Drug Abuse

The first efforts at group control of chronic opium intoxication grew out of those directed at the relief of the individual. That the first experiments along this line were made by the patient alone or assisted by family or friends is told in many of the early chronicles and it was these doubtless that served to awaken the first conception of a situation hitherto unsuspected. Here and there, as the problem grew in Europe and America, physicians began to appreciate its importance, to realize that these cases needed their assistance, and to seek to discover a "cure" or method of treatment that could be applied successfully and leave the patient in a satisfactory physical and mental state.
As we have seen in earlier chapters, at first the terms "appetite," "habit," and "craving" alone were employed to designate this condition but later, theories involving definite pathologic changes were advanced. These fundamental differences as to the nature of the condition and many variations and combinations thereof naturally led to widely differing methods of treatment and widely varying attitudes toward the individual patient.
When professional and public appreciation first began to be aroused, medicine was in its empiric stage—indeed the development of the problem itself is proof of this—and it is quite natural that as in other conditions remedial measures were directed at symptoms. It is not surprising therefore that with such conflicting fundamental theories and the status of medical knowledge of the period there developed to meet the growing need a multitude of "cures" and routine systems that became the vogue and found many or few adherents in proportion to their actual or fancied efficacy or to the persistence and enthusiasm with which their originators or proponents advocated their adoption.
In order to avoid repetition, as far as it is practicable we have selected the principal types of treatment as commonly practised today together with descriptions of such of the earlier efforts as may give an idea of their development. For reasons already suggested no special arrangement except that of chronology has been attempted. The different schools of thought are all represented and if the lines of cleavage are less distinct in this chapter than in some others the significance of the fact is a matter for the reader's interpretation.

George B. Wood-1856.1

"It is satisfactory to know that this evil habit may be corrected, without great difficulty, if the patient is in earnest; and, as the disorders induced by it are mainly functional, that a good degree of health may be restored. It will not answer to break off suddenly. No fortitude is sufficient to support the consequent misery, and life might be sacrificed in the effort. Of the particular phenomena which might result I have no experience; for I have met with no case in which the attempt has been made, or at any rate more than momentarily persevered in. Dr. B. H. Coates, however, states that he has seen well characterized cases in which delirium tremens occurred (N. Am. Med. and Surg. Journ.1 iv. 34); and this result might reasonably be anticipated. The proper method of correcting the evil is by gradually withdrawing the cause; a diminution of the dose being made every day, so small as to be quite imperceptible in its effects. Supposing, for example, that a fluid ounce of laudanum is taken daily, the abstraction of a minim every day would lead to a cure in somewhat more than a year; and the process might be much more rapid than this. Time, however, must be allowed for the system gradually to regain the healthy mode of action, which it had gradually lost."
According to Erlenmeyer,3 the first person to describe the abrupt withdrawal method was Dr. Eder of Vienna in 1864.4

Alonzo Calkins-1871.5

"The specific Rationes medendi or methods of treatment, are in the main two: the Perturbative mode as it may be appropriately designated, which consists in withholding the narcotic peremptorily and absolutely; and the Gradative or Reductionary plan, that which proceeds by regular fractional diminutions. A third and subordinate division is the method by Compensation and Substitution. The cardinal modes are subject to their individual adaptation to considerable modifications.
"The Perturbative Method. Though intemperate persons of whatever description, as Dr. Day remarks, view the sudden withdrawal of their accustomed stimulus with apprehension for consequences, nevertheless a partial suspension is found in the actual trial less endurable than deprivation in the totality. Just as the pendulum oscillates backwards and forwards along its arc times over before it settles quietly at the intermediate point, so in familiar experience it is commonly found easier to swing from one extreme to the opposite rather than to halt halfway. The hungry man, food out of sight, may prolong his fast for days together; a single morsel alone got hold of serves not as refreshment but only as a tantalizer.
"To this plan appertains one particular advantage, that so long as nothing remains there is nothing for abnormal desire to whet itself upon. The observation in regard to all narcotic stimuli is in one respect uniform and invariable, namely this, that the dormant appetite is rekindled as readily and as fiercely no more by a full dose than by an inconsiderable fraction of one. 'Ex una scintilla incendia'—a spark may initiate the conflagration.
"To Dr. Macgowan, Missionary on the Ningpo station twenty years since, appears to attach the credit of priority in the inauguration of this practice. In a letter to the writer he thus speaks: 'Instead of pursuing the course favored here in China by other foreigners my collaborators (the plan of gradual reduction concurrently with the substitution of other toxics in their place), the course followed out at my hospital has been to cut off the opium entirely and at once, with this single modification in instances of allowing a little of the comp. ipecac powder to meet the colliquative diarrhoea so often ensuing. So severe was this ordeal to such as undertook it that only the more resolute of the patients would submit and persevere, but such were sure of coming out of their emaciation and debility, rejuvenated and renovated as if fresh from a dip in the cauldron of some Media.' "
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"A writer in the British Medical Journal of 1867 expresses his views, based upon a considerably varied observation both at home and in the Far East, in the following language: 'Absolute and immediate suspension is for efficacy the far more reliable plan, being less tedious, less exhausting, less the occasion of hard suffering.' Agreeably to his proposition the customary quantity should be cut down at once by one-third, to be followed by rapid reductions on the remaining two-thirds."
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"The successes achieved upon this the heroic method at the institutions (the course held in especial favor there) have been very satisfactory."
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"The Reductionary course, less favored in the asylums as being less active and prompt, has in private practice operated very successfully upon a considerable number of untoward cases. To work feasibly the process must be a qualeab-incepto progress, proceeding by substitutions in regular gradation throughout. The main objection urged against this practice is the fact, that the patient is liable to tire of a course conducted thus slowly and protractedly. Among those particularly partial to this mode is Dr. Bernir of the Haymarket, London, who expresses his approbation from a large observation made in China."

Horace Day-1872.6

"The opium-eater will not regard as amiss some few suggestions as to the mode in which his habit may most easily be abandoned."
"The object I have in view is not, however, so much to make suggestions to medical men as it is to awaken in the victims of opium the feeling that they can master the tyrant by such acts of resolution, patience, and self-control as most men are fully capable of exhibiting. Certain conditions, however, seem to be the almost indispensable preliminaries to success in relinquishing opium by those who have been long habituated to its use. The first and most important of these is a firm conviction on the part of the patient that the task can be accomplished. Without this he can do nothing. The narratives given in this volume show its entire practicability. In addition to this, it should be remembered that these experiments were most of them made in the absence of any sufficient guidance, from the experience of others, as to the method and alleviations with which the task can be accomplished. A second condition necessary to success, is sufficient physical health, with sufficient firmness of character to undergo, as a matter of course, the inevitable suffering of the body, and to resist the equally inevitable temptation to the mind to give up the strife under some paroxysm of impatience, or in some moment of dark despondency. With a very moderate share of vigor of constitution, and with a will, capable under other circumstances of strenuous and sustained exertion, there is no occasion to anticipate a failure here. Even in cases of impaired health, and with a diminished capacity for resolute endeavor, success is, I believe, attainable, provided sufficient time be taken for the trial."
"This effort should be made with the advice and under the eye of an intelligent physician. So far as I have had opportunity to know, the profession generally is not well informed on the subject. In my own case I certainly found no one who seemed familiar with the phenomena pertaining to the relinquishment of opium, or whose suggestions indicated more than vague, empirical ideas on the subject. But even in cases where the physician has had no experience whatever in this class of disorders, he can, if a well-educated man, bring his medical knowledge and medical reasoning to bear upon the various states, both of body and mind, which the varying sufferings of the patient may make known to him. Were there, indeed no professional helps to be secured by such consultation, it is still of infinite service to the patient to know some one to whom he can frequently impart the history of his struggle and the progress he is making. Such confidence may do much to encourage the patient, and no one is so proper a person in whom to repose this confidence as an intelligent physician.
"The amount of time which should be devoted to the experiment must depend very greatly upon these considerations—the constitution of the patient, the length of time which has elapsed since the habit was formed, and the quantity habitually taken. When the habit is of recent date, and the daily dose has not been large—say not more than ten or twelve grains—if the patient has average health, his emancipation from the evil may be attained in a comparatively short period, though not without many sharp pangs and many wakeful nights which call for the exercise of all his resolution.
"The question will naturally suggest itself to others, as it has often done to myself, whether a less sudden relinquishment of opium would not be preferable as being attended with less present and less subsequent suffering. Numerous cases have come under my notice where a very gradual reduction was attempted, but which resulted in failure. Only two exceptions are known to me: in one of these the patient, himself a physician effected his release by a graduated reduction extending through five months. The other is the case of Dr. S., a physician of eminence in Connecticut many years ago."
"The general directions I should be disposed to suggest for the observance of the confirmed opium-eater would be something as follows:
"1. To diminish the daily allowance as rapidly as possible to one-half. A fortnight's time should effect this without serious suffering, or anything more than slight irritation and some other inconveniences that will be found quite endurable to one who is in earnest in his purpose.
"2. For the first week, if the previous habit has been to take the daily dose in a single portion, or even in two portions, morning and night, it will be found advisable to divide the diminished quantity into four parts."
"In the third week a further gain of ten grains can the more easily be made by still further dividing the daily portion into an increased number of parts, say ten. The feeling of restlessness and irritability by this time will have become somewhat annoying, and the actual struggle will be seen to have commenced. It will doubtless require at this point some persistence of character to bear up against the increased impatience, both of body and spirit, which marks this stage of the descent. The feelings will endeavor to palm off upon the judgment a variety of reasons why, for a time, a larger quantity should be taken; but this is merely the effect of the diminished amount of the stimulant. Sleep will probably be found to be of short continuance as well as a good deal broken. Reading has ceased to interest, and a fidgety, fault-finding temper not unlikely has begun to exhibit itself."
"I have not ventured to say in how short a time confirmed habits of opium-eating may be abandoned. In my own case it was thirty-nine days, but with my present experience I should greatly prefer to extend the time to at least sixty days; and this chiefly with reference to the violent effects upon the constitution produced by the suddenness of the change of habit."

A. Stille-1874.7

"It may not be without profit to mention that the most successful means which have been employed to cure the habit of opium-eating consist in the gradual diminution of the dose of opium without the patient's privacy and the equally gradual substitution for it of aromatic and stimulant tonics. Ginger, black pepper colombo and quassia may be employed successively for this purpose .° If this plan cannot be carried out, it is far better, for the sake of the patient to insist upon an abrupt cessation of his habit than to attempt to win him from it by degrees. . . . If he passes safely through the terrible trial of total abstinence, his cure may be counted upon as probable. But he must meanwhile be not only encouraged morally, but physically sustained. Dr. Alexander Fleming ° prescribes 40 minims of dilute phosphoric acid, and 80 minims of tincture of lupulin (d) an hour before meals in a wineglassful of water.
"At bedtime there is given, to promote sleep, tincture of cannabis, 30 or 40 minima and of Hoffman's anodyne a fluidrachm, appropriately diluted. The food should at first consist of milk and beef-tea, for which, as .the appetite improves, more solid aliment may be substituted. Alcoholic stimulants should, if possible be avoided. Zinc, quinia, and iron, under various forms, must afford strength to the nervous system and a due body to the blood and both must be improved by stimulating the skin by means of baths, friction, active exercise, and whatever will tend to withdraw the patient from those habits of solitude and self-contemplation in which his vice has immured him."

E. Levinstein-1875."

The earliest article published by Levinstein describing his method of treatment which we have been able to discover appeared in 1875.10 However, he discusses his method in much greater detail in his book "Die Morphiumsucht" published in 1877 from Harrer's translation 11 of which we quote as follows:
"The chief principle in the treatment of morbid craving for morphia is the deprivation of the drug, the sudden process being preferable to the slow deprivation."
"As soon as the patient has consented to give up his personal liberty, and the treatment is about to commence, he is to be shown the rooms set apart for him for a period of eight to fourteen days, all opportunities for attempting suicide having been removed from them. Doors and windows must not move on hinges, but in pivots; must have neither handles, nor bolts or keys, being so constructed that the patients can neither open nor shut them. Hooks for looking glasses, for clothes and curtains must be removed. The bedroom, for the sake of control, is to have only the most necessary furniture; a bed, devoid of protruding bedposts, a couch, an open washstand, a table furnished with alcoholic stimulants (champagne, port wine, brandy), ice in small pieces, and a tea urn with the necessary implements. In the room which is to serve as a residence for the medical attendant for the first three days, the following drugs are to be kept under lock and key :—a solution of morphia of 2 per cent., chloroform, ether, ammonia, liq. ammon. anisat., mustard, an ice bag, and an electric induction apparatus. A bathroom may adjoin these two apartments. During the first four or five days of the abstinence, the patient must be constantly watched by two female nurses. Male attendants are of no use in cases of morbid craving for morphia, as they are generally more accessible to bribing, and are less to be relied upon and less capable of self-sacrifice. They are, however, wanted for the coarser manipulations, for attending to the bath of male patients, and may then be admitted under supervision."
"During the first four or five days, the nurses must be changed every twelve hours, as the service requires mental and physical ability, and is very fatiguing."
"The first symptoms of the abstinence, showing themselves in weak persons after three or four hours, in strong people frequently as late as fifteen hours, after the last injection of morphia, such as uncomfortable feeling, languid pain in the limbs, yawning, sneezing, slight chill, are no objects for treatment; severe shivering necessitates going to bed, in order to become warm, which, on account of the depressed state of mind, is readily agreed to by the patients.
"Against the usually prevalent headache, cold water and ice compresses, either dropped on the forehead, or on the skull, may be recommended; against the severe griping pains in the epigastric region, compresses, moistened with chloroform, may be applied. Abdominal pains occurring seldom, but being very distressing, are relieved by mustard plasters and hot cataplasms; on account of their simplicity we use the Cataplasmes instantanes."
"Nausea and vomiting, as well as the dyspepsia, lasting for several days, are successfully treated by a solution of bicarbonate of soda, with tinct. nuc. vomit. and ol. menth. pip. Should the vomiting become more frequent at first ice pills, mustard plasters on the epigastrium or instead of the latter a local application of chloroform may be resorted to. In case, however, it should repeat itself twenty or thirty times in the twenty-four hours, thus threatening to exhaust the patient's strength, 1 to 3 tablespoonfuls of a solution of morphia (1 grain in 6 ounces) may be given.
"Should the patient refuse to take food on account of the continuous vomiting, and should severe symptoms of prostration set in, nourishing injections into the rectum must be administered.

"Diarrhoea, occurring regularly during the period of abstinence, is no object for treatment, as it mostly disappears of itself after a few days. Should it become of a severe character, however, or last longer than three or four days, warm water injections into the bowel (temp. 37 degrees C., 98.6 degrees F.) of 1 to 2 pints, repeated two or three tithes in the day, will prove of great benefit.
"The sleeplessness will resist any treatment during the first three or four days, and is the symptom mostly complained of by the patients. Prolonged warm bathing will not be endured by the patients at this time, giving as it does at the most half-hour to one hour's sleep. Hydrate of chloral, per os, or per anum, does not either at this period create sleep, its use often being followed by great excitement. After the lapse of the first four days however it will agree with many. patients, exercising in such instances its hypnotic effects.
"The general debility and psychical depression of the first days will be successfully treated by warm baths, with cold douches of five minutes' duration. Do not allow yourself to be induced to abstain from giving them on account of any of the symptoms of abstinence, as all the patients suffering from the abuse of morphia, even if they have objected to the first bath, immediately begin to feel the comfort created by it, are refreshed afterwards, and impatiently long for a repetition. During the time of bathing, stimulants, such as champagne, port wine, beef tea, etc., may be given.
"The greatest care during treatment is to be bestowed upon the diet, from the commencement of the withdrawal of the drug. During the first three days, food is only to be given in a fluid form ; strong wines and, according to individual susceptibility, pure alcoholic liquors are to be resorted to. They are best given in the same manner as a medicine, every hour or two hours.
"Many people have an intense craving for alcoholic beverages, others greatly objecting to them. The first-mentioned patients may be allowed to drink wine in unlimited quantities, without any ill effects, as by doing so they pass over the first days of abstinence in a less distressing manner; should, however, there be reluctance and distaste for alcohol a light milk diet (2 ounces of milk every hour, or two hours) may be ordered. This agrees well even with persons who are greatly troubled with vomiting."
"The simple collapse will disappear under the above-mentioned dietetic regime, the severest forms, however, requiring an energetic and very attentive treatment.
"It is advisable to guard against looking at every condition of exhaustion as collapse, and the same may be said of patients, especially females, possessing a great talent to simulate conditions resembling collapse; but it is true, nevertheless, that a mistake made under such conditions is not of very great importance and would only have the disadvantage of prolonging the period of the treatment.
"A medical man who does not lose his quiet composure when at the bedside, relying on the apparent facts and considering the intervening symptoms, will neither commit the above-mentioned mistake, nor be guilty of the irreparable fault of overlooking a severe collapse.

"The symptoms of collapse, requiring energetic action, are principally caused by the heart, less frequently by the brain, and only exceptionally by the lungs.
"If the character of the pulse is changing, i.e., the previously soft condition getting threadlike, sinking gradually or at once, after having become irregular, to one-third or a smaller fraction of its former normal frequency; if the patient's face is getting pale, the nose becoming pointed, and if the previous excitement suddenly is replaced by a quiet demeanor, or by fainting fits; if somnolence sets in accompanied by deep and slow respiration—an injection of 6 grain of morphia is to be administered at once as an indicatio vitalis. If within ten minutes the pulse and the general condition do not improve, the injection is to be repeated once or twice until the return of the normal condition is evident. At the same time the patient is to be kept awake by counter-irritation, smelling salts, cold compresses on the head, dropping ether on the skull, by talking loud to him and shaking him; and stimulants such as liq. ammon. anisat., champagne, port wine, brandy, hot coffee or tea with rum, are to be given internally.
"If on the dangerous symptoms subsiding, the patients fall asleep, the respiration and circulation must be watched.
"Should the severe collapse return on the same or following day, the latter only occurring in quite exceptional cases, the same treatment must be resorted to."
In the 1883 edition of "Die Morphiumsucht," 12 Levinstein introduces a modified method of abrupt withdrawal in which small doses of the drug are employed for a time in the case of patients in a serious condition suffering from tabes, phthisis, emphysema, and heart trouble. The indication for its use is increased morphin dosage with symptoms of chronic intoxication in persons who still possess relatively good resistance.

J. B. Mattison-1876-1893.13

In an article written in 1893, Mattison claims credit as the originator of the rapid withdrawal method, stating that he introduced it in 1876. We have been unable to trace the original article in order to verify this position. A good description of his method is contained in the above-mentioned article as follows:
"The modern and humane treatment of the morphine disease—preeminently an American plan—is compassed mainly by three drugs—bromide of sodium, codeine and trional. These form a combination of unrivalled value if properly used, in proper cases and, with certain minor aids, make a method far in advance of any yet presented to accomplish two leading objects--minimum duration of treatment and maximum freedom from pain.

"In 1876, the attention of the profession was invited by the writer, to a new application of the well known power of the bromides to subdue reflex nervous irritation, by commending the use of bromide of sodium in this disease, after a plan quite original, which consisted in giving it, in gradually increasing amount, often enough to secure the effect of a continuous dose, for six to ten days, during Which time the habitual opiate was to be gradually, but entirely, withdrawn, the object being to secure, by this preliminary sedation, a maximum sedative influence from the bromide at the time of maximum nervous irritation from the opiate-ending."
"The preliminary sedation feature of this method consists in giving the bromide of sodium in initial doses of 30 grains, twice daily, at 10 A.M. to 10 P.M., and increasing this dose 10 grs. each day, i.e., 30, 40, 50, 60, etc., until a maximum of 100 grains, semi-daily, is reached on the eighth day. On the ninth and tenth days, this maximum 100 grain dose is given in the evening only.
"This giving of the bromide applies solely to typically eligible cases. With some it is clearly contra-indicated, with others, a minor degree of preliminary sedation will suffice; and with all patients this rule governs: Each case is a law
unto itself, and the length and amount of the bromide giving, and consequent rate of opiate decrease, is determined entirely by individual peculiarity, as shown both before and during treatment. This must not be forgotten; brains must be mixed with the bromide. This is a point of prime importance, and failure to put it in practice will account for ill success."
"During this time of bromidal medication, no other treatment is called for, usually, save a tonic regimen, and such regulation of gastric, renal, and alvine functions as each case may seem to demand, in this respect being markedly and favorably in contrast with any method that does not include preliminary sedation, and which makes essential various anodynes, sedatives, stimulants, and hypnotics during the opiate decrease, if the patient's comfort be conserved."
"Having secured the desired sedation and reached the end of the morphine-taking whatever reflex symptoms present are met, mainly, by codeine. This is the second special factor in the modern treatment of morphinism. . . .
"Of this therapeutical triad, codeine is the most important, for it can be used with good in all cases, whereas some will present in which the bromide should not or need not be employed, nor is trional essential.
"Codeine may be given pure, or in either of three salts—phospate, muriate, or sulphate. . . . The dose should be one to three grains, by mouth or skin, every two to four hours, according to case or condition, and continued in gradually decreasing doses and increasing intervals till no longer required. The dose by stomach should be double that by skin. As a rule, codeine is not called for till after the entire morphine-quitting. If needed earlier, it should be given.
"Cases will present in which the bromide need not, or should not, be used. In these codeine, with, maybe, some hypnotic, a few nights, will serve every purpose.

"The credit of first commending codeine in -morphinism belongs to an Ameri. can physician—Lindenberger, of California—who, in 1885, claimed for it merit after a method of his own. Later, Schmidt, Fischer, and Rosenthal, abroad, asserted its value, and my own experience, large and enlarging, makes me regard it my most valued aid."
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"The third factor in this modern method is trional. Of hypnotics this is the latest, and in treating narcotic habitues the greatest. There is no doubt of this, I have given it hundreds of times, and say whereof I know. It is better than sulphonal—its nearest rival, and which, till the advent of trional, led the list of hypnotics in this condition—having an effect more certain, pronounced, and prolonged. My usual dose is forty grains for males, and thirty for women, given dry on tongue at 7 P. M. in the evening, after the last morphine-giving. It is largely soluble in hot water, milk, soup, or tea, and thus taken, acts quite promptly. It is not only the soporific in these cases, but is markedly sedative, and so serves doubly for good, We use it exclusively during the first six or eight nights, decreasing it gradually to half the initial dose, and then if needed, resort to chloral, paraldehyde, or cannabis. Some cases do not require it. One of the most striking ever under my care, now making a good recovery, has done notably well without it, codeine phosphate having secured several hours' sleep each night. My opinion, steadily growing, of trional in the insomnia of morphine habitues, is that it is the most valuable soporific we now possess."

H. H. Kane-1880.14

"The treatment of the morphia habit is of three kinds: sudden deprivation, gradual deprivation and substitution. The former is the plan of Levinstein, who has treated many cases in this way and with excellent success, so far as accomplishing a cure is concerned. It is necessary, however, that the patient be fully under the physician's control, the best place being an asylum. This plan has two decided objections: if the patients have been using the drug for a long time
, or in large quantities, their sufferings are agonizing, and there is decided danger Of serious and even fatal collapse."
Kane further expresses himself in favor of the method used by Mattison.

C. W. Earle-1880.15

Earle advocates rapid withdrawal reporting that he used fluid extract of coca in three or four cases in all of which it proved of great service although he believes that it is by no means a specific and has no power to disgust the patient with the desire for his favorite drug. He also calls attention to the danger of opium patients becoming addicted to the coca habit and cites one of his cases as an example concluding that "while we have in coca an agent which is of undoubted value, its indiscriminate use should be interdicted." 16

D. Jouet-1883.17

Jouet does not approve of the abrupt method for the majority of cases but believes that where there is no reason to expect severe symptoms it may well be used. He states also that it may be used in insane
cases where withdrawal symptoms usually are not present. Jouet com-
mends Burkart's method of substitution stating that after all injec-
tions are replaced it is easy to withdraw the opium with little danger and good results.

William Pepper-1886.18

. The treatment of the opium habit and kindred affections is a subject which derives its importance from the following facts: First, the gravity of the disease, as regards the functions both of the body and the mind; second, the enormous suffering and misfortune, alike, on the part of the patient himself and on the part of those interested in him, which these affections entail; third, the fact that they are not self-limited, and therefore cannot be treated with indifference or upon the expectant plan, but are, on the other hand, progressive and gradually destructive of all that makes life worth living, and at last of i. life itself ; and finally, because they are capable at the hands of skillful and experienced physicians of a cure which in a considerable proportion of the cases may be permanent."
"a. Prophylaxis.—It is impossible to overrate the importance of a true conception of the duty of practitioners of medicine in regard to the prophylaxis of the opium habit and associated affections. In communities constituted as are those in which the physicians practise into. whose hands this volume is likely to fall, a large—I may say an enormous—proportion of the cases of habitual vicious narcotism is due to the amiable weakness or thoughtlessness of medical men. A majority of the cases occur either in chronic painful affections attended or not by insomnia, or as a result of acute illness in which narcotics have been employed to relieve pain or induce sleep. The chronic affections constitute two classes: First, those manifestly incurable, as visceral and external cancer, certain cases of advanced phthisis, confirmed saccharine diabetes, and tabes dorsalis. In such cases the use of morphine in large and often-repeated doses, although attended with evils and likely to shorten life, amounts to a positive boon. It is neither practicable, nor would it be desirable, to interfere with it. To this class may be added those cases of grave valvular or degenerative diseases of the heart where the patient has become addicted to the habitual use of narcotics. Here, notwithstanding the evils resulting from these habits, among which the likelihood of shortening the period of life must unquestionably be counted, the dangers of the withdrawal of the drug are so great that it must be looked upon as neither desirable nor feasible. Attention must, at this point, be called to the fact that great caution is required in the management of pregnant women addicted to narcotics. Incautious attempts to withdraw the habitual drug are almost certain to be followed by speedy loss of the foetus; and it is to my mind questionable whether anything more than the most guarded reduction of the daily dose should be attempted while the pregnancy continues.
"The second class of chronic cases includes individuals suffering from diseases which are remediable or capable of decided or prolonged amelioration. Among these affections are painful diseases curable by surgical procedures, such as certain obstinate and intractable localized neuralgias, painful neuromas, irritable cicatrices, pelvic and abdominal tumors, and surgical affections of the joints and extremities. Here, either before or after radical surgical treatment, an effort to relieve the patient from the bondage of habitual narcotism should be made. For reasons that are obvious, measures having this end in view should be instituted by preference subsequently to surgical treatment. To this class also belong certain painful affections occupying the border-region between surgery and medicine. These are floating kidney, renal and hepatic abscess, calculus, pyelitis, cystitis, impacted gall-stones, and thoracic and abdominal aneurism. In these cases the possibility of a cure renders it in the highest degree desirable that the opium habit should be stopped. Whether this attempt should be made while the patient is under treatment for the original affection, or deferred until relief has been obtained, is a question to be decided by the circumstances of the particular case under consideration. Finally, we encounter a large group of chronic painful affections coming properly under the care of the physician in which the opium habit is frequently developed. This group includes curable neuralgias of superficial nerves, as the trigeminal, occipital, brachial, intercostal, crural, and sciatic, and visceral neuralgias, as the pain of angina, gastralgia, and enteralgia, and the pelvic and reflex neuralgias of women. Here also are to be mentioned the pains of neurasthenia, hypochondriasis, and hysteria. In this group of affections the original disease constitutes no obstacle to the attempt to break up the habit to which it has given rise."
"Finally, the danger of yielding to the temptation to allow a merely palliative treatment to assume too great importance in the management of painful affections must be sedulously shunned. Too often these precautions are neglected, and the patient, betrayed by a dangerous knowledge of the drug and the dose by which he may relieve not only physical pain, but also mental depression, and tempted by the facility with which the coveted narcotic may be obtained, falls an easy victim to habitual excesses. The lowered moral tone of convalescence from severe illness and of habitual invalidism increases these dangers. Yet more reprehensible than the neglect of many physicians in these matters is the folly of the few who do not hesitate to fully inform the patient in regard to the medicine given to relieve pain or induce sleep, and to place in his hands designedly the means of procuring them without restriction for an indefinite period of time Almost criminal is the course of those who entrust to the patient himself or to those in attendance upon him the hypodermic. syringe. No trouble or inconvenience on the part of the physician, no reasonable expense in procuring continuous medical attendance on the part of the patient for the sake of relief of pain, can ever offset, save in cases of the final stages of hopelessly incurable painful affections, the dangers which attend self-administered hypodermic injections."
*    **
"Finally the dissemination of a wholesome knowledge of the methods by which the opium habit and kindred affections are induced, of the serious character of these affections, and of the dangers attendant upon an ignorant and careless employment of narcotics, would constitute an important measure of prophylaxis. I am fully aware of the evils resulting from the publication of sensational writings relating to this subject. Notwithstanding these dangers, I am convinced that a reasonable and temperate presentation of the facts in the popular works upon hygiene used in schools and in the family would exercise a wholesome influence in restraining or curing the tendency to the practice of these vices."
"Where these habits have resulted in consequence of the medicinal abuse of narcotics in acute cases from which the patient has long recovered, a determined effort to break them up should at once be instituted."
The author describes the abrupt and gradual methods of withdrawal and appears to favor the latter.

