TTOTES ON THE OPIUM HABIT BY ASA P. MEYLERT, M.D. MEMBER OF THE MEDICAL SOCIETY OF THE COUNTY OF NEW YORK ; MEMBER OF HARLEM MEDICAL ASSOCIATION, ETC. ; PHYSICIAN TO THE WOMEN'S CHRISTIAN HOME, NEW YORK G. P. PUTNAM'S SONS NEW YORK: 27 & 29 WEST 23D STREET LONDON : 25 HENRIETTA STREET, COVENT GARDEN 1884 NOTES ON THE OPIUM HABIT BY ASA P. MEYLERT, M.D. MEMBER OF THE MEDICAL SOCIETY OF THE COUNTY OF NEW YORK ; MEMBER OF HARLEM MEDICAL ASSOCIATION, ETC. J PHYSICIAN TO THE WOMEN'S CHRISTIAN HOME, NEW YORK G. P. PUTNAM'S SONS NEW YORK : 27 & 29 WEST 23D STREET LONDON : 25 HENRIETTA STREET, COVENT GARDEN 1884 copyright by ASA P. MEYLERT 1884 Press of G P. Putnam's Sons New York The following paper was read before the Harlem Medical Association, Feb. 28, 1884. The author has been urged to publish it in the hope that it might help to stimulate the profession at large to a careful study of this subject, and to more humane methods of treat- ment than have heretofore prevailed. NOTES ON THE OPIUM HABIT. AT a country village well known to me, there rides and thrives a cheery, hope- ful man, who studied medicine in his youth, but delayed the practice until his locks were whitened with the frosts of many winters. How often have I listened with amusement and wonder to his enthusiastic praise of his own prescriptions. After minutely describing his formula, care- fully prepared to fit some imaginary case, he would invariably end with great vivacity, saying : " That, my dear sir, will act like a charm !" Time has, doubtless, disenchanted my old friend, and facts have led him to distrust many of his therapeutic theories. Practical experience drives us to seek knowl- edge at the bedside. What, we ask, has act- ually been accomplished, under what conditions 5 6 NOTES ON THE OPIUM HABIT. of disease, and with what modifications of plan and purpose ? No intelligent, conscientious physician will say that he has in all respects followed out an origi- nal plan of action, without modification, in any important case. Rarely, if ever, even after long experience, can he, at the first consultation, lay down a course of treatment which proves to be the best course for that case from the beginning to the end. A thoughtful physician can seldom say at the last: " I could not possibly have done better." We do not trust the man who uses such lan- guage as this, since we all know that in every walk in life the man who does not constantly learn from his experience is an imbecile. I propose briefly to review my past treatment of the opium habit,-to take you into my con- fidence, and frankly state the modifications I would now make. No one can read the reports of cases in the medical literature of the opium habit, without feeling shocked at the terrible suffering of the patient in these cases, whether with or without treatment. NOTES ON THE OPIUM HABIT. 7 This is not infrequently excused on the ground that the habit is a great sin and de- serves punishment. I do not propose now to discuss the question of vice or sin in relation to this habit ; but were it a greater sin than is claimed, it would be well to pause and consider who gives us authority to punish the sinner. Even the Author of our religion came not for judgment ; and he never failed to relieve the sufferer. There is need of careful study to improve our methods of treatment. It is a shame and dis- grace to the medical profession, that misery such as this should be permitted in the name of science. It has been my earnest determination to seek what can be done to relieve these unfortunate people, as far as possible, of needless pain. In every case there are idiosyncrasies which must be considered, and which modify methods, but every case adds to the general stock of in- formation, and aids in developing a systematic mode of treatment. Permanent cures can never be performed by any single medicine or combination. Back of 8 NOTES ON THE OPIUM HABIT. the opium habit, there is some physical condi- tion which led up to it, however it may have originated. This requires careful consideration and judicious treatment, or the cure is but tem- porary. There are patients who have been repeat- edly " cured " by various enterprising dealers in antidotes, but in most cases the drug is resumed as the "antidote " is dropped. The opium habit is, almost invariably, charged by the habitue, upon some physician who pre- scribed an anodyne years before, to relieve pain. Thirty years ago a famous belle, much ad- mired, took morphine occasionally," to make her bright when she went to a party." In after-years she took the drug when her children were sick, because she " wanted cour- age,"-" wanted to be strong." As she had eight children it may be presumed that in the natural course of events, with so large a family, she became somewhat accustomed to the use of morphine. However, she declares that she did not then use it habitually. Fourteen years since, at the birth of her youngest child, she suffered greatly, and her at- NOTES ON THE OPIUM HABIT. 