MORPHINISM IN MEDICAL MEN. Read before the American Medical Association, San Francisco, 6th June, 1894. BY J. B. MATTISON, M.D., MEDICAL DIRECTOR, BROOKLYN HOME FOR HABITUES. REPRINT FROM T Journal American Medical Association. MORPHINISM IN MEDICAL MEN. Read in the Section on Practice of Medicine, at the Forty-fifth Annual Meeting of the American Medical Association, held at San Fruncisco, June 5-8,1891. BY J. B. MATTISON, M.D., MEDICAL DIRECTOR, BROOKLYN HOME FOR HAIUTUES. It is a fact—striking, though sad—that more cases of mor- phinism are met with among medical men than in all other pro- fessions combined. It is, too, true that a yen'large proportion of cases in general is found in our own fraternity. In a paper, “ Opium Addiction Among Medical Men,” pre- sented in the Medical Record, eleven years ago—9th June, 1883 —reference was made to the dismissal within a week of a half dozen doctors recovered from this disease, and attention called to the surprising frequency with which it occurs in this particular class. Another decade of professional work exclusively given to the betterment of such patients, has brought no decrease in this number ; indeed, the reverse has quite steadily obtained, so that in a paper, “ The Ethics of Opium Habitues,” Medical and Surgical Reporter, 8th September, 1888, in a resume of 300 cases, we noted 118 doctors, and of 125 most recently under my care, 62 were medical men ; and the latest reference to my record shows a still larger proportion, being more than 70 per cent. Again and again I have been asked with surprise, “ Why do doctors so often fall victims to morphia, when they, more than all others, should know the risk attending its use?” Various factors make up the answer to this query. Insurance statistics prove that medical men attain a shorter average lease of life than those of other professions, and the causes that tend to this lessened longevity play a part in the rise of morphinism. It is also true that the wear and tear of their calling provoke a 1 2 large share of painful non-fatal disorders. Neuralgia, in one or other of its protean forms—especially migraine—which leads the list in the genesis of this toxic neurosis, occurs among phy- sicians with a frequency that may well excite surprise. Add to this the anxious hours, the weary days and wakeful nights which the experience of every busy doctor so often involves, and which, though acting indirectly, still swell the sum of causative conditions in this chronic toxemia, and little wonder that we have a soil specially rich for a sorrowful harvest if, unhappily, the seed be sown. It has been asserted that medical men become morphinists through their calling involving frequent handling of morphia, but that statement in my opinion is not true. Erlendieyer shares in this disbelief. Druggists, whose vocation largely exposes them to the same risk—more so, in the city, than the doctor— do not often become morphinists. A cause peculiar to the medical man, in some cases, is that careless curiosity which prompts him—generally a junior—to note the effect of morphine upon himself, and in so doing incur the risk of addiction. Obersteiner refers to such cases. A young physician asserted that while on hospital duty a patient was dismissed who had suffered from carcinoma of the stomach and been treated with morphia injections. Next day he returned, begging for more, as otherwise he must die. This was in 1869, when chronic morphinism and its results were less known than now. As the doctor was inclined to think the patient was ro- mancing, he tried the experiment upon himself to ascertain the effect, became a morphinist and never recovered. Another case was that of a young physician who, being assistant in a physio logical laboratory, thought himself an interesting subject for ex periment. More than one doctor whose disease had a like origin has been under my care. Another cause -obtains with physicians to the same extent as in non-medical men, and that is the all-too-frequent use of morphia which the modern practice of medicine involves. Of this there is no question. Indeed, it holds more largely with the doctor than with the layman, for the former—fully aware of the opiate’s power to ease pain, pressed by his duties to get relief with the least possible output of time, and declining to make himself an example of the precept tendered his patient, as 3 to the value of patience under suffering, that will permit the use of non-opiate remedies, or, if the morphia be demanded, which, at least, will secure its giving at infrequent intervals, or alter- nating with other anodynes, and so lessen the risk of addiction— lacks a certain inhibitory, so to speak, protection which serves as a shield to the non-professional patient. Still another genetic factor, and, in my opinion, the one which outranks all others relative to the frequency of this dis- ease in medical men, is their ignorance or unbelief as to the subtle, seductive, snareful power of morphia. It is to me quite beyond belief that any doctor fully realizing how swiftly and how surely the trebly pernicious power of this drug takes one captive, will deliberately give himself up to a servitude