A REMARKABLE CASE OF Morphine Tolerance BA AN INFANT. BY \ / V JAMES L. LITTLE, M.D., Professor of Surgery in the Medical Department of the University ot Ver- mont ; Lecturer on Operative Surgery and Surgical Dressing, College of Physicians and Surgeons, New York ; Surgeon to St. Luke’s and St. Vincent’s Hospitals, New York, etc., etc. Reprinted from the American Journal op Obstetrics and Diseases of Women and Children, Vol. XI., No. II., Apiil, 1878. NEW YORK: WILLIAM WOOD & CO., 27 GREAT JONES STREET. 1878. A REMARKABLE CASE OF Morphine Tolerance BY AN INFANT. BY JAMES L. LITTLE, M.D., Professor of Surgery in the Medical Department of the University ot Ver- mont ; Lecturer on Operative Surgery and Surgical Dressing, College of Physicians and Surgeons, New York : Surgeon to St. Luke’s and St. Vincent’s Hospitals, New York, etc., etc. Reprinted from the American Journal of Obstetrics and Diseases of Women and Children, Vol. XI., No. II., April, 1878. NEW YORK: WILLIAM WOOD & CO., 27 GREAT JONES STREET. 1878. A REMARKABLE CASE OF MORPHINE TOLERANCE BY AN INFANT. BY JA.MES L. LITTLE, M.D., Professor of Surgery in the Medical Department of the University of Vermont; Lecturer on Operative Surgery ana Surgical Dressing, College of Physicians and Surgeons, New York; Surgeon to St. Luke’s and St, Vincent’s Hospitals, N. Y., etc. On September 15th, 1877, I was called to see a child in con- sultation with Dr. Jas. O’Reilly, of No. 303 West 42d Street. The history of the case is as follows : The boy was born on January 27th, 1877. About three weeks after birth, he had an attack of inflammation of the right knee-joint, followed by an abscess, involving the joint and causing intense suffering. The mother of the child commenced giving paregoric in small doses, gradually increasing the dose as the pain required it, until a teaspoonful was taken at a time. This not being enough to alleviate the suffering, Dr. O’Reilly advised the mother to give tinct. opii in drop doses. This was done, the doses being carefully and gradually increased until it became necessary to give two teaspoonfuls at a time, and this dose sev- eral times repeated during the day to relieve the severe pain from which the child was suffering. The knee at this time was in a very bad condition, having five or six openings communicat- ing with the joint, and the entire surface being inflamed and ten- der. The leg was drawn up so that the heel touched the buttocks. During the latter part of March, 1877, the use of Magendie’s solution of morphia was begun, the first doses being one drop each, repeated several times during the day until the child had taken four or five drops. This was gradually increased, and so 4 Little : A Ilemarkahle Case of soon did the child obtain a tolerance of the drag that, in a couple of months, from half a drachm to a drachm a day was necessary to quiet it. During the latter part of August, the mother was taken sick with typhoid fever, and at that time the child was taking about half an ounce of the solution a week, in doses of -fifteen drops each. On September 14th, the mother being very sick, and the child screaming violently most of the time, an aunt, who was taking care of the child, gave it larger and larger doses of the Mag. solution, until about two drachms had been taken in a few hours, without any apparent effect. When the physician made his morning visit, he told the aunt to give the child enough of the solution to keep it quiet. At 8 p.m. lie returned, and to his surprise learned that half an ounce of Mag. sol. had been taken without any effect. Having some suspicion as to the reliability of the preparation, he called on a druggist on Ninth Avenue, and had prepared one ounce of Magendie’s solution, using 16 grains of Powers and Weight- man’s morphia. This solution was made in his presence, and sent to the patient. Calling at 8 o’clock the next morning, he learned that the entire ounce had been administered by the aunt to the child, during the night, together with half an ounce of the solution which had been in the house, and which had been obtained from Mr. Alsdorf, druggist, corner Eighth Avenue and 42d Street, thus making the amount con- sumed by the child, then less than eight months of age, two ounces ( | ij.) in twenty-four hours, of which one and a half ounces had been taken within twelve hours. From that time until the death of the mother, which took place a week after (September 21st), the child received one ounce of Mag. sol. daily. For nearly a month after the mother’s death, it was given an average of almost an ounce each day. Some days the child seemed to suffer more than usual, and then large and repeated doses were necessary to insure quiet. On other days, one or two teaspoonfuls were all that was necessary. When the effects of the drug wore oft', the child would scream and moan, and would not cease until the usual remedy was given. When I first saw the child, it was weak and puny, the right knee-joint was stiff and bent at an acute angle. Over the knee-joint could be seen the cicatrices of the live openings which had healed some time before. During the day, it had Morphine Tolerance by an Infant. 