A. Erlenmeyer-1886.'9

Erlenmeyer is considered by some writers the outstanding proponent of the rapid withdrawal method. In his article of 1886, he states that Dr. Pichon who says that the method of treatment by abrupt withdrawal is German and that by gradual withdrawal is French, is incorrect, inasmuch as both are German in origin. In a previous article the author claims he showed that Dr. Samter, a German, wrote on the subject in April, 1864, and that it was not until ten years later, after German medical literature on the subject was well developed, that the first French work appeared by Chouppe (Gazette Medicale 1874-80) and two years later one by Calvet (Essai sur le Morphinisme, 1876). He further states that the abrupt method should not be called German as Levinstein is the only German who used it, while the other German physicians opposed it and employed the gradual withdrawal method.
In his book published in 1883,20 he gives the three methods of withdrawal as follows:

1. Gradual. Oldest. Unsatisfactory.
Disadvantages
(a) Exceedingly difficult to control patient so that he cannot obtain drug secretly. This method does not guarantee this prevention.
(b) Prolongation of morbid phenomena. Does not agree that patient can better endure abstinence symptoms under slow than under sudden method.
(c) Consumption of whole time available for the therapy. Emphasizes need for long recuperation.
2. Abrupt. Levinstein—first advocate.
Advantages
(a) Certainty of success.
(b) Rapidity of cure.
Disadvantages
(a) Almost impossible to practice this method in every hospital.
(b) Very expensive.
(c) Danger to life of patient by sudden withdrawal.
3. Rapid. Erlenmeyer
Erlenmeyer sums up the advantages of the rapid method of withdrawal as follows:
1. Certainty of success as the isolation of the patient precludes access to morphin.
2. Freedom from danger as collapse does not threaten the patient's life.
3. Short duration of abstinence symptoms.
4. A longer period for convalescence.
Erlenmeyer strongly opposes the treatment of these cases in insane asylums as advocated by some writers and states that they should be treated in hospitals for other diseases. He also attacks the employment of cocain in the treatment of morphinism and warns of its dangers.
In 1909,21 he describes the three methods again, not commenting on
gradual withdrawal, stating that abrupt withdrawal is obsolete and
no longer used, and adding a description of three other methods; viz:
The Substitution Method—Substitution of similarly active drugs (opium, cocain, bromides, codein) with reduction of morphin. Erlenmeyer states that the principle of this method is wrong as the patients become chronic users of these substitutes.
The Chemical Method—Developed by Hitzig—In discussing this method Erlenmeyer concludes that it has two disadvantages. 1. Very many people do not take kindly to having the stomach emptied and 2. The hypothesis of the anacidity of the stomach contents during the use of morphin and of the hyperacidity after withdrawal is apparently false.
Suggestion and Hypnosis—Erlenmeyer emphatically denies that this method can cure morphinism.
Erlenmeyer introduced his method of rapid withdrawal about 1883 when he wrote a book on the subject. Since that time his procedure has been practically the same with the exception of a modification which he described in 1893. This, however, has nothing to do with the duration of treatment but involves only the application of a modification of Hitzig's procedure to relieve the hyperacidic condition of the stomach at the end of the withdrawal treatment.
The following is a brief description of Erlenmeyer's method:
The morphin is withdrawn as quickly as possible, but not abruptly and without danger to the life of the patient. Withdrawal is distributed over a period of from 4-10 days and depends on the condition of the patient, the dosage and the number of previous treatments, but above all on the general resistance of the patient. Small doses of 0.30.5 may be withdrawn in from 4-6 days, larger ones of 1.0-1.5 in 8-10 days. There is no set procedure, each patient requiring individual treatment. In this treatment there occurs neither collapse nor a noticeable disturbance of circulation or respiration and no delirium. It is true, nevertheless, that with this treatment the withdrawal symptoms may reach a high degree of severity but the whole course runs only a few days.
It is important to determine in the beginning of treatment the dose that should be administered. Many morphinists do not know for one reason or another exactly how much morphin they are taking within a given period. Some take a very large dose just before treatment begins in order to have it hold over. This measured dose may be determined by experimentation over a couple of days.
The measures indicated by the psychopathologic state of the patient are also of great importance. Steps must be taken to prevent deception and return to the drug and to offset during a later period of the treatment through outside, mechanical means weak will and loss of self-control. The treatment must be carried on in such a way that supply from home is impossible. This is effected in a hospital by means, the selection and carrying-out of which may be left to medical judgment. The location of the patient, his nurses and attendants, his food, baths, etc., are the concern of individual medical care and attention.
Erlenmeyer administers the daily dose in three and sometimes four equal amounts at stated intervals in such a way that the evening dose comes between 10 and 11 o'clock to insure good sleep.
Whenever possible the patient is allowed to eat after each injection. "I cannot recommend too strongly abundant supply of food from the beginning," he states. The author advises against alcohol in any form.
Further than this withdrawal may not be carried out according to rule, everything depending on the condition of the patient and the resulting symptoms. These often develop in rapid succession and therapeutic measures must be applied accordingly. It does not matter if once or twice the dosage is not decreased, thus causing a halt in reduction. In fact sometimes the condition of the patient requires a slight increase. In such necessary variations, one should not be confined too much to single symptoms, but should keep his finger on the pulse, watch for "cold blood" and never forget the needs of the whole situation. The importance of medical personality should not be underestimated. The psychopathic symptoms of restlessness and impatience often vanish on the appearance of the physician. The aggravation here as in traumatic neurasthenia is signum morbi.
Erlenmeyer so modified Hitzig's procedure that he could neutralize in loco the hyperacidity of the stomach contents at the conclusion of the withdrawal without the necessity of emptying the stomach. He accomplished this by giving 1 to 2 litres of Fachinger water daily. Through this procedure not only the gastric but also the withdrawal symptoms disappear. Erlenmeyer has used this method with success for fifteen years. Nevertheless one must regulate the procedure by an intimate knowledge of the patient's condition. The determination of the point at which to begin the administration of the Fachinger water is by no means easy and the ordering of the water in relation to time, number and size of doses often calls for daily adjustment.
Note : Forty years later Erlenmeyer published another article dealing with the treatment of this condition, but inasmuch as so long a period elapsed, this article is presented in its normal chronologic place rather than here.

R. Burkart-1884.22

Burkart prefers gradual withdrawal in the treatment of chronic opium intoxication, introducing a modification of the usual method by gradually substituting opium administered by mouth for the morphin hypodermically administered. He states:
"Since 1872 I have treated the cases of morphinism intrusted to me exclusively by the gradual withdrawal method, being actuated in the selection and development of this method by the following motives:
"Morphinists should undergo the least possible suffering in the treatment of their chronic poisoning, and the mode of withdrawal should make it possible for the patient to abstain from the given alkaloid with the most moderate withdrawal symptoms (Inanitionserscheinungen). The patients should not be deprived of their personal liberty during treatment, at least in so far as they may give up treatment on their own initiative any time, if they wish to go back to morphine again in spite of medical orders. No physical force, but only moral suasion should be used by the attending physician if success is to be attained. The patient promises to submit unreservedly to the orders of the physician during treatment especially as to the withdrawal of the drug, the assignment of a nurse or other suitable attendant and the administration of medicaments. Failure to follow medical orders implies withdrawal from treatment."
"To carry out successfully this method of treatment it is advisable to have the patient in a hospital where continuous medical supervision, a good nursing staff, bathing facilities, etc., are available. Here it is unnecessary to keep the morphinist in detached rooms for the sake of the other inmates as is required in abrupt withdrawal, because it rarely happens that the patients during gradual withdrawal disturb their neighbors by their restlessness and loud noise. Usually my method of treatment for chronic morphine poisoning averts the delirium and excitement which are usually the result of abrupt withdrawal. One can always through reasonable persuasion and personal influence bring the patient to endure the suffering which is occasionally severe and to see it through to the end.
"Gradual withdrawal as I practice it can be carried out also in any private house, since it is really only a question of expense for the patient to prepare and arrange just for himself all of those facilities such as medical aid, nursing attendants, baths, etc., which are necessary to relieve his suffering. In any event, there are unusual cases which make it desirable to undertake gradual withdrawal under such private conditions.
"It is apparent that under such arrangements for treatment the morphinist can comparatively easily deceive the physician and secretly secure for himself the poison in order to satisfy the painful desire for morphine, at least much more easily than he could in a hospital. However, under any condition care and attention on the part of the attendants and physicians are needed to avoid deception lest morphine is taken secretly by the patient."
*    *    *    *
"Nevertheless I have been able to bring about 71 per cent cures in the treatment of morphinists under these conditions. This number means that among my 'not cured' morphinists there were many patients who it is true sought treatment but were not quite ready to stand much suffering and who immediately decided again to give up the cure, as soon as any noteworthy discomfort of withdrawal appeared. That such patients passed under my medical direction was quite natural from the reputation acquired by my method of treatment. . . ."
"In general, even my method of treatment of chronic morphinism is not free of disagreeable and annoying secondary symptoms; sometimes the patients during withdrawal, as stated above, are for a day at a time in a very distressing and deplorable state.
"Usually the period which I have found necessary for withdrawal varies between 14 and 21 days, according to the size of the daily dose. In especially weak cases sometimes I require an even longer period, 4-7 weeks, and have observed the best results as to cure and condition of the patient.
"I require every patient to remain at least 6 days after complete withdrawal under treatment.
"Generally I observe the same injection periods used by the patient during his former use of the drug and inject the morphine solution to correspond with the 2-4-5 times in 24 hours. On the first day I use about the same amount as the patient last used and then decrease the daily dose by about 0.3-0.2-0.010.005 as daily I withdraw in the beginning of treatment larger amounts and later smaller amounts."
"In addition to the subcutaneous administration of morphine all of my patients receive 1-2-4 times daily by mouth 0.03-0.04-0.07-0.09 opium puruin or corresponding amounts of tinctura opii simplex. Usually in cases where over 025 morphine per day has been used I begin the administration of the opium when withdrawal has proceeded to the point where 0.07-0.09 morph. mur. is being administered within 24 hours. When the daily dose of morphine has been smaller, naturally the administration of the opium may be begun later. But in general I am guided as far as dosage and administration of opium are concerned by the severity of the withdrawal symptoms and I do not hesitate to begin administering opium when the morphine dosage is still high (over 0.1 p. day). In any event even where only the slightest withdrawal symptoms are present, I give opium during the last third of the period."
"The psychical manifestations such as anxiety, restlessness, etc., which I previously observed in withdrawal treatment without the substitution of opium, are not nearly so prominent when opium is used, as in abrupt withdrawal. Also the symptoms of the motor nervous system such as tremors, ataxia, paralysis and finally the muscle twitching which is so annoying to the patient do not appear in my treatment or at least do not return so frequently and so intensively as in abrupt withdrawal or gradual withdrawal without the substitution of opium.
"The digestive organs suffer far less in the opium treatment than for example Levinstein describes in his patients and as I must admit in some of my cases who were withdrawn gradually without opium. Usually they rarely vomit. . . .
"The withdrawal of the opium continued after the last injection of morphine is usually not difficult."
The author has not found other drugs such as sodium bromide, potassium bromide, hyoscin, etc., of much use.

B. Ball and 0. Jennings-1887-1909.23 24 25

These authors point out that the treatment of "morphinomania" 26 consists of :
1. Placing the patient in a hospital where he is constantly under medical supervision.
2. Suppressing more or less completely the use of morphin.
3. Relieving the heart action at the proper moment by spartein to which is added if necessary an injection of morphin. It should be remembered that collapse may end in death and the use of morphin will immediately avert it.
The authors recommend the use of nitroglycerin in light cases when rapid but not lasting support is sufficient.
This treatment, Ball and Jennings state, should carry the patient through the acute state of withdrawal.
Ball 27 also writing in 1887, states the following:
"Abrupt suppression, recommended by Levinstein, and practiced by a great number of other physicians, has in its favor one great. advantage; it causes the patient to suffer for a much shorter time. Once the crisis over, once the frontier crossed, the patient no longer feels the peculiar distress of the morphine dipsomaniac; he no longer has the painful sense of depression and of downheartedness which makes him long for another injection. But, on the other hand, by sudden suppression, we run the risk of producing the serious results already described. The patient may be taken with delirium tremens; he may be attacked by acute mania; he may finally (and this is the most serious danger), fall into collapse, which as I have already observed, is sometimes followed by death.
"It is therefore almost impossible to carry through a sudden suppression outside of an asylum or hospital. In fact, immediate sources of assistance are indispensable for the patient during this course of treatment. . . ."
"Gradual suppression is an easier mode of treatment to employ; it is even the only treatment possible to try in the patient's home, or outside of special establishments. First, all the necessary precautions must be taken, to be certain that the patient does not baffle the surveillance to which he is subjected; then is to be fixed the rate at which the daily quantum is to be reduced. . . .
"Adjuvants are clearly indicated during the period of suffering, when the patient is being gradually weaned from his usual stimulant.
"First, and above all, a tonic and nutritious diet is necessary, and at first the patient should rest in bed, leaving it to take a little exercise at a later period, when the first difficulties have been overcome. Then there are many ways of improving his nerve tone. I by no means disapprove of the use of alcohol in moderate doses; but care must be taken to keep the patient within the strictest bounds. . . ."
The author also recommends coffee, caffein, hydropathy, alkaline bromides, chloral, paraldehyde, for insomnia, belladonna, gelsemium sempervirens, extractum thebaicum, and codein to relieve withdrawal pains, valerian to relieve general nervous excitement and baths.
In his book, written in 1909, Jennings 28 fully discusses his method of treatment as follows:
"I am more than ever convinced that in the morphia habit, which is a psychosomatic affection, and in which the mental and physical troubles are interdependent, conditioned the one by the other, the success of therapeutic measures, properly so called, depends on the mentality of the patient, and reciprocally.
"It is quite true that the habit can be 'knocked out' in a relatively short time by hyoscine, atropine, duboisine, piturine and by many other alkaloids, also by synthetic morphine-, or coal-tar derivatives: but such treatments require restraint, and experience shows that the results so obtained are rarely definite. When the weaning has been effected, not by re-education and restoration of the will, but by compulsion instead of guidance, this excites during suppression a latent hostility, which remains as a subconscious fixed idea. The subliminal desire is sure to be revived at some moment of weakness, as a return of craving, and to become the cause of relapse in the future. As Dr. Guimbail has remarked, `to will in the present, is a serious guarantee for the future. Those who treat morphia habitués should not only aim at the suppression of the morphia, but also at the suppression of the desire. To succeed we should in a way effect the education of the dormant will."
"It must not, however, be supposed that in the morphia habit medicinal treatment is only secondary, for encouragement is obviously the best means of overcoming the doubt and anxiety which keep every patient in bondage, and no better encouragement can be afforded to a morphia patient than the relief, by proper treatment, of the misery and wretchedness otherwise experienced, and which are none the less real because they are to a great extent exaggerated by mentality. Suitable physiological treatment must then be the basis of management.
"The method I have advocated during the past twenty years consists of three great therapeutic measures, together with the gradual reduction of morphia, coincidentally with progressive lessening of the strength of the solution, and with the substitution, at a certain point, of rectal injections. Latterly I have supplemented these sometimes by dionine. When the confidence of the patient is complete, and he is able to eliminate from his mentality doubt and anxiety, these measures will be sufficient, otherwise different sedatives may be required.
"But drug treatment is not paramount, and with the exception of heart tonics, and of agents that neutralize acidity, together with the Turkish bath, which respond, as I have shown to three formal indications, drugs and especially hypnotics should be used as little as possible. Renunciation must be effected chiefly by restoration of will, and nothing can be worse than restraint or compulsory suppression."
"To return to remedial treatment, a great many sedatives or hypnotics may be used accessorily and exceptionally with benefit, but if the object in view is permanent cure, and not merely a 'knockout' suppression, they should be avoided as far as possible.
"Dionine has proved of late years more helpful than any drug of the kind that I have given, but one patient for whom I prescribed it, acquired an addiction, and this often happens when this medicine is given as a 'cure,' and the case is not treated under proper direction.
"Of hyoscine I wrote in 1890, when I first reported my experience of it, that it was sometimes useful, but that in other cases I had been entirely disappointed by it. This, after a much more extended trial, is still my opinion.
"The same holds good of atropine, which I find more useful when associated with pilocarpine, for which reason piturine would seem to be more indicated. Bromide I seldom find necessary, and although sometimes very helpful, more rarely it is distinctly detrimental to recovery."
"With reference to management, one of the most important matters is the mechanism of the morphia reduction.
"I. A progressively decreasing quantity of morphia should, for reasons given elsewhere, be given daily in a constant quantity of salt solution; that is, there should be a progressive weakening of solution as well as a reduction of dose. This alone is sometimes sufficient to effect a cure and explains the occasional successes obtained with quack remedies containing nothing but morphia, which may become endowed with a potency which is the measure at the same time of the credulity of the dupe who takes them, and of the cleverness of those who apply in this manner psychology to trade.
"II. If further help is required in this direction, which is not always the case, the hypodermics should be gradually replaced when the patient has decreased to 2 grains by rectal injections (not suppositories): these in their turn must be decreased more or less rapidly, until given up, according to circumstances.
"Concurrently with methodical progressive reduction on the lines indicated, and with whatever means of physiotherapy may be found necessary, I always use the three modes of treatment which constitute what I have termed my `therapeutic triad.' "
"For many years I have been using heart tonics and bicarbonate of soda in morphinism, not as a 'cure' but as part of the treatment which remedies the physiological disturbances, caused by suppression, and which by alleviating two of the principal factors of craving, reduces the otherwise intolerable wretchedness of an ordinary weaning to a perfectly bearable minimum."
*    *    *    *
"Vichy water is not a cure for the morphia habit. As a method of treatment per se there is no doubt that it is, to say the least, an exaggeration, a hasty generalization, and in view of this exaggeration a mistake was excusable ten years ago. At the present, however, the testimony of specialists to its symptomatic value is unanimous and conclusive, and it is surprising to find that in his last edition Sir Clifford Allbutt still remains ignorant of the facts of the case, and still continues to deny the value of Vichy water."
*    *
"The morphia habit is a toxic neurasthenia, a disease of overstimulation, and outside the special indications for cardiac tonics, for a flagging heart deprived of its accustomed stimulation, nearly all of the other somatic symptoms may be looked upon as nervo-katabolic. They react upon one another as the ensemble of the somatic disturbances of function react upon psychism.
"The result of overstimulation is to produce metabolic perversion and to cause fatigue, and the fatigue of the nervous centres causes katabolic insufficiency, the formation of acids, which in their turn keep up a condition of nervous exhaustion by chemical changes of the cells. I first suggested this as a factor of morphia craving in 1887. Two years afterwards Dr. Hagi found excess of acid in morphinism, and it is now admitted that fatigue, whether physical or mental, gives rise to the formation of acids, and that stimulation consists of abnormal elicitation of energy, leaving afterwards, reactive depression, and (with morphia addicts) exhaustion. In ordinary healthy tiredness the acids (phosphoric, lactic, carbonic) are soon eliminated, but when fatigue becomes more or less permanent, as in the toxic-asthenia of morphinism, the nuclei of the neurones, which in their normal condition are alkaline, become acid, and this can be shown histologically. The same thing is true of the muscles of the organism generally. Whenever a tired organ is examined histo-chemically, the acid reaction will be found."
"My third great remedial measure—the Turkish bath—is discussed in another chapter, but before leaving the• question of physiological treatment, a few words are necessary about the administration of purgatives.
"It has been said that morphia in the organism is changed by oxidation into what is called oxydimorphine, and that it is the presence of this substance in the blood, and not want of morphia, that is the cause of craving.
"On this hypothesis the physiological treatment should then comprise the promotion of 'eliminatory discharges' which constitutes a natural means of cure. This plan is adopted in sanatoriums where sudden suppression is carried out, and the violence of the treatment helps no doubt to 'knock out' the addiction.
"Personally I have no experience of any knockout methods, which are entirely inapplicable in voluntary renunciation, based necessarily on the prevention of obsession. Several of my patients had, however, been 'cured' previously in this way, which shows that 'brutal,' as its partisans call it, suppression does not always act as a preventive of relapse.
"Laxatives are sometimes required in the beginning of a normal gradual suppression, but as weaning progresses the bowels regulate themselves. Towards the end there may be some looseness, but this is trifling when intestinal irritability from over-acidity is prevented by bicarbonate or Vichy water. More copious diarrhoea is an indication of a slower reduction."
"For morphia patients who were in the first instance psychasthenics, ill-balanced, irrestrainable emotives or impulsives, and who may be properly called `drug-fiends,.' the case is, however, different. When moral influence and persuasion, by demonstration of the practicability of intentional and persevering effort,—when what Dr. Harrington Sainsbury calls the personal appeal—does not suffice, compulsion of some kind is indispensable. Those who will not submit to guidance must consent to restraint, and the question will then be, what form this should take. Two means of treatment are at our disposal; the special drug sanatorium—hypnotism and hypnotic suggestion."

Paul Sollier-1894.293°

The first article published by Sollier of which we have record appeared in 1894. The following quotation presents a résumé of the development of his method of treatment based on 357 cases treated from that time to 1910:

"The fundamental mistake in the treatment of morphinism, the one which has given rise to the most fantastic articles and to the most incredible ones, consists in considering morphinism as primarily a psychical malady and secondarily as an organic state. As a matter of fact it is exactly the opposite. Even in emotional addicts the organic condition is the prime consideration as far as treatment is concerned.
"The reactions of demorphinisation are there for the finding. Elsewhere I have compared what takes place with what occurs in an infectious disease. Besides, this contention based on clinical observation has been amply confirmed by hematologic studies of morphinists before, during and after withdrawal undertaken by Drs. Chartier and Morat, my assistants at the Sanatorium of Boulogne, which they published in a preliminary paper to the Societe de Bielogie (June 25, 1909).
"The changes in the leukocyte picture enabled them to write in conclusion: `this leukocytic reaction which is observed in the same general character during detoxication of all cases and in a marked and definite manner, even in addicts to small doses (3-20 centigr.) shows what profound changes the whole organism undergoes during its detoxication. It well demonstrates that it is not simply a psychical breaking-up of a habit but that it implies a true crisis, consisting in a violent disturbance of the body, analogous to an acute infectious disease. Besides it is to be noted that this leukocytic reaction of morphinists during suppression is entirely comparable to that occurring in the greater part of acute infections; polynucleosis in the acute stage, mononucleosis during convalescence, accompanied by a reappearance of eosinophiles and mast cells and by the appearance of myelocytes. The understanding of this reaction process, the distinct occurrence of which points to a successful termination of the suppression, is not without value both in prognosis and treatment.'
"As a matter of fact it is not until about the 40th day after withdrawal that the blood curves reach normal. This is why, when we add to these 40 days the state of preparation for withdrawal, it is necessary to continue treatment for from 50 to 60 days before the patient has really finished his convalescence and is in condition to take up his work again. Sixty days considered as an average necessity, and quite enough for competent practitioners of this method of ra,;(1 withdrawal, is not arbitrary but corresponds fairly accurately to the time required by the organic restoration of which the blood picture is an index of prime importance and of exact evaluation.
"I am here reporting the statistics of 300 cases treated at the Sanatorium of Boulogne since July, 1897. They comprise 202 men, 50 doctors, 3 dentists, and 4 pharmacists and 98 women.
"According to the drugs employed they may be classed as follows: 235 pure morphinists; 18 morphino-cocainists; 37 heroinists; 3 morphin or heroin cocainists; 1 chloralist.
"The yearly percentages of these different kinds of addicts is interesting. The morphino-cocainists who represented 16.67 per cent of cases treated in 1897 and 29.40 per cent in 1898 fell to 4.54 per cent in 1900 and 3.33 per cent in 1907, in some years disappearing entirely. Heroinism on the contrary appeared in 1902 with 10 per cent and increased progressively to 1729 per cent-1903, 21.05 per cent-1904, 25 per cent-1905, 21.42 per cent-1906, 15.15 per cent-1907, 19 per cent-1908, 23.07-1909.
"This occurred because the mistake of using cocaine as a substitute for the cure of morphinism was recognized,—a mistake that was replaced by a worse one, that of believing that heroin was endowed with all of the advantages of morphin without its objections, particularly that of addiction-formation.
"To-day a new erroneous belief is being spread, that of considering dionin as a substitute for morphin and some have already begun to spread this idea in relation to a new opium preparation, pantopon. When will it be realized that all the derivatives of opium, whatever they are, have the same objections, the same dangers, and lead to the same addiction, and that the only way of curing an addict is not to give him another poison, but to remove the one he is taking? We even find physicians and medical works advising methods to check the phenomena of elimination or withdrawal, such as the diarrhoea, which they consider a fortuitous circumstance!
"Of what does the method employed in these 300 cases, without the necessity of giving up detoxication for any reason whatsoever, essentially consist? Its technique is to-day very definite and comprises 4 stages: first, preparatory reductions; 2nd, withdrawal; 3rd, active stage of elimination; 4th, convalescence.
"The Preparatory Period lasts for from 5 to 8 days according to the degree of intoxication, the general state of the patient, the functioning of certain organs (intestine, liver, heart, kidney). It is made use of on the one hand to reduce the amount of drug used progressively and according to certain indications shown by the reactions of the patient. (In the case of a morphino-cocainist, it is necessary first to withdraw the cocain, which is done without difficulty; with a heroinist, it is necessary to replace the heroin at once with about double the dose of morphin.)
"On the other hand, this period is made use of to bring the organism into good condition from the point •of view of the elimination of products changed by the poison.
"For this purpose and, first of all, purgatives are given, but only certain ones: calomel and seidlitz. Formerly it was advised to purge the patients once or twice at the time of withdrawal. I soon discovered that this was not enough, and for the last 15 years especially since I realized what the true physiologic mechanism of demorphinisation was, I have been using seidlitz more and more, not only during the preparatory period but for a long time after withdrawal.
"The patient should be purged every day and not until the alvine discharges have been continuously and abundantly set up should one proceed with withdrawal. To withdraw a morphinist who is still constipated is to expose him to all of the serious symptoms which have been previously described and which cause him to dread suppression by the rapid method.
"To-day, through the use of the method which I have advocated for so long and only because of experience with it, these symptoms are no longer to be feared and it is years since I have seen a case of syncope during the course of withdrawal, while it was a very common, in fact almost constant, occurrence formerly.
"It would be a mistake to think that the repeated purging of patients to prepare them for complete detoxication, withdrawal, is enough. The liver and the intestine are not the only channels of elimination for the changed elements resulting from the poisoning, especially with morphin or its derivatives.
"It is necessary to act on all of the glands which are able to store up morphin: the skin glands, the salivary glands. Baths, warm douches, light baths are useful in the first instance; pilocarpin on the day before or the day of withdrawal, cleans out the second ones. Finally it is necessary to make sure of the regular functioning of the kidneys and of their complete cleansing.
"The Second Stage is that of withdrawal. The excretory ducts of the glands being freed, the hypersecretion which results from the stopping of the poisoning easily escapes. The heart is not required to do extra work and remains at almost its normal rate; hence syncope need not be feared. The particular pains and nervous irritability belonging to this stage, and arising from the effort of the body to free itself, and this effort being reduced to a minimum, are also reduced to a minimum. The muscles alone, which have no excretory channels, are the seat of irritability and twitchings, which are however relieved by frequent short, warm baths. During this stage which lasts for from 24 to 30 hours the intestinal evacuations should be kept up so that the patient will not go for more than 4 hours without movements. As soon as there is a tendency for them to stop seidlitz water should be given which besides is always given during the first 2 days of withdrawal, morning and evening. The more free the evacuations the more active and prompt is his reaction and the less he suffers.
"By following this method one is especially struck with one fact, namely, that at the end of 24 hours after the last injection the desire for morphin disappears.
"The third period comprises the 8 or 10 days which follow withdrawal during which the organism continues very actively to free itself from all of the elements affected by the poison. The liver especially, always more or less contracted during morphinism, regains its size and secretes large quantities of bile. The whole digestive tract, from the tongue throughout the intestine, sheds its mucosa; the skin desquamates; the color becomes more normal; albumin disappears from the urine and abscesses heal.
"Baths, douches, daily purgations with seidlitz water together with rest in bed, which should be maintained from the first day of treatment, are the only indications during this period. Formerly, and until about 1895, I insisted on feeding these patients as much as possible during the first three periods. I had soon abandoned giving them at the time of withdrawal, as is advised in journals, port wine or other stimulants. But I gave them bouillon, milk, meat juice and meat jelly.
"I recognize the uselessness of this and now I keep these patients on an absolute diet for the first day of withdrawal with the exception of acid lemonade and then coffee when their stomachs can stand it. After this feeding is increased quickly and follows the patient's own desires during the week of withdrawal. The loss of weight which occurs, caused particularly by the organic dehydration, is quickly made up from the first week on.
"The fourth period is that of convalescence. It is characterized by the return of the appetite, a voracious one, with extremely rapid digestion which allows the patient to take several large meals a day. He takes on an average of 2 kilograms a week and often 2%, 3 or even 5 kilograms as happened in men of robust constitution.
"During this stage the body is yet far from being freed from toxic products, as is shown by the examination of the blood and eliminatory crises, which I have mentioned according to Westphal, will occur unless care is taken. These are very undesirable as they cause a state of discomfort which reawakens the desire for morphin which has disappeared from the day after withdrawal. To avoid them intestinal, hepatic and cutaneous elimination should be carefully stimulated. The activity of the sexual glands which is reawakened very intensely about the 15th or 20th day does not require any stimulation. For skin elimination warm baths and douches suffice.
"For hepatic and intestinal evacuations it is necessary to employ calomel from time to time according to the condition of the liver and to give seidlitz water daily for the first 20 days, then every 3 or 4 days or whenever there is a tendency for intestinal activity to lessen.
"It is surprising how well patients accept these repeated purgings. After a while they ask for them whenever they do not feel well.
"It should be stated that the more they are employed the quicker does their appetite and weight return. It is interesting to see how little these purgations trouble them; half an hour after taking a glass of seidlitz water they are able to repeat, their appetite is in no way affected nor is their digestion.
"Such are the fundamental principles of the physiologic detoxication of morphin addicts and addicts to analogous poisons.
"There are many other things that might be said as to the way in which these general rules should be applied and as to the conditions under which they are best used. There are, of course, many details, many individual circumstances, which require emphasizing on this or that point or omitting in another. The main consideration which must not be lost sight of is to facilitate, stimulate and maintain the most active elimination possible chiefly through the repeated use of purgatives. Consequently nothing should be given to check this elimination and nothing which might add another addiction to the one which is being treated. I cannot insist too strongly on this important point; no substitutes, no analgesics, no hypnotics. In connection with these latter, I would especially mention the immediate and disastrous action of trional, sulphonal, and similar products in recently detoxicated cases who pass quickly, even though small doses only are taken, into a state of hebetude in which they resemble general paralytics.
"Is this method which I have used for 20 years and which has never failed me, the last word in detoxication? I do not claim it and after having perfected it to as considerable a degree as possible I still see details which might be improved. The chapter on intoxications and still more that on detoxications is still far from being clear and there are many discoveries yet to be made. I believe however after a wide experience that what I have told you, in its fundamental principles, gives the greatest degree of accuracy in its application, the maximum of safety in withdrawal and the maximum chance of cure—not only immediate cure, because withdrawal always succeeds, but a permanent cure without relapse—and along with this the shortest treatment and the least difficulty at the time of withdrawal."

William Osler-1894.31

"The treatment of the morphia habit is extremely difficult, and can rarely be successfully carried out by the general practitioner. Isolation, systematic feeding and gradual withdrawal of the drug are the essential elements. As a rule the patient must be under control, in an institution and should be in bed for the first ten days. It is best in a majority of cases to reduce the morphia gradually. The diet should consist of beef-juices, milk and egg-white, which should be given at short intervals. The sufferings of the patient are usually very great, more particularly the abdominal pains, sometimes nausea and vomiting and the distressing restlessness. Usually within a week or ten days the opium may be entirely withdrawn. In all cases the pulse should be carefully watched and, if feeble, stimulants should be given, with the aromatic spirits of ammonia and digitalis. For the extreme restlessness a hot bath is serviceable. The sleeplessness is the most distressing symptom, and various drugs may have to be resorted to, particularly hyoscine and sulphonal and sometimes, if the insomnia persists, morphia Itself." •
"The condition is one which has become so common, and is so much on the increase, that physicians should exercise the utmost caution in prescribing morphia, particularly to female patients. Under no circumstances whatever should a patient with neuralgia or sciatica be allowed to use the hypodermic syringe, and it is even safer not to intrust this dangerous instrument to the hands of the nurse."

