been using to a certain point, beyond which they seem unable to go. Thus, a physician who came under my care reduced his dose from three grains to one-twelfth of a grain in the twenty-four hours, and maintained it at this point for a long time. Finally, however, he returned to the use of the full amount. 116 THE OPIUM HABIT. He employed the subcutaneous method. The majority of patients express their willingness to be rid of the habit, and do endeavor, up to a certain point, to assist themselves, but at this period will power, naturally weakened, gives way, and good resolves are thrown to the wind. It is at this time that every facility for full control of the pa- tient is necessary, for without it the sufferer will invariably stop treatment, claiming that the suffering is beyond his strength, bemoan his sad fate and return to the old habit with renewed force, exclaiming, with Coleridge's son — " O woeful impotence of weak resolve." The treatment of these cases at the homes of the habitues is rarely successful. Some ruse, some strategy, some decep- tion is sure to be practiced, either by the patient, the friends, the relatives or the nurse. Very often the relatives, not understanding the meaning of certain symptoms, distressed beyond measure by the pitiful pleadings of the sufferer, will interpose and at once put an end to treatment, thus unwittingly and with well meaning doing the patient _ an injury of the gravest kind. For, the treatment, persisted in almost to the point of cure and then abandoned, so thoroughly disheartens the person that it takes a long time for him to make up his mind to try it again. Those who are the most likely to behave in a manner such as to cause their friends to interfere, from fear of death or insanity resulting, are hysterical females. Absolute com- mittal to a public or private institution, where the nurses can be absolutely relied upon, and where obedience to the physician's orders are rigidly enforced, is the only rational plan for treating these cases. Then, too, conveniences for baths of different kinds and temperatures, and varied elec- trical appliances, not found in patient's houses, are neces- sary ; more necessary than drugs. TREATMENT. 117 It is best for the patient, if an adult, or the parents of the patient, if he is a minor, to sign a paper, submitting him fully to the entire control of the physician for ten days. On leaving home his trunk and clothing should be thor- oughly searched, and any form of opium or morphine should be removed. On entering the institution in ques- tion, the person is allowed from twenty-four to forty-eight hours' rest, to recover from the effects of the journey, to become acquainted with his surroundings, and to allow the physician in charge to judge fully the amount of morphine taken, and the condition of the different organs. The urine should be carefully analyzed and the result saved for future reference. The windows in the rooms are to be firmly secured, and no extra furniture, sharp instruments, or projections from which hanging could be possible, are to be allowed. Low, iron bedsteads are to be preferred, and the room heated by furnace or steam pipes, well protected. On commencing the treatment, the patient is required to give up all money or valuables he may have about him, .for which he is given a receipt. He is then undressed by a nurse, wrapped in a blanket, and taken to the bath-room, where he is given a bath. While this is being done, an- other nurse, under the supervision of the physician, searches everything the patient has brought with him, includ- ing the clothes just removed, and takes away any morphine or opium that may have been secreted, as, also, scissors, knife, needles, etc. The search must be very thorough, as I have known patients to sew packets of morphine into the lining and waistbands of their clothing. The patient is then brought back to his room, the nurse fully instructed, and the treatment by rapid reduction commenced. The physician himself administers the drug, whether by the mouth or by the skin. I usually reduce the quantity 118 THE OPIUM HABIT. used in twenty-four hours one-third, sometimes one-half, the first day. The following case will illustrate the plan pursued :— Miss B. (sent to me by Drs. Claggett and Walls, of Baltimore), single, aged twenty-seven, born in Virginia". Tall, thin, emaciated. Weight about ninety-eight pounds. Complexion reddish. Dark-brown hair, grayish-blue eyes. Height five feet seven and one-half inches. Extremely nervous temperament. Pupils irregular and contracted. Entered my house for treatment October 16, 1880. Had been taking morphia subcutaneously for eighteen months. It was first given her by a physician, to relieve the intense pain of an attack of pelvic cellulitis. At the end of the treatment, being still a sufferer, she procured a syringe, and continued the injections herself, gradually increasing the dose until the daily amount reached six grains. Some- times it would be less than this. She was accustomed to take three injections in the twenty-four hours ; one in the early morning, one about midday, and one late in the afternoon. She ceased to menstruate three months after she commenced to use the drug, and had not menstruated up to the time of admission. No history of alcoholic excesses in ancestors. Has one sister who is extremely nervous, and a brother just recovering from paralysis of one side of the face. Her face is dotted with pustules, as also the chest. Body and limbs marked by cicatrices of old and recent punctures. Appetite fair, bowels constipated. Somewhat lethargic and stupid in mind, but, withal, very nervous. Is despond- ent, and cries easily, but is very anxious to abandon the habit. There is some vaginismus and spasm of the sphinc- ter of the bladder. October 15, 1880. Seen by Dr. T. Addis Emmet, who TREATMENT. 119 pronounced her to be free from all uterine and ovarian disease, beyond the remains of an old pelvic cellulitis, by which the uterus was drawn somewhat to one side. He recommended the injection of large quantities of hot water. October 16. Was given four grains of morphia, subcu- taneously, in two doses, one at 7 a.m., the other at 3 p.m. Is feeling very much depressed and homesick. October 17. Passed a fair night. Very nervous in the morning. Given one hundred grains of the bromide of potassium. Fluid extract of coca (Parke, Davis & Co.), in half-ounce doses, at 9 and 11 a.m., 2, 4 and 9 p.m. ; also one-half grain pills of cannabis indica, at 8 and 10 a.m., 3, 5, 7 and 10 p.m. Given two grains of morphia at 7 a.m., and one grain at 2 p.m. More quiet ; using beef tea (the juice of steak squeezed into boiling water and sea- soned), sherry and bottled beer. Some pain over left ovary. Ice cream and milk for supper. 8 p.m., Pulse 100. Less nervous ; more talkative and pleasant ; expressed a desire for oysters. Pain over left ovarian region some- what relieved by poultices. Bowels have not moved for two days. Urine. — Specific gravity 1. 018; reaction acid; color pale amber ; odor normal ; sediment slight ; microscopi- cally nothing ; chemically nothing save an excess of phos- phates. October 18. Passed a goodnight. Pupils of medium size and regular. Craves food. Given two -thirds of a grain of morphia, at 7 a.m. Obliged to draw her water ; this had been her habit for a long time. Poultices to left ovarian region. Bromide and other medicines continued as before. Two-thirds of a grain of morphia at 3 p.m. 120 THE OPIUM HABIT. Rather nervous and restless, but bright. Appetite good. Given — B . Mass. hydrarg. , Ext. colocynth Co., aa . . gr.iij. At bedtime. One bottle of beer and some sherry wine. Two-thirds of a grain of morphia at bedtime. Left pupil larger than the right ; both somewhat dilated. Is suffering slightly from bromism. During the day she has taken the following mixture every three hours, while awake : — & . Strychniae sulphat., . . . gr.ss Tinct. belladonnas, Tinct. capsicum, aa, . . giij M. SlG. — Take ten drops every three hours, increasing three drops each day. October 19. Slept well all night. Two-thirds of a grain of morphia at 5.30 a.m. Bright. Appetite good. Dressed herself and came down stairs. Half a grain of morphia at 3 p.m. Medicines continued as usual, with the exception of the bromide, which was given in the form of an elixir (ten grains to the drachm), one drachm after each hemp pill. Pupils regular. Pulse good. 6 p.m., had a severe hysterical convulsion, brought on by talking and thinking about home. Given two-thirds of a grain of morphia. Some headache. Bowels have not moved yet. Given seidlitz powder. October 20. Rather nervous during the night. Tossed from side to side of bed. Bowels moved naturally about 2 a.m. Two-thirds of a grain of morphia at 6 a.m. Pupils contracted and even. Slight headache. Restless. One- third of a grain of morphia at 3 and 9 p.m. Much head- ache. October 21. Bowels moved naturally during the night* TREATMENT. 121 One-third of a grain of morphia at 6 a.m ; one-third of a grain at 2.30 p.m., and one-sixth of a grain at 6 p.m. Appetite excellent. Took some exercise in the yard. Hysterical attack at 5 p.m., after reading a letter from home. Given twelve grains asafoetida. Bromide erup- tion on chest and back. Urine slightly albuminous and containing a trace of sugar. The spasm consisted of moaning, with greatly labored breathing, the moan being made at each full expiration. There was trembling of the hands and twitching of the muscles, accompanied by a feeling of suffocation. Pulse small and frequent. At 6.30 p.m. was sufficiently recov- ered to eat a hearty supper. During the evening she felt well. One-sixth of a grain of morphia at 9 p.m. Ordered half an ounce of tincture of hyoscyamus at bedtime. October 22. Restless all night. Hyoscyamus did not produce more than two hours' sleep. One-sixth of a grain of morphia at 6 a.m. Very nervous and restless all morn- ing. One-sixth of a grain of morphia at 3 P.M. Complains of pain in body, limbs and side. Given a very hot sitz- bath, followed by belladonna plaster to ovarian region. One-twelfth of a grain of morphia at 6 p.m. Less nervous at 7 p.m. Vomited once. One-sixth of a grain of mor- phia at 9 p.m. Still restless. All medicines continued. Pupils dilated and irregular ; right larger than the left. October 23. Passed a sleepless night. Very nervous in the morning. One-sixth of a grain of morphia at 6 a.m. Distressing nausea and vomiting. Given ice and wine. In the afternoon there were some symptoms of collapse. One-twelfth of a grain of morphia at 1 p.m., one-half grain at 4 p.m., one-twelfth grain at 5 p.m., and one-sixth grain at 9.30 p.m. Towards night the nausea ceased. Com- plains of severe pains in limbs and back. Is thoroughly 122 THE OPIUM HABIT. rubbed with whiskey and water. Pupils contracted. 