TI-IE D U]3LII I JOUIQN_A_L OF

MEDICAL SCIENCE.

DECEMBER 2, 1889.

PART I.

ORIGINAL COMMUNICATIONS.

ART. X V I I I . - - O n MorpMnism." By ARTHUR Wu FOOT, M.D., Univ. Dubl. ; Senior Physician to the Meath Hospital ; Professor of Medicine, Royal College of Surgeons; Fellow, King and Queen's College of Physicians.

THE opium habit is at present, in civilised countries, indulged in almost exclusively through the instrumentality of the hypodermic syringe.

Opium smoking, which has long been a national characteristic of the Chinese, has found a limited number of imitators among the lower strata of society in places where Chinamen have introduced the practice.

Opium eating is said by competent observers to be very much on the increase in the manufacturing districts of England, and in the counties of Lincoln, Cambridge, and :Norfolk.

Early in the present century, though there were occasionally cases of people who used opium to excess in the solid form or in solution, the use of morphin by the subcutaneous method was absolutely unknown. I t was reserved for quite modern times-- since about the year 1859--to see the subcutaneous method employed as the principal, and almost the sole, channel for the vicious introduction of morphin into the system, while the terms morphinomania (first employed by Charcot) and morphinism (first

a Read before the Section of Medicine in the :Royal Academy of Medicine in Ireland, on Friday, November 15, 1889. [For the discussion on this paper see page 531.]

VOL. L X X X V I I I . w N O . 2 1 6 , T H I R D SERIES. 2 H

458 On Mor~ohbdsm.

employed by Levinstein) are so recent as hardly yet to have come into general use. The misuse of morphin has certainly been accentuated by a knowledge, on the part of the public, of the hypodermic method of administration, and of the rapid results which follow its employment.

The use of remedies by hypodermic or subcutaneous injection is an outcome of the British school of therapeutics. Two men of inventive mind--Mr. Charles Hunter of London, and Dr. Alexander Wood of Edinburgh--have each claimed the origination of this method. I have often heard the late Mr. Francis Rynd state in the Meath Hospital that he was the first to employ it. The truth of the matter appears to be that the first attempts at hypo- dermic medication were made by Mr. Rynd ~ in 1845, while to Dr. Alexander Wood, in 1855, is due the popularisation of the method. I t was Mr. Charles Hunter who gave the name of hypodermic to the subcutaneous method.

The opium habit, in the form of the hypodermic use of morphin, is more general and more on the increase than many think, and is indulged in rather by the refined and educated classes than by the lower orders. Many notices of its prevalence have lately appeared in America and on the Continent. According to Jouet the habitual injection of morphin is to-day, in France at least, almost a matter of fashion, and presents of pretty syringes in silver cases are exchanged on festive occasions. Zambaco, whose observations were made in Constantinople, says that the ladies of the better classes wear jewelled cases containing hypodermic syringes and artistic bottles for the morphin solution, and avail themselves of convenient opportunities to make reciprocal injections of morphin.

Morphinism has a particular interest for medical men, because quite an incredible number of our colleagues have fallen victims to it. Of Levinstein's 110 cases, 47 occurred in persons belonging to the medical profession, or dependent on it : thus, 32 physicians, 8 wives of physicians, 1 son of a physician, 4 nurses, 1 midwife, and 1 student of medicine, were among his patients. The acquisi- tion of the morphin habit has often been laid to the charge of the medical attendant, who has been blamed for imprudent use of the syringe, or indiscriminate employment of morphin. These charges have been made by some who are entitled to speak with authority. For instance, bTiemeyer, alluding to the morphin habit, observes this practice is not uncommon, and, as it is generally

" Dubl. Med. Pres,, 12th March, 1845. P. 167.

By Da. A. W. FOOT. 459

begun under the physician's recommendation, we may consider ourselves as responsible for its cure. Obersteiner, speaking of the prevalence of morphinism among the profession in Austria, hints broadly that, in his view, there is poetical justice in the fact that this fatal habit should work most havoc among the class of men who, by carelessly prescribing the drug, and instructing in the use of the hypodermic syringe, have been mainly instrumental in dis- seminating it.