9 tending physician administered a potion which brought not only relief of pain, but entranced her senses with visions of rare beauty and de- light. "Doctor, what did you give me? " said she. " Chlorodyne, madame," replied the doctor. " That," said she to me, " was a dreadful mis- take ; the doctor ought never, never to have told me." From that time, until a few months since, her one purpose in life was to obtain chlorodyne, and her occupation, to dream away the hours which intervened between one draught and that which followed it. Eight years since, a bright young lady living in a country place had a severe attack of neu- ralgia. A physician, who was called, left a pre- scription which relieved her of pain and gave her a good night's rest. The following night she repeated the dose on her own account, and thus she continued to do, renewing the prescription as she had occasion. At length, her mother discovering that the little black vial was making frequent trips to the 10 NOTES ON THE OPIUM HABIT. drug store, requested a translation of the pre- scription. " It 's only laudanum, madam," said the apothecary. She then endeavored to have it discontinued, but it was too late, and for more than seven years this unfortunate girl was a most unhappy victim, becoming a nervous, hysterical, prema- turely old young lady, breaking her mother's heart and sending her sorrowing to her grave. The first prescription truly " acts like a charm " upon the distressed patient, whose ner- vous organization is impaired. He well re- members how it smoothed his pillow, changed the hard bed beneath him to softest down, closed his weary eyelids, and whispered dreams of contentment and peace. But the enchantress is now changed to a dragon which holds him under a magic spell. During the brief period of exhilaration, when in dreamy revery, with half-closed eye, he looks listlessly out upon the world, it seems easy to throw off the spell which binds him, and he pro- poses to do so,-but not just now, He is not quite ready. NOTES ON THE OPIUM HABIT. 11 At length the time comes when, spurred to a supreme effort by the pressure of circum- stance,-the taunt of friend or foe, or by the earnest pleading of wife or child,-he resolves to be free from bondage to a degrading appetite. To give strength for thought, reflection, and plan of action, an extra potion is taken. Under its influence he is brave and resolute. He now determines to reform, or die in the attempt. Soon, however, he becomes dispirited, de- pressed, anxious. If he persists and allows the time to pass without his daily dose, a feeling of great distress takes possession of him. He falls asleep, but frightful dreams quickly waken him, trembling and crying out in terror. The judg- ment has come, and the Evil One is reach- ing out his great brown hand to seize him! Time seems to stand still. He stares at the clock, saying : " Are there sixty minutes in an hour ? No, there are sixty hours in every minute." At one moment he is burning up,- then he shivers with cold. Perspiration streams from every pore. Neuralgic pains torture suc- cessively his head, limbs, joints, arms, chest, and back. Indeed, every nerve of the body seems 12 NOTES ON THE OPIUM HABIT. to cry out, and nerves are discovered where none were known to him before. A peculiar, indescribable sensation, more severe than actual pain, torments him from head to foot. Obsti- nate vomiting sets in, followed by persistent, exhaustive diarrhoea. Finally, in deep humiliation, in anguish and tears, he gives up the attempt and bows in sub- jection to his merciless master. There are few who voluntarily resist beyond the first feeling of distress, but I have been told of cases where the patient remained firm in an agony of suffering until friends interfered,- fearing a fatal result,-and administered the usual dose with instant relief. Various preparations of opium and morphine are used by habitues, the sulphate of morphia being the most common. It is taken in quan- tity from one to twenty grains daily. A former patient of mine, a physician, was said to take 180 grains of morphia daily. As this became monotonous he occasionally varied it by con- suming a pound of chloroform. The administration of the drug is usually by NOTES ON THE OPIUM HABIT. 13 the mouth. Some take it hypodermatically, and some per rectum. It is said, also, that the smoking of opium is rapidly increasing in this country. It is taken at night or in the early morning- or more frequently, perhaps, both at night and morning. Some, however, take it three, four, or more times in the twenty-four hours. One pa- tient used to take it every two or three hours, and supplement the dose with a whiskey toddy. The tendency is always to increase the quantity used. The same doses never produce the same results on successive days. There is, except during a brief period of exhilaration, an unsatis- fied longing for something ; sometimes a feeling of intense discomfort, which the habitue seeks to remove by resort again to the drug, and thus the interval is gradually lessened and the daily quantity increased. However much is taken, the habitue rarely has continuous sleep. He tosses and moans, sleeping and waking, a thou- sand times in a single night. A lady patient said to me: " My husband no sooner touches the pillow than he is sound asleep, while I suffer in spite of the morphine. 