Morphinism and narcomanias from other drugs; their etiology, treatment, and medicolegal relations

Preface

Historically, opium mania is a very old disorder. Morphinomania is the modem form of the same disease, and the various drug narcomanias which are associated with it are the new psychopathic forms due largely to modern civilization. There can be no question that these diseases are increasing, as they are certainly becoming more prominent in every section of the country. Although morphinism has been discussed by the profession for many years, the literature is still limited and unsatisfactory. A few volumes written by foreign authors, two of which have been translated into English, and three small works, some pamphlets by English and American writers, together with papers in medical journals and brief notices in some of the late text -books, comprise all that has been written on the subject. The subjectmatter of many of these writings consists mainly of minute studies of different methods of treatment, with some theories and descriptions of the symptomatology and causes. In most of these works the impression is given that morphinism is a mere accidental and incidental neurosis which may be largely influenced by restrictive legislation against narcotic drugs. Every year the increasing prominence of this psychosis calls for more exact studies, with a

6 Preface

fuller recognition of the conditions and causes of the disease. While the general facts of disease have been recognized, they have not been studied to any great extent or from a broad scientific point of view.

Medical colleges have not yet introduced this study into their curriculums, and the dangers from narcotic drugs and other narcomanias are practically unknown to the recent graduate.

Medicolegally, questions of responsibility have been asked with increasing frequency, and there is no literature and no study of the subject to afford an intelligent answer. The special object of this work is to group the general facts and outline some of the causes and symptoms common to most cases, and to suggest general methods of treatment and prevention, and in this way try to bring the subject out from its present empirical stage to higher and more scientific levels, and to encourage further and more exhaustive studies.

This work is intended to give a general preliminary survey of this new field of psychopathy, and to point out the possibilities from a larger and more accurate knowledge, and so indicate degrees of curability which are at present unknown.

The great practical questions which appeal to the medical profession for answers may be stated as follows :

What are the causes and conditions which develop morphinism and lead to other narcomanias, and how can they be recognized, averted, and prevented ?

What means and methods are essential for the

Preface 7

cure in the early stages, and how can they be successfully treated in the later and chronic conditions? What can be done with the growing armies of drug neurotics? How can we care for them and treat them practically? --

These are a few of the problems for the solution of which this work is offered as an aid and guide.

T. D. Crothers.

NOTE OF ACKNOWLEDGMENT

This work is the practical summary of the clinical experience of over a quarter of a century of active treatment and care of narcomaniacs. During this period a great variety of facts and notes have been gathered from papers and books the authors of which are dead or forgotten, making it almost impossible to trace them back to their source. Hence we can only indicate the general sources of obligation, and this is done as a tribute of respect for the pioneer work of journals and authors. All writers must acknowledge the great value of the numerous papers and clinical notes on morphinism and other narcomanias which have appeared in the pages of the "Journal of Inebriety" since its first publication in 1876. Also to the "Alienist and Neurologist" and its distinguished editor. Dr. C. H. Hughes, and his personal writing on this subject. The papers of the late Drs. Kerr of London and Parrish of this country, also of Drs. Mattison, Lett, Waugh, Mason, Mann, Clevenger, Wood, Kellogg, Brown, and many others, have given very helpful and suggestive studies of the subject. The works of Erlenmeyer, Ball, Levenstein, and others have been found very practical and suggestive. The literature written for popular readers often contains many clear psychologic descriptions of these neulo Note of Acknowledgment

roses, yet in reality is untrustworthy. Vivid descriptions of opium and morphin manias have often profoundly influenced sensitive persons, and, all unconsciously, they have imitated the examples read. Medical writers with an imaginative turn have followed the same lines in their descriptions of narcomanias. This literature has no scientific value, and is of only psychologic interest.

Chapter I Page

Early History of Opium. Its Use as a Sedative and Narcotic. Some Theories of Its Value. The First Book on This Subject, Later Papers and Theories. Use Externally through the Skin. Early Use of the Syringe. First Use of Morphin. Recognition of the Danger of Morphin by the Needle. Early Writers and Their Views. First Classification. Its Prevalence in Europe and This Country. Chemical Properties of Morphin. Classes of Persons Using It. Use among Physicians, Difficulties in Determining the Extent of Morphinism. Cheapening of the Drug Increased Its Use. Danger from Teaching Laymen Its Use, Morphinism Due to Modem Civilization and the Strains of Constant Excitement, Neurasthenia and Cerebrasthenia as Active Causes, The Needle Fascination and Mania, Examples of Persons of This Class. Use of the Needle Increasing. Other Drugs Used with Morphin by the Needle. Morphin Peddlers. Injuries from the Needle,