James Tyson-1900.32

"Successful treatment is scarcely possible outside of an institution and even within one serious difficulties beset the way, the chief of which is the deception practised by the patient. Patients should be divested of their own clothing and put to bed in hospital garb, because in this way alone can we be sure morphine is not concealed about the person. In the case of women, whenever possible, a special nurse should be assigned to each case. The latest testimony favors complete and sudden withdrawal of the drug as furnishing a short struggle, though a severe one. Such treatment is usually followed by diarrhoea, vomiting and insomnia. Some counsel even that no adjuncts should be employed, but certainly there can be no harm in the employment of general tonic treatment and remedies directed to the irritability of the stomach and torpor of the liver. A calomel purge is useful at the start. It is a well-established fact that, as in alcoholism, the patient should be well nourished, given such foods as milk, cream, beef-juice, or beef-peptonoids, rich broths and beef-tea. When there is great asthenia, aromatic spirits of ammonium, strychnine, and digitalis may be given, as directed under alcoholism. If possible, an occupation of an absOrbing kind should be furnished. In most cases it is impossible to secure the consent of the patient to sudden and complete withdrawal when the gradual plan must be adopted. The success of either plan depends on securing effectual control of the patient, and if this cannot be obtained all efforts fail.
"To promote sleep, one of the numerous hypnotics of which the present day is rich should be given. Chloralamide is probably the best of these. It is not easy of administration, because of its pungent taste and difficult solubility. Twenty grains (L32 gm.) or thirty grains (1.98 gm.) are a moderate dose, and are easily soluble in a fluidrachm (3.7 cc.) of a mixture of two parts alcohol and one part glycerine. Of such solution two teaspoonfuls should be given in a glass of sherry wine or four tablespoonfuls of milk at the ordinary temperature. Trional and sulphonal or somnal may be given in from fifteen- to twenty-grain (0.99 to 1.32 gm.) doses dissolved in hot water. Hyoscine in doses of 1/96 grain (0.07 gm.) may also be tried. Chloral itself may be used in doses of from ten- to thirty-grains (0.66 to 1.98 gm.). If there is cardiac weakness, the dose should not exceed ten grains (0.66 gm.). Chloralose may be given in from five- to ten-grain (0.33 to 0.66 gm.) doses in wafers or in hot milk. Too much carelessness is practiced by physicians in placing morphine in the hands of patients. On. the other hand, when morphine is judiciously ordered for patients suffering extreme pain only, it is very rarely the case that a habit is established."

M. K. Lott-1901.83

On May 14, 1901, Lott in a paper read before the Brazos Medical Association, Texas, described his method of treatment as follows:
"I have examined the works on therapeutics at my disposal, and I have been unable to find more than a hint at the value of the different remedies which I use and will discuss in this paper. What mention I have found has been brief, and, usually, condemnatory. The statements made by most of the authorities I have consulted, are entirely at variance with my experience with the remedies referred to. I have experimented with them for the past three years, and in some twenty-five cases, and I feel that it is but right that I should give this Association and the profession generally, the benefit of that experience."
*    *    *    *    *
"In the treatment for the morphine habit, or other opiates, or chloral or chloroform, no preparatory treatment is necessary. It is best to begin while the patient is well under the influence of his daily dose. He sleeps longer, and is more quiet than if treatment is deferred until about the time for the patient to take his daily potion."

"The remedies are but few, and most, if not all of them are quite familiar to the profession. They are in almost daily use. They are: Duboisine, atropia, strychnia, and the hydrobromate of hyoscine, hyoscyamine, pilocarpine. I have used all of these, but prefer the hydrobromate of hyoscine as the safest and most easily controlled. I usually begin the treatment by securing a quiet well ventilated room with but a moderate degree of light, and so arranged that the light can be excluded, for, under the influence of hyoscine, or atropine, the pupil is widely dilated, and if there be too much light the eyes are liable to be injured. I secure a careful, competent nurse. He or she should be strong and able to handle the patient, if necessary, for sometimes, if too much hyoscine be given, the patient will require to be protected against self-injury. The room should be downstairs preferably. The patient should be given a good bath and put to bed. I give 1/100 gr. of hydrobromate hyoscine, and after this I give 1/200 gr. from thirty minutes to one hour for from twenty-four to forty-eight hours, .until the patient has taken from forty to sixty doses, sometimes decreasing it, and sometimes omitting a dose altogether, watching carefully the pulse and respiration. The object being to secure hyoscine intoxication, which is readily recognized by the restlessness, dilated pupils, dry throat, hallucinations, etc., which it produces. When this stage is reached, I give the drug just often enough to keep up the delirium from twenty-four to forty-eight hours.
"It may be necessary diming this period, to give a small dose of morphine, even one-fourth grain, once, twice or three times; it will not affect the result in the end.
"Generally it is not necessary during this period to give anything else, though it may be necessary to give strychnia, or nitro-glycerine, or digitalis for the heart; but always remember that hyoscine antidotes morphine, and that morphine antidotes hyoscine. If the patient should get too much of one, I give the other.
"Usually the first few hours, sometimes for four or six hours, but in some instances a much longer period, the patient sleeps. In one instance the patient slept twenty-two hours. The pupils become widely dilated, and the mouth and throat are very dry, and the patient loses the power of co-ordination and would be unable to stand, if permitted to get out of bed; he would likely fall and hurt himself. For this reason, a nurse is constantly at the bedside. Usually after a few hours' sleep a delirium comes on and the patient is quite wild. He imagines that he sees and does things that do not occur. If specks are on the quilt, the patient is likely to imagine them to be chinches, and may spend hours picking them off, often remarking on their appearance and number.
"During this period it is necessary to give the patient water frequently, as the throat and mouth are very dry. At the end of this period, generally, the patient is permitted to come from under any drug, and after a few hours reason is restored. The patient expresses himself as cured. He no longer craves the drug and would not take it.
"At the end of the first stage of treatment, the hyoscine, duboisine, or whichever of the group you have been using, should be left off; and begin a second stage of the treatment with pilocarpine in one-eighth grain doses, which is to be repeated every hour until its physiological effect is secured, then the time between doses is to be lengthened and kept up sufficiently often to maintain the effect, which is elimination of the drugs that have been stored in the cord and in the body; or in other words, until the last vestige of the symptoms of hyoscine have disappeared. The characteristic sneezing and attempting to yawn now commences.
"During the past forty-eight hours no nourishment, or very little, has been taken, and the diarrhea has commenced. This will be likely to vex the patient for some days to come, and until now the urine has been scant and high colored.
"At this perio.l, the end of forty-eight hours, the patient has been relieved of the morphine, and thus far there has been very little or no suffering. And now pain in the knees, elbows and the back often sets in. Sometimes there are cramps. These are to be relieved, and here the ingenuity of the physician is called into play; for the next few days the real battle is on, and the necessities, real or imaginary, of the patient are to be met.
"For the diarrhea, give sub-gallate of bismuth in 30 gr. to 60 gr. doses, with fd. extract of coto bark in 20 to 30 drop doses in water at the time of giving the bismuth. This will relieve the diarrhea in a few days. It is at this time the use of pilocarpine 1/8 gr. and strychnine 1/20 gr. or 1/30 gr., hypodermatically, should be given. Under this treatment, the dryness of the mouth and throat passes away, the urine clears up, the skin becomes moist, and the appetite begins to return, and in a week or ten days the stomach will digest almost anything you offer, and the progress is faster. But the patient is nervous and restless. He sleeps poorly, and there are the pains in the limbs and back. For these and the sleeplessness, a bath either hot or cold, or the Faradic current, will be found very beneficial. Under these methods the sleep will soon come naturally. But it may be advantageous sometimes to give large doses of the bromides of potassium, ammonium and sodium a few times, even adding chloral if necessary. But usually it is best to wait for a natural sleep. The pains can be relieved by rubbing with liniments, or by electricity, bathing, pilocarpine, strychnia, atropine, or a few doses of hyoscine."

G. E. Pettey-1901-1913.34 35

In October, 1901, Pettey published his first paper on chronic opium intoxication in which he introduced his method of treatment.
Although amplified and enlarged upon, Pettey's method of treatment introduced at that time remained fundamentally the same throughout the years of his practice. The following is an abstract of the procedure taken from his book published in 1913.
The author does not approve of the gradual reduction method of treatment. This method, he states, seems to be based upon the idea that the narcotic in the system constitutes the sum total of the malady and that when the last of the drug is withdrawn the patient will be cured, while as a matter of fact he believes that it is a comparatively minor factor in the symptoms which develop, which are due more to the other poisons which it imprisons in the system. Its withdrawal without the removal of these other irritating poisons will not be attended with success. He states that when the narcotic is reduced to any considerable extent below that to which the patient is accustomed, the nervous system begins to feel the irritating effect of the toxins of
i, auto- and intestinal origin with which the system is saturated and in response to this irritation the various manifestations of distress develop.
In regard to abrupt withdrawal he states that authors who consider the use of narcotic drugs a mere vice insist upon their immediate withdrawal and advise it without any regard for its consequences to the patient.
In explanation of the actual treatment followed, the author states the following propositions:
"1. The essential pathology of narcotic drug addiction is a toxemia, the toxins being of drug, auto- and intestinal origin.
"2. At least six of the most troublesome and dangerous complicating symptoms have their origin in a perverted function, viz.: deficient excretion. These are intestinal colic, nausea, vomiting, labored and deficient heart action, and collapse. By thorough elimination these may be prevented altogether, and a number of the other symptoms of nervous and mental origin greatly modified, if not avoided.
"3. The motor function of the bowel is the function most impaired by the effects of opiates.
"4. Purgatives, secretory stimulants, as ordinarily given, which excite intestinal motion by reflex action, do not sufficiently restore that function to bring about effective emptying of the intestinal canal of a drug user.
"5. In order to empty the intestinal canal of a drug user direct, positive stimulation of the motor centers is essential, strychnine being the most suitable agent for this purpose.
"6. Since in narcotic drug users all the nerve-centers are profoundly impressed with the narcotic, resulting in extreme lethargy of intestinal motion, larger than ordinary medicinal doses of strychnine are required to overcome this lethargic state and excite efficient peristalsis.
"7. If the motor activity of the bowel be efficiently induced and maintained by direct stimulation of the motor centers with strychnine, no larger quantity of the glandular stimulants is required to promptly and fully empty the intestines of the drug user than in those not using the drug.
"8. If free peristaltic action is excited while the system is still under the sedative influence of morphine, little, if any, distress occurs and the intestinal canal can be thoroughly and promptly emptied.
"9. Strychnine, if given in sufficient doses, will excite active peristalsis, notwithstanding the restraining effects of the opium.
"10. Unless efficient provisions for the prompt and full excitation of the motor function of the bowel be made, any secretory stimulant given will merely excite excessive secretion in the upper part of the intestinal canal, accompanied by griping, nausea, vomiting, and other distress, but will be unable to empty the canal, reflex action alone not being sufficient to induce peristalsis when the nerve-centers are so benumbed by narcotics.
"11. Deficient heart action leading to collapse in these cases is mainly due to portal engorgement.
"12. When the intestinal canal has been thoroughly cleansed and portal engorgement overcome, morphine or other narcotics can be at once withdrawn from an habitué without danger to life and without the occurence of shock, diarrhea, colic, vomiting, or the slightest appearance. of collapse.
"13. A general hyperesthesia follows the withdrawal of opiates from a habitue, this being the natural reaction from the state of chronic anesthesia to which the drug user has been accustomed. This extends to all of the functions of the body, mental as well as physical.
"14. The severe suffering incident to the abrupt withdrawal of opiates, after thorough elimination has been carried out, has a natural limit of a few days' time. This suffering, severe as it would otherwise be, can be obviated and these days passed in comfort by the discreet administration of scopolamine.
"15. The therapeutic use of scopolamine, for the time it is required in these cases, does not in any way perpetuate the desire or necessity for the use of an opiate. While it relieves pain, induces sleep, and overcomes those distressing symptoms of nervous origin that follow the withdrawal of morphine, its action so opposes the effects of the opiate that, instead of perpetuating the effects of the morphine, it stimulates the centers which have been benumbed by that drug and shortens the time during which its secondary effects would be manifested.
"16. When the patient's system has been thoroughly cleansed from toxic matter, the drug withdrawn, and the patient prevented from suffering with scopolamine for from two to three days, no craving or desire for the drug remains, abstinence symptoms, such as ordinarily follow the withdrawal of opiates, are obviated, and the patient is brought to a condition in which he can pass his time in comfort, eat heartily, sleep from four to six hours out of each twenty-four, and this insures safe and rapid convalescence.
"17. The dose of scopolamine cannot be definitely fixed. The dose varies greatly in different individuals, the range being from 1/300 to 1/50 grain at intervals of from thirty minutes to six hours. At first the smaller dose should be given and repeated at short intervals until sleep is induced, or at least until the patient is free from all pain. After this the dose should be of such size and be given at such intervals as are necessary to overcome all painful symptoms and to keep the patient comfortable. The dose in one case is no index to what will be required in the next; only by a physician experienced in such matters being present and observing the effects of each dose can the proper dose be ascertained and the patient be kept in a comfortable condition.
"18. This patient should not be allowed to suffer. Scopolamine, in remedial doses, does not materially affect the vital functions or leave after-effects on either the mind or body of the patient ; therefore, it should be given until its full physiological effects are manifested, if necessary. To allow the patient to suffer during the treatment impairs his nervous system, lengthens the time during which treatment will be necessary, and materially increases the danger of the relapse.
"19. The period of convalescence during which the patient must be kept under supervision is also considerably reduced, but varies greatly in different individuals. The absence of that train of nervous symptoms, the ability to sleep naturally, to eat heartily, and the improved digestion and assimilation by which the patient rapidly gains in flesh and strength lessen the liability to relapse almost as greatly as this curative plan of treatment lessens the dangers and suffering while under treatment.
"20. The after-treatment in these cases does not consist in the adminstration of drugs, and no drugs should be given unless specifically indicated. There is certainly no place for the administration of alcohol or strychnine in the after-treatment.
"The reduction or suspension of inhibitory control by the effects of alcohol permits an extravagant and premature expenditure of energy, and this is followed by marked depression. This depression is felt to an exaggerated degree by one who has recently been taken off a narcotic drug and such a one will not long tolerate it, but will seek to blunt their sensibilities to it by taking more alcohol. This, in turn, lessens inhibitory control, and energy is again prematurely expended, and this is followed by increased depression.
"Depression from the secondary effects of alcohol calls loudly for a dose of the narcotic to which such a person has been accustomed and if that is taken the person is well on the road to relief. Alcohol in all forms should be interdicted during convalescence and forever after that.
"Strychnine keeps up the active peristalsis and inclines the bowels to empty too often. This interferes with digestion and assimilation and causes diarrhoea by the passage of incompletely digested food through the bowels.
"21. Unloading the intestinal canal and relieving portal congestion lessen the strain under which the heart has been working more than enough to compensate for the loss of the stimulus it derived from the effects of morphine, and, instead of the heart's action being weak or irregular, the character of the pulse is decidedly improved. It has greater volume, is softer, more compressible, and is, in every respect, of better quality than when propelling the blood against the obstruction of an engorged portal system, even though it was supported by morphine. However, should the heart action be weak, or for any reason need support, sparteine sulphate, one to two grains hypodermically, every four to six hours will give it more uniform and efficient support than morphine or any other known drug."
"The author has found the following formula to be a physiologically balanced purgative compound and one that has given excellent results in narcotic cases in his hands:—

R Calomel,
Powdered extract of cascara      as gr. x
Ipecac      gr. j
Strychnine nitrate      gr. 1/4
Atropine sulphate      gr. 1/50
M. and make 4 capsules. Sig.: One every two hours until 4 are taken.
preferably at 4, 6, 8 and 10 P.M., and only after having abstained from
taking dinner and supping on the day on which they were taken.
"Thorough elimination of toxic matter from the system is the primary and most
essential step in the treatment of morphine.
"The principal obstacle in securing action of purgatives in drug addictees arises from the suspension of peristalsis by the primary effects of the opiates. During a period varying from four to eight hours from the time of taking the dose of morphine intestinal motion is almost, if not entirely, absent; but as the early effects of the dose subside, peristalsis is again gradually reestablished."
To be certain of obtaining good peristalsis, 1/20 gr. strychnin should be given 6 or 8 hours after the last purgative capsule and follow this in half an hour with 2 oz. of castor oil or a bottle of citrate of magnesia. The oil or saline should be repeated at intervals of two hours until the intestinal canal has been thoroughly emptied.
*    *    *    *    *
Pettey believes that a period of convalescence of from one to two months should be spent under the direct supervision of the physician. He states:
"Unless a physician has the courage and the therapeutic skill to administer remedies in these cases in sufficient quantities to procure their full physiological effects, he ought not to attempt to treat patients of this class. We must meet conditions as we find them."

A. Morel-Lavallee-1902.36

Morel-Lavallee recommends the substitution of heroin in the treatment of morphinism provided that certain precautions are taken, namely, that the patient is never allowed to know what is being substituted or to give himself the drug under any circumstances.
The following is an outline of this author's method.
The author emphasizes the importance of complete control over the patient, of securing the patient's confidence and then of not deceiving him about the dose reductions or other matters, and of unlimited patience and loyalty on the part of the physician and attendants.
The determination of the de luxe dose is necessary. This consists of that portion taken daily that is not required to maintain a physiologic balance. The withdrawal of this portion causes no suffering. It is important to lengthen the interval between doses, i.e., to reduce the number of injections, even though the total amount is not reduced at first. The patient is encouraged to assist in this and in a few days the de luxe dose is gotten rid of and the patient's confidence is gained.
Thus the "sustaining" dose is reached. This is maintained for several days. The strength of the solution and the amount of each dose are maintained, but the number of doses is now diminished by lengthening the interval. They usually can be reduced to four or at most five injections in twenty-four hours.
At this point the author begins to substitute heroin for the morphin, at first only once a day and only for a part of the dose. The patient does not know of this substitution but notices the delayed effect of the dose and the lessened euphoria. Finally as the substitution progresses these are lost sight of. When heroin is entirely substituted it is gradually reduced, again by lengthening the intervals, as well as lessening the amount until two or even only one dose is taken a day. Tonic treatment is increased as the heroin is decreased. Finally injections of water are reached. The patient should never be told of this latter procedure.

S. Paton-1905.37

Paton states that in private practice gradual reduction should be carried on in preference to sudden withdrawal when the daily dosage has been high, as the latter is apt to be accompanied by severe and at times dangerous effects. In a hospital, however, the drug may be withdrawn at once. The author advises against the use of stimulants except when collapse is imminent at which time caffein, digitalis, whiskey, and strychnin are sometimes beneficial. The bowels should be carefully regulated and any attack of diarrhoea should be checked as soon as possible. Restlessness or delirium, he states, may be combatted by a warm pack or continuous bath. Sedatives should be avoided if possible. As a later treatment he recommends cold sprays, massage, exercises, etc.

A. Lambert-1907-1920.38 39 49

In 1907, Lambert discuses treatment as follows:
"The best method in the majority of cases, is to endeavor to find approximately how much morphia the patient has been accustomed to and cut it at least in half and give this amount in divided doses for the first twenty-four hours. It is very necessary to bring the digestive tract into as good a condition as possible in the shortest space of time, which is best done by the use of castor oil, in half ounce doses, three times a day, for the first week or ten days. When the patients are very weak, it is advisable to give subcutaneous injections of strychnine (gr. 1/60-1/30, gm. 0.001-0.002), at first every four hours. The best drug to equalize the circulation and to reduce the physical craving and suffering to a minimum, is the subcutaneous use of Livingston's solution of ergot as described under alcoholism. To allay the nervousness, warm baths are often very efficacious Kane recommends that they be given at a temperature of 112 degrees F., and the patient rubbed down quickly, placed in bed, and covered up warmly. To combat the insomnia, cold packs are often useful. A tonic of nux vomica and compound tincture of cinchona with capsicum, given three or four times a day, is of great assistance. Often in the first few days champagne or sherry is helpful, but this should not be prolonged, for these patients are as prone to take up other habits as they were originally to take up morphia. Chloral as a hypnotic has been condemned by most writers. Levinstein says that it tends to increase the excitement. Kane recommends bromides, given in large amounts of water, even in one hundred grain doses. The patient should be fed with koumyss and eggs as the most easily assimilated food. If accustomed to coffee and tea there is no reason why they should not be continued."
In the 1914 edition of the same book, Lambert states:
"Most patients addicted to morphine have long ceased to obtain any pleasure from its use. They long to be free from its slavery and dread only the terrible suffering which the deprivation from the drug brings. The question arises whether they should be treated by the slow withdrawal method, in which they are treated symptomatically for whatever symptom seems most distressing, or whether the drug should be withdrawn abruptly, and the patients suffer with full intensity, hoping to relieve them in a shorter space of time, or whether some of the more recent methods, using belladonna or hyoscine, should be employed.

"The sudden withdrawal method does not seem justifiable. The danger of sudden collapse and death is not a theoretical one. Morphinism or the opium habit is a chronic poisoning and must be treated as such. The only safe method is by the rapid elimination of the drug in the body, the quieting of the withdrawal symptoms with some preparations of the belladonna group, and as rapid a withdrawal of the drug as the condition of the patient will justify. Under these conditions collapse need not be feared, and the elimination of the poison and the restitution to health is soonest accomplished."
After briefly mentioning Lott's method of hyoscin treatment and Wagner's method of combining hyoscin, atropin and strychnin, Lambert describes the Town's method 41 in detail stating that this method has the advantage that the belladonna and hyoscyamus do not bring the patients to a stage of delirium or to the condition of helpless unconsciousness as hyoscin does. He closes the section as follows:
"This treatment in my hands in some 600 patients has proved so successful that 80% have remained well. This proves the efficacy of this method of treatment and also that most morphinists, if free from their addiction, are anxious to remain clear."
In 1920 42 he states:
"The several methods by which the drug can be withdrawn are easily performed in an institution, but the personal regeneration must in many cases be continued for months instead of weeks before success can be hoped for. Most patients addicted to morphine have ceased to obtain any pleasure from the use of the drug. Many long to free themselves from its slavery and dread only the suffering that the sudden withdrawal produced. Immediate cessation of the use of the drug without any treatment in these patients is not justifiable; the physical suffering is too intense and its endurance is not necessary. Furthermore, the danger of sudden death is not a theoretic one in the case of the morphinist. A number of methods are used for withdrawal."
Again he mentions Lott's treatment and describes Braunlich's method used in the New York City Health Department.
Again pointing out the advantage of the belladonna treatment mentioned above, Lambert describes it as follows:
"The belladonna treatment has the advantage that the belladonna and hyoscyamus are not pushed to the stage of delirium nor is the patient unconscious at any time, as in the hyoscine treatment. These drugs are never pushed beyond the state of dry throat and dilated pupils and the patients retain their consciousness and freedom of action throughout the treatment. When it is completed, the patient does not express physical craving for the drug; there is real obliteration of the narcotic craving. The belladonna mixture used consists of two parts of a fifteen per cent tincture of belladonna and one part each of the fluid extract of hyoscyamus and xanthoxylum. Patients differ widely in their tolerance of this mixture. It matters not in the treatment how much or how little of the mixture is given, provided the limit of tolerance of belladonna is reached. Some patients will not tolerate more than two drops as a hourly dose, while in others it is necessary to push the dosage up to fifteen or twenty drops. The bottle containing the mixture must be kept well corked and shaken before using. It is best to give it in a capsule, as in liquid form it produces nausea from the monotony of the taste. On the evening before the beginning of the treatment, the patient is given three to five compound cathartic pills and, if very constipated, five grains of blue mass. Six hours later these are followed by a saline. When the bowels have acted thoroughly two or three times, the patient is given, in three divided doses at half-hour intervals, two-thirds or three-fourths of the total daily twenty-four-hour dose of morphine, opium, or heroin to which he has been accustomed. The larger amount of the drug is better if the patient can take this amount. One should observe the effects carefully, however, after the second dose as the amount then equals four-ninths or one-half of the total twenty-four-hour dose. Some patients cannot comfortably take more than this at one time. With the last dose of morphine six drops of the belladonna mixture are given in a capsule."
"This belladonna mixture in doses of six drops (not minims, but drops dropped from a medicine dropper) is given every hour for six hours. At the end of six hours, the dosage is increased two drops. The mixture is then continued every hour, day and night, throughout the treatment, increasing two drops every six hours until sixteen drops are taken, after which it is kept at this dosage, or it may be increased still further if the patient does not show any belladonna symptoms up to this time. It should be discontinued if the patient shows dilated pupils, dry throat, or redness of the skin, or if the voice assumes a peculiar incisive tone and the patient becomes insistent on one or two ideas, these latter being the beginning symptoms of belladonna delirium. The mixture is begun again, at a reduced dosage of about one-half the amount at which it was stopped, after the belladonna symptoms have subsided. This is usually after three or four hours. Ten hours after the initial dose of morphine the patient is again given from three to five compound cathartic pills, with or without five grains of blue mass. In elderly patients or in patients who are physically weakened, these unusually large doses of cathartics are unnecessary, but the majority of patients feel better if thoroughly purged. These cathartics should act in three to six hours and are always followed after six hours by salines. When these have acted thoroughly, the second dose of morphine is given; this is usually about the eighteenth hour. This should be one-half the first dose given; that is one-third to two-thirds of the original daily dose. The belladonna mixture is still continued, and ten hours after the second dose of morphine, that is about the twenty-eighth hour, compound cathartic pills are given again, followed by saline six hours later. After they have acted, at about the thirty-sixth hour, the third dose of morphine is given, one-sixth or three-sixteenths of the original dose, i.e., half of the second dose. This is often the last dose that is necessary, though it may be easier if a fourth dose is given. Ten hours after the third dose of morphine, the same cathartics are given, followed by saline If a fourth dose of morphine is given, it should be half the third dose. During the period between the third and fourth, or even between the second and third dose, if the patient becomes restless and uncomfortable previous to the giving of the cathartics—that is during the ten-hour period after the morphine—he may be given codein hypodermically, one to five grains as may be necessary to quiet him. About eighteen hours after the last dose of morphine is given and after the cathartics and saline have acted, a bilious green stool begins. The cathartics are now discontinued for twelve or eighteen hours, and the belladonna is cut off; the patient is then given one or two ounces of castor oil as a final dosage. If, at any time during the treatment, the patient experiences nausea, calomel may be given in small doses at half-hour intervals instead of the cathartic pills. Sometimes it is necessary to discontinue the belladonna mixture for twenty-four hours after the last dose of morphine is given, using codein to ease the discomfort before the bilious stool appears.
"Recently it has been found in accordance with Gwathmey's recommendation, that if narcotics are given hypodermically with magnesium sulphate, their value is increased from 50 to 100 per cent. From 15 to 30 minims of a 25 per cent solution of magnesium sulphate can be used but it is too concentrated and is absorbed slowly ; 30 to 60 minims of a 125 per cent solution acts more quickly. One-eighth of a grain of morphine given with the sterilized chemically pure solution of magnesium sulphate intramuscularly, or one or two grains of codein with magnesium sulphate, acts to quiet the restlessness of these patients better than large doses of morphine. Hypodermic injections of the magnesium sulphate solution with a small dose of codein at four- to six-hour intervals, or more often, will quiet muscular pain and restlessness better than any hypnotic. It is often wise, during the treatment of these patients, to give them strychnine or digitalis if the pulse seems at all weak, although in recent years this has been done much less than formerly, as the necessity does not seem to arise. Sometimes after the thirty-sixth hour the patient's stool will become clay-colored, but the use of oxgall in small doses is effective in stimulating further biliary secretion. Pain in the legs andInees during withdrawal are relieved by phenacetin and caffein or by pyramidon and the salicylates or two or three grains of sodium nitrate every two to four hours will ease the incessant aching. It is noticeable that magnesium sulphate added to the small dose of codein has greatly reduced the necessity of the other drugs.
"Many patients experience abdominal pains which are not connected with the cathartics and they also suffer from general apprehension. It is well to give these patients ten grains of chloral and. fifteen to twenty grains of sodium bromide for four or six or eight hours; this seems to reduce their restlessness and apprehension, does much to make them comfortable, and helps, besides to diminish the abdominal reflexes, which in some instances cause a good deal of trouble. Sodium bromide continued for twenty-four or forty-eight hours in diminishing doses after the treatment has ceased, does much to relieve sleeplessness from which most of the patients suffer. If the patient shows an idiosyncrasy against codein and it produces a redness of the skin and a rash, dionin may be substituted."

G. F. Butler-1908.43

"The general outline will consist of substituted sensations, substituted ideas, and general tonic and supportive treatment. To accomplish the former purpose, after almost complete withdrawal of the drug has been brought about, codeine, heroin, dionin, hyoscine may be used to create a sense of euphoria, which differs in some respects from the old euphoria of the drug. One of the best hypnotics is a combination of sulphonal with a vegetable narcotic like conium or hyoscyamus. The bromide salts in large doses may be employed. The morphine user is always a victim of toxemia from arrested functions of the kidneys, liver and adrenals, and intestinal antiseptics, laxatives, and cathartics are a necessary part of the treatment. Hydrotherapy properly employed is invaluable. Static electricity or electric baths are of great value in some cases, but not in all. The immediate surroundings of the patient should be made as pleasing as possible. Food and medicine should be given in the most agreeable forms consistent with usefulness, and the same kind of attention paid to every method of treatment employed."
"The treatment of so dire a malady—for such the chronic use of opium must be regarded—demands the utmost forethought, patience and tact. The method of sudden, absolute withdrawal of the drug is admitted by the wisest observers to be fraught with danger commensurate with that of the indulgence to be overcome. Collapse, delirium, and other serious results have attended so drastic a measure, the general opinion obtaining today being that a gradually reduced dose of the drug is the safest and most rational mode of procedure."