The origin of tIze habit may, perhaps, as fairly, and, at all events, more charitably, be traced to some one or other of the following causes : - - ( l ) Relief of pain; (2) insomnia; (3) melan- cholia. Besides these conditions, each of which is frequently directly relieved by the use of morphin, simple curiosity has laid the foundation of the habit. Obersteiner gives the case of a physician who was incredulous as to the rapturous ease which a cancero.us patient alleged he had from morphin, and took one dose himself for experiment. This dose awakened a ravenous appetite, which he could never afterwards overcome. One of Dr. B.W. Richardsou's patients told him he began the practice simply to ascertain what tile effect was like, and that, finding it not unpleasant, he went on until he felt he could not llve without its continuance. Mere imitation has been alleged as the cause of the habit by one who could give no better reason for it than that a friend who lived in tlle house with him had recourse to it, and that he "followed suit."

A receptivity for morphin is, fortunately, not the property of every constitution. I t is only on certain individuals that it operates so as to produce intellectual excitement or psychical pleasure, and by creating an inappeasable hunger for a repetition of the dose, renders these individuals morphia habitu4s. With many even small doses cause such unpleasant effects that they have no wish to renew the experiment. Cases are well known of chronic illnesses which have required large doses of opium for a long time, often for years, yet the patients do not fall victims to the opium habit. I t is, however, a drug not to be trifled with rashly; for the morphia habit has established itself in as short a time as a month in persons who are able to take it without feeling any of its ordinary dis- agreeable consequences.

As a general rule, but one to which there are exceptions, the shorter the time it has been indulged in the easier it is to cure. The morphin disease is also more amenable to treatment if it has

460 On MorpMnism.

not been preceded by alcoholic excess ; for, if so, the alcoholic habit intensifies the narcotic craving, and adds much to the difficulty of treating it. Dr. B. W. Richardson says he has never met with the morphin habit among total abstainers from alcohol. However, on the other hand, it is stated that the abuse of morphin has, ill many cases, replaced the abuse of alcohol, especially in refined society, and that such is particularly the case in some districts where rigid total abstinence principles have been largely adopted by the inhabitants.

The quantity of the drug injected by a morphinist varies greatly. Few are satisfied with anything less than 3 grains in the twenty- four hours ; many vastly exceed this amount ; 15 or 20 grains are not uncommon quantities. In a case reported by Dr. Wm. Stuart of Hawkes Bay, New Zealand, the regular quantity used daily for some months was one ounce of the hypodermic injection of morphin (B.P.), which means a daily dose of 40 grains of acetate of morphin. The estimate of the amount was based on the state- ments of the patient and his wife, checked by the known quantities supplied by different druggists. I t may here be observed that it is often diit~cult to ascertain the exact amount of morphin which is used, because morphinism like alcoholism induces a total disregard for truth, and, in most cases, habitual morphinists become such liars that a knowledge of this particular phase of psychical degra- dation is necessary to rightly estimate their statements. One of Obersteiner's female patients told him herself that no one should believe a morphinist, as they were all alike untruthful.

The inquiry is a very natural one--what becomes of those immense quantities of morphin, and how is it that acute opium poisoning is so rarely observed ? In reply, it may be stated that the toleration of individuals is so variable, that what is a large dose for one is a moderate dose for another; moreover, the maximal doses have been arrived at by degrees, and are not initial ones. The following possibilities may also be suggested in explanation-- that a process of accommodation may be set up in the tissues, re- sulting in a lessened degree of susceptibility, while, at the same time, with a slower absorption a more rapid excretion may be established. Furthermore, morphin'is known to be eliminated with considerable rapidity by the kidneys, and a certain amount is also excreted by the mueous membrane of the stomach. Diedreich assumes that a portion of the morphin introduced into the organism is converted into oxydimorphin, or other analogous substances, which have the

By DR. A. W. FooT. 461

property of counteracting to some extent the toxic effects of the drug. Whatever becomes of it, the fact is patent that the daily use, subcutaneously, of lethal doses of morphin may be persevered in for a length of time without the appearance of the symptoms of acute opium poisoning.

