LAOCOÖN.

“Ille simul manibus tendit divellere nodos,

Clamores simul horrendos ad sidera tollit.”

Virgil, Æneid, Lib. 11.

The knotted coils he 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.
1881.

Entered, according to Act of Congress, in the year 1881, by
PRESLEY BLAKISTON,
In the office of the Librarian of Congress, at Washington, D. C.

Press of WM. F. FELL & CO.,
1220-1224 Sausom Street.

To
Dr. Alexander J. C. Skene,
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 treatment 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 comprehensive, 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.

191 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 statistics have a painful interest, and it must be remembered that this is no exceptional case. In one of our large cities, containing, 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 morphia 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 inhabitant. 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, ending June 30th:—

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.

THE OPIUM AND MORPHINE HABITS.

CHAPTER I.
THEIR PATHOLOGY.

A higher degree of civilization, bringing with it increased 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 ancestors 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 nervous element; a gradual evolution of that or those peculiarities most prominently brought forth by the exigencies 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 permanent 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 hypodermic 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 educated and respectable people in all countries and among all classes, confirmed habituès; 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, hopelessly, 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 imaginary precipices, or falling, falling down dizzy heights. 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 exhaustion 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 impossible 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 wanders; delirium supervenes; diarrhœa and vomiting set in, and sometimes collapse, and a more pitiable object can nowhere be found.

It is at this time that the sufferer, tortured beyond all 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 diarrhœa 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 increase 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.[1] 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 prescribe 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. Habituès 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 habituès 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 curiosity, 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 themselves 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, vaporizing 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 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 counteract 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 picture daily conjured by their fertile imaginations, it would indeed be more surprising. That it does not produce such effects on our plain, work-a-day people is not to be wondered 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 and well written little pamphlet,[2] is of the opinion that the majority of habituès 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 conclusions 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 habituès, 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.

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:—

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 alcoholic 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, or caused him to be careless or negligent of his home relations, 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 subcutaneously, 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 confirmed habituè and also an alcoholic drunkard. One who sees much of this disease meets with some very sad cases.

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.—1 grain of opium to every 25 drops, or 1 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 ipecac to every 10 grains of the powder.

Sulphate of Morphia. Acetate of Morphia.—Salts of opium, 1 grain of either being equal to about 6 grains 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 having 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 habituès use the gum opium, but few, paregoric, and a less number still, Dover’s powder. 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 suppositories. This was the case with one of my patients, a gentleman 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 is used either by the mouth, rectum or hypodermically. 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 anæsthetic effect upon the mucous membrane of the alimentary canal, and gives rise to hepatic derangement 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 instrument 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 world. In my work upon the hypodermic use of morphia[3] I made, in the preface, the following statement, the belief in which has since been strengthened: “There is no proceeding 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, physicians from all parts of this country, England and France, assert this and detail cases. Levenstein[4] gives many instances 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 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.”

Fig. 1.—Hypodermic Syringe. Glass cylinder with metal casing. Indexed on glass.

Fig. 2.—Plain Glass Syringe, with needle. Index on stem.

Fig. 3.—Plain Metal Syringe, graduated on stem.

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.

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 gradual depression of the nervous and circulatory systems.

In consequence of the skepticism evinced by some physicians 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 deplorable 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 symptom, is cured, or it may never be cured. At any rate, the patient awakes to the knowledge that he must have his narcotic. Life without it is unbearable, and instead of 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 intoxication with opium. The majority of habituès 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 morbid 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 suffering 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.

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 continued 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 effect of opium or its alkaloid morphia on the stomach is, in the majority of instances, to increase the appetite and 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 obstructed 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 interference 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 digestion of food is imperfectly performed, and in consequence, a condition of malnutrition results, showing itself in wasting of the muscles and loss of the fatty tissue beneath the skin, especially of the face, breast and abdomen. As the gastric catarrh increases, nausea and finally vomiting ensue, still further debilitating the patient. Derangements 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 bandaged. After about two weeks the dropsy lessened, the spots disappeared and the general health improved sufficiently 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 literary work, that required both knowledge and tact. On his 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 illness, 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, interferes 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 absence of bile in the intestinal canal allows of decomposition 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 diarrhœa. In one patient whom I saw, the fæces collected day by day in the bowels, until impaction resulted and the mass was removed, with the greatest difficulty, 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 fæces 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.