4 p.m. slight symptoms of collapse. Gave stimulants. In place of belladonna, strychnia and capsicum mixture, ordered the following : — R . Strychnise sulph., .... gr.ss. Tinct. belladonnas, . . . gij Tinct. lobelise gj Tinct. stramonii, . . . ■ 3J Tinct. capsicum, . . . . sjij. M. Sir,. — Take twenty drops every three hours, increasing three drops daily. Continued the other medicines in the same way as be- fore. Urine passing freely. Albumen one-twentieth of the bulk. No sugar. Hysterical attack at 9 p.m. October 24. Slept well all night. Given four ounces of milk and lime water every two hours ; also some milk punch. Severe hysterical tetanoid seizure on rising from commode. Lasted over an hour. Great difficulty in over- coming spasm of respiratory muscles. Expiration loud and forcible. Hands clenched. Fingers and toes forcibly flexed. Clonic spasm of muscles of face and jaw. Face purple, veins distended, pulse at wrist hardly perceptible. She was put fully under the influence of ether, with good result. Complained of headache, nausea and soreness of muscles, after the effect of the ether wore off. Says that when she stood, a pain darned into the left ovary, and threw her into the spasm. Medicines continued. Gave hot hip bath, followed by cold douche, and the interrupt- ed current along spine and over ovary. Also massage, which greatly relieved pains in limbs and soreness of muscles. 12 m. Feeling bright and cheerful. Took some bottled beer. Bowels have not moved for two days. Poultice over abdomen. One-twelfth of a grain of morphia at 3 TREATMENT. 123 p.m., also one-twelfth grain at 8 p.m. This was the last dose of morphia. At 9 p.m. another hysterical spasm. Again etherized. Soon after this the bowels moved. 12 midnight. Left pupil larger than the right. Slept from 2 to 5 a.m. October 25. Very nervous and restless. Complains of constriction of chest by an imaginary band. Dyspnoea. At 6 a.m. another spasm on rising from commode. Again resorted to ether, after three hundred and thirty grains of bromide of potassium in an hour and a half 's time had failed to relieve. A few whiffs of ether were sufficient. Some nausea from the ether. 9 a.m., symptoms of collapse that yielded readily to brandy. In a quiet state all day. Stimulants and liquid nourishment every hour. Some vomiting, sneezing and hiccough. Diarrhoea during the day. Face purplish red. Respiration 36 ; pulse 120. Stupid but not sleeping. 6p.m. Improving. Recognizes faces; talks ration- ally, but speech thick. Takes food well and seems to enjoy it. Double Vision. 9 p.m., restless. Wants to get up and walk about the room. Given a subcutaneous injection of water. Slept for two hours. Medicines continued. October 26. Yawning, gaping and sneezing. Com- plains of pain in limbs, also of vesical and rectal tenesmus. An examination reveals a small hemorrhoid. Given a suppository containing half a grain of extract of bella- donna, which seemed to afford some relief. Pulse stronger. Dyspnoea less marked. Given a hypodermic injection of water at 8 a.m., 3 and 9 p.m., much to her relief. Doubts as to whether there was morphine in the solution used, were dissipated by letting her touch her tongue to the needle, which had been previously dipped in tincture of nux 124 THE OPIUM HABIT. vomica. Complexion clearer ; eyes bright ; speech not so thick. Strychnia mixture stopped. 8. p.m. Great rectal tenesmus, with small, offensive stool. Given one grain of extract of belladonna, by sup- pository, and a capsule containing — R . Mass hydrargyri, Ext. colocynth Co., aa ■ gr-iv The mouth tasting badly, she was given the following as a wash : — R . Sods hyposulphite, . . . 3 ss Tinct. kino, Tinct. myrrhse, aa . JJj 01. gaulfheriae, gtt.xyj Aq. rosse, .... ad § iij. M. SlG. — Teaspoonful in half a glass of water. Pains in limbs and body still severe. Much relieved by a hot bath, followed by the cold douche. Hemp pills stopped. Stimulants and liquid food continued. State of partial collapse at 5 p.m. Relieved by the free use of stimulants. October 28. Slept well. From this time she improved rapidly* She was put upon cod-liver oil, cream, milk, generous diet and the following tonic : — R . Strychnia sulph., .... gr.^ 5 Tinct. cinchona co., . . . gij Three times daily. In nine weeks' time her weight increased from about 100 to 146 pounds. The bromide eruption, which was severe, was treated with a wash of soda? salicylate, ten grains to the ounce. November 1 1 . Some puffmess of abdomen and pain in left ovarian region. Given aloes, iron and myrrh, until bowels were moved freely. November 17. Menstrual flow established. Passed TREATMENT. 125 through period with but little pain. Some leucorrhcea followed. Partly relieved by injections of infusion of white oak bark. December n. Again unwell. Less pain. December 23. Discharged well. Absolutely no craving for morphia. In this case the hysterical element was decided, and somewhat modified the treatment. The symptoms that follow the sudden deprivation of morphia are so vividly and well described by Levenstein, who has treated many cases in this way, that I cannot refrain from giving his own words : — "Although persons who suffer from morbid craving for morphia show different symptoms, some of them beginning to feel the effects of the poison after using it for several months, while others enjoy comparatively good health for years together, there is no difference between them as regards the consequences upon the partial or entire with- drawal of the narcotic drug. "In this respect they are all equal. None of them have the power of satisfying their passions unpunished. " Only a few hours have passed since using the last injec- tion of morphia, and already the feeling of comfort brought on by the action of the drug is passing off. They are overcome by a feeling of uneasiness and restlessness ; the feeling of self-consciousness and self-possession is gone, and is replaced by extreme despondency ; a slight cough gradually brings on dyspnoea, which is increased by want of sleep and by hallucinations. ' ' The vaso-motoric system shows its weakness by abund- ant perspiration, by the dark color of the face, which replaces the pale condition apparent during the first few days. 126 THE OPIUM HABIT. "Flow of blood to the head and palpitation of the heart, with a hard pulse, soon show themselves. The latter symp- tom often disappears suddenly, and is replaced by a slow, irregular, thread-like pulse, which is the sign of the begin- ning of a severe collapse. "The reflex irritability increases, the patients begin to sneeze and to have paroxysms of yawning ; they start if any one approaches them; touching their skin causes crampy movements or convulsions ; the trembling of the hands, if not already evident, now becomes distinctly per- ceptible. The power of speech is disordered ; lisping and stammering take place. Diplopia, and disorders of the power of accommodation, frequently accompanied by in- creased secretion of the lachrymal glands, show them- selves. The patients are overcome by a feeling of weak- ness and total want of energy, and are thus compelled to lay in bed. "Neuralgic affections of various parts of the body, pain in the front and back of the head, cardialgia, abnormal sensations in the legs, associated with salivation, coryza, nausea, vomiting and diarrhoea, tend to bring them into a desperate condition. " Some persons will bear up with fortitute under all these trials ; they will quietly remain in bed, and will endure the unavoidable suffering, hardly uttering a complaint. Of the others, although the great minority of them sleep and doze during this trying time, some can find rest nowhere ; they jump out of bed, run about the room in a state of fear, crying and shrieking. Gradually they become calmer, although occasionally their excitement increases. A state of frenzy, brought on by hallucinations and illusions of all the sensitive organs, at last causes a morbid condition, to which I have given the name of delirium tremens, resulting TREATMENT. 127 from morbid craving for morphia, it being similar to that caused by alcohol. Some of the patients, however, will be found walking about in deep despair, hoping to find an opportunity of freeing themselves forever from their wretched condition." The patient whom I treated by the sudden deprivation of the drug was a married lady, aged forty-five, stout and flabby. She had been using morphia by the mouth for nearly sixteen years, in the last year taking from seven to ten grains daily. I saw her one afternoon and commenced treatment the next morning. The drug was taken away at once. That day she began to complain of salivation, dysp- noea, intense grinding pains in the calves of the legs, head- ache, pain about the heart and a strong desire for morphia. The first night she did not sleep at all. Was feverish and restless, tossing from side to side of the bed, moaning, occasionally crying out. Toward morning she became delirious, ran about the room, screamed, attacked the nurse, attempted to jump out of the window and battered at the door. By 8 a.m. she had sunk into a stupor, from which she was occasionally roused by fits of sneezing. A hard, dry s hacking cough supplemented the dyspnoea. Nausea was intense and vomiting frequent. She, on the third day, knew none of those about her, saw imaginary men and animals, wept, laughed, moaned and muttered incoherently. Sordes formed upon teeth and lips; the faeces and urine were passed in the bed. In this state she remained for six weeks, in spite of every effort to arouse her. All day in a typhoid condition ; at night staggering about the room, screaming, crying and attacking the nurse. In the seventh week she began to recognize faces, although her hallucinations and delusions continued. She very slowly regained strength. Pains persisted in the limbs. 