Diagnosis.--The question of diagnosis can hardly be said to arise when the habit is admitted and the applicant professes a willingness to give it up and an anxiety to be cured; but, even in such cases, there is a strange inconsistency in behaviour, as, in a case which occurred to myself of a young medical man, who, while lamenting his infatuation, and professing his desire to be cured, took a charged syringe from his pocket and in- jected himself through his trousers without waiting to strip his leg. This conduct was very similar to that of a lady under Dr. Richardson's care, who was dotted all over those parts of her body that were within her reach with the marks of the punctures she had made, who used to beg, while imploring him to get her out of the practice, to allow her to show him how she did it. :Not unfrequently the real cause of the ill-health produced by morphinism is unsuspected by the family or friend8 of the patient, or the patient intentionally deceives the doctor by a total denial of the practice, or, if forced to admit it, mis- states the amount or frequency of the dose. In such cases it is rather a question of detection than of diagnosis, and corroborative evidence of much importance is afforded by information that the patient procures morphin himself or through others, by the presence of the puncture marks of the hypodermic needle, or by the discovery of morphin in the urine. This latter point is not such an easy matter to determine, and as it requires an elaborate chemical examination, the urine should be submitted to none but a competent analyst. A dlaguostic in morphinism has been derived from a study of pulse tracings. At a meeting of the Acad6mie des Sciences, MM. B. Ball and O. Jennings made a communication to show that the pulse is normal during the period of satisfaction. When the patient begins to feel renewed craving the pulse presents a flat elevated surface, which indicates the diminution of cardiac pressure, and explains the sensation of weakness experienced by the patient. The presence of this flat surface may be useful in the diagnosis of morphinism. (Brit. Med. Jour., May 7th, 1887. p. 1003).

Even when the morphin habit is suspected or admitted, the

462 On Morp]dnism.

amount or frequency of the dose can rarely be fully known, because one of the mental peculiarities of morphinists is secretive- hess concerning the vice, and they invariably deceive those about them in regard to the details of their indulgence. Individuals above reproach in other matters, and previously of unquestionable veracity, lie Without any hesitation in this matter. A patient under Dr. Wilson's car% who had secreted in her room a quantity of morphin, when about to undergo treatment denied either having taken or then having in her possession any opium or mor- phiu whatever, using the expression, " I call God to witness that I neither now have, nor have had since I began the treatment, any preparation of opium or morphia whatever." Within tea minutes afterwards sixty quarter-grain pills of morphin were dis- covered secreted under her bolster. This patient was a devout, refined, and, in regard to other matters, a trustworthy person.

Prognosis.--The prognosis in morphinism is not so favourable as was at one time believed. Yon ~oeck is of opinion that the morphin habit belongs to the category of diseases which are almost incurable. The weaning from it is a laborious task for the patient as well as the physician, and yet thereon rests the only hope of recovery. I t is considered by those who have had the largest experience of such cases to be easier to cure a morphin eater of his craving than a morphin injector. The probability of a cure may be estimated by attending to the following points : - - (1) The duration of the habi~--cases of short existence being more successfully treated than those in which the habit, of long stand- ing, has exercised a deleterious influence on mind and body; (2) the persistence or not of the condition which gave rise to the use of morphin, for if this condition is irremovable a cure is scarcely to be expected ; and (3) the physical and nervous consti- tution of the victim; because very weakly individuals fall into such a state of prostration on the withdrawal of their accustomed dose that it is necessary to give it again; and because intense psychical disturbance follows its stoppage in others of specially nervous temperament. Morphinism has been classed by some--as Laehr and Fidler--among the psychoses, but it is rather the ex- pression of a morbid constitution than a substantive affection in itself ; hence it is that nervous subjects, invalids, and individuals deficient in moral and physical tone, are specially prone to it.

The prognosis is not much affected by the magnitude of the daily dose, except in so far as the larger doses indicate chronicity

By Da. A W. FOOT. 463

in the habit which in itself is an unfavourable point, even in the case of small doses. In Obersteiner's experience the prospect of a permanent cure is distinctly gloomy, unless all the conditions just now mentioned are fulfilled.