Alcoholic stimulants are used by some habituès to increase 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 necessary 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, unsatisfied 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 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 present. 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 alteration, the loss of adipose tissue, the ill-balanced circulation, giving at one time coldness and paleness, at another flushing and undue warmth, and the variable secretion. A plump and well nourished person who commences the use 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 produced, 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 solutions and unclean needles when the drug is given subcutaneously will be spoken of fully presently.

Sensation is variously altered. Sometimes there is a condition of hyperæsthesia, the least touch being intensely painful, the contact of the clothing causing decided irritation. 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 sensations that are very aggravating, as they and the numbness are often looked upon by patients as precursors of paralysis. 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 habituè, 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.

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 amenorrhœa 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 manner on the ovaries as on other secreting glands, i. e., would render them devoid of function under its continued influence. It is likely, therefore, that the menstrual discharge does not show on account of no ovulation taking place; this also would account for the sterility.”[5]

Accompanying this condition of non-menstruation there is always sterility. That this is due to the habitual use of morphia is proven by the fact that these women have borne a child or children before the use of the drug was commenced, and have again become pregnant and gone to full term after the habit was abandoned. So long, however, as menstruation does occur, there is a possibility of the woman’s becoming pregnant.

In the majority of instances sensation is finally lost, although it is usually increased during the first few months’ use of the drug. A patient of mine, a lady who had used morphine by the mouth for sixteen years, found her virile power during and at the end of that time in no way impaired. If anything, it was increased. Her dose of morphine was ten grains. She had not menstruated for a long time. This was the only case in which I tried Levenstein’s plan of at once stopping the drug, and I shall certainly never try it again.

With the suppression of the menstruation, there sometimes come the usual symptoms attending the suppression of this function in non-habituès.

Levenstein states that ladies suffering from leucorrhœa are often cured of this complaint by the habitual use of morphia; the discharge returning, however, as soon as the habit is broken, and causing labor-like pains.

Certain it is that most female patients, on breaking the habit, suffer from a severe leucorrhœa, whether or not they had such a discharge previous to commencing the use of the drug. One of my lady patients who used six grains a day, subcutaneously, had a leucorrhœal discharge before she began the use of morphia, and upon which a four years’ habituation had no curative or modifying effect. As soon, however, as the habit was broken, the discharge increased greatly in quantity, and changed in character, becoming more tenacious.

Spasmodic closure of the mouth of the vagina on attempting to introduce the finger or a speculum, I have noticed in two cases. It, also, readily passes away after the use of morphia is abandoned.

A woman becoming pregnant in the early course of her addiction to this habit will, in the majority of cases, abort before reaching full term, especially if the amount used is large. Levenstein has noted the fact that wives of men addicted to the habitual use of this drug in large doses had in the last two years never carried children to full term, although young, healthy, and having borne children before the husband became an habituè.

There is no question in my mind but that the excessive use of this drug by one or both parents, but especially the mother, in case she is able to carry her child to full term, will modify disadvantageously the physical, mental, or moral development of the child thus born. A physician from the South tells me of the case of a lady who commenced the use of opium at the beginning of her pregnancy. She was delivered of a fair-sized child that grew up in fair, though not robust health, and menstruated at the proper age. She is, however, very simple and childish, still plays with dolls, although a young lady, is very eccentric, and shuns the society of young men. The mother, who is still living, ceased to menstruate at the age of 30 and has never menstruated since, some twenty years. For the past two or three years she has been using sixty grains of gum opium daily.

Dr. Alonzo Calkins[6] relates several cases where the children of such parents were either physically or intellectually deficient. I give but one of them: “At an inquest held by Dr. Macnish it appeared that a child five years of age, though to appearance only so many weeks old, had never been able to walk, nor so much as utter an articulate sound. The mother, during her gestation (as was in evidence), had taken to morphine, using a drachm a day in the months just preceding her demise. A child born before the habit had become fixed showed a normal development and the aspect of general health.” Another case is related where both parents were “healthy and robust by original constitution and by habits of life too, with the exception that the woman had, for a very considerable period, been in the practice of using morphine regularly and to great excess. An infant born subject to the liabilities, had only a very imperfect physical organization, with weak intellectual indications.”

By carefully conducted experiments on animals (pregnant dogs and rabbits), Levenstein found that the continued use of morphia invariably produced abortion, the fœtus being born dead.

With the cessation of the menses the breasts usually dwindle in size, and the voice attains a more masculine tone.