CHAPTER II Some Distinctions, Classifications, and Stages- 42

The Term "Morphinism" Described, Morphin: How Taken. Who Are Morphinists? Who are Morphinomaniacs? The Two Classes and Their Relations. Thought to be a Moral Disorder by Many Persons, Fascinating Effects at First. Nervous Invalids Most Easily Affected. Morphin Hunger. What Constitutes Morphinism? Egotism and Cunning in Explaining the Use of the Drug. First Symptoms, First Pathologic Effects. Predispositions, Hereditary and Acquired. Impairment of the Higher Brain. Three Stages of Morphinism: First, When Morphin is Used for Some Specific Effect; Second, Morphin Used for Its Mental and Physical Effect; Third, Where Morphin Cannot be Abandoned without Discomfort. Examples of These Three Stages. Another Class Who Begin and Suddenly Stop the Use of Morphin without Any Apparent Cause. Examples.

II m

1 2 Contents

Chapter III Page

Study of the Causes Reveals Only Physical Forces. Border-land Neuroses. Uniform Causation. Progress and Development. Only a Few of the Causes and Laws Which Govern Them are Known. First Group are the Neuroses from Inheritance. Diathesis Coming from Alcoholic, Syphilitic, Tuberculotic, and Hysterical Ancestors. Varieties and Conditions. One Class Use Morphin for Exhaustion; Another, for the Pain from Injury and Disease. Children Show These Defects. Morphinism a Psychosis Both Inherited and Acquired. Mental Defects and Characteristics. Atavism, Precocity, and Mental Instability Prominent. Other Causes are Starvation, Intoxication, Brain-strains, and Nervous Drains. Morphin Unpleasant at First. Morphinism from Injury. Examples. Autointoxications Often Causes. Surgical Operations. Injuries to the Cord. Etherization Predisposes to Use of Morphin. Danger from Morphin in Gynecologic Practice. Shock and Excitement Causes. Association with Alcohol.

CHAPTER IV Symptomatology; Peculiarities; Prognosis and Termination 96

First Symptoms. Psychologic Action. Stimulation and Irritation. Unconsciousness of Its Effects. Efforts to Conceal Its Use. Delusions and Illusions. Long-continued Concealed Use. Appearance of the Eyes. Emotional Disturbances. Stolidity and Nervousness. Appetite and Nutrition. Bowels. Mental Symptoms. Changes of Character, Habits, and Mental Activity. Heart Changes. Mental Instability and Feebleness. Delusions of Infidelity Characteristic. Never a Leader, but Always a Critic. Progress Uniform in Many Cases. Unexpected Death Common. The Higher Brain Suffers Most. Changes of Symptoms. Associated Drugs. Insanity Symptoms. Disability to Use Other Drugs to Conceal Their Real Condition. Morbid Fears and Manias.

Chapter V

The Eye. The Voice. The Manner. The Skin. The Appetite. Some Means of Diagnosis. Changes in Appearance. Egotism. The Prognosis. Conditions Which Determine This. Sudden Changes. Relapses. Other Drug- taking. Detection in the Urine. Washing Out the Stomach. Examples.

Contents 13

CHAPTER VI PAGE Treatment; Asylum Conditions; Drugs; Hygienic

Measures 150

Control of Patient. Removal from Home. Private Asylums. Seeking New Remedies and New Methods of Treatment. Exaltation and Delusion. Restraint and Freedom. Different Methods of WithdraM^al. How They Are to be Applied. Some Remedies to be Used. The Needle and the Use of Opium as a Remedy. Narcotics in the Treatment. Insomnia; Its Treatment. Water and Its Application. Different Plans of Treatment. The Author's Plan; Its Details. After the Treatment, Psychic Element to be Noted. Placebos. Time of Treatment. Delusive Symptoms. Theories of the Withdrawal Symptoms. Treatment at Home. Cannot do Business During the Treatment. Examples.

