THE PRPHINE HftBIT, 
Its Causation, Treatment and the 
Possibility of Its Cure. 
JOHN W. ROBERTSON, A. B., M. D. 
Professor of Nervous and Mental Diseases in 
University of California, Medical 
Department. 
BY 
READ BEFORE THE MEDICAL SOCIETY OF THE STATE 
OF CALIFORNIA, APRIL, 1897. 
W A. WOODWARD & CO , PRINTERS, SAN FRANCISCO, THE MORPHINE HABIT, ITS CAUSATION, 
TREATMENT, AND THE POSSI- 
BILITY OF ITS CURE. 
SUPPLEMENTAI, REPORT TO THE COMMITTEE ON DISEASES OF THE MIND 
AND NERVOUS SYSTEM. 
J. W. ROBERTSON, M. D., Livermore. 
\Read before the Medical Society of the State of California, April, 189?.] 
The undue use of morphine, either to relieve pain or for the 
purpose of re-establishing normal tone to the nervous system, 
has become so common, and its abuse is so closely connected 
with the same predisposing causes that underlie all neuroses, 
that an inquiry into its symptomatology and treatment seems 
pertinent. Even of more interest is the study of its causation, 
and the establishment of the fact that, in the great majority of 
cases, it is as much a result of the nervous heredity as is neur- 
asthenia, insanity, epilepsy or dipsomania. By this is meant 
that morphinomania belongs to the group of functional neuroses 
which has as a basis the nervous diathesis; and that when a 
person possessing this constitution, even for a few times ex- 
periences the pleasing exhilaration that opium brings, he not 
only becomes addicted to the drug, but to such an extent its 
slave, that he will sacrifice all in life that should restrain and 
stand between him and his appetite; and will barter honor, 
truth, and all social considerations for the relief of the craving 
so soon established. As a rule the tnorphinomaniac receives but 
little sympathy, and, while the world readily excuses those 
patients who become addicted to the habit because of pain, it 
harshly judges the equally unfortunate who have, as an excuse, 
hereditary compulsion. 
Opium, either in its crude state or refined, together with its 
alkaloid morphine, is of all drugs the one most frequently se- 
lected for the purposes of intoxication. Taken either as an 
extract or alkaloid, smoked, eaten, or injected, its evil influ- 
ences over both body and mind is soon established. 
Opium smoking, so prevalent in China, is to some extent 2 
The Morphine Habit. 
practiced in California, for every Chinatown in the State is a 
focus from which the infection spreads. As a rule, however, 
it is only the vicious and criminal who resort to these dens, 
and even this class soon discard the filthy and nauseous sur- 
roundings for the more seductive and less expensive needle. 
Opiophagia, or the eating of opium, while chiefly practiced in 
the oriental countries, was, until recently, a most common vice 
in both Great Britain and the United States. Of all forms it is 
the easiest to conceal, and can be practiced for a certain time 
without detection, even by the immediate family. Its effects 
do not seem so disastrous as do the other forms, and some ob- 
servers claim increased powers of resistance and endurance 
from its moderate use. 
The invention of the hypodermic needle and the discovery of 
cocaine have added greatly to the dangers of morphine. It is 
possible either to smoke or eat opium for a lifetime, and still 
not absolutely unfit a man for social life, but the hypodermic 
use of morphine, connected as it usually is with cocaine, soon 
brings physical and mental disaster, and in a little while he 
becomes a burden either on his family or the public charities. 
While the invariable excuse for the use of morphine is that 
it was originally taken on a physician’s prescription, and for 
the relief of pain or some other illness that called for opium, 
yet, even after the cause is removed, the patient cannot re- 
linquish the drug. Many authorities assert the causative in- 
fluence of pain, and, while it certainly may act as an exciting 
cause, yet, behind all this is the question of heredity and the 
presence of a nervous diathesis. A normal individual, when 
freed from physical suffering, is often enabled to throw aside 
the drug, but in the neurotic this is not the case, and when the 
real pain is relieved a thousand hysterical ones spring up and 
demand the continuance of the drug. 
The part that heredity plays in all functional diseases or 
states of the nervous system is not to be misunderstood. It is safe 
to assert that no idiopathic case of insanity, chorea, hysteria, 
megrim, dipsomania, or moral insanity can occur, except by 
reason of inherited predisposition; and the same family type 
may assume any of these psychoses; but which particular one 
will develop we cannot predict. It is not contended that mor- 
phinism is a physical disease, such as epilepsy, for instance; The Morphine Habit. 
but it is asserted that it has its origin in the same stalk, and 
while one develops naturally the other is most easily grafted. 