In man the first indication of an effect on the sexual organs is increased desire; this, however, giving way sooner or later to partial or total impotence. The fact, noted by Levenstein, regarding the rarity of conception and parturition in the wives of habituès, has already been spoken of. If the amount of opium or morphine used is small, impotence may not come for a number of years. The power of partial or full erection, without emission, is preserved by some. In those cases where there is inability to impregnate the female, there undoubtedly exists a deterioration of the functional power of the testes. In one case which I saw the testicles were markedly atrophied. In two cases I was fortunate to be able to examine the seminal fluid, a few days after the habit had been broken. These patients, as is usual on recovery, were troubled with erections and nocturnal emissions. In both instances the zoosperms were small, and present in less than the normal quantity. In one case, where it was possible, owing to the patient’s having been previously instructed, I was able to examine this fluid once or twice weekly for nearly two months. Each succeeding examination showed a larger number of zoosperms, each sample apparently better developed than the preceding.

Even large doses sometimes fail to produce impotence. One young man, twenty-five years of age, who has been taking, subcutaneously, ten grains of morphia, for over three years, is a confirmed masturbator, and seems to have frequent emissions.

CHAPTER IV.
GENERAL SYMPTOMS CLASSIFIED AND ANALYZED.

THE URINARY ORGANS.

Albuminuria, usually temporary, is not an uncommon result of the prolonged use of morphia. The deposit, after applying heat and nitric acid, may vary from one-twentieth to one-seventieth per cent. of bulk. In some cases it comes and goes, one day appearing as a slight, hazy cloud, and on another as a measurable deposit. Albuminuria and diabetes are more commonly found in patients who use the drug hypodermically. In some rare instances casts, epithelial, granular, hyaline and bloody, are to be found in the urine, as also free renal cells, apparently healthy. This was the case with the literary gentlemen spoken of in the second chapter. This does not indicate organic disease of the kidney, for after the withdrawal of the drug the albumen and casts gradually disappear.

The specific gravity of the urine varies according to the bodily condition of the patient, the weather and the amount of fluid ingesta used. If sugar is present the gravity is high; if albumen, usually low. In nervous and hysterical women there is a low gravity with an excess of the alkaline phosphates. In nearly all cases the uric acid is increased after the drug has been used for a time, the urea is very materially diminished, due probably to the small amount of food taken, the congested and deranged condition of the liver, and the impeded tissue metamorphosis. The chlorides are always slightly, sometimes markedly, diminished in amount.

Levenstein concludes, from his observations on patients and experiments on animals, in whom the continued use of morphia produced albuminuria, that this affection is due to varying blood pressure in the renal vessels through the nerves supplying them.

Contrary to the experience of Levenstein, I have found sugar in the urine of some (four) of my patients. This, like the albuminuria, was permanent in one case, and came and went in the other three. Its presence was undoubted, it reducing the copper of Fehling’s liquor (previously tested) and answering to the fermentation and bismuth tests. In three of the cases it disappeared after stopping the morphia. The fourth patient is still under treatment.

Levenstein finds that acute poisoning by morphia, in men and animals, is always accompanied by sugar in the urine.

Strangury and retention of urine is occasionally the result of the long continued use of the drug.

The albuminuria of morphia-mania is sometimes accompanied by dropsy of the feet and limbs, less often of the abdomen and pleural sacs. When thus occurring the case is a grave one, and it will take time to decide whether there is not real organic disease of the kidneys, in which case the breaking of the habit may cause death by convulsions.

THE EYES.

It is a rare thing to find actual disease of the eyes that can be traced directly to the abuse of morphia. It is usual to find the retina somewhat congested. Blurring of sight and double vision are sometimes complained of. Muscæ volantes, or specks floating before the eyes, are sometimes seen. One patient of mine who had been near-sighted four years, during which time she had used the drug subcutaneously, claims to have regained full power of sight since the habit has been broken.

The pupils are, as a rule, contracted and regular, occasionally of normal size and irregular.

THE MUSCULAR SYSTEM.

Locomotion is rarely affected during the continuance of the habit, save from weakness. Twitching of isolated muscles, such as the orbicularis palpebrarum of one eye, is sometimes seen. When the doses of opium or morphine become very large, co-ordination is sometimes interfered with. Wasting of the muscles is found in advanced cases, as also is trembling of the hands.

RESPIRATION.

Respiration is rarely affected. In some cases there is shortness of breath on walking fast or going up a long flight of stairs. A low grade bronchitis sometimes exists, as also a short, hacking cough, that seems to come chiefly from irritation in the throat.