CHAPTER VII Opium-taking; Its Prevalence; Diagnosis 197

Use of Opium. Differs a Little from Morphin. General Symptoms. Different Opinions of the Danger of Opium-taking. De Quincey's Delusions a Slow Degeneration Following Its Use. The Psychic Symptoms Less Prominent. Pathologic Symptoms. Effects on Animals. Opium-smoking; Its Fascination. Number of Persons Suffering from Opium-smoking. Prognosis. General Treatment. DeHrium from This Source. Delirium from Morphinism,

CHAPTER VIII Medicolegal Relations of Crime and Responsibility . 223

Faulty Mind and Senses. Some Examples. Loss of Consciousness. Moral Palsy. Untruthfulness. Paralysis of the Will. The Questions of Responsibility. Why Morphinists are Irresponsible, Responsibility in the Disposition of Property. Responsibility in SwindUng and Fraud. Selfishness. Cannot be Trusted as a Witness. Examples. Need of Medicolegal Study, Some Strange Cases, Loss of Memory, Not Often Used for Criminal Purposes, Some Examples,-^

CHAPTER IX Medicolegal Relations of Crime and Responsibility — (Continued) 244

Clinical Histories. Failiu-e to Understand the Degree of ResponsibiUty. History of Inherited and Acquired Defects. Psychic Palsies, Crime Instincts Promi-

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nent. Double Personality. Strange Delusions. Hallucinations and Morbid Impulses. Opium Not Often Used for Criminal Purposes.

CHAPTER X Cocainism: Its Etiology and Treatment 270

First Described as a Disease. Theories of the Value of Cocain. Cheapening the Cost of Production. Use by the Needle. Extent of Its Use. Where Sold. Two Classes Suffer from Its Use More Than Others. Early Causes of Cocain Habit in Previous Spirit and Drug Addiction. Different Reasons for the Use of Cocain. Two Forms of Cocainism. Some General Symptoms. Delusions of Strength and Vigor. Later Symptoms. Comparison with Morphinism. Pathology and Injurious Effects. Treatment and Legal Care Necessary.

Chapter XV Page

The Poison of Tobacco. Symptoms of Tobacco Intoxication. Often Associated with Alcohol and Other Drugs. Tobacco Narcotic Poisoning. Its Use in Any Form Followed by Debility and Exhaustion. Tobacco to be Abandoned in the Treatment of Drug Addictions. Often an Exciting Cause to Other Narcosis. Very Complex and Very Difficult of Treatment. The Cigarette Habit. Its Prevalence and Danger as Noted by Statistics. Analysis of the Cigarette. Poisons which It Contains. Its Immediate Effects. The Treatment of Cigarette Disease. Medicolegal Questions which Come from It.

Chapter I The History Of Morphinism

Early History of Opiunt. Its Use as a Sedative and Narcotic. Some Theories of Its Value. The First Book on This Subject. Later Papers and Theories. Use Externally through the Skin. Early Use of the Syringe. First Use of Morphin. Recognition of the Danger of Morphin by the Needle. Early Writers and Their Views. First Classification. Its Prevalence in Europe and This Country. Chemical Properties of Morphin. Classes of Persons Using It. Use among Physicians. Difficulties in Determining the Extent of Morphinism,. Cheapening of the Drug Increased Its Use. Danger from Teaching Laymen Its Use. Morphinism Due to Modern Civilization and the Strains of Constant Excitement. Neurasthenia and Cerebr asthenia as Active Causes. The Needle Fascination and Mania. Examples of Persons of This Class. Use of the Needle Increasing. Other Drugs Used with Morphin by the Needle. Morphin Peddlers. Injuries from the Needle.

The original home of the poppy appears to have been in the valley of the Nile. The first mention of its use was found in hieroglyphics dating back to a very early stage of Egyptian civilization. Homer describes, in the fourth book of the "Odyssey," a drug, which was evidently opium, sent to Helen from the wife of Thone, an Egyptian king.

2 17

Hippocrates was among the first authors who recommended its use internally. About his time it was condemned because of its effects on the vision and the great and unnatural somnolence which it produced.

In those early days one Ange, evidently a priest, used this drug, and its effects were so pleasing to him that he became very enthusiastic in proclaiming its value to the world.

There are many curious legends concerning the discovery of the effects of opium. One of these describes an Egyptian prince who was lost on a hunting tour and was carried exhausted to a hut and placed on a bed of poppy leaves, upon which he slept for two days ; he then awakened with unusual vigor. This story seems to have been credited, and to have formed the basis of many theories concerning the value of poppy leaves as a remedy direct from the hands of the Deity.

In a very early age there appears to have been much rivalry concerning the superiority of opium cultivated about Thebes, called Thebaic opium, and that grown in Persia near Ispahan, called Persian opium.* Several authorities described the differences in detail, saying that the Persian opium "produced crudities in the stomach" and was not soothing like the Thebaic opium. The difference in price * " Opium and Its Effects." Leigh.

at Constantinople is mentioned as evidence of the value of the Thebaic opium. In those early times many authors disputed as to whether opium came from the white or the colored poppy, or whether it was the meconium of the Egyptians.