E. S. Bishop-1912-1920.44 45

Since 1912, Bishop has written numerous articles on the treatment of chronic opium intoxication. A detailed discussion is found in his book, 1920, as follows:
"In a paper, 'The Rational Handling of the Narcotic Addict,' read before the Section on Pharmacology and Therapeutics, Annual Session of the American Medical Association, 1916, I stated, 'It is not my purpose to enter. into discussion of the various therapeutic methods and therapeutic measures which have been advocated and employed in the treatment of narcotic addiction. Their number is legion, and they include most of the therapies known to lay as well as to medical literature.
" 'Their multitude is conclusive proof of lack of conception and of understanding of addiction-disease in the past. They have been directed towards incidental and complicating manifestations. They have no more place in the treatment of the addict than they have in the treatment of any other disease condition. I know of no medication that can be called "specific" in the arrest of the mechanism of narcotic drug addiction-disease. There is no more of a specific remedy for narcotic drug addiction than there is for typhoid or pneumonia. The wide advertisement of treatment based on supposed "specific" action of the products of the belladonna and hyoscyamus and similar groups is unfortunate. They have, in my opinion, no action as curative agents in narcotic drug addiction-disease which can entitle them to consideration as specific or special curative remedies. The drugs of this group are useful in many cases, intelligently applied to meet therapeutic indications. They exhibit wide variation of action and reaction in narcotic drug addicts at different clinical stages and under different clinical conditions, and their dosage presents an extremely wide range of individual measure. They are dangerous drugs in the hands of the inexpert or careless, or used in a routine manner or dosage. The status which they have acquired as specific medication in narcotic addiction disease I hold to be a medical fallacy which should be strongly opposed and early remedied.' "
"We are nearing the end of consideration of routinely applied procedures, in all diseases. In addiction we are entering upon a stage of attitude and handling in which there shall be in each case comprehension of intrinsic elements and appreciation of their relative importance, and in which there shall be competent interpretation of symptomatology and competent selection and application of therapeutic measures, placing our efforts on a rational basis and adapting handling and treatment to the needs of the individual.

"Our stumbling-block in the past has been that our minds have been too much focused upon the mere use of narcotic drug and upon the stopping of drug use and too little upon the individual we were treating and the mechanism of his disease. We have tended to apply our remedial efforts to narcotic use instead of to narcotic drug addiction-disease."
"The one great point to be kept in mind is that narcotic addicts are sick ; sick of a definite and now demonstrable disease. This disease is variously complicated and widely variable as it occurs in individual patients. Although some individuals, afflicted with this disease, may require custodial or correctional handling—the 'fundamental physical disease cannot be properly arrested nor handled successfully by mental, moral, sociological or penological methods only. Any toxic, worried, fear-ridden or suffering sick man may show psychological or even psychiatrical manifestations or complications, but observing and attempting to control complications only will not cure basic disease.
"Even if it should some day develop that a serum can be produced against the underlying toxins of addiction-disease; and this is not beyond the bounds of possibility; its usefulness and application must remain for the present matters of academic speculation. Other than this possibility, there seems practically no hope of a properly called 'specific medication' in narcotic drug addiction-disease. Even with its discovery, it is highly improbable that a routine treatment applicable to all cases could ever be successfully adopted. In the very few disease conditions in which we can properly be said to have 'specific' medication, routine handling and treatment of all cases is inadvisable and unsatisfactory."
"Intelligent addicts well know that other factors being equal, the less number of times in a day they take their drug, the less constipated and more normal they are, and the smaller amount of narcotic drug they require to maintain them physically and mentally competent. It is unfortunate that this therapeutic principle so widely recognized among intelligent addicts has not received full recognition and therapeutic employment by all of those who handle and treat addiction-disease. Its probable explanation is very simple—apparently a period of inhibition follows the administration of narcotic or opiate drugs; and the length of this period is not in ratio to the size of the dose administered. Consequently the fewer number of times in a day a dose of narcotic drug is administered, the greater amount of competent metabolism is present—the more adequate is the patient's elimination and nutrition—the smaller amount of opiate or its product lies stored in inhibited and atonic cells, and the smaller amount of antidotal substance is manufactured for the protection of the body, and to some extent, the smaller amount of opiate is required.
"In caring for the narcotic addict, therefore, one of the most important therapeutic measures is the regulation of the interval of his narcotic drug administration. I have repeatedly experimented upon addicts who were not confined or under restraint in any way. I explained to them the inhibitory effects of too frequent dosage and instructed them to use the amount of drug they found necessary for twenty-four hours in large doses at longer intervals. This procedure alone, in many cases transforms the pallid, starved, constipated and deteriorated addict within a surprisingly short time into a well-nourished, well-reactive and practically normally functionating individual. With the return of health, vitality, and normal nutrition and elimination, his body requires still less drug and he voluntarily and without mental struggle and nervous strain reduces the amount of drug used. I wish to emphasize that in these experimental cases there were no other therapeutic measures employed in the way of medication."
"It is evident, therefore, that upon the intelligent and competent estimation, measure and control of physical narcotic drug balance and inhibition of function depend the reaction, well being and therapeutic progress of the man who has narcotic drug addiction-disease. These factors also markedly influence the action of all medication, including the drug of addiction, upon the body of the opiate addict. They influence the reaction of the addict's body to all medication. Medication cannot be intelligently administered to the opiate addict unless those who administer it have understanding and clinical appreciation of the widely varying reaction of the addict under different conditions of drug balance and inhibition of function. Failure to recognize and appreciate this fact explains a considerable portion of the past failures and the past mortality attending specific and special methods and treatments, and so-called 'cures.' The dosage of medication administered and the time of its administration should therefore be determined upon with watchful eye to the reaction of the patient, and with intelligent comprehension of the possibilities in reactionary change."
"The method of gradual reduction of dose to the point of ultimate discontinuance is practical and feasible under conditions and at an expense of time and money which are possible to but very few addicts. The forcible reduction of dose without regard to the environmental, mental, economic, physical or other conditions of the average and individual addict, and absolutely ignoring the considerations of the mechanism and symptomatology of his addiction-disease is barbarous, harmful and futile. Enforced reduction of dose below the point of body need is not worth what it costs in nerve-strain, suffering and physical inadequacy. The extent of addiction-disease and the degree of progress in its remedy cannot be measured in terms of amount of drug administered. It must be measured in terms of clinical symptomatology, just as progress is measured in any other disease. Reduction of dose below the amount of body need, prior to the stage of final withdrawal, constitutes a serious therapeutic handicap and is most decidedly contra-indicated. Withdrawal of opiate from an addict whose physical reaction and strength and nerve force have been reduced and depleted by continued reduction of amount of drug without commensurate reduction in the extent of body need is harder than withdrawal from a reactive individual with reserve nerve and physical force who may be taking a much larger dose."
"Of primary importance, then, if a physician, institutional or practitioner, is to have any success in handling a case of opiate addiction-disease, is his attitude towards his patient--divesting himself of all conception of habit, appetite or vice as explanation of characteristic physical manifestations and symptomatology, and approaching the patient as a man with a definite disease requiring and deserving intelligent clinical handling. The patient will be the very first to mark a physician's shortcomings. If he has not confidence in the doctor's ability and understanding of his illness the doctor can help him but little. This statement applies not to addiction-disease alone but to every medical condition.
"There are three demonstrable elements to be determined, measured and controlled in the actual therapeutic handling of cases of narcotic addiction-disease. The first of these is the actual amount of drug which the patient's body demands to maintain functional and organic efficiency and to escape physical distress. The second of these is the extent of auto- and intestinal-intoxication, autotoxicosis and malnutrition. The third of these, which is both a result of and a causative element in the other two, is the extent of inhibition of function."
"In the successful handling of a case of addiction-disease, therefore, the first effort should be to determine approximately the amount of the patient's minimum daily physical need for the drug of his addiction. This need is clinically recognizable and definitely measurable."
"In the estimation of this amount of physical need the procedure is very simple. Have administered to the patient who is manifesting the symptomatology of drug-need, sufficient drug to remove the symptoms and restore him to complete physical, functional and nerve balance. Have the length of time observed which elapses before the symptoms of drug need reappear. Have this repeated several times and information is secured as to what quantity of opiate under the existing conditions will hold that patient in drug-balance for a known length of time. In this way can be mathematically estimated the extent of physical drug-need. The average need for twenty-four hours can be easily computed from the data obtained. It is merely a matter of arithmetic."
"It is therefore much wiser to direct immediate efforts to the securing and maintaining of health, reaction and tone—irrespective of the amount of drug required—until there is time and opportunity for the undertaking of competent withdrawal—a stage of handling and treatment concerning whose physical and clinical phenomena and manifestations and dangers too few are educated to and familiar with."
"I have briefly referred to the elements of intestinal and autointoxication and autotoxicosis. Intestinal and autointoxication, combined with worry, fear, and anxiety, constitute very important causative and controlling factors in whatever mental and physical deterioration has taken place in a case of narcotic-drugaddiction-disease. Physical, mental and moral deterioration are to a very small extent direct results of narcotic drug action per se. As long as a narcotic drug addict is maintained non-toxic, uninhibited and unworried, he is practically at his individual normal, plus an added physical need."
*    *    *    *    *
"The control of auto- and intestinal intoxication in narcotic addiction is as a rule of easy accomplishment if the patient is uninhibited and in functional balance and is not over-supplied or under-supplied with the drug of his addiction. The narcotic addict who is non-toxic and in drug balance and is not harassed by worry or fear needs practically no more drastic methods of elimination than his non-addicted brother. If he is over-dosed his elimination is inhibited; if he is under-dosed his eliminative powers are not capable of response. The element in the securing of evacuation of the bowel in a drug case, as well as in a toxic case of whatever description, is sluggish peristalsis; in other words, it is inhibition of nervous impulse. It is therefore not necessary to load a bowel up with large amounts of drastic and irritating cathartics. Indeed this procedure is very harmful and abortive of ultimate results. An over-irritated intestinal tract is not a good eliminative organ. To my mind the so-called 'typical stool' of the so-called 'Towns Treatment' with its content of jelly mucus has no clinical significance other than its evidence of a production of an exhaustive and irritative mucous colitis and means that however much purging may be accomplished competent elimination from the colon is at an end. Its appearance in a case under my care I should regard as evidence of injudicious treatment. For the bowel elimination of a case of narcotic-addiction there is needed practically nothing beyond the ordinary mild and non-irritating catharsis. All that is needed is to remember that if inhibition of peristalsis has not as yet been overcome, you may be wise to administer, about the time you should get an evacuation, strychnine or other peristaltic stimulators in sufficient amounts to overcome existing inhibition and stimulate peristalsis."
*    *    *    *    *
"I do not use or endorse a 'belladonna' treatment, a 'hyoscine' treatment, nor any other description of specific or routine treatment in addiction-disease. I regard the drugs of the belladonna and hyoscyamus groups, pilocarpine, etc., as extremely dangerous drugs to be routinely or carelessly used in the treatment of addiction-disease. They are rendered safe only after personal experience and study into their action and appreciation of the factors and influences which control their action in the functional, toxic, and narcotic drug conditions. The routine and unintelligent use of the products of these groups of drugs in the treatment of narcotic addiction—under the mistaken impression that they somehow or other have direct curative action upon the disease condition—has been the cause of a considerable mortality and an easily understood opposition among intelligent addicts. Hyoscine or scopolamine and the other members of this group, eserine, pilocarpine, the coal tar products, etc., are at times useful drugs to meet indications in the treatment of a case of addiction. Increasing intelligence in the handling of the addiction mechanism itself, however, renders the necessity of their use less and less frequent and the dosage of them required for therapeutic action smaller and smaller. They should simply be classed as of use among other things, peristaltic and circulatory stimulation and support, indicated eliminants, kindness and consideration, understanding and intelligence or any of the other therapeutic weapons in our possession.
"Elimination and the securing of it in the narcotic addicted has been referred to in this chapter. The chapter should not be closed however, without a word of warning against the excessive purgation with drastic and over-irritating agents employed by some in this condition. Drastic purgation is not at all synonymous with competent elimination. Competent elimination is not to be measured in terms of bowel-movements; but in terms of clinical symptomatology of toxemia, circulation and measure of functional efficiency. Excessive purgation means over-irritation and over-stimulation of eliminative mechanism, -results in the interference with and exhaustion of function and defeats true elimination.
"Presence of good circulatory tone and .absence of congestion in the eliminative organs is to me one of the most important factors in true elimination. The addict who is in good functional tone, has competent circulation, is in narcotic drug balance, and is non-inhibited, needs no more drastic eliminative measures than belong to ordinary rational therapeutics in the non-addicted.
"As to final withdrawal of the drug, and ultimate arrest of the disease, I shall say but little in this book."
"An element in successful withdrawal of narcotic must also remain, as in everything else, the inherent personal gifts and qualifications of the individual operator. A man works best with the tools most adapted to his hand, and operators of different temperaments and of different experience and training will always disagree on points of procedure and technique. My own procedure in final withdrawal is determined largely by my study and measure of my patient and my patient's reactions, addiction and otherwise, during my preliminary or preparatory work, selecting the time for final withdrawal of drug by consideration of similar factors as would be taken into account in an operation of election.
"After a preliminary stage, or stage of preparation, in which I have gotten rid of all possible abnormalities, physical and psychical, with my patient robust and reactive, confident and expectantly happy, with autointoxication, and inhibition removed and the possible residues of opiate or opiate product no longer stored in atonic body cells—the addiction-mechanism, therefore, only kept in activity by the current intake of opiate, which if properly handled and the patient not subjected to exhausting strain and struggle and suffering, can be eliminated in a very short time,—with these conditions consummated, I hasten elimination, keeping well away from exhausting purgation, maintaining my patient's circulatory and other functions, and conducting as rapid a withdrawal as is compatible with my patient's reactive condition and the reactions of his disease.
"In other words, I endeavor by my conduct of the case to reverse the process of development of the physical addiction-disease with its concomitants and complications, as I find it in the individual case, arresting the addiction-disease mechanism only after I have cleared the clinical picture in so far as possible of all other considerations."

J. McIver and G. E. Price-1916.46

McIver and Price made a study of the comparative values of various treatments as follows:
1. The original Lambert method.
2. Lambert's method without the belladonna prescription.
3. Lambert's method without free purgation.
4. Gradual withdrawal.
5. Gradual withdrawal with free purgation.
The following are the results of their study.
They selected several patients for comparison, of approximately the same age and daily dose, whose use of the drug covered about the same length of time.
They conclude as follows:
"1. The original Lambert treatment was more satisfactory than the ordinary, gradual withdrawal.
"2. The Lambert method without the free purgation (using ordinary purgation) was very unsatisfactory, patients suffering intensely and showing a marked tendency to delirium.
"3. The belladonna prescription was the least important element in the Lambert treatment, having little or no greater value than other sedatives, besides having a tendency in certain cases to produce delirium.
"4. Having a fixed dosage for each patient, as in Lambert's treatment, is an undesirable feature, which does not allow for individual differences; to disturb a patient every hour of the day and night is folly; and to try to blend him to a machine treatment is a very unwise procedure.
"5. The best method proved to be gradual withdrawal with free purgation as in the Lambert treatment, and sedatives or stimulants as required in the individual case.
"Patients using daily very large doses of drugs and over long periods of time can only have the drug withdrawn very gradually, without intense suffering or danger of collapse."
*    *    *    *
"The most valuable unit in the Lambert treatment is the method of free purgation. The Lambert treatment, while better than the old method of very slowly withdrawing the drug, is not as satisfactory as gradual withdrawal combined with free purgation and medication to meet the individual requirements.
"Any treatment which does not take into consideration the presence of the antitoxic substance in the body long after the drug has been withdrawn, and provide time, is almost certain to be void of permanent results."

C. E. Sceleth-1916.47

The following is an abstract of the treatment described by Sceleth which he states he used in fifteen hundred cases. It is suitable also, he states, for use in the patient's home by the general practitioner.
Treatment is based on following formula:
Scopolamin Hydrobromid      gr. 1/100
Pilocarpin Hydrobromid      gr. 1/12
Ethyl-morphin hydrochlorid (dionin)      gr. 1/2
Fluid extract cascara sagrada    m 15
Alcohol    m 35
Water qs. ad.      5 1
Patients using more than 10 grs. of morphin a day are given 60 minims of the mixture every 3 hrs. for six days, the dose is reduced to 30 minims on the seventh day and on the ninth day to 15 minims three times a day only.
Users of more than 5 grs. are started with 45 minims which is reduced on the seventh day in a manner analogous to that just detailed; while to those who have been taking less than 5 grs. is given an initial dose of 30 minims only.
Scopolamin delirium develops in about four per cent of the cases and if it does the scopolamin should be omitted for a few doses and added again in smaller doses as the condition improves. He states:
"The greatest danger, however, collapse, does not arise from the scopolamin mixture per se, but incidental to the withdrawal of the morphin. The tendency to collapse is undoubtedly favored by the presence of two drugs which act on the vagus—scopolamin, which is vago-inhibitory, and pilocarpin, which is vagotropic. If the pulse falls below 40 or goes above 120 per minute, the mixture is stopped and the patient is given the only drug which can offset the collapse, namely, morphin itself. The latter is injected in one-third grain doses every fifteen minutes until results are obtained. Patients in collapse, should not be given too large doses of morphin, or its derivatives, after treatment has been in progress for several days, as the dose to which the addict has been accustomed is likely to be overwhelming. The vomiting and insomnia which occur more or less constantly are not due to the scopolamin mixture, but occur with any treatment, and accordingly are not to be looked on as special complication."
"As regards the other steps in this mode of treatment, a few remarks will suffice. The patient on admission is put to bed, given three compound cathartic pills, followed by a saline cathartic (Epsom salt), and at once started on the scopolarnin mixture. During the first few days of the course the diet should be light and easily accessible, and liquids should be pushed; the patient should drink 3 pints or more of water a day. On the tenth day, at which time the mixture is discontinued, strychnin nitrate, one-thirtieth grain, is given for three doses; the following day the amount of strychnin is reduced to one-sixtieth grain, which is continued three times a day for a week.
"By the fifth day, as a rule,' the patient's desire for morphin is gone. He then manifests a desire for a more substantial diet and begins to put on weight rapidly. When the mixture has been stopped, and the patient's strength permits, graded exercises, in the open as possible, are instituted with the purpose not only of improving his physical condition but of allowing him to acquire, a bodily fatigue, which is recognized by all as the best antidote to the insomnia—the abstinence symptom most likely to persist and the most difficult to conquer. A warm bath of 110 F. for ten minutes, or a neutral bath of from 94 to 98 F. for twenty minutes, will often relieve restlessness and insomnia. Carbonated waters are very gratefully received."

F. X. Dercum-1917.48

Dercum recommends complete rest with special feeding, bathing, massage, and electricity. He states:
"The question of the rate of withdrawal is not susceptible of a routine answer, but must be decided with special reference to all the circumstances in each individual case. Some writers advise immediate withdrawal, others rapid withdrawal, and others again very gradual withdrawal. Thus, Gilles de la Tourette advises sudden withdrawal if the patient has been taking large doses, say five to six grains daily, and gradual withdrawal if the patient has been taking less than five grains; while Comby advises sudden withdrawal invariably. It is my own practice not to begin withdrawal until rest treatment is fully under way. We must remember that the morphin habitue labors under an excessive fear lest the drug be withdrawn too soon. Besides, sudden withdrawal always implies a period of frightful physical and mental suffering. Further, the patient is, as a rule, intensely distrustful. I know of no class of patients with whom it is more difficult to establish friendly relations, or in whom it is more difficult to inspire confidence. However, if the patient learns after his first days of rest and isolation that he is still receiving his hypodermic injections, or that he is still being allowed his usual quantity of laudanum or opium, confidence sooner or later asserts itself, especially as the physical comfort resulting from the bathing, massage, and proper diet soon becomes pronounced. Withdrawal may then be commenced, and it is almost always best conducted very gradually. At first, the diminution of the dose is practically imperceptible; later on the reduction may be more rapid. If the patient has been in the habit of receiving hypodermic injections, it is my practice not only to reduce the dose gradually in the manner indicated, but also to begin adding to the injection small doses of strychnin nitrate, say one-fiftieth of a grain (12 milligrams), and if the skin be very moist, small doses of atropin sulphate, say one two-hundredth of a grain (0.6 to 0.3 milligram). These drugs markedly allay the nervousness and suffering of the patient. It is needless to say that after the morphin has been discontinued entirely, hypodermic injections of strychnin or of strychnin and atropin may be kept up for some time without informing the patient of the change. Cocain should never be used; a large number of patients that come under our care for the morphin habit have already acquired the cocain habit. The same remarks apply to the use of alcohol. Many of our cases, indeed, are instances of the `triple' habit, namely, morphin, cocain, and alcohol.
"The reason for withdrawing the drug in the gradual manner I have described, is not only to diminish the suffering of the patient, but also to prevent the onset of serious symptoms. Every now and then, if the drug be abruptly withdrawn, signs of collapse—diarrhoea, sweating, cardiac weakness, and dyspnoea, with excessive prostration—may set in. In other cases, again, mental symptoms resembling those of confusional insanity make their appearance, the patient becoming hallucinatory, delusional, and finally delirious. Such symptoms are not likely to make their appearance if the drug be withdrawn in the manner indicated and under fully established rest conditions."
"The detailed method of diminution depends largely upon the individual case. As a rule, I continue for a number of days the quantity of morphin that the patient is habitually taking; I then begin to diminish the doses given in the early part of the day; those given at night are continued in full quantity for a somewhat longer period. This is contrary to the practice of others, who begin by diminishing the evening doses. I have observed, however, that cutting off the evening doses makes the patient restless and sleepless; while the reduction of the morning doses, though producing restlessness, is not attended by the great disadvantage resulting from insomnia and its attendant evils. No hard-and-fast rule can, however, be said to apply. The patient should be given the drug when he needs it most, and it should be first diminished or withdrawn at those periods when he needs it least. Inasmuch as morphin injected hypodermically is eliminated by the stomach and is subsequently reabsorbed by the intestines, Hitzig has suggested that in treating morphinism we should systematically wash out the stomach. This seems to me an unnecessary precaution. The procedure adds greatly to the distress from which the patient is already suffering, and it is doubtful whether the quantity of morphin thus gotten rid of is really large."

Walter A. Bastedo-1918.49

"Treatment.—L Isolation from friends and hirelings.
"2. Gradual withdrawal of the drug in from two or three days to a week. Accompanying the withdrawal there may be diarrhoea, cramps in abdomen, back, and legs, intense restlessness, mental and physical suffering, and collapse.

Valenti has shown that the withdrawal symptoms in dogs are arterial hypotension and arrhythmia, and that the serum after withdrawal will produce the same condition in normal dogs. Talmey attributes some of the withdrawal symptoms to acidosis, and reports a case developing coma from this cause. Stokes finds a sympathicotonic state.
"3. The substitution for a time of other drugs, of which great favorites are atropine, hyoscine, dionine, and codeine. Keeping the patient in a state of partial narcosis for several days tends to prevent the discomforts which cause the craving for morphia.
"4. Nourishing food, to the extent of overfeeding.
"5. Massage, baths, and general measures to improve the hygienic conditions of living.
"6. Excessive and persistent purgation.
"7. Removal of the original cause of the habit, as by operation on an ovary or other source of pain.
"In morphinism there is no hereditary neuropathic tendency as there is in alcoholism, and the causes of the continuance of the morphine habit is the distress of the withdrawal symptoms. The morphinist will often desire to give up the drug, but never does so of his own free will, because he cannot stand the physical suffering. Yet morphine patients have a greater desire to reform than alcoholics have, and, when once reformed, are quite likely to remain so, unless the pain or worry, etc., which was the original cause of the habit, recurs. Often they go back to the drug for relief from suffering, rather than because of any special craving for it."
"The cutting off of the habitual dose because of some intercurrent illness, such as pneumonia, causes needless suffering and danger."
The author also gives Lambert's method in some detail and mentions briefly Stoke's and Pettey's, concluding as follows:
"It would seem that to obtain a cure as much depends upon the physician in charge as upon any method."

S. E. Jelliffe and W. A. White-1919.5°

"The treatment is usually the prompt removal of the large doses. These can be readily withdrawn until the patient is reduced to the actual necessary amount of drug to get through the day comfortably with, which is about two grains. From this point on withdrawal should be gradual, carefully looking after the symptoms of abstinence as they appear. These symptoms refer particularly to the heart, the nervous system, and the gastro-intestinal system.. Sometimes profound collapse may occur with the withdrawal of the drug. Cardiac conditions should be watched and stimulants administered if there is any sign of weakness. For the diarrhoea opium should be avoided if possible. Acute withdrawal and treatment by atropine for the sympathetic collapse, and pilocarpine or eserine, for autonomic stimulation, may be practiced to advantage."
In a separate work White 51 recommends Dercum's method.

T. F. Joyce-1920.52

The following is a description of the treatment carried on at the Riverside Hospital, North Brothers Island, New York, by Joyce under the New York City Health Department.
The patient first is placed in "preparatory" ward where in six days he is brought down to the smallest amount of narcotic that will hold him without the usual signs of drug deprivation—usually two to three grains in twenty-four hours. During this period of six days' reduction full catharsis is secured but no drastic purgation. Joyce states:
"At six o'clock on the morning of the seventh day the patients are given a large dose of castor oil followed shortly afterwards by a small dose of morphine, the last they receive in the institution unless otherwise indicated. About four hours later the first signs of drug deprivation are usually experienced. This is a signal to start using a therapeutic anesthetic. At Riverside Hospital we use the hyoscine hydrobromate. I may say here that we use hyoscine internally practically with the same object in view that the general anesthetist employs ether, in other words, as these various symptoms reappear, small but adequate doses of hyoscine are given at irregular intervals, depending upon the physiological action in the particular case. Personally I find hyoscine, when used with reasonable care and in small doses, and particularly after thorough and satisfactory elimination a perfectly safe therapeutic agent, wonderfully adapted to this stage of the treatment. During this period, which we have termed the period of therapeutic anesthesia, we are combating all the phenomena attending narcotic deprivation, such as vomiting, general restlessness, intestinal colic, cramps in the legs, and a rapid, feeble pulse. These characteristic symptoms are held in check by the frequent administration of small doses of hyoscine, usually hypodermically. At the end of thirty-six hours, under favorable conditions the hyoscine is discontinued and we arrive at the period of convalescence."
During the hyoscin period no food is given but abundance of alkaline waters. Some cases require 9 to 10 doses of 1/300 gr. hyoscin, others 13 or 14 doses of 1/250 gr. Cocain users often become maniacal and go into convulsions. At this stage a single dose of morphin will counteract these symptoms. The author continues:

"At this stage of the treatment we produce what might be properly termed a modified twilight sleep. After thirty-six to forty-eight hours of withdrawal treatment the patients are found to be moderately intoxicated by the accumulative action of hyoscine; even after a period of twelve hours they experience all the customary signs of their intoxication and we describe this period as the posthyoscine hysteria. This is followed in twelve hours by a general feeling of depression and weakness which lasts from two to seven days, depending upon the recuperative powers of the individual and the duration of the addiction. During this early convalescent period they are given hot baths and mild hypnotics, if indicated, and a restricted diet."
Forty-eight hours after the last dose of hyoscin the majority of patients go to the "first convalescent" ward or if not quite ready to the infirmary. The latter are termed "laggards."
After a week or ten days in the first convalescent ward they are transferred to the "second convalescent" ward. Here their physical reconstruction begins. They have light gymnastic exercises and "occupational therapy." Joyce says the chronic user is lazy and it is necessary to teach him to work.
Joyce states that as yet he has found nothing that will remove the psychic trauma that the prolonged use of drugs inflicts.

J. Biberfeld-1921.53

Biberfeld reports on an attempt experimentally to detoxicate morphinized dogs. The author bases his experiments on the hypothesis that tolerance is due to an alteration in the nerve cells rendering them no longer sensitive to the action of the drug. As a result of experiments in which he sought to restore the normal sensitiveness of the cell, he found that the administration of albumen and a venesection caused a return of sensitiveness to the morphin, but this lasted, however, only a short time.
As to the significance of these findings in the treatment of morphinism, the author states:
"As indicated, the action in the positive experiments was not permanent; in individual experiments it was still apparent on the 2nd day and very slightly so on the 3rd day, but it was principally exhausted on the first succeeding day and the insusceptibility to the alkaloid returned again. This is naturally of especial significance in relation to morphinism in man, which, although not identical, still is comparable with the state of insusceptibility. Nevertheless I think that an investigation should be made on this point, since both agents found to be effective—venesection and albumen injection—are quite safe. With this it would be hoped that at least it would help the patient through the first day of treatment with its difficult abstinence symptoms."

M. Roget -Dupouy-1922-1924.54 54a

The author disagrees with those who advocate abrupt withdrawal as he thinks it predisposes to relapse and the memory of the suffering endured prevents such cases from again seeking treatment, preferring even suicide to a repetition of the treatment. It must not be forgotten, he states, that the constitutional morphinomaniac is afraid of pain and that suicide during painful treatment is not uncommon. He also points out the difficulty of practicing this method except when the patient can be confined, as in custodial institutions, as voluntary cases will leave rather than stand suffering.
Not only for these reasons but also from a purely medical point of view he prefers the slow reduction method. The minimum of pain as compared with the method of Levinstein, leads to a more rapid convalescence and assures the physician of the patient's entire confidence. A case so treated will in the event of relapse or even in threatened relapse seek his physician's help. This situation is a true prophylaxis and the importance of such an influence over these cases should not be lost sight of. Real cure in these cases is a psychotherapeutic cure.
Rapid withdrawal, he claims, even though less rapid than advised by Erlenmeyer, gives rise, in old patients or when there is liver or kidney insufficiency, to symptoms of mental confusion with delirious dream states and hallucinations, not observed in gradual withdrawal, with profuse diarrhoea and severe neuritic leg pains.
Abrupt withdrawal with or without drastic purgations or sedative substitutes such as belladonna, xanthoxylin, hyoscyamus, cannabis indica, etc., is too severe to be warranted and convalescence in cases whose nervous systems and eliminative organs have been so severely shocked is longer and more difficult than when treatment is carried out without severe pain or violent crisis, but such treatment requires several months.