THE CIRCULATION.

Circulation is often affected but chiefly through the agency of the nervous system; witness the flushing of the face, and flashes of heat over the body, followed by a cold, exhausting sweat. There is often irregular and weakened action of the heart, and congestion of the brain. The albuminuria already spoken of is due, in all likelihood, to an affection of the vessels of the kidneys, through the nerves supplying them. The blood itself, owing to a general condition of malnutrition and imperfect digestion, is unquestionably deteriorated. In some cases the vessels rupture, giving us purpuric spots on the body and hemorrhage from the kidneys and bowels. Dropsy, which sometimes occurs, is due, in the majority of instances, to variable blood pressure, and a diseased condition of the walls of the vessels, permitting the easy transudition of the watery element of the blood. Headache, flushing of the face, flashes of heat and the like, from suppression of the menses, is seen during the early period of morphia addiction, but later nothing but the nervous symptoms attendant upon this condition are manifested.

THE MIND.

Early in the use of morphia the effects upon the mind are simply those of pleasant exhilaration, a feeling of perfect contentment, good will toward all, increased conversational power and stimulation of the imaginative faculties. Sleep is preceded by a period of luxurious drowsiness, fertile in pleasant retrospective and magnificent anticipation. There is total banishment of pain and care. It is, indeed, the ideal life of a dreamer, moulded and modified according to the temperament and intellectual tendencies of the individual.

As time advances, however, the duration of these periods is found to become shorter, and it is necessary, in order to obtain the same pleasant result, to increase the amount of the drug. It has, also, to be taken oftener. Sleep, when it comes, is less profound, the dreams not so pleasant. Should the patient pass the accustomed time for the drug, the loss is at once felt and the first symptoms of rebellion show themselves. A further and larger dose is taken, to quiet the rebellious demon that rules them, and again comes the pleasure, though not so satisfying as at first. The hours of freedom from the tyrant become shorter and shorter, sleep refuses to come, grave doubts fill the mind, the temper is no longer even and pleasant, but irritable and capricious, pains show themselves in various parts of the body, the nights are long hours of torment, conversation becomes a burden, suspicion shows itself, a desire to be alone is overpowering, better feelings are blunted, benevolence is replaced by selfishness, mental stimulation and exhilarance by torpor. Friends are neglected, the books that were once interesting are no longer so, amusements pall upon the taste, family ties, once so pleasant, are become burdensome, and life a dreary space, marked only by the hour at which the drug is to be taken. The days are filled with repentance, the hours garnished with resolves no sooner made than broken,

“O woeful impotence of weak resolve,”

the nights years of misery and anguish, teeming with horrors beyond the power of tongue or pen to paint. Here is the plaint of one, now freed from his bondage:[7] “The morphia victim dwells, after the first exhilaration is gone, in a realm of phantoms and shadows. I saw sights more terrible than can be imagined. I felt pains that do not belong to any mortal lesion. I have shrieked my terror, but the shriek only awoke a myriad of devils, who had been sleeping till then unseen by me. Four months of morphia addiction sufficed to bring me to this land of horrors, where no joy came or has come since the making of the world. My days were spent in self-indulgences. Alone in my office, in an easy chair, I could, with poetry and interesting therapeutical works, manage quite comfortably to pass the hours away. But let a patient summon me away from home, and my gloom and despondency was almost insupportable. I was tormented by continual self-conflict. Conscious of the weakness of my efforts to emancipate myself, I kept on planning some new mode of attack, in the nerveless hope that I could defeat the Lethean devil whose thews were strong as steel, and yet I knew, as day followed day, and week followed week, in so far as all this mental warfare was concerned, it could bring me no help in my awful bondage.

“No dark imagery can paint the encompassing horrors of those nights of torment that belonged to the last two months of my twelve months’ morphia addiction. Not one hour that I passed in bed between midnight and noon did I know normal sleep. In dreams that seemed more vivid than reality, I entered gloomy caves, and walked for hours over rotten cadavers, sometimes forced to step on them and be overwhelmed with loathsome odors. I saw faces in the weird darkness, sometimes a thousand at once, and each was made of blood-red flame; they flashed and went out. My nightmared brain was chased and haunted by everything that can exist in a vast hell of phantoms.”