5 taken a dessert-spoonful of the solution and it was quiet, this being one of its better days. The family then promised to send for me when it had one of its “ bad ” attacks, so that I could see the morphia administered. Sept. 19th, I was sent for at 7 p.m., but unfortunately could not go. The messenger who called informed me that the child had taken one ounce of Magendie’s solution since morning, and that he was on his way to the druggist to procure another ounce. The next morning the aunt told me that the child had taken this ounce during the night; thus making for the second time the amount taken in twenty-four hours two ounces of Magendie’s solution, containing thirty-two grains of the sulphate of mor- phia. Being desirous of thoroughly testing the matter myself, on October 8th, I called on Caswell, Hazard & Co., and had pre- pared by my directions a quantity of Magendie’s solution of morphia. At 6 p.m. the same day, 1 called and found the child screaming violently. One drachm of this solution was admin- istered, the child swallowing it eagerly and smiling. A tea- spoonful of water was then offered which the babe instantly rejected. This, the aunt stated, was of common occurrence, it being almost impossible to get the child to swallow water, while it would take the solution of morphia with avidity. On October 13th, not having heard from the case, I called, and learned that during the night of October 8th, the patient had slept very well without repeating the dose. To-day the child is very restless, although three teaspoonfuls of the solution have been taken since one o’clock this morning. Dr. O’Reilly then administered in my presence one drachm of Caswell, Haz- ard & Co.’s solution. This was at 10.30 a.m. At 1 p.m. I called, and found that the child had fallen asleep about fifteen minutes before, and was still asleep. A.t 7 p.m. the aunt called and stated that the child had awakened at about 2 p.m., since which time it had been screaming continually. 1 sent Dr. Maynard to see the patient at 8.15 p.m., and he gave it another drachm of the same solution. The next day, I called and learned that the aunt had administered still another drachm of the solution during the night. Child was quiet this morning. Feeling satisfied that the child would tolerate these large 6 Little : Morphine Tolerance by an Infant. quantities of morphia, I advised the aunt to diminish the dose gradually, but as rapidly as possibly. February 14th, 1878.—Have seen the child several times since last note. The dose of the solution had been so diminished that by the middle of December the child was satisfied with one dose daily, a drachm at bed-time. Since the middle of December the daily dose has been diminished at the rate of about three drops a week. At the present time it takes but ten drops at bed-time. If this dose is not given, the little fellow is restless, cries, and does not sleep. Its appearance has very much improved, it having gained in flesh, and it seems to be as intelligent as most children are at that age. Its weight is eighteen pounds. It is also rapidly regaining the use of the knee-joint, although it is still unable to fully extend it. The patella is freely movable. Dr. O’Reilly states that, during the time the child was taking these large doses of morphine, he attempted to substitute the bromide of potassium, administering it in thirty-grain doses every three or four hours until half an ounce had been taken, without producing any perceptible effect; he therefore discontin- ued it. It may be well also to state that the child’s bowels were habitually costive. It vomited but little, and although it took a sufficient quantity of milk, it was thin and badly nour- ished, looking like a child suffering from marasmus. I would state, in concluding the report of this remarkable case, that there is not the slightest doubt that the statements as given above, in regard to the quantity of morphine taken, are entirely correct, there being no motive whatever for deception. The family have resided in the same part of the city about thirty years, have been patients of Dr. O’Reilly for fifteen years, and have been known to me ten years. The child’s name is Charles Short, and he is now living at No. 524 W. 42d Street. 60 West 40th Street.