I t is a hopeful consideration that in the majority of cases of morphinism to break the habit means to get well, because, unlike alcoholism, the morphln habit does not entail structural lesions of any vital organ. In relation to prognosis, it is well to bear in mind how frequent, in the experience of all, are relapses. They are more common in men than in women, and in persons of feeble physical and mental organisation than in those possessed of bodily and mental vigour. Of 82 men treated by Levinstein, relapses occurred in 61 ; of 28 women, in 10 ; of 38 physicians, in 26. The danger of relapse diminishes with the lapse of time; yet a single dose of morphin or a hypodermic injection may, after an abstinence of months, precipitate a relapse. A medical man, after four attempts at weaning, was treated in Obersteiner's institution, and dismissed apparently well, yet, after three months, he was again in his former state. So great is the tendency to relapse that Jaeckel does not consider a cure to be accomplished by the mere suppres- sion of the morphin hunger. He lays great stress on a con- tinuance of control over the patient in a proper institution, in order to guard as much as possible against relapses. Erlenmeyer contends that the longer a patient, after the discontinuance of the habit, continues under control in an institution the more favourable will be the prognosis of a permanent cure. He does not deny the possibility of successful treatment under propitious circumstances outside an institution; but he is quite opposed to the view of Wallfi that treatment in institutions is not only unnecessary but even injurious.

Treatment.--Emancipation from morphin-slavery is unattain- able by voluntary effort. Jaeckel is unaware of any successful case of self-treatment in morphinism, and does, not advocate its being attempted, even in the case of medical men. The difficulty of breaking the morphin habit is greater in some cases than in others. I t is considered to be easier to cure a morphin eater of his infatuation than a morphin injector. The process of cure, or of what Charcot calls demorphinisation, requires a degree of moral and physical courage seldom at the disposal of a morphin habitu& In the case of the highly gifted and more delicately organised, a fiery trial must precede deliverance. The abject

464 On Morphinisrn.

mental state of the morphinist calls for firmness, gentleness, and tact on the part of the physician and the attendants. Neither the intensity of his craving, nor the reality of his sufferings should be underrated or disputed.

The methods of treatment may conveniently be considered under four heads--(l) the deceptive plan; (2) the substitution plan ; (3) the tapering off plan; (4) the abrupt withdrawal plan. The first two methods--the deceptive and the substitution plans--may be dismissed as hardly worth serious consideration in the manage- ment of confirmed morphinism. The deceptive plan, which con- sists in injecting water, or some solution not containing morphia, seldom does good for any length of time, and is often not even of momentary use to a real morphinist. The injection of a few drops of water, or the very prick of the needle, or even of a pin instead of it, may relieve slight local pains in very nervous or imaginative people, especially if a successful result has been emphatically pre- dicted. In a morphia injector the association of ideas may, perhaps, lend a temporary charm to the sight of the hypodermic instrument, for I have seen the eyes glisten and depression vanish from the features upon the production of a syringe which contained no morphin; but the morphinist is not deceived a second time, and the indignation of one who feels he has been cruelly hoaxed is sure to replace any confidence that might have been reposed in the attendant who adopts the deceptive plan. The victim of morphin hunger is fully sensible that when he begged for bread he has been given a stone.

The substitution plan, which consists in rep|aclng the morphia by some other drug, such as coca[n or chloral, has been aptly described as handing the sufferer over from one enemy to another. The substituted drug sometimes produces even greater havoc than the one it has replaced, because of its introduction into a system already undermined by another toxic agent. Cocain is the drug which has been most championed as an antidote for the morphia habit. On the subject of the treatment of morphinism by cocain, Erlenmeyer has come to the following conclusions :--(1) That its use does stop the morphia craving; (2) that this effect is very transitory, lasting only from 10 to 25 minutes; (3) that coca~n is a real substitute for morphia and not an antidote; (4) that it should not be given, as its effect is so temporary and its use dangerous. Moreover, there is great risk of developing a habit-- cocainismus--whieh is worse than morphinism. (Brain, x., 533).

By DR. A. W. FOOT. 465

The treatment then is narrowed to a choice between the tapering- off plan and the abrupt withdrawal plan, and one or other of these methods is advocated by those who have found the particular course they adopted of use in special cases. There is no unanimity of opinion as to which mode of treatment should be employed, and, before coming to a decision on this point, the following matters have to be taken into consideration--viz., the duration of the habit ; the dose which has become habitual; the cause of the habit; the effects it has had on the patient ; and their strength of constitu- tion. I t by no means follows that the adoption of either method will be ultimately successful in any given case, so far as the cure of the practice is concerned, for it must be admitted that with the best efforts there are many failures to break the threefold cords of the morphin habit; but, nevertheless, failing cure, the patient may be restrained from resorting to increased doses, or the amount may be got reduced from a dangerous to a comparatively safe quantity. Whichever plan is adopted, the advantages are not to be overlooked or forgotten of careful regulation of the diet, change of air and scene, cheerful society, and the administration of tonic remedies.