14 NOTES ON THE OPIUM HA PIT. It is written ' He giveth his beloved sleep.'- Ah ! how the good Lord must love my husband." When restrained, it is usually found that a moderate quantity will really satisfy the craving nearly as well as the larger doses previously taken. The opium habitue is always in danger of death from an overdose of the drug. The least postponement from any cause brings on a feeling of unrest, while longer delay is attend- ed with nervous and mental depression so great that he seizes upon the first opportunity to sat- isfy the intense, almost insane longing. It seems to him that the usual potion could not possibly suffice, and partly from this cause, partly from nervous excitement, and consequent inability to act with discretion, he takes an overdose, with fatal results. Doubtless many so-called suicides by morphia, reported in the daily papers, are of this character. Much has been written upon the effects of the continued use of morphia upon the organ- ism. These are manifestly most marked in their relation to the nervous system. All secretions are checked by the habitual NOTES ON THE OPIUM HABIT. 15 use of the drug. Every gland seems to be in an unnatural state of repose more or less com- plete. As a necessary result the appetite is impaired, food is not thoroughly digested, the bowels are constipated and the bodily functions are all retarded, perverted, or not performed. Unless the habitual use of opium is accom- panied with alcoholic excess, the patient usually becomes emaciated. Where spirit drinking accompanies the opium habit the patient is usually dropsical, the face appearing bloated and unnatural. Probably much of the pain and distress during the interval is due to deficient or per- verted glandular action-to poisons retained in the blood which should be excreted. This may also account for perverted cerebral activity. If the poison of gout or typhoid circulating in the system, affects the brain, is it surprising that effete animal products retained in the body of the opium habitue should cause the mind to wander. Delusions, illusions, and hallucinations are common. Both the intellect and the moral sense are perverted. A lady once told me frankly that I must not 16 NOTES ON THE OPIUM HABIT. believe every thing she said, " for they call me at home the biggest liar in all Rhode Island." Just as an insane man realizes that he is insane, so the opium habitue knows that he is untruthful, perhaps without the power always to think correctly or truthfully. The normal activities of the mind seem to be changed. When the patient is most free from delusions, their influence remains sufficiently to cause perversion of thought; Doubtless every one has realized, when sud- denly awakened, the absurdity of some dream, which a moment previously was very real to the mind. It seems to me that opium acts not only as a stimulant and toxic agent, exciting strange dreams and illusions of the senses, but also, like a mordant,-fixing them upon the memory and interweaving them with the wak- ing thoughts. Patients sometimes begin to tell some im- probable story, and in the very act of telling discover the delusion for themselves. Sometimes the judgment seems to fail along certain lines while correct in other directions. A lady patient once complained to me of her NOTES ON THE OPIUM HABIT. 17 nurse. Every night the nurse changed to a man, and frightened her exceedingly. I en- deavored to show her the absurdity of such a thought, but she was unconvinced. Said she : " If you could point out an error in judgment, I am quite sure I should perceive it, for I am conscious that my judgment does not deceive me. Thus I now see before me ships sailing in the air ; they are plainly visible, but my judg- ment corrects me, for I know that ships do not sail supported only by air." A night or two after, she came to my door, past midnight, holding the nurse by the arm, and in a glow of excitement and exulta- tion, said : " Now, Doctor, will you be con- vinced that I am right ? Here is the man." " Let me see, madam," said I, turning up the gas,-" but look, don't you see that this is Jennie ? Look again." " Ah, yes, he does look like Jennie, I grant you,-but then, you can't trust your senses." The hallucinations of the habitue are most marked when an overdose has been taken, or when he is altogether deprived of his drug. They assume a great variety of expression, 18 NOTES ON THE OPIUM HABIT. sometimes pleasing and sometimes the opposite. They not infrequently pass rapidly from one to the other variety. One patient assured me that her dreams were invariably delightful and pleasing when lying on the right side, whereas if she turned to the left she was beset by horri- ble visions. During the previous night she saw sixty lovely female forms sporting in a bath of great beauty. She was charmed with the sight. This continued while lying on the right side. As she turned to the left side the waters changed to a dark muddy pool, the female forms van- ished, and there appeared a poor, helpless, de- formed child appealing, with an agonized ex- pression, for relief from the serpents and lizards which were creeping over his body and nestling in his hair. If the drug be suddenly discontinued, without a suitable substitute, the patient re-enacts auto- matically in his delirium the scenes to which he is most accustomed. Thus one patient who had taken his narocotic in liquid form kept wander- ing about the room, always however ending his walk at a certain closet, where he would turn the key and take out an imaginary bottle. Ele- NOTES ON THE OPIUM HABIT. 