128 THE OPIUM HABIT. There was trembling of the hands and tongue, inability to read, and she would cry at the most trivial thing. Her nights were filled with terrible sights and dreams, the memory of which lasted her the whole of the following day. Several times there was severe collapse, necessitating the free use of stimulants and an occasional small dose of opium. During all this time tonics, concentrated food, baths and electricity were given, It was fully four months before her mind regained its balance. She was seen once, in consultation, by Dr. G. H. Wynkoop, of this city. That was my first case, and I shall never try the experi- ment again. I know of several instances where physicians have tried this plan and abandoned it. Her urine contained both sugar and albumen in large amount. This afterward wholly disappeared. Here is further testimony as to the efficacy of the treat- ment by sudden deprivation: — "Dr. Osgood {Quart. Jour. Inebriety, June, 1879,) has, in a hospital, during the past two years, treated 800 cases of opium inebriety. His plan, in general, is : (1) The absolute and total discontinuance of the use of opium from the beginning of treatment. (2) A trusty attendant to be with the patient day and night for the first three days. (3) Chloral hydrate for the first three nights, if required. (4) Good food, milk, raw eggs, brandy (in some cases), chicken broth. (The above to be taken in small quan- tities.) (5) In diarrhoea give two-drachm doses of a mix- ture of equal parts of tincture of catechu and tincture of ginger. (6) Vomiting will frequently yield to bismuth in fifteen-grain doses ; and in some cases a single dose of calomel has acted like a charm. Ice is of advantage in some cases. (7) Throughout the entire treatment it should be remembered that the patient is below par, and requires TREATMENT. 129 tonics. Quinine and tincture of iron have a prominent place in our list. (8) The patient should expect to suffer more or less for the first three days, and should make him- self a prisoner for that time. By the fourth day there is usually marked improvement. (9) Usually by the sixth day all desire for opium is gone. The patient then re- quires a change of air and surroundings, and tonics for a few weeks. Out of one hundred cases thus treated there was but one death and that from apoplexy." However well this plan may answer for the Germans and Chinese, it certainly is a dangerous and barbarous practice when applied to American and English people. The dangerous collapse that so often occurs in the carry- ing out of this method JLevenstein combats by small, sub- cutaneous injections of morphine, stimulants, dropping ether on the skull, etc. 130 THE OPIUM HABIT. CHAPTER VII. AGENTS EMPLOYED IN THE TREATMENT OF THE OPIUM AND MORPHINE HABITS. Limited space forbids my illustrating each modification of treatment with pertinent cases, and I content myself with discussing the various drugs and agents used, and the indications calling for their employment. In this way, too, the reader will become acquainted with the various symp- toms that arise in the course of rapid deprivation. BATHS. Baths of various kinds are the mainstay in the treat- ment of most cases of this kind. They are used for four purposes: ( tnat cast off a small scab of skin ; suffers with pain in wrists and knees ; also elbows and ankles, but not so severely as in the wrists and knees ; insomnia and loss of appetite. Bowels regular ; mental faculties are active ; of course nothing like those he formerly possessed, as his physical debility makes him childish, but still he can use his mind and will, to a certain extent ; acts perfectly gentlemanly, although he is as stated. His physical state is that of the debility and tottering of a man of ninety. ' ' A short time afterward the doctor writes : " The chloral eater died some few days ago, in Los Angelos. Was found dead in the water closet of his hotel. The despatch says, ' supposed cause apoplexy. ' I think it was more likely cardiac asthenia." Dr. R. F. Lewis, of Lumberton, N. C, writes me: "A prominent physician of this place who was intemperate in 204 THE CHLORAL HABIT. the use of spirits, morphine, etc., began the use of chloral instead, and for weeks or months was more or less under its influence. He died suddenly after using it in increased quantities the day and night before. No autopsy." Dr. A. R. Kilpatrick, of Navasota, Texas, sends me the following curious note : — "About four or five years ago there was a doctor living at Port Hudson, West Feliciana Parish, La., named (I think) Harris, who wrote several papers for the Med. and Surg. Reporter, of Philadelphia. He wrote one or two papers especially on the use of chloral and on the chloral habit, and very impressively warned people about its use and abuse, and in less than a year after the publication of those pieces I saw his death announced, and that he had been a habitual consumer of chloral, and that it killed him." Here is another case of death from an overdose, in an habituS, contributed by Dr. S. Henry Dessan, of this city : — ' ' The only case where I have known death to be in any way connected with the administration of chloral, was in a case of dipsomania in a hysterical female. I prescribed a combination of fifteen grains of chloral with thirty grains of bromide of potassium, to be repeated every two hours, until sleep was procured ; the effect was obtained after three or four doses. About eight doses were given in the mix- ture. I ceased attending the case, and about a year after learned through the press that the patient had died from an overdose of chloral. On inquiring from the druggist who had prepared the prescription, I learned that the patient continued to use the medicine steadily after my visits ceased, and that for twenty-four hours before death she had used two bottles of the mixture, or in other words ABRUPT WITHDRAWAL — TREATMENT. 205 four ounces of chloral with one ounce of bromide of po- tassium. ' ' Two cases of chloral habituation in men past middle age are reported by Dr. C. A. Bryce of Richmond, Va., where death occurred from symptoms resembling apoplexy. THE HASHISCH HABIT. CHAPTER XII. HASHISCH INTOXICATION. A common practice in some of the far Eastern countries — hashisch taking — is comparatively rare among the people of civilized nations. Here, as there, the practice is not one of steady, daily intoxication with this drug, but it, more like alcohol, is resorted to at certain times, when the system seems especially to crave it, or the temptation is offered. In this it differs materially from the practice of opium or morphia taking. In point of continual craving, we might, I think, arrange these drugs in the following order: Mor- phine or opium, chloral, hashisch, alcohol. It would seem that, as the more intense is the daily or hourly craving for a stimulant or narcotic, the easier it is to permanently destroy that craving when the habit is once broken. Thus a short struggle of from four to eight days will, in the majority of instances, cure the opium patient, while with alcohol or hashisch, less so with chloral, the desire seems to be latent and to crop out at odd times, and under peculiar circumstances. Once the desire is fully sat- isfied, then it remains quiescent for a shorter or longer period, to again show itself in its original, or with increased intensity, at a later date. Hence it is that it is so very difficult to permanently cure dipsomania. With the opium 206 EFFECTS ON THE SYSTEM. 207 or morphine habituS, the desire at first, certain symptoms at a later date, come to the surface and demand a renewal of the drug saturation as soon as the effect of the last dose passes away. We must differentiate between a diseased mental condi- tion that imperatively calls for some narcotic or stimulant, and that craving for these substances that is only devel- oped after their prolonged use, and which did not exist before their use was begun. Both conditions are those of disease; the one always existing, the other springing from the prolonged use of the substance to which they become addicted. Be it distinctly understood that where, through- out this book, I have used the word ' ' habit, ' ' I have meant an abnormal appetite or condition, calling for the use of narcotics or stimulants, that either existed before or was produced by the use of the substance in question. There are those who use hashisch steadily the year round, as many of our countrymen use alcohol; but this is due more to moral depravity than to any special morbid craving for the substance used. Were we able to procure a thoroughly reliable extract of hemp in this country, and did physicians use it as freely, as carelessly, and in as large doses, as they are using opium, morphine and chloral, hashisch takers would be more com- mon. Known in English-speaking countries as Indian Hemp or Cannabis Indica, it is called Hashisch by the Arabians, Gunjah and Churrus by the inhabitants of India, Bust or Sheera by the Egyptians, Dagga or Dacha by the Hotten- tots, El Mogen by the Moors. This is the solid extract. Bangue, Bang or Bendji is the spirituous extract.* Our pharmacopoeia offers a tincture of Cannabis Indica, * Calkins; "The Opium Habit," Phila., 1871. 208 THE HASHISCH HABIT. every drachm of which represents fully three grains of the extract. Some of our manufacturing chemists prepare a fluid extract, and a fairly though not thoroughly reliable extract of hemp is manufactured by the English. The English extract is that usually employed for medicinal purposes, and for the production of intoxi- cation. The only ' habitues that I have known was a woman, thirty-eight years of age, who consumed, daily, nine grains of the English extract. She would roll it up into a little lump, knead it for some time between the fingers, and then placing it in the bowl of a common clay pipe, partly filled with tobacco, light it, and inhale the smoke.* This was done twice daily, about four and a half grains being used at a time. Sometimes she would go a week at a time — at least so she said — without using any ; but I suspect that on those days when she did not smoke it, she used it by the stomach. She was of an intensely nervous temperament, formerly addicted to the excessive use of alcoholic stimulants; of sallow complexion, dull eyes, pupils always widely dilated, pulse slow and irregular, occasionally intermitting a beat ; heart sounds feeble, body poorly nourished, skin dry, bowels usually loose, appetite poor, and urine scanty and high colored, but free from casts, albumen or sugar. She had been using the drug in this way about eighteen months, and found it necessary to occasionally increase her doses. She complained, especially in the morning, when waking from her almost cataleptic state, of intense pain in the left side of the head, and along the course of the sciatic nerve of the same side. She began to use the drug through curiosity, having read of its peculiar effects, and being extremely desirous of find- EFFECTS ON THE SYSTEM. 