The tapering-off plan consisfs in .the gradual reduction of the dose, until none of the drug is required. For instance, a solution of morphin is made of known strength--say, so that each 20 minims is equal to one grain of morphia; then, after each 20 minims are taken from this solution, 20 minims of distilled water are added to it, so that the solution becomes gradually weaker. An analogous tapering off or weaning plan is adopted in the East in the case of opium chewers, by gradually mixing an increasing proportion of wax with the crude opium, till at last there is more wax than opium in the combined mass. Similarly in treating opium smokers, they mix more and more tobacco with the opium before ignition. In the tapering off plan, the patient should not be informed of the progressive diminution of the dose, for some, if acquainted with the details of the process, feel quite distinctly the withdrawal of a small fraction of a grain. Dr. B. W. Richardson considers it better to reduce the dose at each administration than merely to lessen the number of injections in the 24 hours. No tricks are to be played with the patient by injecting water or solutions devoid of morphin, for such behaviour destroys confidence. Erlcnmeyer considers the tapering-off plan of treatment unsatisfactory because of the con- tinuous supervision it requires on the part of someone who can be

466 On Mors

implicitly relied on to provide against the surreptitious use of morphin; and he thinks it further undesirable on account of the prolonged misery it entails, because thd duration of the weaning process must be proportionate to the dose which has becmne habitual. (Brain, x., 533).

The abrupt discontinuance of the drug (the method of Levinstein as it is called from one of its principal advocates) is attended in all cases by indescribable sufferings, and in many by serious dangers, among which collapse and a condition resembling delirium tremens are to be specially considered. Von Boeck, who approves of this method, considers the most effectual plan is to correct the habit suddenly, uno ictu, if we have to do with hardy individuals, admitting meanwhile that the great danger in this method is collapse, which he advises should be obviated by the copious use of wine.

When morphin is suddenly cut off in those accustomed to its use, a remarkable group of symptoms ensue, called the Abstinenz Symptome, or reactionary effects. They are severe and alarming. As enumerated by Obersteiner, they comprise acute diarrhoea; insomnia; great excitement, amounting at times to mania dangerous to those around, and particularly to the physician ; hallucinations ; and collapse. The A bstinenz Symptome are liable to occur under the taperlng-off as well as under the abrupt withdrawal plan, but are seldom so severe under the former. This so-called reactionary stage may last from four to eight days, and, according to Von Boeck's description, the patient looks ill and emaciated, the eyes heavy, the respiration laboured ; they suffer from dyspncea, anxiety, palpitation, frequency of pulse, up to 120, perspirations, great irri- tability, dysuria, pains in all possible nerve regions (especially in the stomach and intestines), anorexia, thirst, diarrhoea, complete insomnia, and this state of things may terminate in death. The abrupt withdrawal of alcohol or chloral is possible and safe, hut in the case of morphin it occasions the direst symptoms both objec- tive and subjective, which nothing will relieve but morphin. Erlenmeyer, struck with the gravity of these Abstinenz Symptome, and particularly with the tendency to collapse, discards the system of sudden withdrawal adopted by Levinstein, and recommends a combination of the third and fourth methods--namely, the com- plete withdrawal of the whole quantity of morphin, not abruptly, but in from six to twelve days. By this compromise he hopes for a successful result, absolute freedom from danger, and a shortened period of suffering. I t seems certain that, with enfeebled indivi-

By Dm A. W. FooT. 4~;7

duals, the amount of the accustomed dose must be graduall.~ reduced, and in such cases the tapering-off plan is preferable to that of abrupt withdrawal. The abrupt withdrawal plan is most applicable when the morphin habit has not been confirmed by long use, and the dose injected has not been excessive. Erlenmeyer records some curious facts, showing that children born of mothers addicted to morphinism are affected just in the same way as if the drug had been directly administered to them and suddenly withdrawn. These infants habitues, and become liable plete insomnia for as long as as they are separated by birth supply.

are, in fact, congenital morphin to serious troubles, such as com- sixty hours (Jouet, p. 41.), as soon from the source of their constant