19 vating his mouth he would raise the hand above it for a few seconds, as if holding the invisible bottle to his lips. Then resuming his ordinary position he smacked his lips with evident pleas- ure. Another patient who had used sulphate of morphia called often for water. Holding the goblet in one hand she picked up from the chair beside her bed some of the imaginary drug with her fingers, and shaking from them the in- visible powder into the glass, drank it up with a relish. There is no question in my mind that physi- ological processes, long accustomed to the influence of the opium stimulus, have not only come to tolerate the drug, but are for the time better performed under its influence, if within proper bounds, than when wholly free from it. This however, is not a per- manent condition. In most cases convalescence after discontinuance is speedy, and the health once restored is better than when under the dominion of drugs. In one case of long addiction the patient had a mild form of chronic mania. Her general 20 NOTES ON THE OPIUM HABIT. health was greatly improved after the cure of the habit, and her insanity was less marked. Yet, notwithstanding, she was never so sane as after a half grain of morphia had been ad- ministered. Physicians who are accustomed to prescribe narcotics daily, and who do not know perhaps of a single instance where harm has resulted, are apt to be somewhat incredulous when told of the prevalence of this habit. Statements on this subject are no doubt exaggerated,-still, when we consider the number of medical Ish- maelites throughout the country, living on their gains, gathered by the sale of " antidotes," to this class of people, who have usually spent their money before they seek a cure,-we must conclude that the evil is widespread. Since I have given special attention to this subject, persons have come to me, secretly addicted to the habit, whom I should not have suspected. Some conceal it, for considerable time, from their nearest friends. A gentleman called on me quite recently, to arrange for the treatment of his wife, for what she called, " a nervous complaint." She con- NOTES ON THE OPIUM HABIT. 21 fessed to me privately that the actual trouble was two bottles of morphine per week, and begged me not to let her husband know it. In all cases where unrestrained, the opium habitue takes a larger quantity than would suffice him. It can usually be diminished from one fourth to one third, without great incon- venience. From this point, however, every re- duction which is not accompanied by some treatment gives pain. The method of cure by gradual reduction alone, without using any substitute, I tried in one case, at the patient's request. I do not propose to repeat the experiment. I was reminded of the humane man who shortened his dog's tail by an inch at a time. In another case I tried to reduce gradually, using tonics to sustain the patient, not using narcotics, nor a substitute of any kind. The case was a lady living out of town, taking thirty grains of crude opium daily. I started her with five grains of morphia per day, in place of the opium, giving at the same time quinine, iron, and phosphates, and directing her to reduce the morphia as rapidly as she was able. 22 NOTES ON THE OPIUM HABIT. It was six weeks before I heard from her. She then reported that finding the initial dose too small, she had doubled it by taking the medicine twice a day. From that she reduced every day a little for nearly a month, when she abandoned the attempt at further reduction, con- tinuing, however, to take the same quantity,- three and three eighths grains,-which she had then reached. This was at the rate of but four per cent, daily diminution. Nothwithstanding the tonics, she assured me that she had suffered terribly, and had been unable to do any thing during the whole time. Recently she returned, and is now under treatment for a cure. Nothing seems more plausible than that a cure by gradual reduction could be easily ac- complished, if the reduction be not too rapid. The case just quoted was that of a woman whose general health was good, whose will power was unusually strong, who had not taken opium very long, and was not taking a very large quantity. It was a most favorable opportunity to try this method. The result proved that, notwithstanding the tonic treatment, she found a daily reduction of four per cent, intolerable. NOTES ON THE OPIUM HABIT. 