209 ing something to supply the place of the alcohol, to which she had become a slave. When not under the influence of the drug her intellect was dull and sluggish, and her temper, at times, bad and unreasoning. During the night, when most completely under the influence of hemp, her dreams were highly pleas- urable ; she seeming to live in a different world, a thought being answered by its accomplishment, a wish by its fulfill- ment ; distances were traversed in a few seconds ; feasts, marked by plenty and variety, the food on dishes of gold, studded with diamonds and other precious stones, were set before her. Everything was done on a scale of magnifi- cence. At times the dreams partook of a highly lascivious character. She assured me that she seemed to be living a double life — the one the real, the other that produced by the hemp. In the latter the incidents of one night's dreams seemed to follow as regularly, and the characters to be as real, as the incidents and people of every day life. There was one peculiarity : if she took a little more than her usual allowance of the drug, she found her dreams of an entirely different nature ; not pleasant, but inexpressibly horrible, new faces and new scenes taking the place of the usual ones, the thread of her dream romance being sud- denly snapped. The same thing occurred, though not so markedly, if she took less than the usual amount. Before commencing the use of this drug she was in fair health, stout, and when not under the influence of liquor, bright and cheerful. She passed entirely away from my observation, and I have never since been able to learn what became of her, though I heard once that she had died, how or when I do not know. I once saw her in one of those deep sleeps produced by 210 THE HASHISCH HABIT. hashisch, and noted that there seemed to be complete anaesthesia, deep snoring respiration, thirteen to the min- ute, dilated and irregular pupils, purplish congestion of the face and conjunctivae, and a spasmodic twitching of the left eyelid that lasted all the time I was with her — two hours. She was possessed of some money, and was very highly educated. She claimed to be the widow of an English army surgeon. In the morning she rarely smoked all that was put in the pipe, and never enough to put her to sleep. Occasionally she added a little opium to the hemp. She was a mental and bodily wreck. Her gait was tottering, and sometimes she would be forced to go in a direction opposite to that in which she desired to move. She expressed no desire to be broken of her vice, saying often that if she wished it she could stop without any trouble. I regret exceedingly that her temper and many peculiarities would not permit my studying her case more closely. The urine examined was obtained by catheteriza- tion during the semi-cataleptic spell already spoken of. The mental effect of this drug has been variously de- scribed by different authors. Thus, Calkins* says : — " The mental condition is an ideal existence, the most vivid, the most fascinating. Time and space both seem to have expanded by an enormous magnification ; pigmies have swelled to giants, mountains have grown out of mole- hills, days have enlarged to years and ages. De Moria in wending his way one evening to the opera house, seemed to himself to have been three years in traversing the corri- dor. De Saulcy having once fallen into a state of insensi- bility following upon incoherent dreamings, fancied he * Op. cit. p. 323. EFFECTS ON THE SYSTEM. 211 had lived meanwhile a hundred years. Rapidity as well as intensity of thought is a noticeable phenomenon. De Lucca, after swallowing a dose of the paste, saw, as in a flitting panorama, the various events of his entire life, all proceeding in orderly succession, though he was powerless in the attempt to arrest and detain a single one of them for a more deliberate contemplation. Memory is sometimes very singularly modified nevertheless, there being perhaps a forgetfulness, not of the object, but of its name proper, or the series of events that transpired during the paroxysm may have passed away into a total oblivion. "The normal mental condition is that of an exuberant enjoyance rather than the opposite, that of melancholy and depression, though the transition from the one state to the other may be as extreme as it is swift. Oftener the subject is kept revolving in a delirious whirl of hallucina- tory emotions, when images the most grotesque and illu- sions the drollest and most fantastic crowd along, one upon another, with a celerity almost transcending thought. (Mirza Abdul Roussac.) ' ' Command over the will is maintainable, but temporarily only. As self-control declines the mind is swayed by the mere fortuitous vagaries of the fancy ; and now it is that the dominant characteristic or mental proclivity has its real apocalypsis. The outward expression may reveal itself under a show of complacency and contentment in view of things around, or suspicion, distrust, or querulousness of disposition may work to the surface, or may be, a lordly hauteur that exacts an unquestioning homage from the ' profanum vulgus' by virtue of an affected superiority over common mortals, is the ruling idea of the hour ; or per- adventure, the erotic impulses may, for the time, over- • shadow and disguise all others. 212 THE HASHISCH HABIT. "Amid the ever-shifting spectacular scene the sense of personalidentity is never perhaps entirely lost, but there does arise in very rare instances the notion of a duality of exist- ence ; not the Persian idea precisely, that of two souls occupying one and the same body in a joint stock associa- tion, as it were (the doctrine as alluded to by Xenophon, in the story of the beautiful Panthea), but rather the idea of one and the same soul in a duplication or bipartation else, and present in two b5dies." Many persons who have put themselves once or twice under the influence of this drug claim that no such pleasant effects, but rather torturing and horrible conditions are pro- duced. The results when the drug is taken in this way, like those produced by tobacco on boys who smoke for the first time, should not be taken as a true estimate of the results obtained by the continued use of either. A curious, interesting and valuable experiment was made upon himself by Dr. H. C. Wood, of Philadelphia, who is especially qualified to undertake and record the results of such an observation. He says*: — "When given in full doses, cannabis Indica produces a feeling of exhilaration, with a condition of reverie, and a train of mental and nervous phenomena, which varies very much according to the temperament or idiosyncrasies of the subject, and very probably also, to some extent, accord- ing to the nature of his surroundings. The sensations are generally spoken of as very pleasurable ; often beautiful visions float before the eyes, and a sense of ecstacy fills the whole being ; sometimes the venereal appetites are greatly excited ; sometimes loud laughter, constant giggling, and 'other indications of mirth are present. Some years since, * Materia Medicaand Therapeutics, Phila., 1877, p. 326. EFFECTS ON THE SYSTEM. 213 in experimenting with the American extract, I took a very large dose, and in the essay upon the subject {Proceedings of the American Philosophical Society , i86^f, vol. xi. p. 226), the result was described as follows : — " 'About half-past four p.m., September 23, 1 took most of the extract. No immediate symptoms were produced. About seven p.m. a professional call was requested, and, forgetting all about the hemp, I went out and saw my patient. While writing the prescription I became per- fectly oblivious to surrounding objects, but went on writing, without any check to or deviation from the ordinary series of mental acts connected with the process, at least that I am aware of. When the recipe was finished, I suddenly recollected where I was, and, looking up, saw my patient sitting quietly before me. The conviction was irresistible that I had sat thus many minutes, perhaps hours, and directly the idea fastened itself that the hemp had com- menced to act, and had thrown me into a trance-like state of considerable duration, during which I had been stupidly sitting before my wondering patient. I hastily arose and apologized for remaining so long, but was assured I had only been a very few minutes. About seven and a half p.m. I returned home. I was by this time quite excited, and the feeling of hilarity now rapidly increased. It was not a sensuous feeling, in the ordinary meaning of the term ; it was not merely an intellectual excitation ; it was a sort of bien-ttre — the very opposite to malaise. It did not come from without ; it was not connected with any passion or sense. It was simply a feeling of inner joyous- ness; the heart seemed buoyant beyond all trouble ; the whole system felt as though all sense of fatigue were for- ever banished ; the mind gladly ran riot, free constantly to leap from one idea to another, apparently unbound from 214 THE HASHISCH HABIT. its ordinary laws. I was disposed to laugh ; to make comic gestures ; one very frequently recurrent fancy was to imi- tate with the arms the motions of a fiddler, and with the lips the tune he was supposed to be playing. There was nothing like wild delirium, nor any hallucinations that I remember. At no time had I any visions, or at least any that I can now call to mind ; but a person who was with me at that time states that once I raised my head and ex- claimed, ' Oh, the mountains ! the mountains ! ' While I was performing the various antics already alluded to, I knew very well I was acting exceedingly foolishly, but could not control myself. I think it was about eight o'clock when I began to have a feeling of numbness in my limbs, also a sense of general uneasiness and unrest, and a fear lest I had taken an overdose. I now constantly walked about the house ; my skin, to myself, was warm — in fact, my whole surface felt flushed ; my mouth and throat were very dry ; my legs put on a strange, foreign feeling, as though they were not a part of my body. I counted my pulse and found it one hundred and twenty, quite full and strong. A foreboding, an undefined, horrible fear, as of impending death, now commenced to creep over me ; in haste I sent for medical aid. The curious sensations in my limbs in- creased. My legs felt as though they were waxen pillars beneath me. I remember feeling them with my hand and finding them, as I thought, at least, very firm, the muscles all in a state of tonic contraction. About eight o'clock I began to have marked ' spells' — periods when all connec- tion seemed to be severed between the external world and myself. I might be said to have been unconscious during these times, in so far that I was oblivious to all external objects, but on coming out of one it was not a blank, dreamless void, upon which I looked back, a mere empty EFFECTS ON THE SYSTEM. 