Apropos, the following from Moore’s “Veiled Prophet of Khorassan”:—

“Dreadful it was to see the ghastly stare,

The stony look of horror and despair,

Which some of these expiring victims cast

Upon that mocking Fiend, whose veil, now raised,

Showed them, as in death’s agony they gazed,

Not the long-promised light, the brow whose beaming

Was to come forth, all conquering, all redeeming,

But features horribler than Hell e’er traced

On its own brood; no Demon of the Waste,

No church-yard Ghole, caught lingering in the light

Of the blessed sun, e’er blasted human sight

With lineaments so foul, so fierce as those

The Impostor now, in grinning mockery, shows:

‘There, ye wise Saints, behold your Light, your Star,

Ye would be dupes and victims, and ye are.

Is it enough? Or must I, while a thrill

Lives in your sapient bosoms, cheat you still?’”

Thus it is, pursued to the very grave-edge, these victims loathe the drug they once loved. Business is gone, family broken, friends lost, moral sense blunted or destroyed, mind incapable of healthy action, body wrecked, and they see no hope here or hereafter.

They will lie and steal, do almost anything to obtain the drug with which and without which they are finally in a veritable hell. The face becomes sallow and soggy, the eyes bleared and expressionless, and the final result is either death or insanity. Some persons go on using these drugs for years before the symptoms here described supervene; some are thus affected in a few months.

Having reached this stage they cannot arouse themselves from their terrible infatuation. Gloomy and hopeless, the world and the people in it no longer interest them. A patient whom I saw some years ago, a young Spaniard, was suffering from insanity from the use of morphine. Hour by hour he would sit folding, refolding and cutting paper into small bits with an old lancet. He would speak to no one, notice no one. This went on for months. He was sent to an insane asylum finally, and on searching his trunk some two score morphine bottles, as well as the greater part of the trunk, was filled with these minute scraps of paper. I have never been able to learn what became of him.

A lady patient of mine, well advanced in years, would save scraps of tin, old bits of rags, glass stoppers of bottles, and the like, setting great store by them. She laughed heartily at her collection, and threw them away one week after her emancipation.

Sometimes there is a mawkish sentimentality exhibited toward the opposite sex; sometimes there is mock modesty or direct abhorrence.

In the majority of instances these people are great liars, especially about matters concerning their habituation; often also about trivial things, where falsification is absurd and absolutely without excuse.

Occasionally there is a loss of connection between ideas in talking, incoherence and silliness. The speech is, as a rule, slow and somewhat drawling, and often interrupted to wet the lips, which become dry and parched. Severe pain in the head and about the region of the heart is sometimes complained of, also in the “small of the back.”

In some cases, more especially those of an intensely nervous organization, the prolonged abuse of opium or morphine produces a condition characterized by cerebral excitement, analogous to that of delirium potatorum. These people are, however, less violent, and the affection usually passes away in a short time, without treatment.

THE NERVOUS SYSTEM.

On the nervous system the effects of opium and morphine are most manifest. Taken at first to relieve pain and disorders of this system, having their chief action upon it at all times, their continued use reacts with deadly intensity. Twitching of isolated muscles, trembling of the hands and of the tongue, when protruded, and occasionally paralysis of one eyelid, are seen. The pains that supervene have no distinctive character, as do those that come from the abuse of chloral.

Itching of the whole or parts of the body is sometimes very troublesome. Herpes zoster (shingles), an eruption following the distribution of the nerve filaments upon the trunk, occasionally occurs, as also does urticaria (nettle rash). The very disorder for which the drug was first taken, is, in some instances, aggravated or perpetuated. This was first noticed by Dr. T. Clifford Allbutt[8], of England, and I have seen the same in some instances.

In the condition of delirium sometimes occurring, the pupils, usually contracted, are occasionally irregular and dilated.

The whole nervous system is unstrung, or more properly, too highly strung, so that it vibrates to little things that in health would pass unnoticed. They jump at the falling of a book or the shutting of a door.

Hysterical women still continue to have their customary attacks, sometimes in an aggravated form.

The following interesting case history has been kindly sent me by Dr. Judson B. Andrews:—

A woman,[9] thirty years of age, single, seamstress, with no hereditary tendency to insanity; was of a highly nervous and excitable organization, emotional and irregular in feeling; at times buoyant and lively, and then gloomy and depressed. Her health during early life was delicate, though she suffered from no definite form of disease. At the age of twenty, in April, 1862, she was seized with pain in the head. It was of short duration, but very severe, and during its continuance the patient was delirious. Attacks of the same character, both in the severity of the pain and the mental disturbance, have occurred since, at intervals of from one to three months.[10] In 1864 she had acute rheumatism, and in 1865 a severe attack of diphtheria.