galling alike to body and mind, and which, in most cases, ends only with life. Such a suicidal course is opposed to reason, to com- mon sense and to fact. In expressing this disbelief you will quite likely infer my skepticism as to the common opinion regarding the ethical status of our confreres whose ill-starred fortune has brought them such wretched result. I have long held, and still hold, with steadily growing belief based on nearly twenty-five years’ study of this disease, and an acquaintance intimate more or less with the history of many hundred cases, that medical men do not become morphinists from an innate propensity to evil, from a merely vicious desire to indulge in the pleasures of the poppy—pleasures which, be it never forgotten, soon and surely give place to its pains—but rather that they are impelled thereto by force of physical conditions that, with the largely prevailing failure to realize the risk incident to incautious morphia using, are, practically, beyond control. This phase of the subject need not detain us, for it has been noted with detail in two papers, “The Ethics of Opium Habitues,” Brooklyn Medical Journal, August, 1888, and Medical and Surgical Reporter, September, 1888. In reviewing the various causes of morphinism in medical men, the most hopeful feature is the fact that they are largely preventable. In this lies the strongest incentive to presenting this paper, the largest promise that it may do good. Regarding the cause first cited—the wear and tear of an over-active professional life—he must be specially sanguine who 4 would expect to improve conditions along this line to an extent likely to largely lessen such untoward result; though it can not be denied that the cares of a medical calling are less exacting than a decade or two ago, and so figure less as a genetic factor in this disease; yet I am bound to confess the outlook much more encouraging should careful and concerted effort be made to make less active the other causes to which we have referred. Regarding the misdirected zeal of the hapless seeker after self evidence of the effects of morphia, we can only again warn him—and earnestly—that the experiment is fraught with danger, and the rash act may prove his ruin, for the spark thus applied may set aflame that which will only be extinguished with life. He is a fool who does it; and the truly wise man will curb his spirit of inquisitive research along this line, if only on the score of personal well being; besides, no such self-sacrifice is called for, inasmuch as the peculiar effects of morphia, both as to bless- ing and bane, are now quite patent to all. No one who has given the subject special thought will be likely to question an assertion that the use of morphine in the medical practice of to-day, is in excess of what an actual need demands. And in direct proportion, more or less, to this excess stands the increase of morphinism. As a factor, applying to cast s in general, it outranks all others, though as regards medical men, it holds, in my opinion, second place. Custom and convenience share in its causation. Custom, because experience has brought a belief in the anodyne-soporific power of morphia, which, while well founded, has not been attended by an equally well-grounded belief in its possible power for ill. Convenience, because its promptly pronounced effect favors it as first choice when speedy relief is desired, and especially where, as too often happens with the younger men in the profession, the wish to score such a brilliant result as may prove a stepping stone to rapid profes- sional advancement outweighs a due regard for untoward remote effect, from which appreciation a frequent giving of morphia— or any opiate—should never, it is well to say, be exempt. This is a truism, the force of which should never be forgotten. Leading all others as a genetic factor in morphinism in medical men, is their failure to realize the insidious power of morphia to speedily get a grip, disturbing and destructive alike to functional well-being of brain and brawn, and, in almost 5 every instance, one too great to be broken by any self-effort they can command. At this writing I am consulted by a young physician whose case emphasizes this point. Sixteen months ago death left him wifeless and childless. In a specially un- happy moment of his grief he took a dose of morphia. It acted kindly, brought transient relief from his mental pain. A week went by before the second dose was taken, and then—the old story : Quite mistaken as to the poppy power and his own strength to resist—again and again, till his capture was quite complete. Commenting on his case, he assured me he knew the risk attending morphia taking, and never should have incurred it had he fully realized how direful the result of that risk to him would be. It is quite beyond credence that a doctor, gifted with sound sense, would wittingly put his neck in such a noose. Granting this, the only reason for taking such a perilous hazard, is, as before asserted, an inadequate appreciation of the morphia’s power to enthrall. Touching this point, enlarged experience confirms an asser- tion made ten years ago, that “the subtly ensnaring