The A bstinenz Sympto~e, or reactionary effects, are liable to occur upon the sudden stoppage of the accustomed dose, whether the habit has been of long or short duration, They are more violent, and developed with greater rapidity, in some cases than in others. Some patients rest quietly in bed, enduring with fortitude sufferings from which there is no escape; others, silent and apathetic, present the appearance of abject despair. With the greater number restlessness is continuous, and very often extreme ; they are with difficulty kept in bed--if left to themselves they run frantically about the room, moaning, bewailing their condition, and imploring the attendants for that which alone is capable of relieving their distress. This stage of excitement may gradually subside, giving way to a state of the most profound exhaustion, or it may develop into a condition which, being accompanied with hallucinations, delirium, and tremor, closely resembles the results of alcoholism. At times it is necessary to have recourse to physical restraint, as in a case reported by Von Boeck of a young doctor who could be cured of giving himself morphin injections only by being actually shut up in a room for more than a week. He resisted like a maniac, scratched at the walls with his nails, wept and shrieked from misery, ate nothing, was unahle to sleep, and had diarrhoea. At last, after some days of untold suffering, he began to feel better-- to eat and sleep. From that time his weight rapidly increased, his appearance grew fresh and healthy, and he recovered his taste for tobacco, so that he smoked and drank beer as in the days of his health. Having regard to the likely occurrence of these Abstinenz Symptome, the desirability of conducting the treatment away from the patient's home can scarcely be questioned,

468 On Morptdnlsm.

and it is a fact that cases in which the home treatment of morphinism have proved successful are certainly exceptional.

The sudden interruption of the morphin habit by acute disease may give rise to very puzzling symptoms. Attention has been drawn to this matter (see La~tcet, 1887, Vol. II.. p 300) by M. Richardi~re, in relation to the case of a physician, a morphin injector, who got pneumonia. Most alarming symptoms of dyspncea, cyanosis, weak and irregular heart-action and excessive rapidity of pulse, caused the greatest anxiety for the result. M. Richardi~re believes that a fatal issue was prevented only by a recognition that these were the Absti~e~z Syrnptorne of a morphinist, rather than due to the pneumonia, and by a prompt recourse to the stimulant for which the system was craving.

In cases where the habit is denied or concealed Charcot relies for the diagnosis on the occurrence of the characteristic Abstinenz Syrnptome which supervene when the drug is withheld during the process of demorphinisation.

The assistance to be obtained from drugs in conquering the opium habit is maintained by Dr. Fleming, who advocates the sudden suspension of the habit as infinitely more efficient and easier to the patient than the gradual diminution of the dose. He recommends the administration of large doses of phosphoric acid and lupulin to counteract the immediate effects of the suspension of the drug. Having interdicted all use of opium, and taken the necessary pre- cautions against its being obtained surreptitiously, he orders--Acidi phosphorici diluti, 5x; tincturm lupulinm, 5xxx.--M. Of this two drachms are to be taken in a large wineglassful of water every four hours. The dose may be increased or lessened according to circum- stances. If insomnia is very protracted, he gives, at bed-time, the following draught :--1~. Tinctur~e cannabis Indicm, m.. xxx ad lx; spiritfis mtheris, 5i ; aquae sambuci, ad ~ss.

In the case of a gentleman, addicted to morphin for seventeen years, and who had sometimes taken thirty-two grains in the day, Dr. Seymour Sharkey found the most effectual means of quieting the extreme restlessness, which occurred upon the sudden with- drawal of the morphin, to be grain doses of extract of belladonna as suppositories, with 3i doses of tincture of hyoscyamus. A detailed account of this very remarkable case, in which a cure of the habit seems to have safelybeen accomplished by the sudden stoppage of the drug, when used in enormous excess, will be found in the Lancet. ~

Vol. I I . 1888. ]?. 1120.

By DR. A. W. FOOT. 469

The weaning process is facilitated in some by the administration of ammoniated alkalies, bitters, or ethereal substances. Thus, Coleridge experienced sensible relief from the use of ammoniated tincture of valerian.

Dr. Oscar Jennings, of Paris, from his sphygmographic observa- tions on the pulse in morphinism, deduces the necessity of using, in the treatment of such cases, a circulatory stimulant of some kind to replace the withdrawn morphin. Of such medicines he has found nitro-glycerine to produce the same improvement of the pulse as morphin, and patients taking it declare the sensation of warmth and comfort following its use is like that which they experience on first receiving morphin after deprivation of it.