In a later article Dupouy includes in his handling of treatment, withdrawal of the drug, detoxication, conduct of convalescence, and prevention of recurrence. In a brief review of the better known methods of treatment he characterizes abrupt suppression (Levin-stein's method) as possible only in exceptional cases of vigorous and robust subjects, stating that he rejects it as dangerous and extremely painful. The "American way," of which he takes the Lambert method as typical, rapid suppression with active purgative and substitution, he states is brutal and difficult to bear and not free from danger. He presents, as his choice, slow withdrawal with diminishing doses of morphin over a period of at least three weeks, a modification of Joffroy's psychotherapeutic method.
His method in detail is given in the following extract:
"A. The basal principle is that the subject should remain constantly in ignorance of the dose of morphin injected. Knowledge on this point, especially when the dose reaches a minimum, two or three centigrams, almost inevitably causes an emotional reaction, anxious apprehension, painful neuropathic manifestations, insomnia, etc., while absolute ignorance of the dose favors our measures of encouragement and psychotherapy. Thus we have been led to continue the injections several days after complete withdrawal, making use in subjects who have reached zero of serum injections, pure or containing spartein, with the same technique as in injecting morphin.
"The day zero is reached is a particularly delicate period in the treatment: we hold it indispensable that it be not known to the patient, so that he may be spared every superfluous reaction of an emotional nature. This emotional influence is sometimes so strong that it is apparent in demorphinized subjects many days after their serum injections have been suddenly stopped without their having knowledge of what was contained in the solution, or rather of what was no longer contained in it. They imagine their last centigram of morphin is being withheld, they are apprehensive, they become distressed and suffer.pain.
"B. A second principle is rigorous observance on both sides of regularity of injection. I habitually give four injections a day after always taking the pulse; in the morning between seven and eight o'clock, about midday, about seven o'clock, and in the evening between nine and ten. I give one injection before breakfast and one before dinner, for these encourage the patient to eat. Without morphin there is anorexia, sometimes even a feeling of nausea in the presence of food. The contentment that morphin affords overcomes spasm and disgust. Advantage should then be taken of this quiet if not happy moment to ingest nutriment.
"The hours agreed upon and all explanations made and all reasons assigned once for all, these should be strictly respected by both doctor and patient. If it has been agreed that the first injection should be given at quarter before eight o'clock in the morning and the second at quarter to twelve, the physician will stoutly refuse, whatever may be the entreaties of the patient on this score, to anticipate the moment of injection. But in return he ought to appear at the hour and the minute agreed on with his patient, with all the paraphernalia, syringe, vials, etc.
"We should realize in fact that the morphinomaniac in a condition of need awaits anxiously the instant for the injection which is to ease his suffering. And we should help to relieve this anxiety by inspiring him with absolute confidence in us, in our word, in our solicitude on his behalf. We ought not then under any pretext to increase his suspense and especially to abate the satisfaction afforded him by simply watching the clock, many times consulted during the hour that precedes our coming. Twenty-five minutes more, fifteen minutes more, three minutes more to wait! The certainty of our scrupulous exactitude on the part of the morphinomaniac is an element far from negligible in our psychotherapeutic treatment.
"C. The third principle is to ignore nothing in the psychology of the morphinomaniac. Never to lose sight of the fact that he is, in the great majority of cases, asthenic (if his moral energy was normal, he would not find himself obliged to come into our hands, he would effect his own withdrawal), algophobic (if he did not dread suffering, he would not have resorted to morphin), a toxicomaniac, that is to say one obsessed by the drug, passionately devoted to all the poisons that stupefy and excite the nervous system, adding cocain to his opium or disguising it with hashish, alcohol, or ether, and in this quality of toxicomaniac sympathizing with all like him and always ready to convey to them surreptitiously or to accept from them the little packet of white powder ; in fine, constitutionally unbalanced, his moral sense diseased, emotional and imaginative."
"D. Now a few details of technique of some importance, which I have learned through experience with these patients, disturbed over everything and most of all by a drop escaped from an ampoule, from the syringe, or from their skin, and trying instinctively to learn the strength of the solution or the dose they are receiving. Do not use ampoules, which cannot be manipulated as desired in the view of the patient, but vials prepared in advance, from which the dose shall be drawn directly in such manner that the injection shall always be carried out in the same way and shall always contain the same amount of two centicubes (excepting, of course, where your addict will allow you at the outset to give him three, four, or five centicubes or even more).
"Seat of injection. Do not give injections in the abdomen or in the arm or in the anterior or anteroexternal aspect of the thorax: the patient watches all you do to him, and if the syringe slips or if you have the misfortune to spill, to "lose" a drop of the precious fluid, there will be jeremiads and recriminations which you must know how to escape. Have your patient lie face downward or in a three quarter position in such a way that you can puncture him at leisure in sound skin in the superoexternal aspect of the buttock or in the lumbar region without his seeing anything.

"A preliminary touch with tincture of iodin, a pledget of cotton under the needle to catch the drop which may be squeezed from a defective joint that it may not fall on a skin thirsting for this occurrence, finally a wiping afterward with an iodized tampon.
"The solution. This ought to be of adjustable strength since we recommend always to give when possible an injection of the same amount, one or two cubic centimetres. Hydrochlorate of morphin is dissolved in isotonic serum, filtered and sterilized. Joffroy used to add a little bitter quassia to prevent the patient from detecting by taste the strength of the solution injected, a drop of which he could procure by finding it'left either at the neck of the vial, on the piston or needle of the syringe, or even near the site of injection, or perhaps by squeezing out a little of the injected fluid after the doctor was gone.
"The needle. It ought to be completely sterilized and acutely sharp. We prefer very fine and short needles (fifteen or twenty millimetres, according to the thickness of the skin). The syringe filled, the needle poised for stabbing, the skin held between two fingers without wrinkling, a slight stab quick and free, a slow pressure on the piston—all is over. The injection, performed by the physician himself as often as possible, should be above criticism.
"E. The decrease. Diminution of the dose begins from the day of undertaking treatment. Cocain can be totally suppressed at once without inconvenience when, either for the purpose of increasing the thrill of temporary exaltation, or simply to avoid encountering the mildly disagreeable sensation of local tension following every hypodermic injection, the patient is accustomed to add it to his morphin. Next may be dropped what Joffroy called the 'proportion of luxury' and we estimate as a quarter or a third of a medium dose (forty to sixty centigrams a day), half or two-thirds of a strong dose (a gram and more). One may proceed rapidly in the early days and suppress very easily three-fourths of the initial dose."
*    *
"According to the initial dosage, we decrease each day or each injection five centigrams, four, three, two, one, a half, or a quarter of a centigram. Do not decrease uniformly the dose of the four injections in one day, which should be equal at the beginning of the treatment. Diminish the first more rapidly and the third more in correspondence with its successor than the second or especially the fourth. Beginning with two or three centigrams, the dose will decrease only for one or two injections a day, leaving the others at the same figure two or three days continuously, thus establishing transient levels, 'rest stations.' In this way we are able to replace first the morning injection, then that before dinner by an injection of serum (pure or sparteinized, according to the case).
"No serious occurrence ought to attend gradual demorphinization when so carried out, only a few unpleasant cramps in the feet and calves of the legs, a little acidity, difficulty in reading, in moving, in interesting oneself in a definite occupation, temporary disgust for food, finally a few bad nights, chiefly near the zero mark. These slight discomforts are not even universal, but I prefer to encounter them: with them I am more certain of attaining the end normally.

I distrust cures that are brilliantly successful, patients who laugh and sleep well; there is generally some deception that the patient risks paying for in the end with real suffering when, the store he concealed on arrival or received clandestinely being exhausted, he suddenly effects his own withdrawal. The pulse curve faithfully indicates the general condition and marks unimportant complications which may arise. It ought always to be taken, if not at each injection, at least morning and evening and at the same hour in the day."
The author prefers not to give hypnotic drugs for the insomnia, but when they are necessary recommends a mixture of one part of bromidia with three parts of veronidia, or the old bromide and chloride mixture with balneotherapy.
"G. Cessation of injections. After injecting isotonic serum for a few days, substituted for the morphin solution without anything said, the four injections may be withdrawn all at once, or they may be stopped in succession, one after the other. I generally follow the latter course. But I am not anxious to withdraw these injections. I wait until the patient himself tires of them, feels wearied, and begs me to stop. I am not troubled if they become a little painful when the serum contains spartein or pilocarpin: I prefer, in the interest of prophylactic psychotherapy, that the last recollection he has of injections should be frankly disagreeable to him, repulsive."
He decries the substitution of other opium products, such as heroin, dionin, pantopon, etc.

II. DISINTOXICATION.

"The treatment of morphinomania does not consist in merely reducing the patient to zero, even with the precautions we have just indicated. It includes as well treatment of the anatomical and functional disturbances resulting from chronic intoxication of the organism.
"Morphin affects not only the nervous system, but also the liver, the heart, the kidneys (this is very evident in animals subjected experimentally to chronic opium intoxication). It is the reason for offering a number of rules to complete the therapeutic management of demorphinization.
"As much rest in bed as possible. Instead of constant confinement in bed, a chaise longue in the bedroom, or still better in the open air.
"Lactovegetarian alimentation. Plenty of milk and other fluids. Various infusions, particularly mint and linden-orange. Fresh eggs. Green vegetables and sharp salads. White cheese. Fruit sauces. Bananas. In some instances I have availed myself with great advantage of iced food, iced milk or chocolate, ice cream, natural ice.
"Frequent laxatives, which accomplish regular elimination of the morphin with which the organism, especially the liver, is saturated and avoid those sudden bilious attacks that are so extremely debilitating. Give every day or every second day a package of sulphate of sodium alone or with sulphate of magnesium, or else a half glass of laxative water, or a coffee spoonful of calcined magnesium or a Chatel-Guyon tablet in a little water. Hypodermic injections of sodium sulphate (morphin dissolved in sulphurized serum in the proportion of five or ten centigrams to the cubic centimetre) are very effective, but are painful and I have abandoned them.
"Assistance to hepatic function: cholagogues, boldin, hepatic extract.
"Cardiac support in morphinomaniacs who are aged or physically enfeebled or have particularly nervous hearts: camphorated oil, spartein; sodium bromide in case of erethism. An attempt has been made to establish it as a principle that each centigram of morphin withdrawn should be replaced by a centigram of spartein. I have tried this and abandoned it: it is useless and sometimes harmful. I give spartein at the conclusion of the treatment, five to twenty centigrams, when I see an indication for it."
Following the three weeks of reduction he recommends one week to complete the "secondary injections of serum" and a convalescence of four to six weeks with tonic and dietetic treatment.
As a prophylaxis against relapse he recommends the establishment of complete confidence in the physician, avoidance of the old environment, mental and moral re-education, and a willingness on the part of the physician constantly to be ready to aid the patient at times of weakness or depression when relapse is especially threatened.

C. C. Wholey-1922.55

Wholey gives the following description of the method of treatment followed at St. Francis Hospital, Pittsburgh, Pa.:
"The withdrawal period extends over a week to three weeks, at times longer in debilitated individuals, according to the physical and mental conditions presenting. We use morphine hypodermically, except in those who have never used the needle—at times even in these—given regularly before meals and at bed time with p. r. n. doses additional where there is much distress, for first few days, of one-third to one-fourth the regular dosage. It is almost never necessary to give more than gr. I. regular dose, regardless of amount being taken and usually less, with the free catharsis immediately established. We give the dose which meets the demands of fair degree of comfort and circulatory support and sleep for two to three days and then reduce according to unit of initial dose. If one grain in beginning, it is first reduced to two-thirds, then one-half, then one-third, one-fourth, one-sixth, one-eighth, one-twelfth, one-sixteenth, and at times one-twenty-fourth, then drop one or two doses daily, substituting therefor strychnin or water (patient is always kept in entire ignorance) until water is being given entirely. In some patients the water is continued for a week before they are told the truth. Compound cathartic and vegetable cathartic pills, blue mass—two compound cathartics morning and evening for the first few days with blue mass gr. X the first day—salines—enough of all to induce very free purgation the first four or five days and then less—Tr. Belladonna—Fl. Ext. Xanthoxylin—Fl. Ext. Hyoscyamus (Towns Mixture) is used routinely from the beginning, unless patient shoWs idiosyncrasy, to point of tolerance, fifteen to twenty drops, at times more, every two hours at first then decreased but continued during most of course. Nights are not disturbed if patient sleeps. Sulphanol, Trianol, Adalin, Bromides used as sedatives and hypnotics—fifteen to twenty grs. Trianol or Sulphanol or mixture of both at bed time, gradually reduced. Hydrotherapy after first few days, good food, etc. While the general medical care follows a pretty definite plan, it is departed from whenever indicated and is made to fit the patient's condition. One case had a marked idiosyncrasy for Belladonna. A careful substitution of hypnotics (paraldehyde being especially serviceable) was made. Strychnin has proven an excellent aid in debilitated or aged cases, as a substitute and adjunct. From the beginning of the treatment, an effort is made to establish the most friendly relation between doctor and patient and to establish mutual confidence. In keeping with the mental and social status of the patient, appeal is made in the particular way which seems best calculated to reach the type of individual being dealt with. In all of them they are made to understand that the problem is theirs and that merely being freed from the physical dependence on the drug is but a start in the solution of the successful breaking of the habit. The patient's situation in life and his particular problems are analyzed and wherever it is possible to point out any relationship between his habit and his particular situation in life, this is done. Appeal is made by pointing out the consequences of his habit to himself and to others; he is frightened where this is necessary by specifically mentioning the lunatic asylum—the poor-house, etc. As said above, the patient is given an understanding of the exact situation as far as this is possible in keeping with his ability to grasp the same. Patience and firmness are absolute requisites in treating these patients, on the part of those in charge. If the patient deceives or relapses, one offence is not sufficient cause for casting him off. Some of the most successful "cures" have been accomplished in those who have relapsed several times. The difficulty of the problems are pointed out and every effort is made to maintain the individual's self-respect and to prevent his being affected by the general attitude toward the whole class of addicts, indiscriminately designated as "dope fiends." Many cases are mentally defective and their condition can be seen from the beginning and time is not wasted in futile attempts at their regeneration, outside of the physical and medical requisites employed. The habit is often part of a psychoneurosis and this has to be taken up and treated just as one would remove a source of physical discomfort which is apt to occasion a return to the drug.
"To re-state in general terms our method of handling these patients medically, I would say that for the majority of cases it is absolutely necessary to have them in closed wards, or conditions of supervision which render it impossible for them to procure the drug, or to discontinue the treatment under slight discomfort. The more intelligent patients, and those whose character has not suffered greatly, willingly co-operate in any such procedure. When patients are placed under these conditions knowingly, the fact of their being under strict guardianship in itself has a very beneficial effect. However, before instituting such steps as those just indicated, there is a frank statement of facts regarding conditions of treatment, and the patient's consent and co-operation obtained (this of course does not apply fully to certain individuals who are placed in an institution by police authorities, etc.).
"As far as the medical treatment applies merely to getting the patient off the drug, we look upon this, generally speaking as a rather simple problem. It is a matter largely of applying one's knowledge of general medicine to such cases of toxicity. The length of time varies as stated previously, with the physical and mental state of the patient. In a general way it is accomplished by the judicial use of thorough purgation, and a gradual reduction of the drug, securing sleep by the use of hypnotics, and insuring proper nutrition to the patient. Belladonna and hyoscyamus are excellent adjuvants for obtunding the distressful symptoms of withdrawal. The patient never leaves physically uncomfortable, nor having any physical craving for the drug, if we have been able to carry out our plan of treatment.
" . . . Of course, throughout the treatment we have already begun by suggestion and otherwise, our endeavor to effect a real cure by re-educating the patient and enabling him in every way possible to avoid future pitfalls. The real difficulty, of course, lies in the fact that during all the period of the use of the drug, the individual has established a distorted abnormal set of nervous and mental reflexes. Whenever his nervous system, by way of its sensory paths, is informed by aroused sensations of pain and discomfort of something being wrong in his organism, he has by use of the narcotic distorted this normal message into one which gives him exactly the opposite conviction of his condition; in other words, he is made to think that all is well, when the normal mechanisms of his body have endeavored in every way to enable him to know that something is wrong, and that the proper thing should he done about it. This reversal of normal sensations goes on for such a long period, and becomes so deeply established, with the inevitable breaking down of morale, that later on, even when he has been freed medically from the use of the drug, he is, under situations similar to those in which he has been in the habit of resorting to the drug, unable to resist the call of the deeply established perverted reflex. The ability to withstand this situation, of course, varies with the caliber and character of the individual, but for every individual who has perverted his instinctive reflex activities to the extent above indicated, there is a point at which he practically loses control and acts more or less automatically, and will take the drug if it can be procured.
"If the psychology of this situation could be understood more generally, our whole attitude and method of handling narcotism would be changed, and individual cases would have much greater opportunity of rehabilitation, especially where the patients themselves are intelligent enough to grasp the meaning of the situation sufficiently to avoid conditions that deprive them of their decision, and will bring about their subsequent resort to the drug."

Sir W. H. Willcox-1923.56

"Sudden Withdrawal.
"Where the general health of the patient is good and where the addiction is of short duration sudden withdrawal is advisable. I think the dangers of sudden withdrawal have been somewhat exaggerated, and in many cases the hesitation to cut off the drug without delay leads the patient to think that his cure is hopeless. It has been my experience that where the general condition of the patient is good and there is every facility for careful nursing, sudden or very rapid withdrawal may be safely effected and is the most satisfactory method.
"In confirmation of this view I may quote the results of the experience of medical officers of prisons in this country which have been kindly given me by Sir Malcolm Delevingne. It is a frequent occurrence for drug addicts to be sentenced to terms of imprisonment, and the invariable rule with regard to them has been sudden withdrawal of the drug. In no case have any alarming symptoms occurred and in only a very few isolated patients has any narcotic drug been given at all. In these cases on one or two occasions a very small dose of liquor morphina has been given by the mouth, but never has any narcotic drug been given hypodermically.

"Gradual Withdrawal.
"In cases of addiction of long duration, especially if the general physical condition is of low standard, gradual reduction is advisable. In cases of this type hyoscine has been advocated, a mild hyoscine delirium being produced for thirty-six to forty-eight hours by repeated small doses given hypodermically. At the end of this no morphine is given. The advantage of the hyoscine treatment is that in a long-standing case sudden withdrawal is effected. The disadvantage is that there is apt to be a more pronounced development of symptoms during the period of after-treatment. It is doubtful whether any ultimate advantage is gained from hyoscine treatment.

"After-treatment.
"After withdrawal has been effected the after-treatment is very important, and in this stage, in addition to general hygienic and medicinal methods, psychotherapeutic treatment is most valuable. The cultivation of the will power and of a feeling of hopefulness and certainty of recovery are most important factors for success in this phase of the treatment."

O. Wuth-1924.57

This author points out that routine methods of treatment should be avoided as each ease should be treated individually, but states that in general he found very little success in the use of bromides and narcotics including chloral and scopolamin. He prefers the antipyrin group. He further refers to promising results obtained by Klee and Grossman in the use of cholin by injection, which he believes supports his hypothesis as to the mechanism of the withdrawal symptoms.

E. Meyer-1924.58

This author prefers abrupt withdrawal in the treatment of morphinism, stating that by freeing the patient from the drug as quickly as possible a maximum of time for the psychiatric treatment and physical rehabilitation is allowed. After naming the commonly observed physical withdrawal symptoms, he states:
"In general all of these symptoms need not develop to an alarming degree, if the proper attention is given them, especially in regard to the heart disturbances. The psychotic symptoms show marked psychogenic characteristics, sometimes actively demonstrative. In general we can say that the so-called abstinence symptoms, at least the psychotic ones, are psychopathic reactions. Their danger is greatly exaggerated, with great harm to the patient, and exists according to our experience in the mind of the patient himself and unfortunately in that of many physicians."
After reviewing the drug therapy involved, the author continues:
"If we look back over the course of treatment we recall a sullen, annoying, unreasonable resistance on the part of the patient and a thousand objections to withdrawal. Generally after 3-4 days, sometimes sooner, along with a sense of physical well-being, there appears an understanding of the measures used by the physician and often an exaggerated gratitude and desire to proceed with the treatment. A few days later the picture changes again. The patient loses his original understanding of the situation . . . and often shows no control or tact in regard to his many different desires and complaints. If he succeeds in getting through this stage, which may last days or weeks . . . generally, except in the case of a very degenerate individual, there will result renewed understanding, active argument as to the desirability of cure, and a reasonable assurance of success. It is desirable then in general to keep the patient, as long as possible, under treatment, which is necessary to increase his understanding and will-power. The patient is still sleeping badly and perhaps he must undergo periods of uneasiness. In addition to understanding and cooperation the patient must also be enjoying for a long time the best possible sleep and an even, quiet disposition before release. The longer release can be delayed, the greater the gain. Transition to freedom should be a very gradual process. . . .
"In view of the danger of relapse arrangements should be made with the patient or his family for an early re-examination. At first he should report within 3 months, then, after 6 months, etc. and remain at the clinic for a few days in order to assure control conditions. These observations should be made in the same strict manner as the withdrawal treatment in order to establish his complete freedom from the use of narcotics. Our results in this regard are very limited for we have observed that often even in the most extreme abuse of the drug withdrawal produced no noteworthy disturbances, that the injury of the reaction and the contraction of pupils are not regular symptoms, so that such an examination prolonged over even a number of days need not reveal a renewed used of the drug. It should be noted that perhaps the urinalysis according to Loofs could make possible for us a clinical-chemical control of morphinism or perhaps still further confirmation is needed, according to the findings of Leake, who found certain changes lasting 10 hours and longer brought about by morphin in the blood. . . .
"Our experience shows that the highest aim of treatment is and will remain prevention; conscientious care in the administration of morphin and prohibition of the possession of needles by the patient. Moreover, the prescribing of morphin solution, such as is still considered proper for insomnia, unrest, and general, nervous conditions, is anything but harmless and should be avoided, the more so because there are other substitutes for his purpose. . . .
"In this connection the question may be raised as to how long morphin may be administered regularly in the treatment of severe, chronic painful conditions. In my opinion this may be done only where death is certain in a short time and then only when there is no substitute. To such a degree must the chronic abuse of morphin be considered harmful."

M. Mignard-1924.58a

In his article dealing with the psychology and psychotherapy of drug addicts, the author defines such cases as "individuals who habitually seek certain states of intoxication induced by exogenous substances generally taken in doses which do not immediately endanger life but may induce various kinds of euphoria or analgesia." It follows that there are individuals who are habitually—or will be—under the influence of the drug. The psychology is a mixed one--that of the intoxicated individual and that of the addict himself—really an indivisible whole. In his handling of his theme, however, he confines himself for the most part to the characteristics peculiar to the addict, such a habit, passionate craving for the drug, and the perversion of the instincts though recognizing that the episodes of intoxication are a part of the vicious circle.
He distinguishes two types of drug addicts—addicts by occasion and addicts by disposition. The former, he states, are those whose previous state of mind does not render them especially liable to drug.addiction, but a special occasion, such as their having been given the drug while under treatment, starts a habit. In their case the habit precedes the perversion of the instincts and for a long time dominates the scene. Their passion for the poison is consequently less fundamental and less
irrational; there is left, however, some element of resistance on which the psychotherapist may lean.
"Frequently, the addict by occasion would like to shake off the yoke; almost always he is unable to do it unaided. From the point of view of his defects he seems to be without will-power rather than without morals, whether it be that a primitive defect of will favors the development of the unlucky habit on occasion, or that a secondary impairment of will results from the development of the habit aided by the effect of the drug."
The addict by disposition, the author states,
". . . was entirely prepared by his natural disposition or by a psychological state which had been developing for a long time under the influence of circumstances, to seek in habitual intoxication the false appeasement or deceptive solace —the dulling of consciousness, at all events—which his discordant inclinations demand. Very often he has himself gone after his drug, or if the occasion came unsought, it merely awakened in him his natural inclination towards a sort of slow euthanasia, which, as we shall see, is at the root of the drug addict's mentality.
"The psychology of the addict by disposition is, therefore, essentially marked by the primitive character of the perversion of the instincts. The latter develops into drug addiction, but almost always it has already manifested itself in many other ways. Want of morality is. here the rule and begins to display itself early. The effects of habit are only secondary, as well as those of impaired will-power; and for a long time the pervert plays with them. He is a dilettante of addiction as also, very frequently and simultaneously, of lying, stealing, abnormal erotism. He is rarely a man of a single drug, but very often the fickle, and yet assiduous, lover of many drugs. He delights in dignifying his ill-omened inclinations by means of a false varnish of art, science, or philosophy."
He continues as follows:
"From the psychological point of view, therefore, drug addiction is a morbid habit, an abnormal passion, a perversion of the instincts. The morbid drug habit, like all habits, springs from the repetition of an act in the past and tends to its repetition in the future. Through the repetition, organic automatisms are established, which facilitate the execution of an action already performed several times and thus lure on the desire—at first physical and then mental—to repeat the action. So long as mental spontaneity remains mistress of habits, as happens, notably, in the case of habits directed towards an end which is voluntarily prosecuted, the established automatisms are merely excellent tools in the service of thought. But if the psychic organism, far from directing habit, allows itself to be carried away by it, the organized automatisms exercise an increasing sway over mental spontaneity, reversing the normal exchange of influence between these two orders of activity. In this manner there develops a state of mental subduction tending to result in a morbid mentality, as we have shown in other articles. But in the case of the drug addict, the power of habit, generally tyrannical enough, finds itself reenforced by adjuvant factors of the greatest importance.
"The weakening of the will, the clouding of the intelligence, the blunting of the higher forms of sensibility, are, especially in the long run, among these adjuvant factors. They depend, no doubt, less on the psychology of the addict than on that of the intoxicated individual. But the two psychologies are, as we have said, inseparable. These phenomena of mental degradation become in time preponderant. They end by constituting the principal obstacle to the suppression of a habit which rapidly becomes irresistible.
"This habit is all the more irresistible because it is associated with a morbid passional condition. This passional condition is constituted in the beginning by the immoderate desire for toxic euphoria, whether this euphoria results from a passing exaltation, as in alcoholic drunkenness, or from an agreeable torpor, as in opium-smoking, or finally, from the disappearance of suffering, as in therapeutic morphinization. But soon the signs are inverted. The intoxicated individual no longer enjoys the intoxication, but suffers terribly if he is deprived of his toxicant. Not only the nervous system, but the entire organism unfortunately has become accustomed to the poison, which has become a sort of paradoxical nourishment. This nourishment slowly kills, but the lack of it begets a tyrannical craving. The psychic organism feels its influence by experiencing a distressing anguish soon complicated by an intolerable anxiety. The craving, once established, manifests itself in violent form at each attempt to break off the habit; more than that, it demands a fatal continuance. Like all passional states, the passion for drugs brings about an emotional subduction. It directs the mind of the patient exclusively to the realization of its desire. It absorbs gradually all his other inclinations, all his other sentiments, turning them from their course before destroying them for its own advantage. This is the perversion of the instincts which we shall discuss immediately. But it disturbs the intelligence by first exciting the imagination in the direction of the euphoria which is being sought, and then warping the judgment for its own justification. Gradually, it substitutes itself for the will, the primitive or secondary atrophy which we have already. mentioned. In the end it reduces the patient to veritable slavery.
"The perversion of the instincts, as we have said, may be primitive and anterior to the drug habits; but if it was not pre-existent to them, it always develops, if they last long enough, as their consequence. This results, as we have just shown, from the fact that the passion for the drug gradually replaces those systems of inclinations which constitute the instincts, beginning with the highest, the most disinterested ones, and ending with the lowest, those which affect the maintenance of the vegetative life itself. At the beginning, drug addiction deflects, to its own profit, the superior orientations of the mental life, gradually substituting itself for them. Religion, philosophy, arts, sciences, social instinct, are at first exploited for the profit of the habitual intoxication before being completely abandoned for it. This is the period of supposed drug-inspiration. It has been justly said that certain great poets were such in spite of their addiction and not because of it. It might be added that their works, fine though they were, would have been more sound without the addiction. Soon, moreover, the flame, colored for a moment by these artificial hues, grows low, flickers, and dies. This is the period when the addict's negligence, laziness, want of morals, become fixed —simple results of the substitution of morbid inclinations, sentiments, and activity, for normal inclinations, sentiments, and activities
"Other perversions are developed in defense of the principal one. The drug addict becomes a liar—and sometimes an extremely ingenious one, especially in the matter of obtaining his favorite drug. Just as readily he becomes a thief. Some, no doubt, do not even hesitate to kill, particularly if the nature of the intoxication inclines them to violence, as is evident among alcohol drinkers, cocain-sniffers, and—more rare in our climates—hashish eaters (whence the word assassin is said to be derived).
"Finally, the drug addict sacrifices to his evil idol not only his superior unselfish instincts, but also those which affect the preservation of his miserable existence. He no longer seeks anything beyond stupor, complete forgetfulness, the drug-induced Nirvana in which, he knows, his life will founder shortly after his intelligence. From the very beginning, moreover, his morbid passion had death for its goal. Logre is quite right when, from this point of view, he compares the mentality of the drug addict with that of the melancholiac, for in both, the perverted instincts turn toward destruction. The drug addict, in particular, is first and foremost a lazy person, who prefers euthanasia to patient effort towards the good which is characteristic of a normal existence. Whether he assumes the deceptive appearance of a heedless optimist or that of a hopeless pessimist, the drug addict is always the more or less conscious disciple of an integral nihilism. That is the beginning and the end of his psychology."
In what follows the author outlines in considerable detail the basis and the essential mechanics of the psychopathic treatment he advocates.
"The psychotherapy of the drug addict proceeds very naturally from the psychology we have just sketched. It will not be necessary, therefore, to give a systematic exposition of it; it will suffice to draw its main lines, corresponding to the different stages of the cure.
"a. The withdrawal period is one of the most important and, at the same time, most distressing stages of the psychotherapeutic treatment. It calls, almost always, for a certain degree of coercion, because it is an attempt at breaking, more or less abruptly, a vicious habit.
"Now, it is exceptional for the subject to be able to impose on himself and maintain by himself the discontinuance of addiction practices in the environment which permitted their birth or their development. Nevertheless, I have witnessed the complete and absolutely voluntary discontinuance of a habit of drinking alcoholic 'aperitifs' twice a day, in consequence of the appearance of disquieting symptoms, a habit of many years' standing, at that. 1 likewise have found it possible to cure a woman who was addicted to morphin and was very eager to be cured, without subjecting her to restraint—by a rather slow method, to be sure. But these are exceptional cases. It may be accepted as a principle that the psychotherapy of the withdrawal period calls for the breaking of the habit by means of comparative' isolation, under conditions which do not permit the resumption of the use of the drug either openly or surreptitiously. In fact, in the present state of our legislation, such a cure almost always requires internment, and is, therefore, not generally possible except on the occasion of an episode in which ordinary psychopathy has become pronounced mental alienation. For even when the drug addict wants to be cured, he is not likely to be able to do it without entrusting to others the task of blocking his stratagems, sometimes despite his future rebellion. Herein lies the beneficence of the legal dispositions in certain countries, which for this purpose and under certain guarantees, permit the voluntary abdication of freedom.
"We shall not dwell on the difficulties of the withdrawal, on the firmness, on the ingenuity of the surveillance, which must be opposed to the ruses of the drug addict, to his violence, to his attempts at exciting pity, to his use of all the means at his disposal for obtaining the poison of which he is being deprived, more especially as he is plunged into a state of deep anxiety by the condition of abstinence. We shall merely repeat that the isolation need only be relative, and that advantage should be taken of the need for surveillance to assist the patient morally. This moral assistance is indispensable; it should be at once sedative and tonic and extremely patient. Without yielding on any essential point, insisting all the while most firmly on the suppression or the progressive diminution, as may be indicated, of the use of the drug, one must be able to quiet the patient, encourage him constantly, and give him the comfort of active sympathy, sovereign requirement for so many asthenics and persons suffering from anxiety.
"This moral medication against despair and discouragement, applied steadily and skilfully, may bring the best results.
"Advantage should be taken of the patient's temporary confusion and of the confidence inspired in him by a good psychotherapist for the purpose of investigating the particular causes of his addiction. Without being exactly psychoanalytical, these investigations might nevertheless be of considerable service.
"The psychological disclosure of the ideoemotional systems associated with the recollections of the origin of the vicious habit are sometimes of the greatest importance. To cast full light on the validity of the pretexts invoked, to seek the real causes behind them, is to teach the patient to know himself better and, in consequence, to direct himself better; it is to destroy a number of false ideas, hidden adjuvants of the favorite vice; it is to give more force to clear consciousness and to reduce the force of the subconscious and of its morbid influence; it is to combat the fear of phantoms by showing their inanity. By all these methods and by various mild distractions, which should be administered very discreetly, the spontaneous attention of the patient will be diverted.
"One should try to turn it patiently, gradually, from its one direction and transfer it to other objects. Thus the second period of the psychotherapeutic cure will be ushered in.
"b. Reeducation period. The directive principle of this period might be stated as follows: Only that is destroyed which is replaced by something else. But it is not another poison that should replace the one withdrawn. While developing his bad habit, the addict had gradually discarded normal activities; the progressive resumption of these activities is a good means of setting aside the vicious autoinatisms in their turn.
"As a matter of course, work is going to have a very important—the central place, if you like—in this resumption of activity. Is not the overcoming of indolence the destruction of one of the deepest mental roots of drug addiction? The work chosen must be work adapted to the means, the tastes, the condition of the patient at the time. In the way of manual labor, work in the field or garden generally gives good results for men, household duties for women. But it is important that the work should be agreeably presented and that its resumption should be progressive. It should also be sufficiently varied. It must be interrupted by diversions. In short, manual work alone will not suffice. Every man has intellectual needs which turn towards evil if they are not directed towards the good. Every manual laborer should receive a certain amount of intellectual culture. But intellectual and artistic occupations and distractions should be chosen even more carefully. In this line, a very small thing may cause great good or great harm. One should try to instruct without boring, to divert without demoralizing—above all, to incite the interest and the taste to a personal search for the beautiful, the good, and the true, so that in the future the attraction of the evil habits might be displaced by the attraction of these. But this brings us to the third and last point which we must develop.
"Before doing that, however, we ought to mention that it is also advisable to give physical exercise to intellectual workers. Too narrow specialization is bad mental hygiene, and advantage may be taken of the withdrawal cure for remedying this fault. Sports, in moderation, may render great service.
"c. Consolidation period. The addict, having been thus weaned and reeducated, still remains very weak from the moral point of view. He has got rid of the bad habit; he has resumed good ones. But where will he find the strength to resist future temptations? What beneficent sentiment will he be able to oppose to the germination of evil passions, one of which had already led him astray? Only the sublimation of his inclination, enlightened by intelligence, will supply him with this triumphant dynamism.
"Appeal can be made, and undoubtedly should be made, to all the normal inclinations for the purpose of barring the road to an eventual offensive return of the passion for drugs. Reasonable anxiety regarding the preservation of his health, provided it does not turn to hypochondria, may, as we have illustrated, play a decisive role in the cure of an addict. But selfish, egoistic inclinations and sentiments, relating to the individual organism directly, rarely suffice to keep the individual from being attracted to the poison, since the attraction has precisely the character of inverting the sign of these inclinations and of transforming them into destructive instincts. Whoever seeks only physical satisfaction may prefer drug-induced torpor, even if fatal, to the trials among which a normal human existence strenuously pursues its happiness, and especially its spiritual happiness.