215 space, but rather a period of active but aimless life. I do not think there was any connected thought in them; they seemed simply wild reveries, without any binding cord — each a mere chaos of disjointed ideas. The mind seemed freed from its ordinary laws of association, so that it passed from idea to idea, as it were, perfectly at random. The duration of these spells, to me, was very great, although they really lasted but a few seconds to a minute or two. Indeed, I now entirely lost my power of measuring time. Seconds seemed hours ; minutes seemed days ; hours seemed infinite. Still I was perfectly conscious during the intermissions be- tween the paroxysms. I would look at my watch, and then, after an hour or two, as I thought, would look again, and find that scarcely five minutes had elapsed. I would gaze at its face in deep disgust, the minute-hand seemingly motionless, as though graven in the face itself; the laggard second-hand moving slowly, so slowly it appeared a hopeless task to watch during its whole infinite round of a minute, and always would I give it up in despair before the sixty seconds had elapsed. Occasionally, when my mind was most lucid, there was in it a sort of duplex action in regard to the duration of time. I would think to myself, it has been so long since a certain event — an hour, for example, since the doctor came; and then reason would say, no, it has been only a few minutes ; your thoughts or feelings are caused by the hemp. Nevertheless, I was not able to shake off this sense of the almost indefinite pro- longation of time, even for a minute. The paroxysms already alluded to were not accompanied with muscular re- laxtion. About a quarter before nine o'clock I was stand- ing at the door, anxiously watching for the doctor, and when the spells would come on I would remain standing, leaning slightly, perhaps, against the doorway. After 216 THE HASHISCH HABIT. awhile I saw a man approaching, whom I took to be the doctor. The sound of his steps told me he was walking very rapidly, and he was under a gas-lamp, not more than one-fourth of a square distant, yet he appeared a vast dis- tance away, and a corresponding time approaching. This was the only occasion in "which I noticed an exaggeration of distance; in the room it was not perceptible. My ex- tremities now began to grow cold, and I went into the house. I do not remember further, until I was aroused by the doctor shaking or calling me. Then intellection seemed pretty good. I narrated what I had done and suffered, and told the doctor my opinion was that an emetic was indicated, both to remove any of the extract still remaining in my stomach, and also to arouse the nervous-system. I further suggested our going into the office, as more suitable than the parlor, where we then were. There was at this time a very marked sense of numbness in my limbs, and what the doctor said was a hard pinch produced no pain. When I attempted to walk up- stairs my legs seemed as though their lower halves were made of lead. After this there were no new symptoms, only an intensifying of those already mentioned. The periods of unconsciousness became at once longer and more frequent, and during their absence intellection was more imperfect, although when thoroughly aroused I thought I reasoned and judged clearly. The oppressive feeling of impending death became more intense. It was horrible. Each paroxysm would seem to have been the longest I had suffered ; as I came out of it a voice seemed constantly saying, ' You are getting worse ; your par- oxysms are growing longer and deeper; they will over- master you; you will die.' A sense of personal antago- nism between my will power, as affected by the drug, grew EFFECTS ON THE SYSTEM. 217 very strong. I felt as though my only chance was to struggle against these paroxysms — that I must constantly arouse myself by an effort of will ; and that effort was made with infinite toil and pain. I felt as if some evil spirit had control of the whole of me, except the will power, and was in determined conflict with that, the last citadel of my being. I have never experienced anything like the fearful sense of almost hopeless anguish and utter weariness which was upon me. Once or twice during a paroxysm I had what might be called nightmare sensations ; I felt myself mounting upward, expanding, dilating, dissolving into the wide confines of space, overwhelmed by a horrible, rend- ing, unutterable despair. Then, with tremendous effort, I seemed to shake this off, and to start up with the shudder- ing thought, next time you will not be able to throw this off, and what then ? Under the influence of an emetic I vomited freely, without • nausea, and without much relief. About midnight, at the suggestion of the doctors, I went up-stairs to bed. My legs and feet seemed heavy, I could scarcely move them, and it was as much as I could do to walk with help. I have no recollection whatever of being undressed, but am told I went immediately to sleep. When I awoke, early in the morning, my mind was at first clear, but in a few minutes the paroxysms, similar to those of the evening, came on again, and recurred at more or less brief intervals until late in the afternoon. All of the day there was marked anaesthesia of the skin. At no time were there any aphrodisiac feelings produced. There was a marked increase of the urinary secretion. There were no after effects, such as nausea, headache, or constipation of the bowels. "The sense of prolongation of time which I experienced was to me very remarkable, but. is not uncommon in these 218 THE HASHISCH HABIT. cases. It is evidently due to the immense rapidity of the succession of ideas. The mind, without doubt, measures time by the duration of its own processes, and when an infinitude of ideas arise before it in the time usually occu- pied by a few, time becomes infinitely prolonged to the mind. It is a lifetime in the minute. A very common mental phenomenon, not yet mentioned, is a condition of double consciousness, a sense of having two existences, of being at the same time one's self and somebody else." Pleasurable as may be the stage of excitement or intoxi- cation, fascinating as may be the dreams that follow, the evil effect upon the body is rapid and decisive. Wasting of the muscles, sallowness of the skin, hebetude of the mind, interference with coordination, failure of the appetite, convulsive seizures, loss of strength, and idiotic offspring, seem, from all accounts, to be the uniform result of the long continued use of this drug. CONCLUSIONS. 219 CHAPTER XIII. CONCLUSIONS. A careful study of the facts presented in the foregoing chapters teach us several lessons well worth considering, and suggest certain cautions and reforms that are greatly needed. From the abundant evidence upon this point I think we must conclude that the abuse or habitual use of narcotics is steadily upon the increase, especially the subcutaneous use of morphine ; that these drugs are, in the majority of instances, first taken to relieve pain, and not for simple gratification of a morbid appetite ; and that the drug used and the manner of using it is in consonance with the preva- lent medical practice of the time in which the habitues lives. There are two classes especially blamable for this — the physicians and the druggists. In the early history of the use of the hypodermic syringe the danger of contracting the habit through its frequent use was not recognized, and the physician was not then to blame. At the present time, however, knowing fully the dangers incident to its use, the physician is criminally careless in placing the instrument in the hands of the patient or her friends for their use. If he does not appreciate the full extent of the danger, he is culpably ignorant, and certainly deserving of punish- ment. The deaths, and dangerous accidents, and the spread of the continued use of narcotics, is due, to a great extent, to the druggists, who, in many cases, sell the drug without a 220 CONCLUSIONS. physician's prescription, and without any reasonable excuse on the part of the patient, in direct violation of the law. Chloral is sold to men just recovering from a spree ; pre- scriptions containing large amounts of these drugs are renewed for patients for whom they were not originally given ; the druggist himself often prescribes a mixture of chloral, morphine and bromide of potassium, for repentant drunkards, or for patients suffering from insomnia. When spoken to about this matter, they coolly excuse their practices with the remark that "if we don't do it, some other druggist will; and why should we lose the money. ' ' The laws relating to the sale of poisons are loose and inefficient, the practice rotten, and the statute really a dead letter. Dangerous and even fatal consequences* are not, then, so much to be wondered at. Another matter in this connection needs attention, viz : the lying pretensions of a few charlatans, notably in the West, who, by specious advertisements and deceitful lies, induce the victims to these habits to buy their medicines, or come under their care for treatment. Their so-called specifics are simply preparations of opium or morphine, and their treatment is based upon the plan of substituting one form of the drug for another. These sharpers are utterly without conscience, and do not scruple to prey upon and undermine the health of their victims, in order to gain a few dollars. It is about time that the people found out that honest, honorable and trust- worthy physicians, who have only the good of the patient at heart, do not advertise. It is a shameful fact that the religious press tolerates the advertisements of these charla- tans in their columns. As a rule, the vilest advertisements are to be found in these newspapers. Owing to the moral * Kane ; " Deaths from Chloral." N. Y. Medical Record, Dec. 25, 1880, Jan. i, 1881. CONCLUSIONS. 