Great care is needed in the case of pregnant women addicted to opium, because incautious attempts to withdraw the habitual drug are, according to some authorities, almost certain to be followed by the loss of the foetus. That this is not always so is shown by a study of Braithwaite's case of the abrupt plan of treatment in a young woman in the habit of using large doses of morphin. During the demorphinisation of a pregnant woman, a patient of .M. Tarnier, the movements of the foetus became so lively, and the uterine colic so sharp, that the process had to be interrupted (Jouet, p. 41).

Strange as it may at first sight appear, in the treatment of morphinism the question may arise, is it right or necessary to interfere at all? The decision in such a case turns upon the motive which led to the commencement of the practice. In the large majority of cases the alleviation of physical pain is alleged as the excuse ; but if the person be a sufferer from malignant disease beyond the range of surgical skill, and if their pain be relieved, and life rendered endurable by habitual injection of morphin, there is little more interference called for than such as would lead to a systematic regulation of the dose within the limits of safety. The same course may be adopted in a case where symptoms of diabetes or heart disease are favourably controlled by the use of what would otherwise be excessive doses of morphin. In such cases it is impracticable, nor would it be desirable, to interfere with the habitual use of morphin. I t may be even advantageous in some cases to acquire the habit. Dr. Lutaud believes that the methodical subcutaneous injection of strong doses of morphin, from two to nine grains daily, is highly beneficial in cancer of tile uterus. I t checks the hmmorrhage, causes the pain to disappear,

470 On Mo~Thinism.

acts as a necessary stimulant to the patient, and prolongs life. His observations in this direction were suggested by his remarking that in female morphinists menstruation becomes suppressed directly the dose of morphin reaches a certain strength. (Brit. Med. Jour., 5th :Nov., 1887. P. 1,018).

I t is noteworthy that a liking for morphln, amounting to what has been actually termed morphinomania, has been noticed several times in some of the lower animals--in cats and especially monkeys. A physician in Cambodia, M. Ludovic Jammes, communicated to the Acaddmie des Sciences, Paris, through M. Vulpiau, the case of some monkeys belonging to an opium smoker. These animals lived habitually with him in an atmosphere saturated with the products of the combustion of opium, and, moreover, were fond of eating the residue left in their master's pipe. I t was observed that during prolonged absence of this man the animals, after four or five days, became languid, and showed all the symptoms of depression usual in demorphinication. On the return of their master the monkeys gladly resumed their habits, and recovered their good humour. The facts stated did not astonish M. Vulpian. who presented the communication to the Academy, under the title of "Morphinomania in Animals." (Loud. Med. Rec., 15th Aug., 1887. 1).374.)

Levinstein, a in a recent paper on the "Convalescence" from morphlnism, states that, were more attention paid to this critical period, fewer relapses would take place. The whole therapy of the convalescence after the withdrawal of morphin or coca~n may be summed up in careful oversight of the patient, strict abstinence from alcohol, and the avoidance of all unpleasant psychic impres- sions. I t is a notable fact that when several persons under treat- ment for morphinism are together in an institution for the care of such patients, they are very apt to associate with one another, to talk freely of their affection, and often to combine in deceiving the physician in charge. This association should be prevented, for there is nothing more ruinous to the recovery of the lost will-power than to allow the thoughts or conversation to run on morphin.

There are other directions in which the subject of morphinism presents points of interest--for example, in relation to medical jurisprudence and to life assurance; but the limits of the present communication forbid me from entering upon their consideration.

a Deutsch. reed. Wochenschr. 1888. 85, 715. Inter. Journ. Med. Sci. 1888. P. 622.

By DR. A. W. FooT. 471

Appended hereto is a list of some of the more important publi- cations on the subject of morphiuism : - -

Bartholow.--" Hypodermatic Medication." 1882. P. 120. Bernhuber.--" _?Ertz. Intelligenzblatt." 1878. Boeck, Von.--Vegetable Poisons. "Von Ziemssen's Cyclopedia," Vol.

XVII. Braithwaite, James, M.D.--" Lancet." 21st Dec, 1878. P. 874. Burkhardt.--"Die chronische Morphium-Vergiftung." Bonn~ 1877. Busey.--"Philadelphia Medical Times." 1876. Calvet.--Essai sur le Morphinisme. "Th~se de Paris." 3876. ]~rlenmeyer.--Die Recidive der Morphium-Sucht. "Centralbt. f.