"Emotional response to family and society is a much greater help. In the laboring circles of Paris, where the sentiments of the ex-alcohol addict are very often better than his reason, I have seen several cases of repentance firmly established—after an adequate withdrawal cure—through sincere pity for wife and children. Professional honor, the desire to be a useful human being instead of a pernicious shred—these may be very serviceable in the consolidation. One must know how to cultivate all these sentiments in the addict after the withdrawal, and for this purpose contact with him should not be lost too quickly; it will be well to see him occasionally for a long time after the apparent cure.
"The disinterested search for philosophic and scientific truth, the noble con. templation of art, are excellent ways of sublimation for him who can attain them. Finally, a sincere and active faith in the real significance of the highest ideal—that is the crowning point of a truly complete cure. That he may no longer run the risk of injuring others, that he may destroy his former demoralizing scepticism forever, the ex-addict must have a deep faith in the essential worth of the good.
"In one sense, every cure of drug addiction, which is serious enough to have lasting results, implies a complete new birth of mental trends, and is thus equivalent to a sort of conversion."

C. Romer-1925.58b

After reviewing the more recently advocated methods of withdrawal from the drug, Romer emphasizes the role of the family physician, both in preventing morphinism in the first place and in the prevention of relapse after treatment. He states:
"The withdrawal cure must be followed by a period of consolidation, which
should last as long as possible—several months, if at all convenient; this period should likewise be spent in the institution under medical supervision, but with increasing personal freedom, and should be utilized for observing and influencing the total personality. Unfortunately, this period is seldom observed. The patients hurry out of the institution; they overestimate their power of resistance altogether too much and even their relatives, for obvious reasons, are more willing. to listen to the extravagant talk of the patient than to the warnings of the physician.
"It is very difficult to get an idea of the duration of the results obtained in the institution. Many patients are lost sight of ; as to others. the report comes that they soon relapsed; only a few—those whose circumstances are especially favorable—probably have lasting results to record. Most of my patients already had on record more or less frequent relapses before entering my institution, and I assume that the next relapse was not long in coining despite a successfully accomplished cure. My inquiries in open and closed institutions met with pretty much similar answers.

"The prognosis of morphinism is, consequently, not to be characterized as favorable. A godd share of the blame surely lies in the defects of legislation. Stricter official supervision of the traffic in morphin and its substitutes has been demanded by physicians often enough, but always in vain. Quite recently, a special attempt was made by John to direct the attention of the government and all the officers and organizations concerned to the inadequacy of the present condition. Bolten reports that the comparatively small number of morphinists in Holland is to be referred to the rigorous legislation. Nevertheless, until we can count on aid from the law in Germany—which I, too, consider important—it is the duty of physicians to take in hand unaided the fight against morphinism, as well as it may be done."
"It is always a question of especially constituted people who belong to the large group of psychopaths. Some painful organic disease, or experiences which permitted the development of neurotic symptoms, may furnish the occasion for resorting erroneously to morphin. There cannot be too much emphasis on the advice that morphin should be used as sparingly as possible with nervous people, that it is better not to use it at all, on principle, no matter how passionately these patients may plead their sufferings as reason. One can manage just as well with other more harmless remedies, as luminalnatrium, hyoscin, paraldehyde, etc., often even by means of mere suggestion, such as the moment may inspire. Beware of morphin in bronchial or nervous asthma!
''The nerve specialist must try day by day to make clear to his patients the origin of psychogenic complaints, and he knows the difficulty of this task, for the layman takes the standpoint that, if he feels a pain somewhere in his body, there must be some organic lesion there. As a result of this firm conviction, the patient permits the removal of appendix, ovary, etc., as the case may be, or a plaster cast or other things of the sort to be put on, or—he becomes a morphinist. . ."
*    *    *
"It is not possible, within the limits of a short discussion, to cast any more light on the road travelled by such a patient until he finally became inexorably a victim of morphinism. Generally he has wandered from doctor to doctor without revealing his true nature and without the knowledge of his family physician, if he has one. Secrecy is compulsory in these trips. But if a physician has perceived that someone is using morphin without a valid reason, he should leave no means untried to bring that person as early as possible to a withdrawal cure, which should be combined, at all events, with a causal psychic treatment; cf. }korner: Beitrage zur Behandlung der Psychoneurosen. Klin. W ochenschr. Vol. 3, Nr. 9. 1924.
"Naturally, exception should be made for those patients who have arrived at the use of morphin by reason of incurable, painful, or distressing organic disease. Nevertheless, even in such diseases, when they last for decades, as tabes, there should be warning against beginning to administer morphin too soon.
"It is a source of great injury to many families that the family physician is growing more and more rare--through increasing specialization, on the one hand, and lack of time, on the other. And yet, a family physician would be so emphatically desirable, particularly for the timely recognition and diagnosis of nervous functional disorders. Well acquainted with the peculiarity of his patients, he can be their best adviser. Furthermore, in consultation with colleagues, he can give the latter knowledge of important particulars. This is all the more important for the reason that words cannot be chosen too carefully, because a nervous individual listens with anxious, yet frequently well-concealed attention to every word of the physician. If, for example, he is told that there is no disease in his organs now, but that there had been at some previous time—were it only very light apical catarrh, or very slight myocardiac weakness, or that the X-ray picture indicates that years ago there had been a gastric ulcer—such a statement may become the starting-point of severe neurotic complaints and hypochondriac depression, which drag on for years, are unusually difficult to banish, and may possibly lead to morphinism; cf. Bumke, 0.: Der Arzt als Urheber seelischer Storungen. Dtsch. med. Wochenschr., 51 Jg., Nr. 1. 1925. If traces of former diseases are discovered in a nervous individual, the findings should be kept from him so long as there is no occasion for treatment.
"It would be highly desirable, therefore, if the good old custom could be revived again, whereby every family had its house or family physician, whose manifold duties no specialist can undertake and whose opinion would be of weight in all decisions affecting the well- or ill-being of individual members of the family. The present-day physician, who—in contrast to earlier times—is already trained in psychology at the university, will surely attain the same or even better results than the respected family physician of earlier times, if he connects his psychological studies with his general medical knowledge and grounds them in the rapidly increasing experience due to his intimate relations with
land and people. In his hand lies the prophylaxis against many nervous and psychic lesions, which are often slow of development—and prophylaxis against morphinism belongs in this class. Probably, too, the relapses to such morbid conditions might thus be obviated."

Erich David-1925.58c

After reviewing the relative merits of cholin, luminal, veronal, medinal, etc., in the treatment of the withdrawal symptoms, the author calls attention to the problem involved in relapses as follows:
"There is one problem, however, which in my opinion has thus far been handled very inadequately. Everybody knows that the patient is not yet cured when the stage of acute abstinence symptoms has been passed, but rather that the iraportant'stage of convalescence has but just begun. As to how long the latter stage lasts we read and hear the most varied opinions. According to one, six weeks suffice—the body-weight has by now attained its peak; hence, regulated activity is now the only correct procedure. Someone else takes the view that while convalescence has generally been achieved after six weeks, institutional care for as long a period as possible, and constant, most careful supervision, are still absolutely required. And so we find in literature such varying estimates as 6 weeks, a quarter, a half, and even one year.
"A priori we should believe that it would be easy to prove by means of statistics which view is the correct one, since we should only have to determine whether more relapses were to be recorded among those cases which had been under observation for only 6 weeks than among those which had been under medical supervision for one-half to one year. Statistics, however, indicate nothing of the sort. Rather, it is well established that there is unfortunately as great a percentage of relapses after one-half or one year as after 6 weeks. This unfortunate result must, I thought, surely have a cause, and for this reason I determined to follow up this problem, especially as in the literature there are frequent statements to the effect that observation for as long a time as possible after the withdrawal is absolutely necessary, but nowhere could I find any penetrative statements as to the cause of the very high percentage of relapses. A priori it was, of course, clear to me that a convalescence of 6 weeks could not suffice, for while the patient is now physically quite fit, psychically he is not yet ready to withstand all the fluctuations of life without morphin. For example, he is at this time not yet ready to do regular and concentrated mental work. The days seem endless, but he has not yet the energy to busy himself with work. As a matter of course, the recollection of his former great capacity and the oppression of his complete lack of energy seduce him now to a relapse.
But if the patient remains longer than 6 weeks under strict medical control, he grows slowly also psychically more resistant; his energy increases and he is gradually enabled to concentrate and to do regular mental work. This happens in almost all cases after about four to five months, and therefore I was always of the opinion that that was the time to discharge the patient and let him stand on his own feet. The experience of another, unfortunately, taught me otherwise. I saw again and again that half a year or even a year of the strictest control did not altogether exclude a relapse, even when the economic situation was of the best—I am speaking, of course, only of patients who were possessed of the firm determination to remain free. Consequently, the latter factor cannot by itself be decisive in solving this problem."
The author then gives in the patient's own words an account of the circumstances leading up to his relapse after treatment and observation in an institution for nine months. He apparently considers the case typical of a large group and continues his analysis of the causes of relapse and concludes as follows:
"And so a man who had had institutional care for three quarters of a year, and who had completely regained both capacity and desire for work, had a relapse a few days after his discharge. First of all we see that unfavorable external or economic conditions may, no doubt, frequently help to bring about a relapse, but that they by no means play a decisive part. Other factors, apparently, are also in the cast. The first to be considered are a certain exhaustion and languor without the possibility for external reasons, of rest and recuperation. In addition—and this is perhaps the most essential—there is the feeling of ennui. Time refuses to pass; hours seem endless; the patient feels lonely; suddenly there comes the recollection of the time when he used to take morphin. Then he was never bored; he felt well; he was never tired and weary; time just flew. To be sure, he also sees at once the great dangers which might be consequent upon his use of morphin. An inner contest takes place; on the one hand, inhibition is still too strong; on the other, he consoles himself with the thought that just one injection would surely not lead to immediate addiction —he will look out for that. But this inner conflict is followed in most cases—and that is the worst feature—by a certain restlessness, anxiety, and finally, perhaps, by trembling, and outbreak of sweat. This condition always resolves the inner conflict in favor of morphin. In other respects it is surely one of the finest arrangements of nature, that all pain• is very quickly forgotten—much more quickly than pleasure. But for the patient newly withdrawn from morphin, this law of nature is certainly not a blessing. Quite the contrary! Generally it is fatal for him. The benefits derived seem to him much greater than they really were; longingly he thinks of the glorious time when he soared through life, half-lost in dreams, building fantastic air-castles. But the infinite dangers, and particularly the torments he endured, are underestimated.
"From the above we see first of all that even after three-quarters to one year of strictest control, although physically and psychically capacity and desire for work have been completely restored, we cannot yet speak of a cure of morphinism. One might assume, to be sure that a patient who has had ample experience in his own body of the dangers in the use of morphin, would be forever immune. But, as we have seen, such is not the case. Furthermore, that a cure has not yet been achieved is evident from the fact that patients who have abstained for one year bear the first injection magnificently; they experience a euphoria and feel themselves physically and mentally much more capable. Yet, according to their own accounts when they took morphin for the first time in their life, they could not bear it at all; they felt miserable and began to vomit. A further proof of the fact that we may not yet speak of a cure even after a year, we find in the circumstances that the patients under consideration could in a very short time attain to such large doses—in the case related above, 0.3 after eight days; yet at the beginning of their trouble, they could not have borne them without most severe manifestations of poisoning.
"The latter fact, especially—that patients, after three quarters to one year interruption, could immediately bear an injection of rather high percentage (0.03-0.04) experienced a euphoria and felt possessed of greater capacity, whereas after their first application of morphin, they felt ill, became dizzy, and vomited; and furthermore, that despite the long pause, they were so resistant to morphin that they could increase the daily dose with such great rapidity; that some of them, according to their accounts, even had to do it and considerably more quickly than at the beginning of their addiction (as has already been said, such rapid increase would be absolutely impossible for a person who never in his life had taken morphin without most severe manifestations of poisoning),—is surely absolute proof that certain permanent alterations have been made with reference to morphin; in no other way could we explain this resistance. Just what these alterations are is as yet a mystery. But we shall not go wrong if we assume that the deeper grounds for the high percentage of relapses after morphin cures are to be sought also in these resistance-producing alterations.
"And so, just as we strive nowadays to explain the general picture of a psychic disease by taking into consideration not only the congenital factor, but also the disposition, some particular experience, the environment, the effect of the endocrines, of infections, and of exhaustion, we must suppose that a number of factors cooperate in bringing about the relapse to morphinism. And finally, it is also evident from the above conclusions that among the causes of a relapse, along with external influences, such as a particular experience, environment, and exhaustion, there is also an inner factor, which is most likely conditioned not only by the personality make-up and constitution, but also by ductless gland and cell changes.
"Theoretically one might picture the situation somewhat as follows: after addiction, the morphin combines with some cell component; after withdrawal there is no substitute for this combination; there is, therefore, a vacancy and a consequent longing, lasting for a long time, for a reunion with morphin; hence that craving for morphin which is naturally particularly strong in the first days, when the vegetative regulating center in the mid-brain is completely out of balance. But even in the first weeks and months after the withdrawal, during which the vegetative nervous system tries to regain its equilibrium, this craving can probably not be completely inhibited so long as energy is below par and capacity and desire for work have not yet been completely restored. The craving persists and undeniably brings about a relapse in almost all cases. It is quite otherwise, however, in the instances we have presented above—in which abstinence has gone on for perhaps a year. In those cases, the vegetative nervous system, and consequently, body and mind, have so far regained their balance, that capacity and desire for work are completely restored. The craving for morphin, therefore, has gradually been so inhibited and replaced by other interests, that it is generally imperceptible. The entire psychophysical organism has regained its balance and suppressed the craving for morphin. But woe, if on some occasion the latter rises to the surface of consciousness at a time when, because of general over-exertion and ennui, it is impossible to divert it by means of other interests. Then there is a reunion of all the factors which, as we have seen above, play the leading part in a relapse; the vegetative system is thrown out of balance while the craving for morphin begins its assault with the heavy artillery of restlessness, anxiety, trembling, sweating, etc., until the tormented body pays the required tribute.
"Somewhat after this fashion we shall have to explain physiologically and psychologically the causes of the exceedingly high tendency to relapse after a morphin cure.
"It has not yet been possible for me to become acquainted with patients who have relapsed after an interruption of more than a year. Therefore, we can only say that within a year after the withdrawal a final cure cannot yet be assumed, but that after an interruption of a year there still persist in the body such alterations as together with external factors explain the high percentage of relapses. Whether the situation changes after a number of years, I have no knowledge. At all events, the prognosis of morphinism presents a very poor picture.
"Since we now know the more immediate causes of relapsing, it is perhaps quite proper to draw a few conclusions therefrom.
"First, we shall have to answer the question as to how long the patient must be kept under strict medical control, and when it is time to discharge him and set him on his own feet. Statements in the literature, as we have already mentioned, vary so tremendously. As we have seen, after six weeks the patient is generally physically well, but he still feels the lack of the stimulation furnished him thus far by morphin. The days seem endless, but he has not yet the energy to busy himself with work. He has not yet regained completely the capacity and desire for work, and just because of that, he will inevitably be seduced to a relapse by the recollection of his former greater capacity and the oppression of his complete lack of energy. That he is not yet mentally recovered, we can easily prove by giving him some easy scientific book to read and asking him to give a report on it after a few days. The patient will not yet be capable of doing that. If it is at all possible for him to read the book through intelligently, it will take him weeks and weeks to finish his task.
"This lack of stimulation, however, passes after several months, and I am willing to say that after four to five months every withdrawn individual has completely recovered capacity and desire for work. If he is then assigned the task just mentioned, he will perform it very quickly with utmost satisfaction. This test seems to me the most infallible indication as to whether the time for discharging him has arrived. To retain him any longer in an institution, just because it is true that physical alterations with reference to morphin still exist, would be absolutely senseless, since we have seen that the same phenomena are present even after a year. The prognosis is unfortunately very inauspicious. Someone will, of course, retort: if a complete cure is not to be assumed after a year, the only conclusion to be drawn is that internment for a longer period is absolutely required, if complete success is to be achieved. That is true enough, but first, a patient will hardly submit to that in view of the present-day difficult economic conditions, and secondly, who knows whether the physical alterations with reference to morphin will disappear even after a series of years?
"From the purely scientific standpoint, therefore, we shall have to answer the question as to how long strict supervision is absolutely required for a morphin cure by saying that a complete cure cannot be attained even after a year, but that after four to five months capacity and desire for work have been completely regained, and that this moment seems the most proper for permitting the patient to resume his vocation.
"If, unfortunately, it is not yet possible to remove beforehand the inner factors which play so important a part in bringing about a relapse, nevertheless the above conclusions teach us something else of great importance,—namely, that physical fatigue or mental lassitude, especially when associated with ennui, constitutes the greatest danger for an individual who, having been withdrawn from the use of morphin, is again freely following his vocation. It must be thoroughly impressed upon the patient before his discharge that diversions, such as concerts, the theatre, moving pictures, or any other pleasures, are of utmost importance for him, and that he must indulge in those to the utmost extent. It is highly appropriate to arrange, if possible, a program every day and to carry it out, so that every hour is filled with some activity or diversion. Naturally, the program must be so arranged that overexcitement and overwork are excluded. The best course is for the patient, after four to five months of strictest supervision, to take up his regular work and at the same time get all the diversion possible. Above everything, the patient must avoid being alone, and for this purpose it would, naturally, be most appropriate that he should constantly have about him a dependable, energetic person, acquainted with the patient's particular nature.
"A closer observation of the personality of those who fall victims to morphin discloses that they are mostly individuals who have been born with an unstable vegetative nervous system, and hence, are frequently quite inadequate to the demand life makes upon them. They are always persons who must be ranged in the large group of psychopaths. And therefore, it is of utmost importance, during the entire period of withdrawal, to deal with them psychotherapeutically, and to educate and develop in quite pedagogic fashion the personality of the individual. But even after the discharge, it is absolutely necessary to keep in contact with the patient and to concentrate all effort on the development of his individuality and personality. Unfortunately, this almost never happens. And yet, this therapeutic procedure is probably of extreme importance. For, as we have seen, the internal factors play as essential a part in causing a relapse as the external factors. And even though we cannot remove all internal factors, it would surely be a real step in advance to exclude at least one of them by educating and developing the personality. It might well be that thus a relapse would in many cases be precluded."

Ph. Klee and 0. Grossman-1925.59

These authors, in reporting on the therapeutic uses of cholin in a considerable number of conditions, point out that the withdrawal phenomena due to a disturbance of the vegetative nervous system can
be controlled by the administration of cholin. They advise further studies of its use in this connection.

R. Krauss-1926.5°

The author gives the history of a case of homosexuality during the course of which severe gastric pain and diarrhea developed, apparently from nervous causes. Codein and later morphin to the point of addiction were required to control these symptoms until in the course of psychotherapeutic treatment for the homosexuality, the symptoms disappeared spontaneously, not to return. The author utilizes this case to illustrate the importance, in cases of opium addiction, of determining and removing the psychogenic cause of the condition, as quoted in the following:
"The case we have presented is, finally, an obvious proof of the fact that all our efforts to cure morphin addicts—even those who are willing to be cured—are in the end without result, if we do not succeed in removing the psychogenic cause of the abuse of morphin, thereby effecting a change in the personality. For the purpose of these therapeutic efforts I have found Frank's method of treatment by far the best. I admit that in the handling of the various psychotherapeutic methods, the personal attitude may play an important part. So far as my attitude is concerned, there is decisive significance in the fact that in the Frank method of treatment the pathogenic material is drawn forth by the patient himself, and by him exclusively; that the patient himself separates what is essential for causing the disease from the non-essential; that the recognition of this essential part has direct 'compelling authority' for the patient; and that as compared with other methods of treatment, this method leads to final success in the same patient in a comparatively short time.
"And finally, this method of treatment permits the person who is applying it to remain objective, so far as that is at all possible in psychotherapy. The transference to the director of the treatment is eliminated, as well as the necessity of subjective explanations and interpretations through the aid of symbols; in short, the role of the doctor remains that of the director of the treatment of a psychic disease in the same way as in the individual treatment of some physical disease."

Nerio Rojas and Jose C. Belbey---1926.61

These authors describe their use of adrenalin during demorphinization with consequent abatement of the withdrawal symptoms. They state that they refrain from discussing the "pathogenic and chemical interpretation" of the beneficial effects observed.
In three cases suffering from acute withdrawal symptoms they obtained uniformly beneficial results. In other cases (the number is not stated) they observed individual variations in the effect according to individual susceptibility to adrenalin. In some of them disagreeable effects were observed which led them to conjecture that a constitutionally neurovegetative factor might invalidate the method, sympathicotonic individuals giving poor results. In the vagotonic constitution the results were beneficial.
They infer that half a centigram of adrenalin (1-1000) may replace any morphin injection of the day. The majority of the patients, they state, do not recognize the substitution.
In a few animal experiments in which rabbits and dogs were used they observed the lessening of the severity of withdrawal symptoms after twenty-four to forty-eight hours' abstinence in morphinized animals. They conclude their article as follows:
"Collecting and correlating the facts obtained in our clinical experience, we assert that the initial diminution of morphin is easy, presenting no inconvenience. The real difficulty lies in the critical moment of zero and the next few days. We have experimented with many substances represented to alleviate the patient's sufferings in this situation, sodic luminal in large doses, bromides, prolonged baths, sulphate of berberine, whose enthusiastic proprietors recommended it, etc., without any result. The anxiety has always prevailed. Adrenalin alone, on the contrary, advocated by numerous authors as a cardiac tonic in case of necessity, has given us an excellent result as a substitute for morphin in the conditions already described."

T. M. Bogolow-1926.62

In an abstract, this author is quoted as having experimented with the use of oxygen subcutaneously in the treatment of narcotic addiction, and as having followed its employment in certain mental diseases, both in France and Russia. The abstract continues as follows:
" . . . He observed the abatement of motor unrest, the return of sleep and appetite, gain in weight, increase in the hemoglobin and the number of red blood corpuscles, as well as the clearing up of complicated schizophrenia and the more rapid occurrence of convalescence. Subacute and chronic schizophrenics, encephalitics, katatonics are not affected. Furthermore, addicts, morphinists, etc., were treated, proceeding on the assumption that narcosis is related to a sort of asphyxia, which one endeavors to diminish in the case of surgical narcosis by a simultaneous administration of oxygen. The patients were: 12 morphinists, 1 heroinist, 2 opium eaters, 1 veronalist, 3 cocainists, 3 morphinistcocainists, 5 alcoholics. The oxygen is best injected into the epigastrium or subcutaneously under the shoulder blade at the level of the eighth rib, for which the pressure in the bulb is sufficient. After the insufflation (200-280 corn. ?) the patient must lie still for % hour, so that the gas does not penetrate in large quantities into the throat or inguinal region, which causes pain. On the average, 5 or 6 insufflations are necessary, which are best given daily—since the effect lasts about 24 hours—although intervals of about two days can be made. Practically all the typical symptoms usually disappear after half an hour, the patient becomes fresh and hopeful and asks for more oxygen. The personal reports of two physicians who were morphinists are full of enthusiasm for this method of cure. The insufflation of oxygen under the skin makes it possible to withdraw the narcotic immediately (only in 3 difficult cases was it impossible to withhold medication), so that the duration of treatment is considerably shortened. The very rapidly ensuing improvement even occasionally permits a continued ambulatory treatment. It is, therefore, a method obviously worthy of attention, one to which the patients gladly submit and which, up to the present, has given no bad results."

Alexander Lambert and Frederick Tilney-1926."

The authors give an account of their experience with the use of a patented preparation—narcosan--in the treatment of drug addition. They state that narcosan "is a solution of lipoids, together with nonspecific proteins, and water soluble vitamines." The lipoids are said to be secured from soy beans and cotton seeds, the vitamines from plant seeds, the nonspecific proteins from alfalfa seeds or Hungarian milletnarcosan being a mixture of these ingredients. In this connection they give the following:
"The theory of the action of narcosan in the body is that narcotics, such as morphine, call forth in the body certain protective substances to neutralize them. If the narcotics be suddenly withdrawn, and not given, these neutralizing substances are themselves toxic to the body. The lipoids in narcosan neutralize these toxic substances in place of the narcotic.
"After seventy-two hours, because the withdrawal symptoms are over, these neutralizing reactions have ceased, the lipoids are then continued to replace the depleted lipoids in the body. The nonspecific proteins of the narcosan solution are added to stimulate the blood forming tissues. This is a theory which scientific investigations must prove or disprove.
"In this regard it is interesting to note that the work of van Leeuwen confirms the idea that the lipoids exert a definite influence on the action of alkaloids in the body. He has shown that cephalin augments the action of pilocarpine, while lecithin inhibits this action of cephalin on the pilocarpine.
"He has also proved that the serum of men and animals inhibits the action of cocaine, without destroying the cocaine, and has further shown that lecithin possesses the same inhibiting effect on the cocaine. In an interesting discussion, he holds that this effect is produced by a physical combination in the adsorption of the drug, and is not due, as many others believe, entirely to the destruction of the drug by the liver. Other workers have found that animal tissues render inert other alkaloids such as digitaline and strychnine.
"But the work of Greenfield and Pellini shows that up to the present time, though sedulously sought for by many investigators, these neutralizing or protective substances to morphine have not been proven to exist in the blood of human beings or animals tolerant to morphine. Nor was any toxic substance found present in the blood as a result of morphine habituation. The validity of a theory, however, of how narcosan acts is a question aside from its value and effectiveness as a remedy for narcotic addiction."
They report on the results of this method of treatment in 219 men and 147 women, in which they produced "a successful withdrawal of the drug in a few days, in some instances with but little discomfort, and in all instances with less suffering than the ordinary withdrawal method." They continue:
"The patients sleep without hypnotics of any kind during and after their treatment, and at the end of a few days are hungry, and digest easily all that their renewed and voracious appetites cause them to take.
"The treatment is easily carried out with much less detail than with the belladonna treatment, and with no delirium as in the hyocine treatment, and leaves the patient free from depression, and, as must be emphasized, with a returned ability to sleep."
*    *
"All these patients previous to admission to the narcotic ward had had their baths, their thorough investigation as to whether or not they were concealing any narcotic on themselves. On admission to the ward they were given a capsule composed of :
Hydrargyri chloridi mitis    gr.i    gin. 0.06
Ext. Colocynthidis    gr.iii    gm. 0.18
Ext. Euonumin    gr.ss    gm. 0.06
Resinae Podophylli    gr.ss    gm. 0.03
Capsici    gr.ss    gm. 0.03
Pulv. zingib.
Strychninae sulph.}aa    gr.1/60    gin. 0.001
"This was followed three or four hours later by a dose of epsom salts; as soon as their bowels acted they were given one c. c. of narcosan hypodermically. This was given intramuscularly, in the muscles of the upper arm, or in the shoulder at the back of the arm. These narcosan hypodermics are given thus every four hours for the first twenty-four hours, then every six hours for three days and nights, and then every twelve hours for three days and then once a day for about ten days, or until the patient has had about forty injections. No injections of morphine or heroine must be given. If these narcotics are given, intense distress, nausea and vomiting, headache, and a sense of benumbing collapse is produced. In fact, the administration of morphine or heroine can produce a serious collapse. If the patients succeed in smuggling in narcotics and take them, these symptoms soon are evident. The narcosan treatment is self-protective against the patient indulging on the sly in narcotics. If patients are nervously collapsed from the sudden withdrawal of their narcotic before treatment begins, they should be given narcosan immediately to quiet them, especially the women, who are more likely to become wildly hysterical under these circumstances. This quiets them and then they should have their cathartics."
The authors then discuss in some detail the symptoms evinced during the first days of treatment, appearing convinced that the patients sleep more, suffer less, and regain their appetites sooner than with other methods they have used, making a rapid convalescence.
In twenty-seven patients, divided into different groups, and selected at different periods in the course of treatment, examinations were made "to ascertain if variations in metabolism occurred in the body during the treatment"   the blood being tested for urea nitrogen, uric acid, creatinin, and sugar, and the amount of carbon dioxide combined with the plasma. Red and white cell counts and hemoglobin estimates and differential counts were made simultaneously, as were also urine analyses. The findings of these examinations are given in detail. The authors give no formal conclusions, but at the end of their article they state:
"The question here investigated is purely a medical decision of the value of narcosan as a treatment for narcotic addiction. Narcosan is equally efficacious in the treatment of other narcotics, as alcohol and veronal."