Take for instance a neurotic family: Its founders may be two 
individuals, neither of whom possesses a markedly nervous 
temperament, but both have similar nervous tendencies, and 
their conjoined effect is such that their children are typical 
neurotics. Or, suppose the mother to be tubercular and the 
father an alcoholic, we have a resulting family, each individual 
member of which in time develops a neurosis. One child may 
be an idiot, and all the rest unduly precocious. Probably some 
of these children die early of tubercular complications, for pre- 
cocity is but another name for scrofula. In youth, one may 
develop epilepsy, another chorea, a third megrim, while of 
those who escape the neuroses of development, many later 
break down when tried in the crucible of human endeavor and 
competition, and fall by the wayside, either as hysterics or 
neurasthenics, or possibly they manifest the more active types 
of insanity. Very many of us escape all pitfalls and go through 
life possibly eminently successful, the nervous temperament 
even adding to our peculiar fitness for specialized work. It is 
from those possessing this highly developed nervous system 
that the genius and man of strong character spriugs, as well as 
the crank, and that other and more confirmed class, the mono- 
maniac and moral idiot. Why one fails when others succeed, 
is often due to some blot on the brain, some mental defect that 
clogs the machinery and unfits the sufferer from association 
with his fellow beings, simply because of some slight but inex- 
cusable moral weakness. 
“ He rode a horse with wings that would have flown, 
But that his heavy rider kept him down.” 
To the alienist these all equally bear the marks of the 
neurotic stigmata. Too great concentration of energies and 
disposition in any one direction may result in an abnormal 
mentality, yet it is to those possessing this nervous force and 
energy that we owe much of the world’s progress. It has been 
well said that it is the crank that turns the world. It is not 
claimed that the possession of this temperament leads neces- 
sarily to the use of morphine, but it is certain that it strongly 
inclines to the easy assumption of the habit; and that, when 
morphine’s charms are once experienced, it is far more difficult The Morphine Habit. 
to cure them, for they possess a hundred morbid ideas, desires 
and neurotic longings that the normal man cannot realize, and 
which only alcohol or opium will satisfy. They take it, not 
because of pleasant dreams or toxic oblivion, but simply 
for the purpose of controlling or ballasting their unstable nerv- 
ous organization; neither asking forbidden pleasures nor undue 
exhilaration, only demanding that rest and peace which is the 
heritage of the normal man. 
The symptoms characterizing the morphine habit all refer to 
an unstable nervous state, either of the body or mind. The 
bodily symptoms are emaciation, weakness, ataxia, and paresis 
of the sphincters, which Levinstein and other writers have in- 
cluded under the name of morphinism in contradistinction to 
morphinomania, under which term they include loss of will- 
power, moral degradation, imbecility, and other mental perver- 
sions. For the first few months its use apparently gives men- 
tal strength and bodily vigor. The victim is exhilarated, 
moves with alacrity, and life is full of zest hitherto unknown. 
Neurotic longings and physical infirmities are forgotten, and 
for the first time, possibly, the patient experiences the sensa- 
tion of being normal. He is certain of his own mastery, and 
the honeymoon following the first knowledge of the drug is 
bliss unspeakable; not that visions such as De Quincy has fam- 
iliarized us with are of usual occurrence, or that delusions and 
hallucinations are generally present. These may come with 
overdoses of the drug, but, at least in the early stages, are 
temporary. The patient, probably beginning with one-quarter 
grain used occasionally, soon adopts it as a daily habit, and 
rapidly increases it to four or five grains. Later, finding that 
excessive doses are necessary to produce the old-time effect, he 
becomes alarmed and attempts to stop the drug. He reduces 
the morphine and possibly resorts to alcohol as a stimulant, 
but the fight is a losing one, and while he may temporarily re- 
duce the amount, he cannot throw aside the habit. Finally, 
thoroughly frightened, he seeks relief; probably takes some 
advertised cure and stoutly asserts his freedom, yet secretly in- 
dulges to a greater and greater extent, and, despairing of any 
relief that morphine can bring, gradually adds cocaine. When 
this stage is reached all hope of unaided recovery goes. The 
patient grows more infirm, more debased physically and mor- 7 he Morphine Habit. 
5 
ally, until he becomes a pariah amongst his fellow men. The 
desire to reform is a real one, and they are willing to sacrifice 
everything they hold dear in life — except morphine — could 
they only recover. 