It was probably used to produce sleep and to quiet the brain and nervous system. The priests believed that in some way it led the mind into the spiritual world, and that the sleep following its use was a bridge to connect the soul with the home of the gods. One of the Persian proverbs declared that opium taken internally was a remedy for many diseases, and that it also produced a disease.

Historically, the use of opium as a medicine began in the first centuries of the Christian era; and it appears to have been given for the removal of pain and discomfort. The discovery of the value of the juice and the extract was probably made by the Greeks.

The growth and use of the plant seemed to spread very rapidly eastward, probably by those ancient traders, the Arabs. In this way it passed into Persia, India, Java, and China, where it has had a firm foothold ever since. By the early medical men opium was called a stimulant, and its sedative effects were thought to be prophylactic and preventive. It was used as both a domestic and a special remedy.

The Arabian physicians seemed to have made the first studies of its value in diseases, using a decoction of the plant which was, no doubt, that of the bruised leaf and seed-pod, or an infusion made from the crushed stems. The soothing effect of this watery extract was more marked than that of any other drug. For a long time opium was used as a remedy with widely varying popularity, although always invested in myth « and conjecture. Its narcotic effects were explained by all sorts of theories, and the plant was studied with superstitious reverence. The literature is a curious medley of shrewd conjecture and fanciful theories concerning its effects and action on the brain and body, lacking in moderate scientific spirit.

The period of exact study begins with the last century ; and while the sociologic and moral effects of opium-taking have attracted much attention, the exact medical study has not advanced very far, and is still a neglected field. A century ago, in 1786, ''Opium and Its Effects" was the subject of a prize essay by Dr. John Leigh before the Harveian Society, England. This essay had a wide circulation at the time, and was the beginning of a new literature. It described opium and its value in a variety of diseases, giving experiments and details, proving its usefulness in many ways. This book was dedicated to George Washington, and many copies were sent to this country, some of which may yet be found in the libraries.

In many sections of Europe the poppy was cultivated, and used as a domestic remedy for pain and headaches and general diseases. According to some old books and papers, it was widely used, principally for its effects in suppressing dysentery and diarrhea. One of the earliest attempts to use opium was advocated in a little book published in 1809 by Dr. Ward, of Manchester, England. He claimed that opium (probably a solution evaporated to a paste) rubbed on the skin would be absorbed by the lymphatics, and thus allay irritation and pain and produce sleep more pleasantly than by any other method. This was no doubt the first reference to what eventually became the hypodermatic use of opium and its alkaloids.

In 1855, Dr. Wood, of Edinburgh, advised making an incision in the skin and injecting the drug into the tissue. Before that time, in 1838, Dr. Rolland, an English physician, praised the use of opium paste for local neuralgias; also for painful sores. Later a syringe was used by which a watery solution of opium was injected. From this time the syringe came into use for the purpose of introducing medicines under the skin, and was supposed to be a very great advance in the therapeutics of that day.

Anstie and others wrote at some length, praising this method for its economy and freedom from irritant effects. It was also claimed to be more rapid and permanent, and to interfere less with the functions of the body than any other method of administration. Therapeutic authorities in those days urged *that hypnotics or anodynes should never be administered by the mouth in acute diseases attended with anorexia.

The discovery of the chemical properties of opium makes an interesting page of medical history. The poppy plant and opium had attracted so much attention by its wide range of usefulness that the attention of chemists was early drawn to it. Dr. Luria,* in his recent essay on opium, says:

" From the dawn of the last century our best and most eminent physiologic chemists have devoted special care and attention to the study of this most marvelous plant. To the indefatigable researches of these pioneers in the field of physiologic chemistry the medical world owes a great deal of gratitude, as their investigations into the nature of the poppy plant carried them to the discovery of those vegetable alkaloids which have proved to be the active principles of the plants wherein they are found, and that since have had such a remarkable success in the treatment of disease. The honor and the

*" Morphine and Its Alkaloids," by Dr. Luria. "Merck's Archives," April and July, 1901.