23 We must therefore-if we adopt this method, -consider something less than four per cent, as adapted to the average patient. Suppose that the average consumption be es- timated at ten grains of morphia daily,-and this is a low estimate. Suppose, again, that the patient continues the drug to the one tenth grain daily before leaving it off altogether,-and this would be a minimum limit. To reduce from ten grains to one tenth grain, at three and one half per cent, daily, would re- quire 130 days, or nearly four and a half months; at three per cent, daily, would take i52 days, or five months; at two and a half per cent., 183 days, or six months ; at two per cent., 229 days, or eight months ; at one and a half per cent., 306 days, or over ten months ; at one percent., 459 days, or over fifteen months. Those who know how easily the opium patient is alarmed by any sudden shock, and how naturally relief is sought from the bottle for every ill or mischance in life, need no as- surance that a cure, which must necessarily ex- tend over so long a time, is utterly impracti- cable for the average patient, outside the walls of an institution. 24 NOTES ON THE OPIUM HABIT. There remains, therefore, practically, but one general course of treatment which seems to me worthy of consideration for breaking up the opium habit,-namely, that by substitution. Doubtless there are many recent cases who have become somewhat habituated, but in whom the habit has not become the chief object of daily care, who can be gradually cut down until the drug is dropped; but it is not so with the confirmed habitue. The treatment by substitution involves the gradual reduction of the drug, substituting how- ever some narcotic, sedative, or soporific, in its place. If there is any antidote, which will, by its administration, allow the total and instant cessation of morphia without pain, I do not know it. This is claimed by nostrum vendors, but I have seen no proof that even the best anti- dote is any thing but a poor attempt at reduc- tion and substitution. One of my present pa- tients was cured once by gradual reduction without substitution,-relapsing, she was after- ward twice " cured " by nostrums, but the habit was resumed when the " medicine " gave out on each occasion. NOTES ON THE OPIUM HABIT. 25 In discontinuing the opium the symptoms which give most trouble are : ist.-An intense nervous irritability with pro- found mental depression. Not only is the pa- tient sleepless, but his wakefulness is immeas- urably magnified. Looking into a microscope, and observing ob- jects extended along the line of vision, which are too small for detection by the naked eye, we form new conceptions of space. Could we construct a microscope for observing infinitesimal portions of time, we could better understand the feelings of our opium patients. Our conception of time is unconsciously in- fluenced by the number of distinct impressions conveyed to the sensorium. Any thing which excites attention to a multitude of separate mat- ters of detail lengthens the idea of time, whereas, that which gives occupation to the mind along single, even lines, shortens our con- ception of time. The impressions, constantly repeated, made by organic poisons circulating in the blood, and coming in contact with millions of sensi- tive nerves, which normally are bathed in 26 NOTES ON THE OPIUM HABIT. healthy blood plasma, produces this condition of hyperaesthesia, and causes an impression of time almost infinitely prolonged. The patient is so intensely conscious of distinct and dis- agreeable nervous impulses, repeated with al- most infinite frequency, that time seems an eternity. 2dly.-There is neuralgia, an intense local- ized pain, shifting from point to point, due prob- ably to the same causes as the hyperaesthesia before described. So great is the distress from these causes that, unless relieved, the patient will almost invariably destroy his own life if he can do so. How idle, therefore, to think of the habitue denying himself the drug when he can get it ; -how inhuman also to lock him up without seeking to relieve such an agony of suffering. 3rdly.-There is profuse perspiration, with coldness of the surface, and chills, alternating occasionally with burning heat. 4thly.-Nausea and vomiting soon follow, and continue probably from twelve to thirty-six hours unless relieved. 5thly.-Diarrhoea, persistent and exhausting, comes early, and remains several days unless NOTES ON THE OPIUM HABIT. 