When fully under the power of morphine and the first pleas- 
urable sensations have disappeared, the bowels become consti- 
pated, relieved by occasional diarrhoea; the appetite diminishes 
and the body emaciates. Frequently there is paresis of the 
sphincters, both rectal and vesical, and the heart becomes irri- 
table with a frequent and compressible pulse. Venereal de- 
sire, at first increased by the drug, gradually lessen until men- 
tal masturbation takes the place of virile power. The skin is 
sallow, the eyes sunken, the face emaciated and expressionless, 
giving the well-known morphine facies which, with an ataxic 
gait constitute the main symptoms of morphinism. The mor- 
phinomaniac symptoms are equally well-marked. Its early 
effects are an increase of the mental power and ability to carry 
out life’s routine, but as soon as the habit becomes firmly estab- 
lished, and the patient after a few half-hearted attempts at 
abstinence, finds his only course one of concealment with drug 
increase, he loses all interest in his work and his former pleas- 
ures, and concentrates his whole energy on supplying himself 
with the opiate. He neglects business, no longer cares for 
social life, consorts with those similarly afflicted, and sinks 
into hopeless physical and mental decadence. 
The effect of morphine upon the mind, whether for the relief 
of pain or because of natural inclination, is destructive; and no 
one can become its victim without lowering of moral tone and 
loss of will-power. They may theorize as well as ever, but let 
a few hours elapse without their accustomed stimulant, and 
their unquiet nerves and uncontrollable longings cause them 
to jeopardize their souls for the drug, and there is no com- 
mandment in the decalogue they would not break to gain men- 
tal ease. No matter how honorable, upright and conscien- 
tious a man’s past life may have been, let him become thor- 
oughly addicted to morphine and I would not believe any 
statement that he might make, either with reference to the use 
of the drug or on any subject that concerned his habit. This 
extends further and clouds his moral perceptions in all rela- 
tions of life. Authorities even go further than this and claim 6 
The Morphine Habit. 
imbecility with organic brain changes. While I cannot claim 
to speak authoritatively, my experience has been large, and 
my observations do not confirm this statement. I do not 
deny occasional mental deficiency, yet while at Napa and 
later when temporarily in charge of the Home of Inebriates, 
many morphine cases were committed as insane, yet not a single 
one exhibited either delusion or hallucination, and all were 
voluntarily committed for the purpose of cure. They showed 
no mental change on the day of their discharge, and they were 
all discharged “cured,” differing from their condition on ad- 
mission, yet in the broader sense of the term, they were all in- 
sane, morally insane. They could not tell the truth; they 
were boasters, perhaps not so much in the belief that they 
would never relapse, as in detailing the amount of drug taken. 
They ridiculed any possibility of relapse, yet many left these 
institutions and hardly let the day elapse before they were back 
in their old haunts. 
Briefly summarized, morphine does not produce active in- 
sanity. Unlike alcohol, which when long and excessively 
continued, produces chronic pathological changes, morphine 
simply destroys the bloom of the mind, obtunds moral sensi- 
bility, and only when excessively used produces temporary 
mental aberration. 
The treatment of these cases is a most difficult matter, and 
my main reason for dwelling on the nervous and mental state 
is to show the difficulty of properly caring for these patients, 
while they are allowed the slightest liberty of person or free- 
dom of judgment. There is certainly no royal road to cure, no 
Soteria or other patent medicine that will in a night charm 
away desire. The only chance is in the slow and permanent up- 
building of the body, and the protection of the patient against 
himself till his will-power can reassert its old mastery. 
To stop the drug is the first but not the most difficult step in 
treatment. Whether the drug be withdrawn abruptly or grad- 
ually is a matter of indifference. Our books warn us against 
the sudden withdrawal because of probable heart failure. My 
experience does not bear this out. Certainly fifty cases, many 
of them in extremis, were admitted to Napa, and it is fair to 
presume that when so radical a step was taken their cases were 
considered desperate. In every instance they presented the The Morphine Habit. 
7 
same general appearance: an emaciated body, a haggard face, 
—pale, drawn and expressionless; eyes lusterless and gait un- 
steady. They belonged to the dregs of society, and nearly all 
were graduates of the opium-joints in Chinatown. We could 
never determine on what just grounds they were committed, as 
none presented any mental symptoms only moral degra- 
dation. The invariable practice was to shut them in a small 
room after bathing and supplying fresh clothing. This was 
necessary because they always came with their own clothing 
lined with morphine powders. Within twenty-four hours they 
were in a state of frenzy, begging and pleading for relief. Soon 
they became bed-fast, vomited, and occasionally purged a vis- 
cid green bile peculiar to this disease. Nothing, either medic- 
inally or dietetically, was done for their relief. The breakfast 
consisted of mush with syrup and fat bacon, and their other 
meals were equally unappetizing. From the sixth to the 
eighth day they rallied sufficiently to walk around the ward, 
and in two weeks were usually able to go out and relish their 
food. Within a month their appetite was voracious. The re- 
turn to physical health was rapid, and in from six weeks to 
two mouths the patient was strong, robust and apparently in 
full possession of both physical and mental health. They 
were loud, and possibly honest, in their assertions of reform, 
but in no single case, with one exception, do I know that the 
patient did abstain. While death may follow any mode of 
treatment, our experience demonstrated that sudden withdrawal 
was not dangerous, even though it seemed heartless. 