A. Erlenmeyer-1926.64

The author has reviewed critically the earlier theories seeking to explain morphin tolerance and the withdrawal symptoms, including the work of Alt, Faust, Marme, as well as the more recent ones of Cloetta, Legewie, Valenti and Hirschlaff, Filrer, Jastrowitz, Wuth and David. After briefly noting the salient points of the earlier writers, he continues in much greater detail a discussion of the more recent ones as follows:
"The best explanation still seems to be the one given in 1883 by Professor Marme, Gottingen. He gave hypodermic injections of quite large but not fatal doses of morphin to dogs for some time, and after putting the animals to death, he found in the organs of the lesser circulation oxydimorphin, which he succeeded in isolating. When he gave healthy dogs injections of this oxidation product of morphin in the form of the more soluble hydrochlorid, administering it in small, gradually repeated doses, the dogs developed regularly symptoms of
poisoning which resembled in every particular the abstinence symptoms caused by the withdrawal of morphin, and which vanished when he gave the dogs injections of medium doses of a morphin salt. Because of their bearing on our later analysis of the behavior of heart and blood-pressure during the withdrawal period, I shall here give Marme's findings pertinent thereto word for word. He found in these dogs: 'strong pulse acceleration without vagus paralysis, marked lowering of blood pressure with simultaneous dilation of the peripheral blood vessels, lowering of the body temperature and debility resembling collapse.'
From these he drew the conclusion that oxydimorphin is formed in the organism
of morphinists as a result of the prolonged administration of morphin injections,
and that it begins to develop its toxic effect only when the morphin effect has abated or ceased altogether.
"There is opposition to this hypothesis, too. Legewie objects that the oxydimorphin developed in the organism is again rendered ineffective by morphin `in a (single) breath' Here, it seems to me, there is a misunderstanding with reference to the time, for the mutual influencing of morphin and oxydimorphin takes place not simultaneously, not 'in a breath,' therefore, but one after the other. So long as morphin is being administered to the organism, the oxydimorphin cannot develop its effect; the latter appears only when the morphin is withdrawn. I shall return to this later. We must also distinguish between morphin administration and morphin effect, which, as already shown, do not cover each other but stand in a definite relation to each other, the disturbance of which determines tolerance, because despite increased administration the effect slackens.
"Of special significance in the pathological picture of morphinism is the `craving'—in every respect the most important symptom.
"In order to have a correct understanding of its development, one should not overlook the fact that the continued administration of morphin exerts an entirely different effect on a morphinist from that exerted by a single medium dose of morphin injected into a healthy person. While the latter causes nausea, even vomiting, feeling of faintness, heart-weakness, pulse-acceleration, and lowering of blood-pressure, the former occasions just the opposite feelings, sensations, and states—namely, pleasant feeling, euphoria, increased power, and in the heart and vessels, strengthening of the contraction, invigoration of the pulse, and rise of the blood-pressure. Since every morphinist has once had the first morphin injection, there arises the question: by what means and at what time of the continued abuse does this reversal of effect take place? It is brought about as follows. The morphin, originally foreign to the body, becomes an intrinsic part of the body, as the union between it and the brain cells keeps growing stronger ; it then acquires the signficance and effectiveness of a heart tonic, of an indispensable element of nutrition and subsistence, of a means for carrying on the business of the entire organism. In the first years of our knowledge of morphinism, a sharp distinction was made between `chronic morphin poisoning' (Burkart, 1877) and 'morphin-craving' (Morphinsucht) (Levinstein, 1875), and the development of the craving was regarded as the sign of the reversal or of the transition from the. first to the second. The observation was correct, even if the explanation did not come until 20 years later. This reversal does not occur abruptly, but very, very gradually. If morphin is withdrawn before this reversal, the abstinence symptoms do not appear. If, however, the withdrawal is made after this reversal, then there comes into existence a 'vacuum' as Legewie says, i.e., the abstinence symptoms, that host of painful sensations, intolerable feelings, oppressive organic disturbances of every sort, combined with an extreme psychic excitement, intense restlessness, and persistent insomnia. In such moments the craving for morphin is born and rapidly becomes insatiable, because the patient has learned during the period of habituation, when abstinence symptoms always set in after the effect of the last morphin dose had passed off, that those terrible symptoms are banished as if by magic by a sufficiently large dose of morphin. Whether the craving then directs itself to a single, definite, elective effect of morphin, whether it is dependent on that, is an idle question, for the patient, as a rule, has no knowledge of fine pharmacological distinctions of this sort, and even if he were acquainted with them, such a therapeutic differentiation is a matter of complete indifference to him in the terrible and exciting moments of abstinence; he requires alleviation and removal of his complaints, and to that end resorts to morphin because he knows that precisely this remedy can remove his complaints with utmost certainty and swiftness. The craving may, therefore, be conceived theoretically as a passionate desire for comfort, alleviation, and help, provoked by physical complaints, or at all events, generally augmented by illness, or—to follow up Legewie's conception of the vacuum—it may be designated as a 'desire for being filled.' In so speaking, I am thinking first of all of the cardiac weakness and the lowering of the blood-pressure. Practically, however, it is to be conceived and estimated as a thoroughly psychopathic or even psychotic symptom, which is just as peculiar to the morphinist as to the alcoholic, the opium-smoker, and the cocain-sniffer, but also as to the habitual thief and the moral delinquent—except that in each case the object of the craving is different.
"Recently, of course, an explanation of morphinism has been sought in our broadened views regarding the autonomic nervous system, and the function of the endocrine glands. In this connection there are two theories, as yet quite unreconciled.
"Otto Wuth seeks, first of all, to explain addiction and abstinence as results of disturbances of the vegetative nervous system and says that in the former the parasympathetic tonus is raised, while the sympathetic is lowered, and that in abstinence, on the other hand, the parasympathetic tonus is lowered and the sympathetic raised. In addition, he believes in the participation of the endocrine glands, and principally of the thyroid gland in the pathological picture of morphinism, and this in the sense of a lowering of the activity of the thyroid gland during the addiction stage and an increase of the same during
abstinence; he does not, however, settle thereby the question of the primary point of attack of morphin. He then gives an explanation of the symptomatology of the disease, which is somewhat prepossessing: Morphin is administered to the body for various physical and psychical complaints. It acts as a depressant on the function of the thyroid gland and of the organs which have nervous and humoral connection with it (sympathicus, adrenal system), i.e., as a stimulant of the parasympathetic tonus. Now the organism endeavors to restore the vegetative-endocrine balance which has thus been disturbed, and to bring the heightened tonne down to the desired level. Consequently it is necessary to enlarge the dose in order to obtain the same effect from further morphin administration. Thus Wuth explains the cause of addiction. To this there is added a second consideration. Animals which have no thyroid gland have a diminished sensitiveness to morphin. In the use of morphin, therefore, the diminished efficacy of the poison is conditioned by the depression of the function of the thyroid gland. Wuth also calls attention to the fact that psychopaths are the very individuals who are continually complaining of their countless vegetative-neurotic symptoms, and he finds in this the explanation for
the fact that psychopaths are precisely the individuals who represent the largest contingent to morphinism. He then—to dispose of the matter here—evaluates this hypothesis for therapeutics and demands a remedy for the control of abstinence symptoms which shall act as a depressant on the endocrine-vegetative tonus, i.e., the sympathetic, though no view holds this raised during abstinence, and he believes that he has found such a remedy in cholinum hydrochloricum." I shall return to this later.
"Erich David has arrived through his experiments with reference to addiction at precisely the opposite results. He has to admit, however, that certain particular symptoms of both the addiction and the abstinence period do not fit into his scheme and find a better explanation in Wuth's conception. He assumes for addiction a diminution of the parasympathetic tonus, but admits that the contraction of the pupils and the retardation of the pulse during this period can be ascribed only to an increase of the parasympathetic tonus, which Wuth does assume for this period. In accord with his conclusions regarding the biotonus as a whole, he tries to explain also the psychic symptoms of the three stages of morphinism assumed by him. For to the periods of addiction and abstinence be adds a third—that of convalescence, which begins when the body weight begins to increase after the withdrawal has been completed. The stage of addiction he likens to the melancholic phase of manic-depressive insanity. I must observe here that the detailed description given by him of the general psychic disposition of a patient during this period applies at most only to `Grammatiker' " and even to these only after many years of abuse. The withdrawal stage resembles, according to him, the manic-depressive mixed states while for the stage of convalescence he finds a counterpart in the manic phase. In conclusion David concedes 'that just as with Basedow's disease, there is a striking similarity between the second stage, that of withdrawal, and Freud's anxiety-neurosis, in which we must, in all probability, assume a disturbance of the endocrine activity of the genital glands.' He then produces his theory of morphinism, according to which we must think 'that morphinism involves an exogenously produced lesion of the vegetative centers, by which metabolism is regulated, in the basal ganglia of the midbrain.'

"Various objections may be offered to these explanations. For example, it is not proper to compare the effects of a single dose of morphin administered to a healthy person with the effects which appear in addicts. Furthermore, I do not consider it admissible to apply without reservation the results of animal experiments as to addiction to htiman beings. Quite apart from the fact that this is absolutely inadmissible as regards the small laboratory animals (rats, pigeons), even morphinized dogs, which had been morphinized with increasing doses in order that the experiment might approach as closely as possible the conditions for human beings, are far from presenting the entire picture of physical addiction symptoms in human beings, and show no abstinence symptoms whatever even on abrupt withdrawal." Finally, it should not be forgotten that, quite apart from the fact that, as Ganter says, 'the terms sympathicotonia and vagotonia are handled somewhat too freely,' sympathicotonic and vagotonic stimulations frequently run alongside each other, that they appear simultaneously, that they are, therefore, not to be sharply distinguished from each other in so complicated a complex of symptoms as morphin abstinence, and may not serve as a certain basis for a final explanation of the latter. Thus, for example, the augmented cardiac frequency of the abstinence period depends on the raising of the sympathetic tonus, while the diarrhea occurring at the same time depends on the raising of the parasympathetic tonus. Or, according to Glaser, we find the same increase of the sympathetic tonus in the addiction period (suppression of saliva, dryness of oral mucous membrane, stoppage of the gastric juice secretion with resulting constipation) and also in the abstinence phase (acceleration of cardiac activity), while the hyperhidrosis present at the same time in the latter is dependent on a raising of the parasympathetic tonus. According to this, the antithesis between Wuth and David—both of whom seek to explain the phases.of addiction and abstinence as totalities conditioned by this simultaneous appearance of sympathicotonic and vagotonic stimulation—could in reality be only an apparent one.
"So far as practice is concerned, these theoretical and discordant speculations bring us not a step forward; on the contrary, they unhesitatingly lead the patient back to morphin instead of setting him free. Wuth himself says that during the withdrawal 'the general narcosis of all the vegetative centers by means of fever narcotics " or by means of small morphin doses continuously administered throughout the earlier period (slow withdrawal) is not to be neglected." Without
doing violence to these words, it must be said that out of regard for his theory, Wuth again recommends slow withdrawal, long since discontinued. That would be a serious relapse. This recommendation is not modified or mitigated by the fact that 'small morphin doses' are to be given only throughout the 'earlier period,' for the former as well as the latter are relative concepts, which are determined more by the subjective attitude of the physician than by the objective indications and requirements of the symptoms. And when Wuth adds a few lines farther on 'that, starting from our view regarding the nature of morphinism, we have before us numerous new therapeutic methods,' and when in another place he designates as the next task 'the opening up of a new fertile field for therapeutics in a different and hitherto neglected sphere, on the basis of his hypothesis,' I cannot subscribe to such a conception. I must point out first that precisely the control of abstinence symptoms by means of even small morphin doses may become one of those sources from which the danger of a relapse takes its growth. Next, I must emphasize the fact that all treatment of individual abstinence symptoms is always only a symptomatic alleviation of the patient, and that the aim of the treatment, or better, the principle of the cure cannot possibly consist in the discovery of a remedy ingeniously thought out on the basis of theories and hypotheses, but solely and alone in prophylaxis: We must
come to know the cause of the abstinence symptoms as a totality of symptoms, we must disregard the troublesome doctrine of the elective action of morphin, and we must find a remedy or procedure, which will aid us to remove the cause of the abstinence symptoms, and to prevent their appearance.
"How far we are led from our goal by the explanations founded on the functions of the autonomic nervous system, the following discussion may show. If, among the abstinence symptoms, the flow of tears and saliva, the copious secretion of perspiration, the increased excretion of gastric juice accompanied by gastric and intestinal pains and diarrhea, and also vasomotor disturbances accompanied by arrhythmias of the heart, are to be regarded as vagotonic, and therefore parasympathetic symptoms, then atropin should surely banish all of them. But in reality atropin is of no avail against these abstinence symptoms—at any rate, not in the permissible doses.
"It is equally impossible to harmonize these recent explanations and their proposed therapeutic methods with the earlier conclusions as to the behavior of the heart and the blood-pressure. Years ago I demonstrated by means of sphygmographic investigations" that the full, powerful, and regular pulse of a morphinist becomes during the abstinence period small, weak, more rapid, frequently arrhythmical and dicrotic, giving evidence thus of cardiac weakness, and that a sufficiently strong injection of morphin quickly restores to this pulse its former powerful qualities. Next I determined by means of auscultatory measurements the systolic and diastolic blood-pressure, and I discovered that, as a result of the withdrawal, the pressure is lower than it was before the beginning of the withdrawal, i.e., when it was still under the influence of morphin, but that it may be restored to its previous height by means of a copious morphin injection. Wuth now asserts that the blood-pressure is raised during the withdrawal period and recommends for the purpose of lowering it intravenous infusions of cholinum muriaticum. To this I have two objections. In order to settle objectively this antithesis of opinions, I once requested the `Psychiatrische und Nervenklinik' of Cologne University (Professor Dr. Aschaffenburg) to undertake blood-pressure measurements in connection with their withdrawal curves. These turned out in accord with my earlier discoveries and views. Dr. Kurt Blum, Assistant Physician of that clinic, sent me the following report:
"W.W.; 42 years old; wounded in 1917; right leg amputated in 1921; morphinist since that time; as stated, 3 injections daily. Admitted August 20, 1925. Blood-pressure 110/60. Immediate complete withdrawal. During the second night, intense restlessness, small, frequent pulse. Blood-pressure 100/60. Because of this, 0.01 M. The very next day, blood-pressure 120/65. Hence, morphin restored the blood-pressure which had fallen during the abstinence period.
"Next, I am unable, despite the best intentions, to discover in the publications of Klee and Grossman, who, on the basis of Wuth's hypothesis, applied cholinum muriaticum in two cases, any confirmation or support of that hypothesis. Regarding one patient, in whose case the investigation lasted 3 weeks, they say: `The patient, who before the cholin infusion was feeble, apathetic, or excited, became, even while the infusion was being made, vigorous, lively, and talkative. The pulse became full and tense.' For 5-8 hours the hunger for morphin was completely stilled. The dose which was withdrawn is not stated. Regarding the second patient, who had injected daily up to 2 g. of eukodal, they report: 'Here, too, the patient looked more vigorous immediately after the injection. She became livelier, and—what was especially striking—the previously irregular, small pulse became regular and full like a digitalis pulse.' And in another place they make the general statement: 'With a certain concentration (of the infused cholin solution) in the blood, there appears, with few exceptions, a noticeable slackening of the pulse-beat (5-10-20 per minute). The pulse often appears to the feeling finger as if under the influence of digitalis. Extrasystoles were rarely observed.' These words, as I understand them, allude to that regulatory effect of digitalis, which raises and augments the low blood-pressure in case of cardiac insufficiency. Moreover, when the circulation is undisturbed and the cardiac nerves are intact, the decrease of cardiac frequency speaks for a heightening of the blood-pressure. Finally, I call attention to the observation cited above, which Marme made in the case of dogs which had been treated with oxydimorphin. If Marme's hypothesis is correct, then these findings, applied to human beings, show that cardiac weakness and lowering of the blood-pressure appear during the withdrawal period of morphinism.
"The question suggests itself as to the reason for these contradictory views. The answer, too, is obvious. It is in effect that we are not justified in expecting or supposing that the cardiac weakness and lowered blood-pressure produced by a single, medium injection administered to a healthy man will also follow the habitual use of morphin by a morphinist. Disregarding the fact that according to general experience, morphinists are individuals with impaired nervous system (psychopaths), on whom, as is well known, all opiates, including morphin, have a restorative and stimulating effect, surely the transformation of morphin, originally foreign to the body, into something which is an intrinsic part of the body and a necessary and indispensable means for vital activity, together with the increase of power to work and achieve resulting therefrom, point to the fact that no cardiac weakness, no vascular atony, no lowering of the blood-pressure, can be connected with it. The cardiac-vasomotor state of morphin addiction is hypertonia, that of morphin withdrawal stoma.
"Of the more recent theories regarding the nature of morphinism, none has given a complete, generally recognized explanation. Nevertheless, I shall not succumb to the obvious temptation of advancing a new one. I shall, however, call attention to two older ones, which have almost fallen into oblivion.
"One, no doubt the first and oldest, which in all modesty, however, did not yet claim the name of a theory, comes from the time when `morphin abuse' was still regarded as a curiosity. It furnished the basis for the 'gradual withdrawal' and said that the symptoms which developed during the addiction or intoxication period faded and receded during the withdrawal cure. Its substance was the aphorism: Cessante causa cessat effectus. (When the cause ceases, the effect ceases.) In proportion to the size of the dose withdrawn, this simple fading and recession turned into symptoms which were the reverse of the intoxication symptoms—which even passed over into violent, and often explosive, symptoms, when Levinstein's 'abrupt withdrawal' came into vogue. They impressed themselves as something new, and for that very reason were not understood at first. This increase to violent contrast with the intoxication symptoms was most distinct in the behavior of the gastric juice: During the intoxication period, as a result of the narcotic effect of the morphin excreted into the stomach, the gastric juice glands are 'lulled to sleep' and finally suspend their function altogether with consequent anacidity of the gastric contents and constipation—during abrupt withdrawal, on the other hand, these glands awaken to a violent resumption of their function with consequent hyperacidity of the gastric contents and severe attacks of diarrhea. It might have been said, and it has been said, that with the smallest withdrawal of the habitually injected poison, a withdrawal cure might run its course almost without a symptom. But just there lay the impossibility of carrying it through. If, for example, 1 mg. of morphin were to be withdrawn daily—which can be done without producing the least abstinence symptom—from a morphinist with a daily consumption of 0.5 g. through months and years, 500 days would be required for the withdrawal cure. Time and money are both lacking for such a cure in a hospital, while the patient, if left to himself, cannot summon the necessary will-power, firmness, and self-control. A cure of this sort, therefore, was and is unfeasible in practice, however correct it may be in theory. But the thought on which it was based explained—and that is our concern here—the nature of morphinism—an explanation which permits either the destruction or the binding of morphin in the organism, or both, to be adduced as cause of the addiction and the increase of the dose accompanying tolerance or immunity.
"The second of the older theories is the one set up by Marm—that abstinence symptoms are to be conceived as oxydimorphin poisoning. I have already made mention of it. The decision as to its validity depends on the question whether in the habitual misuse of morphin the balance of effect falls to morphin or to oxydimorphin. This is of especial importance with regard to the effect on heart and vessels. Oxydimorphin develops from the injected morphin, but it becomes effective only when the morphin has ceased to be so. This undoubtedly happens several times a day, according as the morphinist is acustomed and able to make his injections more or less frequently. But however often it may happen that the fresh injection is delayed, i.e., that it is made some time after the effect of the previous injection has passed off, so that opportunity is given for the development of the oxydimorphin effect—at all events, the
morphin doses are always chosen strong enough to overcome and annul the oxydi-
morphin effect, and then the duration of the morphin effect is always much greater than that of the oxydimorphin effect. There cannot, therefore, be any doubt as to the fact that in the oscillating play of morphin and oxydimorphin effects, as continually displayed in the life of a morphinist, the first is by far preponderant. The heart of a morphinist, therefore, enters the withdrawal cure, not relaxed and weakened through the effect of oxydimorphin, but, on the contrary, well prepared and equipped for the struggle with the morphin withdrawal through a previously acquired hypertonia. From the teleological standpoint, therefore, we must wonder at the curious fact, already pointed out, that morphin under conditions of addiction produces an effect contrary to that produced by morphin administered but once, for if the withdrawal had to be got over with a heart which had had its power of resistance reduced once by morphin (with its peculiar property of weakening the heart and lowering the blood-pressure when the dose is isolated) and again by oxydimorphin with its simlar effect, then a withdrawal cure would surely be a procedure extremely perilous to life. The first supposition does not hold, however. Since abstinence resulting from quick and sudden withdrawal of the habitual stimulant always brings the contrast of the symptoms of addiction, then, if addiction morphin also weakened the heart and lowered the blood-pressure, the beginning of the withdrawal would encounter a hypertonic heart, and could, therefore, be endured much more easily. And even if this more vigorous heart served only to paralyze the heart-weakening effect of oxydimorphin, which in any case does make its appearance• during the withdrawal cure, then the entire situation during the abstinence period would still be better than it actually is. Precisely in the difference between the effect produced by a dose of morphin administered just once to a healthy person and that produced by morphin when habitually incorporated, lies the fatal development of the morphin craving, and the question I raised once before is still justified—namely: Might not humanity have been spared the morphia craving, if the effect of morphin on heart and vessels were such as weakened the heart and lowered the blood-pressure also in the case of habitual administration of large
doses? I answer this question in the affirmative with complete conviction.
"So long as no casual treatment of the abstinence symptoms is possible, i.e., so long as there has been no remedy discovered or method devised for preventing their appearance, their treatment can be symptomatic only. For such the following directions may be of value:
"1. Rapid withdrawal under conditions which guarantee certain and safe accomplishment.
"2. Treatment of the gastro-intestinal symptom-group by alkalization of the gastric and intestinal contents through the oral or rectal introduction of large quantities of alkalic-muriatic mineral water, freed as much as possible from CO,. Internal lavage.
"3. Treatment of the cardio-vascular symptom-group by remedies which regulate cardiac frequency and rhythm and raise the lowered blood-pressure. It is best to introduce this prophylactically.
"4. Treatment of the neuro-cerebral symptom-group by sedatives and hypnotics which should be changed daily and which, of course, should not be chosen from the morphin-group.
"5. Dependable supervision during convalescence. Abstinence from alcohol. Occupation and work in gradual amounts carefully determined.
"For details, see my work on the Treatment of chronic morphinism which has just appeared in the Sixth Edition of Penzold and Stintzing's Handbuch der
gesamten Therapie."

Ministry of Health of Great Britain—Departmental Committee on Morphin and Heroin Addiction-1926.7'

This Committee," after listening to proponents of different forms of treatment, which involved abrupt withdrawal, rapid withdrawal and gradual withdrawal, together with the use of medical and other adjuvants, came to the following conclusions:
"Opinion was, on the whole, strongly in favour of the gradual withdrawal method in preference to either of the alternative plans. The evidence appears to show that it is more generally suitable, and more free from risk than either the abrupt or rapid withdrawal methods. It entails less strain and distress upon the patient, is unattended by collapse, and other withdrawal symptoms may in large measure be prevented by its adoption.
"Though there was thus a distinct conflict of opinion as to the merits and demerits of the various methods, the following inferences may, we think, be regarded as established:
"(a) That each patient requires individual consideration.
"(b) That abrupt or rapid withdrawal may be advisable in cases of young healthy adults in whom the addiction is of recent date and only moderate doses are being taken. Otherwise, the gradual method is to be preferred.
"(c) That abrupt or rapid withdrawal is specially dangerous in the case of old or seriously debilitated persons, of patients with advanced organic disease, and those who are taking exceptionally large doses.
"(d) That abrupt or rapid withdrawal should not be carried out except in a well-appointed institution and with the aid of skilled nursing and constant medical supervision. It is therefore, unavailable for the treatment of those who cannot or will not enter institutions.
"(e) That it would be unsafe to draw any conclusions of a general nature from the peculiar success which appears to have attended the prison cases treated by the abrupt method. These persons were confined under close observation and subject to a discipline more strict than could be enforced in any voluntary institution ; they received prompt medical aid in any emergency, and the dose of drug that had been habitually taken by most of the prison addicts appears to have been comparatively small."
In their consideration of the prognosis in these cases and of the importance of permanent cure, the Committee reports as follows:
"It was specially insisted upon by several witnesses that the actual withdrawal of the drug of addiction must be looked upon merely as the first stage of treatment, if a complete and permanent cure is to be looked for. As one witness put it, the real gain to the patient by withdrawal of the drug is to enable him to make a fresh start in new and more favorable circumstances, and little more than that can be expected from the actual treatment itself, whatever the method employed. A permanent cure will depend in no small measure upon the after-education of the patient's will power, and a gradual consequent change in his mental outlook. To this end it was regarded as essential by one witness that full use should be made of psychotherapeutic methods, both during the period of treatment and in the re-education of the patient. It was not considered that a lasting cure could be claimed unless the addict had remained free from his craving for a considerable period-1% to 3 years—after the final withdrawal of the drug. Scarcely less important than psychotherapy and education of the will is the improvement of the social conditions of the patient, and one physician informed us that he made it a practice, wherever possible, to supplement his treatment by referring the case to some Social Service Agency. It was also regarded as important that the physician in charge of the case should, while the patient is under his care, make a thorough study of the causes, pathological and other, which originally led the patient to take drugs, and try to remedy them. Pain, insomnia or other physical malady must be suitably treated before the patient is released from observation.

Prognosis.

"Evidence we have received from most of the witnesses forbids any sanguine estimate as to the proportion of permanent cures which may be looked for from any method of treatment, however thorough. Relapse, sooner or later, appears to be the rule, and permanent cure the exception. With two exceptions, the most optimistic observers did not claim a higher percentage of lasting cures than from 15 to 20 per cent. One eminent authority, however, who employs the abrupt withdrawal method reinforced by certain auxiliary measures of a drastic character, was of opinion that a real cure may be expected in about 66 per cent. of the cases in which the patient is willing to accept treatment and in whom the treatment is not contra-indicated. The witness who had practised the rapid withdrawal method (referred to in paragraph 39) gives a percentage of cures as high as 70 per cent., but other observers who have tried the method have failed to obtain successful results in such high proportions. In this connection may also be mentioned the remarkable results obtained by one of the general practitioner witnesses who, by the employment of the gradual reduction plan, had obtained success in 8 cases out of 12 which he had treated. Some of these cured cases had been under observation for years and had not relapsed.
"While therefore, the ultimate outlook in any individual case is always serious it can by no means be considered hopeless and every effort should be made by thorough and suitable treatment to free the patient from his addiction. It must be borne in mind, however, that those witnesses who were most sanguine as to the proportion of permanent cures that could be obtained under the best possible treatment, recognized that the results they described could only be secured by treatment in institutions. Looking to the small number of such institutions in this country, as well as the cost of the treatment which, reasonable as it usually is, is beyond the means of some of the patients, and the impossibility under the law as it stands, of compelling persons suffering from addiction to become inmates of institutions, it is clear that under present conditions there must be a certain number of persons who cannot be adequately treated, and whom it is impossible completely to deprive of morphine which is necessary to them for no other reason than the relief of conditions due to their addiction."

George S. Johnson-1927.73

In twenty-four "unselected cases addicted to the use of opium or its derivatives" this author employed narcosan and was able to check the subjective and objective effects of this preparation with twelve cases treated according to the ordinary hospital routine: namely, abrupt withdrawal of all narcotics, with the use of bicarbonate of soda to combat any acidosis, detoxication by the daily use of high colonic irrigations, and the control of restlessness by the use of continuous baths.
The narcosan was administered according to direction and certain routine daily observations were made in regard to appetite and sleep. Except for the substitution of narcosan, the cases were treated exactly as were the control cases; so that the author believes that results were comparable. Two of the twenty-four patients underwent both types of treatment at different times.
The author reports on his study and findings as follows:
"Publicity attendant upon the introduction of the narcosan treatment resulted in twenty-two of the twenty-four cases entering the hospital thoroughly convinced of the efficacy of the drug. In view of the well known suggestibility of these patients, we feel that this has been an important factor in the subjective reactions to treatment.
"All of the patients treated showed the characteristic withdrawal phenomena to a greater or less degree. Seventeen showed nausea and vomiting and they and the remaining seven showed restlessness, irritability, abdominal cramps and pains in the legs. Eleven patients stated that they were definitely relieved by narcosan injections, seven stated that they could see no influence on their immediate withdrawal symptoms and the remaining six were definitely opposed to the use of narcosan, feeling that it added to their discomfort.
"Only one patient showed abnormal blood sugar, having 139 mg. per 100 cc. of blood on the morning after admission. This blood sugar was 92 nig. per 100 cc. three days later. The remainder of the patients showed a range of from 82 to 116 mg. per 100 cc. There was a definite rise in the non-protein nitrogen of the blood, the average determination on admission being 30 mg. per 100 cc. and the average determination on the third day being 36 mg. per 100 cc. The extremes noted were 24 and 36 mg. per 100 cc. on admission and 30 and 48 mg. per 100 cc. on the third day. The urea nitrogen showed a similar change, the average determination on admission being 13.5 mg. per 100 cc. and the average for the third day being 18.5 mg. per 100 cc. The extremes noted here were 11 and 16 mg. per 100 cc. on admission, 15 and 26 mg. per 100 cc. on the third day. In all of these patients the blood chemistry determinations were within normal limits upon discharge from the hospital. Leucocytosis, with a relative polymorphonuclear increase was noted in most of these cases under treatment. The extremes noted were 5,400 cells and 19,300 cells with an average of 12,600 cells. The percentage of polymorphonuclear cells ranged from 63 to 92, the average being 77 per cent. The urine examinations showed a high specific gravity during the period of emesis and diarrhoea and a few showed indican and albumin at that time, but no other changes were noted.
"The influence of narcosan on the amount of sleep obtained by the patients undergoing treatment has been stressed in the report previously mentioned and careful observations were made in this regard. The average amount of sleep obtained during the first 96 hours under treatment was 16 hours or an average of 4 hours per night. During the second period of 96 hours an average of 24 hours' sleep was obtained, an average of 6 hours per night. During the remainder of their stay in the hospital the patients averaged 61/2 hours' sleep per night..
"Contrasted with this sleep record is the record of those patients treated in the Colorado Psychopathic Hospital before narcosan was used. During the first 96 hours this group averaged 20 hours of sleep, an average of 5 hours during each night. In the second 96 hours, an average of 25 hours' sleep was obtained or 6% hours per night. During the remainder of their stay in the hospital, an average of 7 hours of sleep per night was obtained.
"The sleep curve of the two patients who have taken both types of treatment is interesting. The first patient slept on an average of 4 hours per day during the first 4 days under narcosan and an average of 7 hours per day under the routine hospital treatment. During the 2nd period of 4 days, 6% hours of sleep were obtained under narcosan and 7 hours of sleep under the hospital routine. The second patient slept 51/2 and 61/2 hours per night for the two periods under narcosan and 7 hours each during the two periods under the hospital routine. Both of these patients attested the advantages of each method of treatment and both returned to the use of the drug shortly after their release from the hospital.
"The information gained from a study of the weight curves of these two groups of patients was not significant. Each group showed a rapid loss in weight during the period of the acute withdrawal symptoms with a rapid return to their admission weight or more."
"The follow-up reports have not been encouraging. Of the 24 patients treated, only 9 had permanent addresses. Information of the remaining group was obtained from other associates. Information has not been obtained on six. Of the 18 about whom reports have been obtained, 11 have returned to the use of drugs. Of the control group there was no information on 8, but 4 were known to be off of drugs."