power of morphia is simply incredible to one who has not had personal observation or experience.” One of the finest specimens of physical manhood we ever knew, a physician who survived the horrors of Salisbur}' prison when the death rate averaged 80 per cent., fell a victim after only one month’s hypodermic using. Since then, case after case has been under my care in which the initial stage was still shorter. The most notable was an athlete of superb physique, who withstood the rigor of an Arctic winter as surgeon to a polar expedition, and then went down before a three weeks’ daily quarter grain dose of morphia to ease the pain of an injured ankle! So much for the genesis of this disorder. What the rem- edy? It is easy to moralize on the weak will—as many, mis- takenly, are wont to put it—of our hapless brother living under this blight, but talk about “ weak will ” as a reason why strong men succumb to morphia—and I make bold to say that the man does not live who, under certain conditions, can bear up against it—is twaddle. Far better is it to face the fact that morphinism finds most often its favorite victims in the noblest profession known, and then, recognizing the causes that make this fact, 6 bestir ourselves to such precept and practice as will tend to re- move this blot on the scutcheon. Can this be done ? Yery largely, yes. In this hopeful belief lies the one redeeming feature of the prevalence of this toxic neu- rosis in our own guild. Morphinism is on the wane, in my opin- ion, and I am optimistic enough to think the day not far distant when it will be largely a thing of the past. But to reach this happy result it becomes the bounden duty of every physician to inculcate, by teaching and by example, the paramount im- portance of the causes we have cited that tend to the rise of this disease. Two points call for special comment. These are the over use of morphia and the under thought of its danger. Regard- ing the latter, let me warn, with all the weight I can command, every doctor who may be dallying with this drug or who may think its self-taking called for—and this warning holds with special force if the subdermic method be practiced—let me warn him that he is inviting disaster by jeopardizing interests vital to his well being, and let me urge him to pause, and to ponder well, whether, despite this warning, he dare take such risk. Let him not be blinded by an under estimate of the poppy’s power to ensnare. Let him not be deluded by an over-confidence in his own strength to resist; for along this line history has re- peated itself with sorrowful frequency, and—as my experience will well attest—on these two treacherous rocks hundreds of promising lives have gone awreck. I have no wish to pose as an alarmist, but I tell you, gentle- men, that many a doctor who gives himself a daily hypodermic dose of morphia for a fortnight will come perilously close to the danger line—beyond which, bondage begins. Let him not chance it; rather, let him, if the opiate demand be imperative, consign its giving to other hands; let it be by mouth ; and oftener, let it be codeine, which, as an anodyne and sporific, has not yet had the measure of merit it deserves, and which, as tending to tolerance, is vastly less riskful than mor- phine. In a paper before the American Medical Association two years ago, “ The Prevention of Morphinism ” (reprint at command, and by the reading of which I would have every one of you the gainer) attention was called to the value of codeine. Enlarged experience has confirmed the opinion then expressed, 7 and while I am glad to note the demand for it is steadily in- creasing, I earnestly urge its still larger use as one of the most promising factors to favor a decline of the morphine disease. Regarding the over-use of morphia, never was there so little excuse for it as now, for never were the means at command to ease pain and bring sleep, equal those of to-day. Modern medicine is richly equipped in this regard, and if these resources be fully availed of, it will go far in a decrease of this ill. As tending to this, teachers in medical schools should realize that they have opportunity to wield great influence for good, and by word and deed they should improve it. To do so would strike right at the root of this evil, for I truly think the junior members of the profession are the greatest sinners in this regard ; and if, by timely counsel from their preceptors and college in- structors, the thousands who year after year begin a medical career can be brought to believe the danger incident to an in- cautious or needless giving of morphia, and then shape their practice in keeping with that belief, the good work will be largely done. Slowly, yet surely, the therapeutic trend is in this direction. More and more, the older medical men, impelled by larger wisdom, or an experience often unhappy, are quitting the syringe ; more and more rarely are they using morphia. The influence of this example must make itself felt on the younger men, and when to this is added the teaching we have commended, the dawn of a better day will not be distant. May that good time coming soon come. Prospect Place, near Prospect Park.