In private practice the gradual reduction of the opiate is the 
only procedure possible. The patient will not willingly endure 
the unnecessary suffering entailed by the sudden withdrawal. 
It is not a difficult matter to gradually reduce the drug from 
the daily five to ten grains to three-quarters of a grain within 
the first week, but it will probably take another week to re- 
duce to one-quarter of a grain, and another week still to alto- 
gether stop the drug. It is not well to let the patient know 
when the drug is withdrawn as the mental influence is strong, 
and the mind as well as the body demands treatment. Fortu- 
nately, we have remedies that greatly assist us in strengthening 
the nervous system that it can successfully stand the shock of 
withdrawal. Strychnia, hypodermically, and the red extract 8 
The Morphine Habit. 
of cinchona, internally, are excellent stimulants, and while 
they are not as beneficial as they are in alcoholism, yet they 
powerfully assist. In the lighter cases, especially where no 
cocaine has been used, the more serious evidences of shock, 
vomiting, rapid pulse and physical prostration may be slight; 
but where excessive and long-continued abuse has wrecked 
the system they will be pronounced, and will continue more or 
less during the withdrawal. In fact the rapidity of withdrawal 
is to be regulated by the severity of these symptoms. 
The strychnia solution should be i to 200, and of this 10 
minims can be used not less than twice, and possibly four or 
five times in the twenty-four hours. So specific is its action 
that the system may stand one-half grain without developing 
physiological symptoms, should the necessity be great. With 
this, equal parts of red cinchona and fl. ext. cocoa is prescribed, 
of which one drachm may be taken two to four times daily. 
But with all this stimulation the system is occasionally rebel- 
lious, and the nervous system so unstable that bromide of potash 
is added. The object in giving it is to overcome the nervous 
paroxysms, and when it is resorted to, it should be pushed to 
narcotism. In other words 90 to 120 grains are daily given, 
and while bromism continues the morphine may be fully and 
finally withdrawn. Even from the beginning of the treatment 
the morphine is never given alone, but in connection with 
strychnia, and the patient must be kept in ignorance of the 
amount of drug taken, and especially of its final discontinu- 
ance. These excessive doses of strychnia and cinchona are to 
be decreased as rapidly as possible, and by the end of the sec- 
ond week their administration can be reduced to two daily, 
during the third week to one, and discontinued in the second 
month; the strychnia to be again resorted to when symptoms 
demand it. The diet to be prescribed is, at least for the first 
two weeks, milk, to which as the appetite returns, scraped 
steak is added, and later a generous diet. By the end of six 
weeks the appetite is enormous and the body responds quickly. 
By the end of the second month the patient presents every evi- 
dence of health, and it is now that the difficult portion of the 
treatment begins. Before this a special nurse has been neces- 
sary and the patient has welcomed his companionship, but with 
returning strength he resents surveillance, insists that his moral The Morphine Habit. 
9 
strength equals his physical, and too often persuades his friends 
that he is perfectly cured; but such is not the case. Whether 
he stays under supervision or goes home the result is the same. 
By the end of the third month he becomes restless, irritable, 
and is the prey to all the old-time neurotic longings. He still 
asserts his freedom from desire, yet, unless carefully watched, 
will resort to coffee, alcohol, or other stronger stimulants. It 
may again be necessary to resort to strychnia and bromide, al- 
though not necessary to produce bromism. Until several such 
attacks have been successfully combated, the patient remains 
in danger of backsliding. At my sanitarium, six months is the 
shortest time I will receive such a case, and the limit may be 
prolonged to twelve months. A shorter time invariably results 
in relapses, discouragement, and a return to hopeless slavery. 
For this reason the great majority never recover; but where 
sufficient time has been successfully expended and the neurotic 
taint is not too strong, re-establishment of the will power may 
proceed to such an extent as to overcome the lessening nervous 
outbreaks. Where there is no hereditary taint and the disease 
for which the morphine was originally prescribed can be cured, 
the prognosis is as hopeful as in cases of non-hereditary alco- 
holism; but the treatment, even in milder cases, must be of at 
least six months duration. To discharge a patient at the end 
of the second month because his physical system is restored, is 
a waste of time and effort, and can only succeed in very excep- 
tional cases. When the disease has affected the mind to such 
an extent that organic weakness is present, no treatment can 
benefit. Time and protection of the patient against temptation 
till he is restored mentally, as well as physically, is the only 
rational method of treatment.