221 weight supposed to be carried by these sheets, owing to their large circulation among the people, who look upon every word therein contained as truth, these announcements and endorsements do the people an infinite amount of harm. Can it be that the financial "backers" of these papers overrule the scruples of the religious editor ? If so, while a good investment financially, it must be a very poor one morally. I have emphasized the fact that the continued use of chloral is not so liable to end in the formation of a habit, as is the prolonged use of morphia or opium ; not that phy- sicians may exercise less care and discrimination in its employment, for the danger is sufficiently great, but simply to refute the statements of some men who are gone wild upon the subject of habituation and inebriety, and who suggest measures for reform, and plans for restraint and treatment, as impracticable and impossible as their state- ments are whimsical and truthless. Finally, be it distinctly understood, that many of the symptoms enumerated as occurring in both the morphine and chloral habitu&s, but especially the latter, are only found where the drug has been used in large amount, or for a long time. Every symptom will, moreover, be modified somewhat by the systemic peculiarities of each patient. The "mixed" habits, so called, where patients are using two or more narcotics at one time, have not been discussed separately, as they possess no distinctive characters, and the physician who understands the prominent points of each will have no trouble in detecting and treating these cases. INDEX. A. Abortion from excessive use of morphia, 43- , . Abscess from hypodermic injection of morphia, 71. Absorption of morphia, rapidity of, 83. Accidents from subcutaneous use of mor- phia, 71. Ady, Dr. A., case by, 152. After-treatment of opium and morphia habits, 140. Ages of opium and morphia takers, 25. of chloral takers, 150. Akland, Dr. Fr., on chloral habit, 151. Albuminuria from continued use of opi- ates, 46. in chloral takers, 182. Alcoholic stimulants used by opium tak- ers, 38. in treatment of morphia-mania, 139. Allbutt, Dr. T. Clifford, observations of, 54- Alopecia, in morphia takers, 40. Amaurosis from continued use of opiates, 47- in chloral takers, 197. Amidon, Dr. R. W., experiments of, 99. Andrews, Dr. Judson B., case by, 54. Anstie, Dr., case by, 175, 178. Aphasia from prolonged use of chloral, 171. Arton, Dr. J. H., case by, 180. Ascites from excessive use of morphia, 35, 36. Atkinson, Dr. A., case by, 76. B. Barker, Dr. Fordyce, 29. Barkitt, Dr. F, W., case by, 102. Bartholow, Prof. Roberts, observations of, 90. case by, 72. Baths in treatment of morphia takers, 130. Beaumetz-Dujardin, case by, 71. Belladonna in treatment of morphia tak- ers, 136. Bidlack, Dr., case by, 152. Bigelow, Dr. H. C, case by, 184, 198. Bile, effects of continued use of opiates on, 37. Blalock, Dr. W. C, hydrocyanic acid in treatment of opium habit, 137. Blood, effects of chloral on, 186. " Bloating" in morphia takers, 39. Bond, Dr. Thos., case by, 170. Bouchut, chloral diabetes, 182. Braine, Dr. F. W., case by, 88. Bradley, Dr. Edward, cases by, 184, 199. Brandeis, Dr. R. C, case by, 180. Brown-Sequard on chloral paralysis, 178. Bromides in the treatment of opium tak- ers, i^6. Bryce, Dr. C. A., case by, 205. Bunting, Dr. James, case by, 170. C. Cable, Dr. W. W., case by, 91. Calkins, Dr. Alonzo, observations of, 44, 210. Calvet, observations of, 96. Cannabis Indica in treatment of opium habit, 137. continued use of, 206. Capsicum in treatment of opium habit, 136. Casts in urine of morphia takers, 46. Change from opium to alcohol, etc., 38. Chills, nervous, in chloral takers, 177. Chloral hydrate, continued use of, 149. in treatment of opium habit, 137. Circulation, effects of chloral on, 186. in morphia takers, 48. Civil condition of chloral takers, 150. Civilization as a modifier of the nervous system, 17. Claggett & Walls, Drs., case sent by, 118. Clark, Dr. Alonzo, case by, 93. Clinical Society of London, report of, 149. Coca in treatment of opium habit, 136. Coleridge, amount of opium used by, 27. Color of skin in morphia takers, 38. Compton, Dr. W. M., observations of, ^ I55 ' ... Constipation in opium takers, 37. Corona, injection of drugs into veins, 90. Cram, Dr. C. W., observations of, 155. Craving for stimulants and narcotics, 33, 207. Crothers, Dr. T. D., case by, 173. Cullen, Dr. C. R., observations of, 194. D. Dabbs, Dr. G. H. R., case by, 186. Dangers, of chloral habit, 202. Davis, Dr. G. W., case by, 171. Deaths from chloral, 202. Delmont, Dr. F.,caae by, 194. Delirium in abandoning chloral, 200. Dessau, Dr. S. Henry, case by, 204. DeQuincey, confessions of, 22, 33. preparation and amount used by, 27. Diabetes from morphia taking, 41, 46, 47. chloral taking, 182. Diet in the treatment of morphia absti- nence, 138. Digestive apparatus, effect of opiates on, 34 Mo: chloral on, 180. Diplopia from excessive use of morphia, 47- Diseases of the present day, peculiarities of, 17. Doane, Dr. H. H., case by, 172, 185. Douche, cold, uses of, 131. Dover's powder, 27. Dreams, 19, 20, Drunkards, use of chloral by, 163. Dyspepsia in opium takers, 34, 142. Dyspnoea in chloral takers, 195. E. Earle, Dr. C. Warrington, observations of, 24. Electricity in treatment of opium takers, 132. Elliot, Dr. Geo. F., case by, 200. Eruptions in morphia takers, 37, 38. INDEX. 223 Erysipelas from subcutaneous injection of morphine, 74. Eyes, effect of prolonged use of opiates on, 47- chloral on, 197, 201. F. Faeces, in morphia-mania, 36, 37. Feltz & Ritter on chloral diabetes, 182. Folsom, Dr. Norton, case by, 113. Formation of opium and morphine habits, 18, 31, 32. Fowler, Dr. Geo. R., observations of, 84. Francis, Dr. Sam'l W.,.case by, 84. Fry, Dr. Frank H.,case by, 172, G. Gastric juice, effect of opiates on secre- tion of, 34. catarrh in opium takers, 35. Georges & Bernard-Claude, experiments of, 92. Graham, Dr. Arthur, case by, 78. Griswold, Dr. Gaspar, experiments of, 97. H. Habit, opium, how formed, 18. Hemorrhoids in morphia habitues, 37. Hemorrhage from mucous surfaces in chloral takers, 182, 201. Hair, falling of in opium takers, 40. Ham, Dr. O. F., case by, 185. Harrington, Dr. H. L., case by, 80. Hashisch habit, 206. Hayne, Dr. A. P., observations of, 171. Haywood, Dr. Burke, case by, 198. Heartburn in morphia takers, 37. Herpes zoster in morphia takers, 40. Holbrook, Dr. M. L., cases by, 153. Houtz, Dr. J. A., observations of, 87. Husted, Dr. N. C, case by, 198. Hutchinson, Dr. Wm, F., case by, 132. Hydrocyanic acid in treatment of mor- phia taking, 137. Hypodermic injection of morphia, 24, 30, 145. Hysteria, how modified by opiates, 54. I. Impaction of faeces, 37. Impotence from prolonged use of opiates, 45- Incoherence of morphia takers, 53. Ingals, Dr. E. F., case by, 79. Inglis, Dr. T., case by, 159. Injection of morphine into a vein, 75. Insanity from continued use of chloral, 168. opiates, 52. Insomnia, best remedy for, 140. Intellectual grade of opium takers, 25. Jaundice from continued use of opiates, 35, 37, 38. Jewell, Prof. J. S., observations of, 84. Jones, Dr. N. Jasper, case by, 163. Dr. E., case by, 76. K. Kane, Dr. H. H., experiments of, 95, 98. Keyes' solution of morphia, 72. Keyser, case by, 198. Kidneys, effect of prolonged use of opi- ates on, 39, 46. Kiernan, Dr. J. G., observations of, 192. Kilpatrick, Dr. A, R., case by, 204. King, Dr. Willis P., case by, 168. Kinsman, Dr. D. N., case by, 169. Kirn, Dr. Ludwig, observations of, 187, 195. L. Labbee, chloral diabetes, 182. Lactucarium, 138. Lee, Dr. Benj., case by, 175. Leucorrhoea in opium takers, 43, 141. Levenstein, observations and experiments of, 30, 42, 45, 47, 62, 106, 107, 182. Lewis, Dr. Morris J. , observations of, 183. Dr. R. F., case by, 203. Ligature in subcutaneous medication, 100. Lobelia, 137. Locomotion in opium takers, 48. Loose, Dr., observations of, 30. Lupulin, 138. Lusk, Prof. W. T., observations of, 94. Lying propensities of opium takers, 52, 53- Lyman, Prof. H. M., case by, 154. M. MacDonald, Dr. Carlos F., on the chlo- ral habit, 152. Malaria, symptoms of, in opium takers, 62. Mattison, Dr. J. B., observations of, 30, 136. I 75, i7 8 » I 79- Marsh, Dr. Madison, observations of, I55-- Maudsley on chloral in insanity, 171. McAllister, Dr. W. F., case by, 30. Medico-Chirurgical Society's ca^es and experiments, 83, 98. Meldon, Dr. Austin, case by, 103. Memory, effect of continued use of chloral on, 170. hashisch on, 211. Menstruation in morphia takers, 41, 142. ■ chloral takers, 185. Miller, F. H., case by, 84. J. A., case by, 184. Mind, effect of prolonged use of opiates on, 49. chloral on, 165. hashisch on, 211. Morgan, Dr. Herbert M., observations of, 201. Morphia habit, the, 17. subcutaneous use of, 24, 30, 145. M'Rae, Dr. A. E., case by, 193. Murphy, Dr. W. Kirkpatrick, cases by, 165, 178- Muses volantes, 47. Muscular system, effect of continued use of opiates on, 48. effect of continued use of chloral on, 194. N. Neal, Dr. W. A., case by, 77. Nervous element, growth of, 17, 18. system, condition of, in opium takers, 53. system, condition, of, in chloral takers, 174. Neuralgia from prolonged use of opiates, 53, 142- chloral, 174, 175. Neurasthenic patients, danger of using narcotics and stimulants with, 31, 32. 