27 checked. Without aid, delirium soon follows the terrible suffering first described. Thus when man denies relief, the dear Lord sends oblivion. The perspiration and diarrhoea-due doubt- less to the sudden relaxation-are yet valuable, if kept within suitable limits, since they serve to eliminate much of the poison from the system. Probably there is no single remedial agent which meets all the indications presented by these symptoms so well as the hot bath. It removes poisonous matters from the circulation, bathes the terminal nerve loops in a bland, in- different fluid, and warms the body chilled by profuse perspiration. It may be frequently re- peated with advantage, and nourishment may be given in the bath. After careful drying of the surface, the patient, wrapped in soft, warm flannels, will usually have a refreshing sleep. Small quantities of beef peptonoids, acidu- lated with a weak solution of phosphoric acid, usually check vomiting and are gratefully re- tained. The diarrhoea, if excessive, yields generally to hot-water enemata. 28 NOTES ON THE OPIUM HABIT. Electricity helps to allay nervous irritability, but is more valuable in the subsequent stage of treatment. Central galvanization and general faradization I have employed with advantage. The question now comes fairly and squarely, What can we do with drugs ? Can we relieve these symptoms? Can we prevent them alto- gether? That we can relieve them is unques- tionable, and the time may be near, when in many cases they can be altogether prevented. The desideratum is a substitute which will take the place of the narcotic, which will not harm the patient, and which can itself be dis- continued at will. The search for such a sub- stitute is doubtless like seeking the philoso- pher's stone. As in other conditions, no single prescription can be adapted to all cases. There are sometimes conditions of disease present which totally prohibit the use of medicines which otherwise would be of great value. However, we must make progress in the treatment of these cases. The evil is spread- ing rapidly. It must not be, that the cure of this habit shall continue to be a terror little short of death itself. NOTES ON THE OPIUM HABIT. 29 My own experience in the use of drugs does not coincide altogether with that of others who have written upon this subject, and whose opinions I respect. Every workman can best use his own tools. We, as physicians, find fre- quently that we do not succeed so well with another's prescription as with our own ; nor so well with his as he does, in cases seemingly alike. The bromides are generally reccommended and are probably more used by the profession at large, in these cases of opium habituation than any other drug. I had used them with good results in general practice, and was quite prepared to like them, but I have been greatly disappointed in them. There may be cases where they will accomplish more than any other treatment, and I do not advise that they be thrown overboard. The best method of administration, where they are used, is, I believe, that advised by Dr. J. B. Mattison, of Brooklyn,-namely, to give them twice in the twenty-four hours at about twelve-hour intervals, in doses gradually in- creasing. To avoid danger I would begin with 30 NOTES ON THE OPIUM HABIT. a small dose,-say fifteen grains of bromide of sodium, and increase it gradually until bromism is induced. Nux vomica should be simultane- ously administered, as Dr. Mattison advises. The morphia can be gradually reduced as the bromides are increased, until at about the ninth or tenth day when bromism is present, it may be discontinued altogether. I have never used bromides in any case, but that it was better for their use than no treat- ment would have been. They are far better than nothing ; they promote sleep, relieve pain, and tide the patient over the worst period,- namely, that immediately after the drug is dropped. Yet they have, with me, invariably weakened the patient, increased the delusions, prolonged the convalescence, and left the battle to be fought out at the last with other things. Hydrobromic acid is, I think, less objection- able than the bromides. Coca is highly recommended. I have given it in several cases without result. In mild, or recent cases, it may be very useful. Strychnia I have found exceedingly useful where there was much nervous depression. I have given it hypodermatically in doses of one- NOTES ON THE OPIUM HABIT. 31 sixtieth to one-twentieth grain, and in some cases have given it in combination with other remedies. Hydrocyanic acid is highly praised by some. I have never given it alone, but have used it in combinations to allay gastric irritation and for its sedative influence. Chloroform I have used, in combination, for its sedative effect. Cannabis indica has proved useful in moder- ate doses,-quieting the nervous system and promoting sleep. Hyoscyamia, in moderate doses, is a most efficient sedative and soporific. In small doses there is no effect that I have discovered, while in large doses there is profound stupor. The dose of one grain, noted in Ringer, is probably a mistake. I have rarely used more than one-tenth, and never more than one-sixth grain doses. Quinine is a good stand-by in many , cases. Two or three grains, with one grain ext. can- nabis indica, forms an excellent combination to relieve neuralgic pains and general hyperaes- thesia. Capsicum, ginger etc., are useful adjuvants 32 NOTES ON THE OPIUM HABIT. Finding it necessary to prescribe an anodyne without morphia, for cases cured of the habit, in neuralgia and intestinal colic, etc., I prepared a combination of chloroform, ether, cannabis indica etc., as follows, with more or less hyoscya- mia, which has likewise succeeded in quieting the pain to a considerable extent after leaving off the drug. Formula for anodyne without morphia. 