After the local disease of the throat had apparently subsided vomiting supervened, and was repeated every few hours for some five weeks. To relieve this condition and procure sleep, hypodermic injections of morphia were successfully employed for about one week, and the patient rapidly regained her health. Some two years after this, or in July, 1867, she had an attack of inflammation of the bowels and peritoneum, and for four weeks was delirious most of the time. She improved somewhat in health, but for the four months succeeding had frequent attacks of frenzy, during which she often threatened to take her own and her mother’s life, and became very difficult to 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 considerable 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 always study out some plan to get the morphia. She has used as much as two drachms in a week, in one or two well-authenticated 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 complained 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 ago, in 1867, she was obliged to call in help, as the patient threatened and intended to take her own life. That both before and after she began the use of morphia, her conduct was peculiar and erratic; that she was emotional and easily disturbed 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 destructive of clothing, pulled her hair out, was noisy, incoherent 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, 1871. She was carried to the ward and placed in bed. Examination 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 continuance 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 nourishment. Chloral, in thirty-grain doses, was then administered, 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 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 mental strength, and became quite stout. At time of next menstrual period the right breast swelled to an extraordinary 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 success, 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. Menstruation 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 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 shoulders. The largest number extracted in any one day was twelve.

On one occasion ether was administered, but the difficulty 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. Afterward, 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 hyperæsthesia of surface. The right arm was swelled, hot 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 diarrhœa supervened and the evacuations of bowels and bladder were involuntary. She became unconscious, and finally comatose, and died on the 25th 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; abdomen, 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 epigastric, and one in the right iliac region, the point impinging 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 muscular 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 between the thumb and forefinger, and the points, forced through the skin, were seized and the needles extracted 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 patient 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 examined 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 administered, 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 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 abdominal 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 peritoneum, 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 ventricles were empty, and the choroid plexus contained numerous small cysts upon its surface, filled with serum.

Thorax.—The lower lobe of the right lung was hepatized. 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 subjected 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 sometimes 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 certain 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 intermittent 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 conditions showed any similar symptoms.

“We may distinguish a light and a severe type of intermittent fever, when brought on by a morbid craving for morphia. Both forms resemble real malarial fever, inasmuch 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 immediately 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 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 intermittent 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 sensation, 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 generally 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 morning and occurred again the next. It was followed by profuse 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, 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 habituè, 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 administered. 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 frequently caused the patient to become wet all over while in a cold room and quite quiet.

Before his admission into the Maison de Santé 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 examination of the internal organs shows no abnormal condition, excepting an enlarged spleen. Pupils of middle size, equal, reacting well. On December 10, 1875, the afternoon, patient received the last injection of morphia.

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. Patient 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 complains of giddiness, restlessness and palpitation of the heart. In the morning there is a chill followed by heat and profuse sweating. Vomiting, diarrhœa. 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, exhaustion and restlessness compel him to go to bed.

December 23. Has slept from 2 to 5 A.M. with interruptions. 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 then in the course of the day. At 11 P.M. 40 grains of chloral were given.

December 27. Restless sleep, much interrupted. Patient 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 restless 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 MORBID 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 consequence of severe pains from a gunshot wound in 1871. 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, diarrhœa 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 Santé,’ 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 stimulants, 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, and at the time of his admission into the Institution the intermittent had again returned to the quotidian 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 enlargement of the spleen.

The morphia was at once withheld.

December 21. Patient had a restless night, feels exhausted and knocked up; yawns, complains 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 extremities, 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.

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 hyperæsthesia 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 morphia 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 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.

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 erysipelatous 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 habituè. 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 over, was scarred, contracted and discolored, as though she had been badly burned and then pricked all over with India ink.

Dujardin Beaumetz (quoted by Bartholow[11]) relates a case where these injuries resulted in death.

These abscesses are due, in the majority of instances, to (a) carelessness in injecting, (b) unclean needles or syringe, (c) 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 habituè who had a clear solution 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, injecting 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 troublesome complication. Such a case is related by Dr. Roberts Bartholow, as follows: “One of the most inveterate subjects 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.”

RESULT OF SUBCUTANEOUS INJECTION ([see p. 71]).

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 convinced of the practicability of making a solution of the sulphate of morphia, of the strength of Magendie’s, without 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 satisfaction 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:—

“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 of green glass.”