224 INDEX. Nordlin, Dr. J. H., observations of, 151. case by, 185. Nose, reddening of, in opium takers, 39. Nussbaum, Prof., case by, 84. O. " Observer," case by, 85. GEsophagus, paralysis of, 180. Opium habit, the, 17. smoking, 29. preparations of, 27. P. Pack, the cold, 131. Paralysis from continued use of chloral, 177. Park, Dr. Roswell, case by, 170. Parker, Prof. Willard, case by, 94. Parrish, Dr. Jos., observations of, 21, 153- Pathology of opium and morphine habits, 17-27. Pepper, Prof. Wm,, intravenous injection of milk, 87. Pepy's Journal, extract from, 95. Personal experiences of an ex-opium hab- itue, 50. Perrigo, Dr. James, case by, 171. Perspiration in opium habitues, 39. Pflueger's theory of artificial menopause, 42. Photophobia from chloral, 197. Physicians, how to blame, 18. Pollak, Dr., on chloral habit, 155. Pollock, Dr. C, case by, 173. Pregnancy in morphia takers, 43. Preparations of opium commonly used, 27. Preservatives for morphia solutions, 74. Prevalence of the opium habit, 18. Progeny, effect of continued use of mor- phine on, 44. Prognosis in opium habituation, 143. chloral habituation, 202. Purpura hemorrhagica from excessive use of morphine, 35, 40. Q. Quantity of opium and morphine used by habitues, 28. R. Rapidity of absorption of morphine, 98. Reiman, Dr.. observations of, 151. Remondino, Dr. P. C-, case by, 203. Respiration, effects of chloral on, 195. Richardson, Dr. B. W., on the chloral habit, 156. Roberts, Arthur, case by, 89. Dr. John, observations of, 183. S. Schlaugenhausen, Dr., opinions of, 151. Schiile, observations of, 193, 198. Seguin, Dr. E. C, case by, 78. Semen, condition of, in opium habitues, 45- Sensation modified by prolonged use of opiates, 41, 70. Sex of opium habitues, 25. chloral takers, 150. Sexual organs, effects of continued use of opiates on, 41. effects of continued use of chloral on, 184. Shettle, Dr. R. C., observations of, 194. Shurtleef, Dr. G. A., observations of, 153. Skin, effects of continued use of opiates on, 38, 71. chloral on, 187. Sleep of morphia takers, 49. Sleightholme, Dr. J. Pennock, case by, 90. Smith, Prof. A. A., on chloral habit, 152. Dr. Q. C, observations of, 164. Dr. Nathan R., observations of, 192. Specific gravity of urine in morphia tak- ers, 46. chloral takers, 183. " Spectator," case by, 85. Sterility from continued use of opiates, 42. Stimulants, 139. Stools, character of, in opium habitua- tion, 36. Strangury from prolonged use of opiates, o 47 " • Stramonium, 137. Strychnia, 136. Sudden deprivation, dangers of, 127. Symptoms of abstinence from ^morphia, 125. chloral, 200 T. Taylor, Dr. Isaac E., 29. Temper in opium habitues, 49. Temperament of chloral takers, 162. Testicles, atrophy of, 45. Tetanus from subcutaneous injections, 101. Thomas, Prof. T. Gaillard, cases by, 31. Thornley, Dr. J. G., use of chloral in in- sanity, 151. Treatment of opium and morphine habits, 106. chloral habit, 200. Tupper, Dr. Aug. M., case by, 80. Turnbull, observations of, 194. U. Upham, Dr. W. R., case by, 177. Upshur, Dr. J. N., cases by, 184. Urinary organs, effect of continued use of opiates on, 46. effect of continued use of chloral on, 181. V. Vaginismus from continued use of opiates, 43, 62. Vaso-motor disturbances due to chloral, 177. Veiled Prophet of Khorassan, 51. Veins, puncture of, by hypodermic needle, 75. Vertigo in chloral habitues, 179. Vesical tenesmus from opium habituation, 62. Von Mering and Muscuhis, uro-chloralic acid, 183. W. Washington, Dr., 29. Webb, Dr. J. W. F., cases by, 184, 192. Wells, Spencer, observations of, 194. Wenger, Dr. E., case by, 88. Wilson, Dr. E. T., case by, 78. Wood, Alexander, 29. Prof. H. C, cases by, 83. ' on hashisch; 212. Woodling, Dr. M. E., case by, 75. SELECT LIST OF BOOKS PROM THE CATALOGUE OF MR. PRESLEY BLAKISTON, 1012 Walnut Street, Philadelphia, FOR GENERAL. AND SCIENTIFIC READERS. &&* Any of the following books will be sent, postpaid, upon receipt of the price, or they will be found in the stock of most booksellers throughout the United States and Canada. ON SLIGHT AILMENTS. Their Nature and Treatment. By Lionel S. Beale, m.d. Large 12uio. Cloth. Price $1.75. Among civilized nations a perfectly healthy individual seems to be the exception rather than the rule ; almost every one has experienced very fre- quent departures, of one kind or another, from the healthy state ; in most instances these derangements are slight, though perhaps showing very grave symptoms, needing a plain but quick remedy. CONDENSATION OS CONTENTS. The Tongue in Health and Slight Ailments, Appetite, Nausea, Thirst, Hunger, Indigestion, its Nature and Treatment, Dyspepsia, Oonstipatiou, and its Treatment, Diarrhoea, Vertigo, Giddiness, Biliousness, Sick Head- ache, Neuralgia, Rheumatism, ou the Feverish and Inflammatory State, the Changes in Fever and Inflammation, Common Forms of Slight Inflam- mation, Nervousness, Wakefulness, Restlessness, etc., etc. OPINIONS. " It abounds in information and advice, and is written for popular use." — Philadelphia Bulletin. " Singularly clear and felicitous." — Sanitarian. "A valuable work for the family library."— Boston Transcript. " A thoroughly practical work for non-professional as well as medical readers." — Cincinnati Gazette. " It belongs to that class of works to which high commendation belongs." — New Haven Palladium. "A scholarly book, singularly free from all technicalities, and almost as valuable to general readers as to members of the profession." — Chicago Inter-Ocean. 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Second, to show how varied and important are the Health Hints contained in the Bible, and third, to prove that the secondary trendings of modern philosophy run in a parallel direction with the primary light of the Bible . 12mo. Cloth. Price $1.25. NOTICES OF THE PRESS. " The anonymous English author of this volume has written a decidedly readable and wholesome book." — Philadelphia Press. "The scientific treatment of the subject is quite abreast of the present day, and is so clear and free from unnecessary technicalities that readers of all classes may peruse it with satisfaction and advantage."— Edinburgh Medical Journal. HEALTH AND HEALTHY HOMES. A Guide to Personal and Domestic Hygiene. By George Wilson, M.A., M.D., Medical Officer of Health. Edited by Jos. G>. Eichardson, Professor of Hygiene at the University of Pennsylvania. 12mo. Cloth. 314 pp. Price $1.50. CONTENTS. OHAP. PAGE VI. Exeroise, Eecreation and Training, 187 VII. Home and Its Surround- ings, Drainage, Warm- ing, etc., 221 VIII. Infectious Diseases and their Prevention, 269 "A most useful and, In every way, acceptable book."— New York Herald-. OHAP. PAGE. I. Introductory. 17 11. The Human Body, 33 III. Causes of Disease, 66 IV. Food and Diet, 119 V. Cleanliness and Cloth- lug, 169 Presley Blalciston's THE AMERICAN HEALTH PRIMERS. Edited by W. W. Keen, m.d. Bound in Cloth. Price 60 cents each. The Twelve Volumes, in Handsome Cloth Box, $6.00. I. Hearing and How to Keep It. With illustrations. By Chas. H. Burnett, m.d., of Philadelphia, Aurist to the Presby- terian Hospital, etc. II. Long lire, and How to Reach It. By J. G. Richardson, m.d., of Philadelphia, Professor of Hygiene in the University of Pennsylvania. III. The Summerandlts Diseases. By James O. Wilson, m.d., of Philadelphia, Lecturer on Physical Diagnosis in Jefferson Medical College. IV. Eyesight, and How to Care for It. With Illustrations. By George C. Harlan, m.d., of Philadelphia, Surgeon to the Wills (Eye) Hospital. V. The Throat and the Voice. With illustrations. By J. Solis Ooben, m.d., of Philadelphia, Lecturer on Diseases of the Throat in Jefferson Medical College, etc. VI. The Winter and Its Dangers. By Hamilton Osgood, m.d., of Boston, Editorial Staff Boston Medical and Surgical Journal. VII. The Month and the Teeth. With illustrations. By J. W. White, m.d., d.d.s., of Philadelphia, Editor of the Dental Cosmos. VIII. Brain Worli and Overwork. By H. C. Wood, Jr., m.d., of Philadelphia, Clinical Professor of Nervous Diseases in the University of Pennsylvania, etc. IX. Our Homes. With illustrations. By Henry Hartshorne, m.d., of Philadelphia, formerly Professor of Hygiene in the University of Pennsylvania. X. The Skin In Health and Disease. By L. D. Bulkley, m.d., of New York, Physician to the Skin Department of the Demilt Dispensary and of the New York Hospital. XI. Sea Air and Sea Bathing. By John H. Packard, m.d., of Philadelphia, Surgeon to the Episcopal Hospital. XII. School and Industrial Hygiene. By D. F. Lincoln, m.d., of Boston, Mass., Chairman Department of Health, American Social Science Association. This series of American Health Primers is prepared to diffuse as widely and cheaply as possible, among all classes, a knowledge of the elementary faots of Preventive Medicine, and the bearings and applications of the latest and best researches in every branch of Medical and Hygienio Sci- ence. They are not intended (save incidentally) to assist in curing disease, but to teach people how to take care of themselves, their children, pupils, employes, etc. They are written from an American standpoint, with especial referenoe to our Climate, Sanitary Legislation and Modes of Life; and in these re- spects we differ materially from other nations. The subjects selected are of vital and practical importance in every-day life and are treated in as popular a style as is consistent with their nature. Each volume, if the subject calls for it, is fully illustrated, so that the text may be clearly and readily understood by any one heretofore entirely ig- norant of the structure and functions of the body. The object being to furnish the general or unscientific reader, in a compact form and at a low Select List of Boohs. price, reliable guides for the prevention of dlsoase and the preservation of both body and mind in a healthy state. The authors have been selected with great care, and on account of special fitness, each for his subject, by reason of its previous careful study, either privately or as public teachers. HOTIOES OF THE PKES3. "As each little volume of this series has reached our hands we have found each in turn practical and well-written." — New York School Journal. " This is volume No. 5 of the ' American Health Primers,' each ofwhich The Inter-Ocean has had the pleasure to commend. In their practical teachings, learning, and sound sense, these volumes are worthy of all the compliments they have received. They teach what every man and woman should know, and yet what nine- tenths of the intelligent class are ignorant of, or at best, have but a smattering knowledge of." — Chicago Inter-Ocean. "The series of American Health Primers, edited by Dr. Keen, of Phila- delphia, and published by Presley Blaklston, deserves hearty commenda- tion. These handbooks of practical suggestion are prepared by men whose professional competence is beyond question, and, for the most part, by those who have made the subject treated the specific study of their lives. Such was the little manual on * Hearing,' compiled by a well-known aurist, and we now