credit of having been the pathfinder of this new era of investigation, belong to the apothecary Sertumer, at Einbeck, in the province of Hanover, Germany. The seed sown by Serturner fell -upon fruitful soil, and thus, in 1803, Derosne announced to the scientific world his discovery of a crystalline body that he obtained from opium, and which he called the 'salt of opium,' believing it to be the active principle of the drug. But such was not the case, as was later demonstrated by Robiquet. In 1804 Seguin isolated another crystalline body, which time and experience have proved to be the real narcotic principle of opium. But Seguin did not realize the importance of his discovery, only considering it as a m^ere scientific curiosity, which, however, attracted but little attention. Thus the matter remained qtiiescent until, in 181 7, Sertumer again proclaimed the existence of a saline compound in opium, endowed with a peculiar alkaline principle and united to a peculiar acid, thus clearly demonstrating the real nature of the substance discovered by Seguin and himself a little over a decade before. This salt, destined to play an important role in modern therapeutics, he called 'morphium.'"

A description of the other alkaloids and derivatives of opium will show the value of this plant: '' Besides morphin, which exists in opium with sulphuric and meconic acid, there is also to be found in it a certain amount of lactic acid; but this is held by many chemists to be only an accidental constituent originating during or subsequent to the process of the collection of the juice. In the course of time several other basic substances have been isolated from different varieties of opium, but their amount rarely exceeds i per cent. Among these is to be named the oldest alkaloid, the one that was discovered in 1803 by Derosne and named by Robiquet ' narcotin,' a name which it still retains. It exists in amounts varying from 2 to 4 per cent. Then narcein, codein, thebain, papaverin, meconin, cryptopin, meconidin, hydrocotarnin, laudanosin, protopin, laudanin; also a few other bodies of a feebly alkaline or neutral nature, as lanthopin, etc. Besides, there are several derivatives. The most important so far derived from morphin is called apomorphin. All the organic bases of opium produce a deviation of the plane of polarization to the left. Opium contains, besides, in no mean amounts, several resinoid bodies. Furthermore, it exhibits a variable amount of mucilage, a gum distinct from the ordinary gum-arabic. It also contains pectin, albumin, and a waxy material consisting chiefly of palmitate and creotate of cerotyl; also calcareous salts in amounts varying from 4 to 8 per cent. Not infrequently sugar is also found in opium, but the question yet awaits solution whether this is a natural constituent of the opium or whether it forms a part of the adulteration, of the drug. The amount of mucliage present influences the value of opium for smoking purposes a good deal, since the Chinese estimate its value roughly by the mere ' touch ' ; that is to say, they gage it by the rapidity or slowness with which a thread drawn out from the mass will break by its own weight. These are the principal chemical constituents of opium, of which morphin and codein are quite extensively used in medicine, while narcein has found favor with a few physicians. Narcotin itself is practically never used ; but a derivative of it, cotarnin, is very much used at present as a hemostatic. Its hydrochlorate is known as stypticin, and is employed extensively in menorrhagia, metrorrhagia, subinvolution, hemoptysis, etc. Its (stypticin's) dose is from | to 2 grains, and il; may be given in pill form, in solution, or hypodermically. "

Opium had been given subcutaneously in the form of pastes or injected as a watery solution under the skin for a long time. One of the earliest references to the use of morphin in this country was by Drs. Isaac Taylor and Washington, of New York. In 1839 in dispensary practice it was given with a syringe for various purposes. In 1843 Drs. Wood and Rynd made a solution of morphin to be used by the needle. Fordyce Barker, in 1856, brought over from Edinburgh a small syringe by which he used morphin under the skin. Tiemann began to make needles about this time, patterned after the one of Barker.

In 1864, the ''Lancet" published a number of articles pointing out the danger of the use of morphin as an addiction. This was probably the first warning note against its use.

In 1866 Pravaz introduced into the French army a compact little syringe by which morphin was injected under the skin, in the treatment of wounds in both field and hospital. This popularized its use, and from that timic the use of morphin by the S3n:inge has extended widely to all classes. Enthusiastic physicians used the needle for nearly all conditions of pain, and wrote praising this method of treatment. Several elaborate papers appeared giving minute accounts of the best methods of using morphin by the needle. Elaborate theories of the physiology of the drug administered in this way, and the technique of its administration, multiplied rapidly, and for a long time occupied much space in medical literature. Occasionally some one pointed out bad results from its use, but this attracted little attention. Finally a book on this subject, by Dr. Kane, sounded a strong note of warning in the conclusion that morphin should never be used hypodermically in chronic disease of the kidneys, and that it was dangerous in delirium tremens and mania; also that its use in anemia and diseases of the lungs was full of peril.