9 Chloroform, .1000 Spt. aether, sulph., .025 Tinct. cannabis ind., .175 Acid hydrocyan, dil., .030 HyoscyamiaK q. s. 01. menth. pip., .003 Tinct. capsici, .003 Alcohol, .350 Glycerine, .314 M.-Dose 10-60 TT[ in syrup-repeated every half hour if necessary. This preparation is obviously contra-indicated in cases of heart disease, etc. Alcoholic stimulants have been much admin- istered to help break up the opium habit. Whether these ever succeed I do not know. I have had two cases where this treatment had previously been unsuccessfully tried,-the result being to fix both the alcoholic and opium habits upon the patient. I have been accuS' NOTES ON THE OPIUM HABIT. 33 tomed to treat the alcoholic habit first where the two co-exist. The treatment must however be modified according to the case. Frequently there is some chronic disease which must like- wise have attention and which must always be kept in mind. An old injury which has long been forgotten may now demand recognition. One of my patients suffered greatly from acute synovitis and swelling of the left knee which came on as the opium was abandoned, and which she attrib- uted to a severe injury received many years previously. In all cases that 1 have seen, tonic treatment is required after the habit is broken. Iron, quinine, cod-liver oil, columbo, gentian, etc., are now in order, and may be followed by pepsin, pancreatin, etc., as the appetite improves. At the same time special attention must be given to the disease or disorder which led to the formation of the habit, as well as to complica- tions which have since arisen. It seems to me important also to discontinue drug medication altogether, as soon as it may properly be done, before the patient is finally 34 NOTES ON THE OPIUM HABIT. discharged. The habit of taking medicine for every ail sometimes prevents permanent suc- cess. It is sometimes asked: "Are there not cases which are better left alone?" I have never seen such a case. If such exist, the habitue himself is the last person to adjust the quantity to be taken. There are, doubtless, cases of cancer, phthisis, etc., where narcotics must be used continuously. I should advise that in all such cases the phy- sician should keep the administration as far as possible in his own hands. By changing from one preparation to another, and from one nar- cotic to another, relief will follow more surely than by the continuous use of any single medi- cine. Then, at the proper time, if there is evidence of habituation, the physician may apply suitable treatment for discontinuance, and the patient thus be relieved without knowing that a habit had been formed. Those who have observed the effect of opium, only as administered to relieve pain and promote sleep in ordinary cases, are quite ready to en- NOTES ON THE OPIUM HABIT. 35 dorse the favorite name of the fathers : " Mag- num Bonum Dei " ; but those who have seen the shipwreck it has wrought upon the moral nature of those habituated, will say, that if ever there was a Devil's drug, it is this. Probably in a majority of cases the habit begins without the fault of the habitue. He is innocent of any wrong purpose in relation to it. He finds himself a captive, unable to escape from his prison-house. He tries again and again, ineffectually. If ever a poor soul needed help, he does, and that quickly. At length he passively yields to what he calls his fate. A little longer and he comes to enjoy it. He continues to denounce others for placing him there, but makes no further effort to escape. He becomes intensely selfish and supremely self-conscious. He lives in an imaginary world of his own creation. He is its central figure. Nothing grows on its soil but the poisoned fungus. Every one suffers from contact with him. Those who refuse to minister to his depraved appetite, be they father, mother, wife, or child, are bitterly, passionately denounced and 36 NOTES ON THE OPIUM HABIT. cursed. Thus he goes on from bad to worse, -and then cometh the end. It should be understood that opium habitua- tion means death,-mental, moral, and physical. Every one who cannot instantly drop it, is drifting toward destruction. He does not see it perhaps. Like the Rhine boatman gazing at the vision of beauty upon the cliff above him, he is swiftly dashed upon the rocks below. He should be roused to action before it is too late. If he yet retains one spark of natural affection he is worth saving ; and if after weary days and sleepless nights spent in caring for him, he should seek to show gratitude by some sub- stantial acknowledgment,-then gentlemen re- joice exceedingly,-not that your reward has come, for it will not come in this life, but be- cause the opium demon has surely departed. Dr. A. P. MEYLERT No. 14 East 34TH St. OFFICE HOURS IO TO 12.30 A.M. NEW YORK