have a companion treatise, in Eyesight and How to Care for It, by Dr. George C. Harlan, surgeon to the Wills Eye Hospital. The author has contrived to make his theme intelligible and even interesting to the young by a judicious avoidance of technical language, and the occasional introduction of historical allusion. His simple and felicitous method of handling a difficult subject is conspicuous in the discussion of the diverse optical defects, both congenital and acquired, and of those injuries and diseases by which the eyesight may be impaired or lost. We are of the opinion that this little work will prove of special utility to parents and a 11 persons intrusted with the care of the eyes." — New York Sun. "The series of American Health Primers (now entirely completed) is presenting a large body of sound advice on various subjects, in a form which is at once attractive and serviceable. The several writers seem to hit the happy mean between the too technical and the too popular. They advise in a general way, without talking in such a manner as to make their readers begin to feel their own pulses, or to tinker their bodies without medical advice." — Sunday-school Times. " Brain Work and Overwork. By Dr. H. O. Wood, Clinical Professor of Nervous diseases in the University of Pennsylvania. This is another volume of the admirable "Health Primers," published by Presley Blakis- ton. To city people this will prove the most valuable work of the series. It gives, in a condensed and practioal form, just that information which is of such vital Importance to sedentary men. It treats the whole subject of brain work and overwork, of rest, and recreation, and exercise in a plain and practical way, and yet with the authority of thorough and scientific knowledge. No man who values his health and his working power should fail to supply himself with this valuable little book."— State Gazette, Tren- ton, N.J. Presley BlaMston's WHAT TO DO FIRST in Accidents and Poisoning. By Charles W. Dulles, M.r>. Illustrated. Brno. Oloth. Price 50 cents. PREFACE. Whoever has seen how invaluable, in the presence of an accident, is the man or woman with a cool head, a steady hand, and some knowledge of what is best to be done, will not fail to appreciate the desirability of possess- ing: these qualifications. To have them in an emergency one must acquire them before it arises, and it is with the hope of aiding any who wish to prepare themselves for such demands upon their own resources that the following suggestions have been put together. OPINIONS. "Of special practical value, and we commend it to all." — Lutheran 06- server. " Ought to be in everybody's hands." — Times, Philadelphia. " Its usefulness entitles it to a wide and permanent circulation."— Boston Gazette. "Just the thing for an emergency." — Portland Transcript. "Of great practical value to the public." — Wisconsin State Journal. " A complete guide for sudden emetgencies." — Philadelphia Ledger. "So plain and sensible that it ought to be introduced into every female seminary." — Evening Chronicle, Pittsburgh. " The suggestions are of priceless value." — The Traveler, Boston. " The book is invaluable." — Providence Press. " A valuable addition to the domestic library."— Boston Transcript. " Merits an extensive sale." — St. Louis Courier of Medicine. " This is an exceedingly useful and well arranged little book." — North American. " The instructions of this little book are necessary and timely."— Christian Secretary. " Contains a variety of practical suggestions that no household can afford to do without." — Contributor, Boston. EYESIGHT, GOOD AND BAD. The Preservation of Vision. By Robert Brudenel Carter, m.d., f.r.o.s. With many explanatory Illustrations. 12mo. Cloth. Price $1.50. PREFACE. A large portion of the time of every ophthalmia surgeon Is occupied, day after day, in repeating to successive patients precepts and injunctions which ought to be universally known and understood. The following pages contain an endeavor to m^ke these precepts and injunctions, and the reasons for them, plainly intelligible to those who are most concerned in their observance. WHAT 13 THOUGHT OP IT. "A very valuable book, and should be in everybody's hands." — North American. " A valuable book for all who are interested in the best use and preser- vation of the vision."— J?". E. Journal of Education. " A compact volume, full of information to all classes of people." — Book- seller and Stationer. "A comprehensive treatise, well calculated to educate the public."— Kansas City Review. " Gives excellent advice." — Chicago Journal. "To teachers particularly the book is of interest and importance." — Educational Weekly. Select List of Books. ON HEADACHES. Their Causes and Cure. By Henry G. Wright, m.d. Ninth thousand. 16mo. Oloth. Price 50 'cents. ON DEAFNESS, GIDDINESS and Noises in the Head. By Ed. Woakes, m.d. Illustrated. 2d edition. 12mo. Oloth. Price $2.50. HYGIENE AND SANITARY SCIENCE. A Complete Hand- book. 4th revised edition. Containing chapters on Public Health, Food, Air, Ventilation and Warming, Water, Water Analysis, Dwell- ings, Hospitals. Removal, Purification, Utilization of Sewage and Ef- fects on PublioHealth, Drainage, Epidemics. Duties of Medical Officers of Health, etc. By Geo. Wilson, M.A., m.d. 12mo. Oloth. Price $2.76. " A sound book, by a very competent writer." — London Lancet. WATER ANALYSIS For Sanitary Purposes, with Hints for the Interpretation of Results. By E. Frankland, ph.d., d.o.l. Illus- trated. 12mo. Oloth. Price $1.00. "The name of the author is a sufficient testimonial to its accuracy and its praotical value." — Boston Journal of Chemistry. BY THE SAME AUTHOR. HOW TO TEACH CHEMISTRY. Beinj Six Lectures to Science Teachers. Illustrated. 12mo. Cloth. Price $1.25. THE ART OF PERFUMERY. The Methods of Obtaining the Odors of Plants and Instruction for the Manufacture of Perfumery, Dentifrices, Soap, etc. etc. By G>. W. Septimus Piesse. 4th edition enlarged. 366 illustrations. 8vo. Cloth. Price $5.50. POTABLE WATER. How to Form a Judgment on the Suit- ableness of water for Drinking Purposes. By Charles Ekin. 12mo. Price 75 cents. HEALTH RESORTS of Europe, Asia and Africa. The result of the Author's own observations during several years of health travel in many lands. By T. M. Madden, m.d. 8vo. Cloth. Price $2.50. THE OCEAN AS A HEALTH RESORT. A Handbook of Practical Information as to Sea Voyages. For the Use of Invalids and Tourists. By Wm. S. Wilson, m.d. Illustrated by a chart showing the ocean routes of steamers, and the physical geography of the sea. 12mo. Cloth. Price $2.50. DWELLING HOUSES and Their Sanitary Arrangements and Construction. By W. H. Oorfield. Illustrated. 12mo. Oloth. Price $1.25. DRAINAGE FOR HEALTH. Easy lessons in Sanitary Sci- ence. By Joseph Wilson, m.d. Illustrated. 8vo. Cloth. Price $1.00. SANITARY EXAMINATION OF WATER, AIR AND Food. By Cornelius B. Fox, m. d. 91 engravings. 12mo. Oloth. Price $4 00. NUTRITION IN HEALTH AND DISEASE. A Contribu- tion to Hygiene and Medicine. 3d edition. By J. Henry Bennett, m.d. 8vo. Cloth. Price $2.60. HYGIENE AND CLIMATE in the Treatment of Consump- tion. 3d edition. By J. Henry Bennett, m.d. 8vo. Oloth. Price $2.50. PRACTICAL HYGIENE. A Complete Manual for Army and Civil Medical Officers, Boards of Health, Engineers and Sanitarians. 5th edition. With many illustrations. By EJ. A. Parkes, m.d. 8vo. Cloth. Price $6.00. VOCAL HYGIENE AND PHYSIOLOGY. With special reference to the Cultivation and Preservation of the Voice. For Singers and Speakers. With engravings. By U/ordon Holmes, m.d. 12mo. Cloth. Price $2.00. Presley Blakiston's Select List. WORKS ON CHEMISTRY. CHEMISTRY, INORGANIC AND ORGANIC. With Ex- periments and a Comparison of Equivalent and Molecular Formulae. 295 Engravings. By C. L. Bloxam. 4th London edition revised. 8vo. Cloth. Price $4.00. NOTES FOR CHEMICAL STUDENTS. Compiled from Fowne's and Other Manuals. By Albert J. Bernays, ph.d. 6th edition 16mo. Cloth. Price $1.25. MEDICAL AND PHARMACEUTICAL CHEMISTRY. Synthetical, Descriptive and Analytical. 2d edition, completely re- arranged and revised. By John Muter, m.a., m.d. Royal 8vo. Cloth. Price $6.00. HANDBOOK OF MODERN CHEMISTRY, Organic and Inorganic. ByC. Meymott Tidy, m.d. 8vo. 600 pages. Cloth. Price $5.00. A PRIMER OF CHEMISTRY. Including Analysis. By Arthur Vacher. 32mo. Cloth. Price 50 cents. COMMERCIAL ORGANIC ANALYSIS. Being a Treatise on the Properties, Proximate Analytical Examination, and Modes of Assaying the various Organic Chemicals and Preparations employed in the Arts, Manufactures, Medicine, etc. 8vo. Cloth. Price $3.50. MISCELLANEOUS. ON HOSPITALS AND PAYING WARDS throughout the World. Facts in Support of a Rearrangement of the System of Medi- cal Relief. By Henry C. Burdett. 8vo. Cloth. Price $2.25. COTTAGE HOSPITALS; Their Origin, Progress and Man- agement 2d edition, enlarged and illus. By Henry O. Burdett. $4.50. DEFECTS OF SIGHT AND HEARING; Their Nature, Causes and Prevention. By T. Wharton Jones, r.E.s. 2d edition. 12mo. . Cloth. Price 50 cents. IMPERFECT DIGESTION; Its Causes and Treatment. By Arthur Leared, m.d., f.b.o.p. 6th edition. 12mo. Cloth. Price $1.50. COMPEND OF DOMESTIC MEDICINE, and Companion to the Medicine Chest. By Savory and Moore. Illustrated. 12mo. Cloth. Price 60 cents. HOW TO WORK WITH THE MICROSCOPE. A Com- plete Manual of Microscopical Manipulation. Containing full descrip- tions of all oew processes of investigation, with directions for examining objects under the highest powers, and for photographing microscopical objects. By Lionels. Beale, m.d. 6th edition, enlarged and containing over 400 illustrations, many being colored. 8vo. Cloth. Price $7.60. MICROSCOPIC MOUNTING. A Complete Manual, with notes on the collection and examination of objects. By Jno. H Martin 2d edition. With 150 illustrations. 8vo. Cloth. Price $2.75. SECTION CUTTING. A Practical Guide to the Preparation and Mounting of Sections for the Microscope. By Sylvester Marsh Illustrated. 16mo. Cloth. Price 75 cents. THE MICROSCOPE IN PRACTICAL MEDICINE. With full directions for examining, preparing and injecting objects, the vari- ous secretions, etc. By Lionel S. Beale, m.d. 4th edition. 600 illus- trations. 8vo. Cloth. Price $7.50. SEA AIR AND SEA BATHING ; Th. 5 ir Influence on Health. A Guide far Visitors at the Seaside. By Chas. Parsons, m.d. i8mo. Cloth. Price 60 cents. lillllP WWk /■■'.'-■",','