In 1864 Nausbaum appears to have been the first of the German physicians to call attention to the injurious effects of repeated injections of morphin. From this time the literature of this subject attracted attention. A few cases were reported of ill effects following the injection and its continuous use afterward, but these were considered anomalies, and explained as caused by the weak will of the patient.

In 1870 Dr. Allbutt published in ''The Practi-^ tioner" a strong paper pointing out the danger from repeated injections of morphin, and the difficulty of restraining the patient. He distinctly showed that while thi^ drug relieved the severe pain for which it might be given, it caused an artificial craving with marked symptoms of poisoning. This was probably the first outline of morphinism as an intoxication and disease. Later, Laher, Fielding, Hirschfeld, Michel, and others wrote confirming these statements, giving examples to sustain their views.

In 1877 and 1879 Lewenstein wrote a monograph on morphinism. His work contained the best account of this disease up to that time. Dr. Clark, in 1879, gave in the "Lancet" a good description of the withdrawal symptoms of morphinism, and Griffiths, in the ''Guy's Hospital Reports" of that year, confirmed and added to this a clinical history of cases.

From this time on a great many writers, both at home and abroad, have described these cases and some of the symptoms with more or less minuteness and accuracy. Drs. Parrish and Mattison, in this country, contributed excellent papers:* Parrish, on the philosophy and causation of opium addiction; Mattison, on methods of treatment.

In Germany, writers began to classify and describe the disease. According to Regnier, they could all be divided into two classes: Those who could stop the use without suffering, and those who had gone beyond this stage, where the craving was irresistible. Another writer made three classes : Those who use morphin for pain; those who continue it after the causes have been removed; and those who use it for the pleasure which it gives. A number of authorities finally settled upon two classifications : one in which the morphin was used for pain; and the other for pleasure.

Later researches have thrown doubt upon these distinctions. All modern writers recognize the

*" Diseases of Inebriety." Crothers. E. B. Treat & Co., 1893.

rapid growth of this disease and its prevalence where it is least expected. The possibility of concealing its use for many years has made it a most seductive addiction. Its use is prevalent in France and Germany, where entire villages are said to be filled with morphin-t akers .

From the amount of morphin consumed in unknown ways, evidently there is a very large number of habitues in the United States. The sale of morphin in some large cities indicates that not half of the amount sold is traceable to legitimate demands by physicians and hospitals. The enormous balance is consumed in some unknown way. Statistics of the sales of drug-stores show that a very large part of the total is bought by laymen. In one village in central New York a small drug-store sold forty ounces a month. In towns where there is no restriction on tHe retail sale of morphin, certain stores sell regularly large quantities to persons who are known to be addicted to its use.

It is said that the regular morphin consumer patronizes several stores from one to two years; then changes, going to some other place. Often these rounders are known to many druggists, who sell them small quantities daily or weekly until they appear to be diseased; then the drug is refused. Not being able to purchase it themselves, they buy through an agent.

There are large numbers among the lower classes of the great cities who consume morphin constantly. Some local statistics would seem to indicate that business men, speculators, and persons who lead a life of excitement are among the prominent consumers. The broken-down alcoholics are known to contribute a large proportion of 'their numbers to this class of purchasers. One author asserts that merchants, lawyers, physicians, and politicians, with women of the leisure class, are the most numerous of the drug-takers.

Some recent statistics indicate that the medical profession furnishes a large proportion of cases. In France and Germany, among the morphin cases known, the physicians are most prominent. In a study of 3244 physicians in this country 10 per cent, were estimated as either secret or open users of the drug.* These figures are sustained by a great variety of evidence from many sources.

It is difficult to determine the extent of morphinism in any one occupation in this country. One reason is that many persons in different situations after a few years' addiction to morphin become invalids and die from other diseases, the morphinism not being recognized as the original cause. It has been asserted that there are over a hundred thousand persons constantly using morphin in this

*" Medical Record." Crothers. November, 1899.

country alone. This assertion is sustained by a careful study of comparative statistics.

From hospital and drug-store statistics it is evident that the percentage of persons using morphin varies widely in different towns. One of the collected lists of addresses for sale is that of ten thousand morphin-takers. While it is impossible to verify such lists, it is evident that they represent the most noted and confirmed cases, and do not include the pauper or tramp, whose presence is so familiar in the large cities during the winter. In all probability they belong to the middle and lower classes, with a sprinkling of wealthy persons who are chronic cases.

Ordinarily not one-tenth of the cases of morphinism are known to any except their most intimate friends. Some authorities believe that even less than this percentage is known, and therefore unsuspected. Statistics in certain localities sustain this assertion.