Nervenheilkunde." 1879. Fiedler.--Ueber den Missbraueh der Morphin-Injectionem. "Zeitsch.

fiir prakt. Medicin." 1874. Fleming.--" British Medical Journal." 15th Feb., 1868. P. 137. Jouet . --" ]~tude sur le Morphinisme Chronique." Paris, 1883. Kormann.--"Deutsche reed. Wochenschrift." 1877. Krage:--" Ueber Albuminuria und Glycosuria nach Morphium."

Griefswald, 1878. Kunz.--Die Morphiumsucht. Baier, "2Ertz. Intelllgenzblatt," 1876. Laehr.--Ueber Missbrauch mit Morphin-Injectionem. "All. Zeitsch.

fiir Psychiatrie." 1872. Leidesdorf.--Die Morphiumsuch. "Wien. med. Wochenschrift." 1876. Levinstein.--Several Papers in the "Berl. klin. Wochenschrlft." 18757

et seq. " D i e Morphiumsucht." Berlin, 1877. Lewin.--Ueber Morphiumentoxicationen. "Zeitsch. f. prakt. Mediein."

1874. Martin.--The Opium Habit. " Philad. Med. Times." 1874. Mattison.--" Philadelphia Med. and Surg. Rep." 1874. ":New York

Med. Record." 1876. Michel.--Ueber Morpbiuminjectionen und Morphinismus. "Wtirtemb.

reed. Correspondenzblatt." 1876. Moinet.--On the Administration of Opium. "Edin. Med. Journ." 1875. Obersteiner~ H , M.D.--Chronic Morphinism. "Brain." Vol. II.

Jan., 1880. P. 449. Richardson~ B. W.--Morphia Habituds and Their Treatment.

"2Eselepiad." 1884. Richter.~Casuistik zum Morphinismus. "Berl. klin. Wochensehrift."

1876. Sharkey, Seymour, M.D.--" Lancet." 1888. Vol. II. P. 1,120. Stuart.--" Brit. Med. Jour." l lth May, 1889. P. 1,051. Whipham, Thomas, M.B.~" Clin. Soc. Trans." LondoD~ 1875. Vol.

VIII., p. 108.

472 Laparotomy in Obstruction of tlte Bowels.

Wilson, James C., M.D.--Article-on the Opium Habit and Kindred Affections. Vol. V., ~t)epper's System of Practical Medicine."

Zambaco.w"De la Morph6omanie." Paris, 1883.

ART. XIX.--Case of Obstruction of ts Bowels successfully Treated by .Laparotomy. Under the care of J. J . CRANNY, M.D., F.R.C.S.I. ; Surgeon to Jervis-street Hospital, &c.

So many lives have been lost from obstruction of the bowels, not only in former times, when medical treatment alone was adopted, but even recently and notwithstanding the advances in abdominal surgery, that I think it a duty to place on record the following case : --

G. C., aged sixty-five, an ex-military officer, sent for me early on the morning of Tuesday, October 1st, 1889.

The previous evening, after a fatiguing day, he had dined rather hurriedly on grilled turkey and sausages, from which meal he dated all his trouble. Through the whole night he was in pain and had sickness of stomach. A dose of morphin hypodermically gave him much relief. He was ordered hydrocyanic acid in draught. For the remainder of the day he was quite easy, and at the evening visit felt he would be all right after his bath, &c, next day ; up to this no movement of the bowels. Next morning he had a rhubarb draught, which was soon rejected by the stomach. He was ordered a couple of colocynth and hyoscyamus pills, with 2 grains of calomel ; these were also thrown off, and he took two more with a similar result. A large enema was administered this evening with a fruitless result.

Next day, October 3rd, I had the benefit of a consultation with my friend, Dr. ] ). J . Hayes. We ordered him ext. belladonna and succus papain exsiccat, in pill, every second hour, also a mixture containing liq. potassm, and gentian. For two days there was an apparent lull in the symptoms, but no evacuation from the bowels, not even of flatus.

On the morning of the 5th of October he was ordered 5 grains of calomel. Soon after this his stomach began again to be sick, and the vomiting became stercoraceous. In the evening Dr. Hayes again saw him with me, when we agreed that an operation would be the only means of saving h~m, and we determined to perform it in the morning, should he consent. On Sunday morning he almost suggested Lhe operation himself.