CONCLUSIONS.

"1. Patients treated for narcotic addiction by the use of narcosan show the usual withdrawal signs.
"2. Of 24 patients treated, 11 were subjectively relieved by the narcosan while 13 could see no effect or were made uncomfortable.
"3. Of the 11 patients who were subjectively relieved by the narcosan, .7 were known to have returned to the use of morphine and the status of three is unknown.
"4. Narcosan is not as effective in controlling sleeplessness and restlessness as methods previously employed at the Colorado Psychopathic Hospital.
"5. Narcosan is not of any added value in the treatment of drug addiction and this treatment remains a psychiatric problem."

M. G. Carter, T. J. Orbison, E. H. Steele, C. A. Wright and E. H. Williams-1927.74

These authors review the theories of Lambert and Tilney on the action of narcosan in the treatment of opium addiction, that narcotics "call forth in the body certain protein substances to neutralize them" and that these substances are toxic and are neutralized by the lipoids in narcosan when the narcotic is withdrawn. They disagree with this hypothesis and also with that to the effect that there is a definite toxic substance in the blood as a result of morphin taking or withdrawal.
They state their reasons for disagreement and their own theories as follows:
"We disagree with this clinical deduction because it seems to us that the evidence presented by the clinical picture of addiction, and certain chemical features, indicate primarily rather a disturbance of the endocrine system—either primarily or secondarily to the sympathetic nervous system. There is no question about the endocrine hypofunction in these cases, as indicated by the lowered blood pressure, low basal metabolism, and generally weakened condition, which may be improved by direct action of endocrine substances. This was suggested several years ago in the book Opiate Addiction by Edward Huntington Williams, the Macmillan Co., 1920. Also, the symptoms presented in so-called withdrawal, which, most significantly, are more uniform than in almost any other form of disease, are apparently manifestations of a disturbance of the endocrine system—hypoendocrine rather than toxic, in our judgment.
"Our opinions on this subject were formed after a clinical, pathological, and chemical study of drug addiction cases over a period of several years, observations of numerous forms of treatment and experimental treatment directed to stimulating and sustaining the endocrine system during the withdrawal of the drug. This was done by the administration of various endocrine substances themselves, and also by the solution of vegetable proteins administered hypodermically. The cases in which this treatment was given showed such satisfactory results as to still further confirm our belief that our theory of endocrine involvement in drug addiction and withdrawal is more tenable than Bishop's theory of special toxic substances in the blood. In this connection it seems significant that many observers who have administered nonspecific vegetable proteins, regard their action in the body as stimulants to the endocrine system—vegetable hormones, someone has called them.
"Now, it happens that narcosan contains one of these vegetable protein substances, alfalfa protein, apparently prepared in practically the same manner as is described in the preparation of 'alfalfa proteal No. 39,' which is available and on the market, and has been for several years. The action of this vegetable protein suggests that it is an endocrine stimulant, hormonic in action, and it appeared to us in observing cases of drug addiction undergoing narcosan treatment, that the effects produced were those of a protein stimulant—an endocrine system stimulant—rather than the neutralizing of a toxic substance in the patient's blood. The effects are similar to these produced by alfalfa protein alone."
They state that in their experience, patients treated with alfalfa protein alone present the same clinical picture, have just as little suffering and are in quite as good condition at the end of their treatment as are those treated with narcosan. Acting on their belief that the symptoms of morphin withdrawal are due to "a functional upheaval in the endocrine system rather than of a toxic nature and that hormone balance might be restored or assisted by the use of certain endocrine
products in addition to the alfalfa proteal" they instituted the following treatment:

". . . . Thus, in addition to the proteal of alfalfa, administered as referred to above, the male patients were given five c.c. of orchitic substance injected into the gluteal muscles in the beginning of the treatment and repeated at three day intervals. In the female patients a preparation believed to be the ovarian hormone (so thought by the manufacturers, and certainly an active preparation) one c.c. was administered daily.
"The results of this treatment obtained in a series of six cases up to the time of making this report (and a considerably larger series since then) were most gratifying. The patients suffered little discomfort, some of them none at all. most of them were able to be up and about the wards rather than confined to bed, and the nursing care was minimized being much less than in any other form of treatment that we have observed except narcosan.
"In addition to this treatment primarily, we found it expedient to keep the patient alkalinized with sodium bicarbonate, and, to combat the inevitable nervousness, we administered strychnine, one thirtieth of a grain hypodermically every six hours, as suggested by Lambert and Tilney in their narcosan treatment. Strychnine was the sheet anchor of the treatment given by the late Dr. Bishop, and its value is recognized by every one who attempts the treatment of drug addiction.
"It will be seen from the above that this proteal treatment, as we call it for convenience in designation, is essentially a foreign protein endocrine treatment. Clinically it seems to be highly satisfactory, quite as much so as the narcosan treatment. Financially, it has the advantage that the protein substances used are inexpensive costing only a few cents for the treatment in comparison to the rather large number of dollars required for the purchase of narcosan.
"Moreover, these proteals are not a patented preparation—no secret formulas —but are open to anyone, and can be prepared by any reasonably skillful laboratory worker at a cost of only a few cents."
The authors summarize as follows:
"1. The patients taking proteal treatment suffered very little discomfort, and remained in comparatively good physical condition.
"2. Necessary nursing care was minimized.
"3. It is probable that such vegetable proteins as those from millet, rape, hemp seed, etc., will give quite as satisfactory results as the alfalfa protein, since there is a definite and similar response when they are administered.
"4. The action of the foreign protein in these cases seems to be fortified by the simultaneous administration of such endocrine preparations as orchitic substance and ovarian products. The rationale of this is suggested by the fact that drug addiction almost invariably affects sexual function.
"5. There is also considerable evidence suggesting that testicular and ovarian preparations when administered act as 'general stimulants' to the entire endocrine gland system. If this is true, certain x-ray treatments ought to be helpful in these cases.
"6. Proteals are neither secret nor patented preparations. They cost only a few cents, either to make or to buy."

Lawrence Kolb-1927.75

In a second article dealing with his studies of a series of 210 cases of addiction among all social groups, Kolb reports his findings as to the cause of the so-frequently occurring relapses following curative treatment. He states that at the present time relapse is more common than formerly because recently-adopted narcotic control measures have been more effective in preventing the addiction of stable, normal persons, than of unstable, psychopathic persons, and further, the coercive features of narcotic laws have forced a cure of the more hopeful of the curable cases, and that now it is those who by nature are more predisposed to relapse who become addicted, thus creating a class of addicts which is peculiarly liable to relapse. He further states in this connection that although relapses have always been frequent, they have never been so frequent nor has permanent cure been so difficult as is commonly supposed, and that the popular misconception about the difficulty of permanently curing drug addiction is traceable to two factors, as follows:
"(1) As a rule drug addicts as well as their physicians conceal the addiction as long as it is possible to do so, consequently the addiction of cured cases is seldom heard of before cure is effected and is never mentioned afterward; (2) the repeated treatments of so many relapsing cases make a one-sided impression on the uninformed and unreflective mind. By a study of the subject we have been led to believe that there are thousands of cured addicts in the United States today, and if we class as former addicts all of those persons who after several weeks of opiate medication suffered for a few days with mild withdrawal symtoms—such as restlessness, insomnia and over-activity of certain glandular functions—the number of cured addicts must exceed those who remain uncured."
In what follows Kolb gives certain information relative to the cases studied, and reviews the fundamental reasons for relapse:
"The conclusions of this paper are based on a study of 210 addicts embracing all classes of society, from successful professional men to habitual criminals. They had relapsed a variable number of times ranging from one to twenty. The duration of abstinence from narcotics varied from three days to ten years, but each addict included in this series of cases had abstained at least once for as long as fourteen days. Nearly all of them had been off the drug at one time or another for three months or more and the majority had experienced periods of abstinence for as long as six months. Abstinence was enforced in many instances due to confinement in prison for violations of narcotic laws but all except a few of the prison cases had sought treatment and voluntarily abstained either before or after their prison terms. The first voluntary abstinence was likely to last longer than subsequent ones. As a rule the time would shorten with each attempt at cure until finally there would be nothing but fruitless efforts at treatment with no abstinence at all.
"The idea is widely held that opiates bring about a state of moral perversity that renders addicts indifferent to cure and therefore liable to relapse, or that in many cases these drugs produce some physical change that makes their continued use necessary and the impulse to return to them irresistible. It seems plain, however, that induced moral perversity has nothing to do with it and that physical dependence upon opium though important is, except in rare cases of prolonged addiction, only temporary and is second in importance to psychological factors in bringing about relapse to the drug.
"It has long been recognized by students of the subject that the addict is generally abnormal from the nervous standpoint before he acquires the habit, while some like Block assert that normal persons never become habitues. It is probable that Block does not class as habitues persons who because of certain painful conditions are necessarily addicted in the treatment of them. If his assertion allows for this exception and is limited in application to countries which like the United States have laws that protect people from the consequences of their own ignorance, its accuracy is supported by my own findings. Ninety-one per cent of this group and eighty-six per cent of a group reported elsewhere by me deviated from the normal in their personalities before they became addicted.
"The fact that becomes so clear upon the study of cases, that most addicts are in the beginning abnormal, is in the viewpoint of many persons obscured by the more obvious fact that the habitual use of opium creates in any type of person a temporary physical dependence upon it. This dependence being the most striking thing is often erroneously thought to be the most important, if not the only important, cause of addiction and frequent relapse. The passage within recent years of laws making it a penal offense to possess or sell narcotics and the consequent arrest of numerous addicts who for ingrained mental reasons take narcotics but who for social reasons blame the narcotics themselves, and complain about the physical discomfort of treatment that is so often forced on them, has served still further to concentrate attention upon the less important factor of physical dependence."
In the 210 cases studied, the author finds that psychic causes produced the susceptibility to opiates and cocain, and that the cause for relapse was primarily the same as that responsible for the original addiction, reinforced later by memory associations and habit and by
the induced physical dependence that gradually developed, the memory associations and habit being part created by the physical dependence.
The primary psychic factor remained fairly stable during the entire period of addiction, while the other three factors increased in intensity with the passage of time, bringing about a change in the relative importance of the various factors. Kolb states:
".    . The force of physical dependence increased more rapidly than the
other two variable factors. In persons who had been addicted for no more than a year the primary psychic factor was almost solely responsible for relapse in those who had abstained from the drugs for as much as fourteen days and the importance of physical dependence was insignificant. In those who had been addicted for fifteen years or more the force of physical dependence equalled, if it did not exceed, the primary psychic factor as a cause of the relapses that occurred during the first few months after treatment with complete withdrawal of the drug. The importance of physical dependence as a cause for relapse increased more rapidly in neurotic patients than in those who were considered to be normal. It was so important in some cases of long-standing addiction of nervous persons as to preclude the possibility of recovery by any means except enforced confinement over long periods of time."
As to the attitude of addicts toward their addiction and toward treatment, he says that some cases regard their addiction as beneficial rather than harmful, while others, much more numerous, feel that having progressed to their present state they would be better off if left alone. The former accept treatment only under physical restraint and relapse as soon as they regain their liberty; the latter seek treatment only because of the urging of friends, the difficulty of maintaining
themselves as addicts and because of their fear of the law. They usually relapse promptly. The author continues as follows:
"Most persons who become addicted to opium or its preparations through medical means become alarmed as soon as they become aware of their dependence upon the drug and adopt strenuous methods, if necessary, to throw off the habit. This is easily done in the beginning; those who fail have physical diseases that make the use of the drug desirable or necessary at certain times, or they have psychopathic traits that render them especially susceptible. The medical cases that remain uncured belong to one of these classes. They are always ashamed of their addiction although they often defend it. Shame is a sentiment which affects even the deliberate dissipators; and practically all addicts, except the worst of the criminal psychopaths, would like to be cured. This is true even of those who have given up the struggle and who would spend the rest of their lives without giving a serious thought to another treatment but for the coercive measures that are brought to bear on them.
"That this attitude of indifference to treatment is a late development is shown by the fact that of those who were addicted before the passage of the Harrison Law, comprising 40 per cent. of the total number of addicts in this series of cases, all but three had taken treatment at least once, and some had taken it several times before the law was passed. It is also significant of an earnest desire for cure that 20 per cent, of the entire number had at some time during their addiction careers voluntarily abstained from the drug and without assistance from physicians, hospitals or prisons, succeeded in breaking the habit. Many of these simply 'lay around home and kicked it out' without telling members of the family the real cause of their discomfort. These successful self-treatments occurred usually during the first two years following the beginning of addiction but they sometimes occurred later, especially in patients who were addicted to cocaine and an opiate at the same time. One of the latter who had been addicted off and on for twenty years got off the drug at home with very little discomfort and without any assistance whatever. One physician, after two years of addiction to morphine, repaired to the woods with a camping outfit and a servant and returned in three weeks cured. He relapsed two years later because of a painful illness and was cured twenty years after this because of the activity of narcotic agents.
"Though the sincerity of addicts who seek cure is for the time being beyond question, the motives which prompt many of them are fundamentally inadequate and therefore usually ineffective.
"The motive for cure in newly created addicts is the instinctive revolt they feel and the vague fears that arise when they find themselves victims of a habit that they cannot control. They discover that they are in a situation that they have been taught to regard with contempt and this creates the alarm above referred to. If cure is not immediately and permanently effected the instinctive fears wane and later on are replaced as motives for cure by well defined fears of the law, by fear of social ostracism or financial dependence, and to a less extent by fear of the physical harm that the drugs might do to them. The discomfort and physical depletion caused by inability to secure at all times an adequate supply of drugs has furnished an added motive for cure to many of those who repeatedly relapse. These addicts after struggling with the situation for a time seek treatment in disgust. Others, less sincere, seek it in desperation because they have no money whatever to buy the drug they need, or because a successful raid by the authorities on peddlers has temporarily cut off their supply. A large proportion of repeaters give as a reason for seeking cure that they have revolted against the idea of giving so much of their money to drug peddlers. An addict who in his motive for seeking cure illustrates the motives that prompt many others, came home one winter night %eyed up for the usual dose that had been delayed only to find that his wife, in a burst of indignation, had thrown his heroin away. The street cars being tied up because of a snow storm he walked to his peddler's nearly two miles, through the snow and returned to find that for two dollars he had bought an innocuous drug; another trip brought the same result, and the third one failed to secure even an interview. In disgust he sought and accomplished a cure, but relapsed in a few months. Four years later a shortage of drugs, following a wholesale arrest of peddlers, prompted him to be cured again. He has been drunk three times during the twelve months following this last treatment, but at present writing seems determined not to relapse to narcotics.

"Reasons Given for Relapse

"The reasons the addicts gave to account for their relapses often did not furnish more than superficial evidence of the real cause, but there was a tendency to overemphasize the importance of physical symptoms. A large proportion of the psychopaths, who with full knowledge of its danger, had dissipated with an opiate until they became addicts, were unable to give any reason for the relapses that occurred during the first three years of their addiction. Many of them frankly said that they just started to take the drug again and had no excuse to offer other than that they returned to their old environment. This same type of patient would, after eight or ten years of addiction, give weakness or discomfort as an additional reason for their later relapses. Some intelligent psychopaths said they returned to narcotics to get relief from the blues that followed certain difficulties. One highly unstable professional man brooded over the failure he had made of life because of narcotics and traced his final relapse to this brooding.
"The frankness of the psychopathic characters contrasted markedly with the evasiveness and self-pity of those who had frank neuroses, and with the complaining attitude of certain temperamental cases. The physical necessity for narcotics loomed large in the minds of the latter. They seized upon any remembered discomfort as an excuse for relapse; a healed wound, a leg broken twenty years ago, a mild hemorrhoidal tendency, an old cured neuritis, and other conditions from which they received no discomfort while taking an opiate were credited with causing pain when the drug was withdrawn.
"Ten per cent. of the entire number of addicts in this series of cases got under the influence of liquor and took the first dose of narcotics while their inhibitions and judgment were lowered—but only a few of them blamed alcohol. Alcoholic dissipation was apparently a deliberate first step in their relapse, taken in order to give them courage to throw their good resolutions overboard and return to opium.
"The medical cases that were considered to be nervously normal attributed their early relapses to the return of the more or less painful physical conditions for which they first took narcotics, and the later ones to this same cause or to weakness and inability to work when not taking the drug."
As to the physical reasons for relapse, Kolb reports as follows:
"Opium, unlike alcohol, does not cause, so far as known, any destruction of tissue or permanent protoplasmic change. It does, however, bring about some very obvious functional changes. These result from the efforts of the body cells to adjust themselves to a drug, the normal effect of which is to inhibit cellular and glandular activity so that when the adjustment is made the cells and organs, though bathed in the drug, perform most of their functions in a degree approximating normality. This functional adjustment becomes strikingly evident when the drug, after having been used continuously over a prolonged period, is suddenly withdrawn. The inhibiting influence having been removed there is an increased functional activity of practically all organs and tissue and the nervous system, being suddenly relieved of a benumbing influence under which it has learned to record impressions with normal intensity, becomes hypersensitive. More numerous and more intense impressions are therefore sent by the tissues and organs to a nervous system, which, because of its hypersensitiveness, records them with magnified intensity. The net result is the withdrawal symptoms, some of which are very distressing. Collapse which sometimes occurs is probably due to an excessive relaxation of vasomotor control due to sudden removal of the artificial check under which the system has been functioning.
"Nearly every addict in this series of cases discontinued one or more treatments upon which they had ventured before the opiate they had been taking was completely withdrawn, or they returned to the drug a few days later. These abortive attempts are not classed as relapses, but failures of treatment. Such failures were due mainly to the acute physical symptoms accompanying withdrawal and to the unfavorable mental reaction resulting from them.
"The various types of addicts reacted with different degrees of intensity of physical symptoms, the objective evidence of which was similar. Intelligent persons with outstanding temperamental traits complained more than any others, the purely neurotic and the dull neurotic came next, while the psychopaths complained least of all."
"The acuteness of the intellect of the temperamental persons and their natural disgust or distaste for disagreeable things, caused them to exaggerate the importance of physical symptoms as it caused them to exaggerate the every day trifles and inconveniences of life out of all proportion to their significance. There may be some physical reason, in addition to their natural sensitiveness, why temperamental and neurotic addicts suffered more than the others. In any event, it was observed that the complaints of normal persons under treatment were adequate to the situation, and the temperamental addicts who showed few objective signs of suffering whined bitterly, while many of the psychopaths who had made up their minds to undergo treatment complained very little even though they vomited, had dilated pupils and showed other signs of distress. The temperamental addicts who gave up treatment before complete withdrawal was accomplished, did so because of the discomfort which they were unwilling to endure, while the psychopaths merely changed their minds. The depression that resulted from the whole physical situation and the lack of the soothing effect of narcotics on their normal mental unrest gave them a different outlook on the world, and in this state, they came to the conclusion that cure was not worth while. Some of them went through with the treatment, however, seemingly to save their faces; they remained in the hospital until the acute physical suffering was over and then left for the purpose of getting narcotics."
"The acute symptoms that contributed so much toward failures of treatment had very little to do with relapses that occurred two weeks or more after the opiate had been withdrawn, Almost without exception, the early cases felt comfortable and began to gain weight before the end of this period, but slight insomnia and mild restlessness often persisted for several weeks longer and in some there was an indefinite feeling, probably largely physical in nature, that something was missing. Many also experienced a greater fatigability than had been usual with them, but, as a rule, the early cases said that they had no physical desire or necessity for the drug within two weeks after it was withdrawn. In some instances this attitude watt probably an expression of forced optimism. In any event there was in many of these cases some slight physical reason for relapse for as long as two months. These reasons were not in any way compelling, but they added something to the various factors that impelled the unstable to give up the struggle for cure.
"The acute stages of glandular and nervous overfunctioning resulting from the withdrawal of opium are also quickly over in long-standing cases of addiction, but in some of these it requires months of abstinence from the drug before all of the body functions return to normal. For the first few weeks after withdrawal of the drug these addicts, although they begin to gain in weight, may have occasional mild pains in the legs and uncomfortable sensations in the abdomen. They are very sensitive to cold and the men at first suffer with excessive seminal emissions which they think weakens them. A feeling of languor and loss of 'pep' is very common and many of them get discouraged because of it. If discharged from the hospital during this period the difficulties that they encounter on the outside accentuates their weakness and discontent and prompts them to seek relief in drugs again. Yet many of the patients in this series passed through this critical period outside of institutions and relapsed months later for reasons altogether foreign to the withdrawal symptoms. But in some of the long-standing cases, particularly among the more nervous, there remained fatigability, periodic diarrhea, palpitation of the heart, restlessness and distressing insomnia. Complaints of lack of energy and undue fatigue were very frequent, and some who had been addicted ten or more years claimed that this condition lasted for from six to nine months after cure and was the chief reason for their relapse. `I never had any "pep" until I took the drug again,' was a common statement. Attempts to justify their relapse doubtless caused some to exaggerate the importance of this symptom, but it was so commonly complained of and it bears such a close relation to other symptoms that could be explained by loss of vasomotor tone that it may be considered to be present to a certain extent in a large proportion of cases. A feeling that they would 'fly to pieces' was experienced by some of the more nervous types who were deprived of the drug after taking it fifteen years or more. In a few instances the nervous symptoms were so grave as to make a return to narcotics advisable. . . .
*    *
"That the nervous manifestations following the withdrawal of opium are as a rule only temporary, even though the drug has been used for long periods, is shown by the fact that cases are cured after many years of continued addiction. In this series there are some physicians who were cured after twenty years and one after forty years' indulgence, but there was nothing abnormal in their original make-up. The reason for their previous relapses was the lack of sufficient motive to impel them to neglect their work until the withdrawal symptoms had so far subsided as to enable them to pursue it again. The narcotic division by threatening prosecution provided them with the motive they needed, The forty years addict was sixty-five years of age—he was slightly restless at times, but in no way uncomfortable after nine months of abstinence. Another physician not included in this series, because he never relapsed, took 25 grains of morphine daily for most. of eighteen years. On five different occasions he tried to treat himself at home by gradually reducing the drug but failed because he would not give up his work in order to do it. Finally he took a cure through the urging of the narcotic inspectors. Insomnia was distressing for about two months and in addition there was for five months some painful bladder condition that he attributed to the medicine given during the course of treatment. He, however, never thought of returning to morphine to relieve this condition and one year after the original treatment he was a perfect specimen of health. These two cases illustrate that for several months after the withdrawal of opium normal addicts do have some symptoms that could be used as an excuse to return to the drugs but that they do not do so when the motive for cure is greater than the motive for relapse.
"The motive as well as the desire for cure in many abnormal persons is as great as in normal persons but the motive for relapse is so much greater that the cure motive is less likely to gain a permanent ascendency over it. The motive for relapse is in some of its phases continuous and is subject to exacerbation. This is why certain unstable persons relapse months after all physical reasons for it have disappeared.

Psychic Reasons Given for Relapse

"It has already been intimated that in most cases the fundamental basis for relapse is to be found in the faulty mental make-up of the individual addicts and that the cause for addiction and the cause for relapse are in their most important phases basically the same.
"The unstable individuals who constitute the vast majority of addicts in the United States may be divided into two general classes: Those having an inebriate type of personality, and those afflicted with other forms of nervous instability. The various types find relief in narcotics. The mechanism by which this is brought about differs in some respects in the different types but the motive that prompts them to take narcotics is in all cases essentially the same. The neurotic and the psychopath receive from narcotics a pleasurable sense of relief from the realities of life that normal persons do not receive because life is no special burden to them. The first few doses, especially if larger than the average medicinal doses, may cause nausea and other symptoms of discomfort, but in the unstable there is also produced a feeling of peace and calm to which they are not accustomed and which, because of its contrast with their usual restless and dissatisfied state of mind, is interpreted as pleasure. These people have in their normal state unusual impulses and disturbing mental conflicts because of them. They feel inadequate or inferior, their usual restlessness and anti-social conduct are expressions of compensatory strivings against this, or specific acts may be pathological outlets for impulses not properly directed. The narcotic properties of morphine and heroin are sufficient for the time being to remove all of this. Inferiority is replaced by confidence, restlessness by calm, and discontent by contentment. The degree of contrast with their usual selves is in direct proportion to their degree of deviation from the normal.
"The pleasure derived from opium varies from a slight feeling of calm in persons who approximate normal in their nervous constitution to feelings sometimes approaching ecstasy in the extremely psychopathic. The greater susceptibility to addiction of the more abnormal cases is thus explained. The personality survey and clinical study of the 210 cases that form the basis of this paper shows that their nervous abnormality is the most important cause for the frequent relapse of addicts of the present day. In the psychopaths who make up the larger proportion of them, the pleasurable effect of opium was dulled by the increased tolerance consequent upon excessive indulgence in it and beclouded by the discomfort and uneasiness of their situation. With benumbing of pleasure and increase of discomfort a point was finally reached where they sought release from the distress of their new situation. By resort to cure they would get rid of the physical discomfort and the inconvenience of addiction and improve physically as well as socially for a time, but with cure and the passing of their newly acquired troubles, their former restlessness and discontent returned and sooner or later they sought relief for this by resorting to narcotics again. This cycle of events was repeated time and again in some cases, the final result as to relapse being more certain as the other contributing factors (physical dependence and memory associations) grew in importance with the duration of addiction.
"A very large proportion of these addicts deliberately addicted themselves with full knowledge of the difficulties incident to a life of addiction. Many of them had been social problems before they became addicted and the make-up of others was such as to insure that a large proportion would have run contrary to established social customs in some serious way even if they had not become addicts. By inference, then, it may be assumed that such cases relapse for the same reason that they become addicted. The inference is not so clear in the case of certain socially acceptable persons of normal or superior intellect who become addicts. These are temperamental or very neurotic persons, some of whom are highly useful or gifted citizens. Opium gives them a feeling of relief or contentment far in excess of that experienced by the average normal persons who because of illness are occasionally compelled to take it. The first few doses usually are taken for legitimate purposes, but, as with the psychopaths, the drugs also give such persons a pleasurable sense of calm that impels them to continue the drug—often in ignorance of the danger, sometimes in spite of it, until they become addicted. When such cases finally try to free themselves of the drug, the memory of the relief that it gave them from the underlying unrest of which their peculiar traits or symptoms are an expression, is a serious handicap in their struggle to do without it. As before stated, these people also exaggerate the ordinary difficulties of life more than do average normal persons and they register physical discomfort and pain much more acutely. It thus happens that some very useful and even gifted citizens have tried without success to be cured of drug addiction because of the force of the seductive calm that opiates gave them and because the discomfort of withdrawal seemed to them to be unbearable."
The influence of memory association and habit the author discusses as follows:
"In addition to the important etiological factors incident to the type of person who becomes addicted in the first place and the complicating physical symptoms which follow the use of opium over long periods of time, the taking of the drug results in the formation of numerous memory associations which are themselves potent reasons for continuing the drug or bringing about relapse. In this sense, opium addiction is a real habit. It is a common observation that no man lightly gives up anything to which he has accustomed himself. We see this plainly exemplified in the cured tobacco smoker who relapses after a period of abstinence and feels great relief in doing so. A cured smoker who usually does not crave tobacco may feel an intense desire resembling hunger when he gazes upon a box of cigars or sits in the company of friends who are smoking. The genesis of this desire is apparently wholly mental. The craving is due to memory associations and the habit the smoker has acq6ired of releasing a certain amount of energy by smoking when placed in certain environments. If smoking is indulged in, the aroused but pent-up energy flows smoothly into an accustomed channel, the tension is relieved and relief is obtained. Habitual indulgence in opium creates memory associations similar to those connected with the use of tobacco and adds some of its own. The craving that some cured addicts experience after the state of physical discomfort is over, and the 'hankering' for the drug that they speak. of, is due largely to these memory associations. The impelling force of habit and the satisfaction derived from gratifying it, is seen in the morphine or heroin addict, who, when deprived of his customary drug, stabs himself with needles or safety pins, so-called 'needle-addiction.'
"The addict relieves himself of oncoming discomfort several times each day by taking a hypodermic of morphine or heroin. Due to difficulty in obtaining opiates he is often in actual pain before securing relief, and he worries a great deal about his source of supply. There is thus formed a strong association between distress, both physical and mental, and taking the drug. After a cure the first disappointment or illness he suffers brings forcibly to his mind the method of relief he has learned so well. The impulse to resort to it is strong and the stock from which addicts are recruited insures that resistance to it will be weak. We see this cause illustrated in an addict who said, 'The winter came on, I was cold all of the time and could not stand it without the drug . . .' and in the one who suffered a mild attack of influenza and gave as his reason for relapse that he was weak and had to boost himself with the drug. It is chiefly memory associations that cause many cured cases to feel discouraged and have the 'blues' on a rainy day.
"The return of addicts, especially of the unstable type, to their old environment adds greatly to the danger of relapse. Recently cured cases are restless, they as a rule are without employment and they naturally turn for company and diversion to their old companions among whom there are usually some addicts.

Nearly all of those who have abstained from narcotics for several months report that they have no desire for the drugs unless they see some one else take them or unless they associate with other addicts in situations which they formerly enjoyed. By arousing memory associations this unfavorable environment creates a craving that the unstable cured cases seldom resist for any great length of time. The power of memory association is illustrated by the case of a patient who voluntarily stayed two months in the hospital and was off the drug five weeks of that time. He thought daily of certain former associates with whom he had been accustomed to take morphine. He complained that he could not get the subject off his mind and that it kept alive his craving. A small party in which he formerly played poker and took morphine with a few friends, was reenacted several times in his dreams. The result was that the intense desire continued after the physical discomfort had passed.
"It was noted in other types of cured addicts, as well as the cured inebriates, that any frustrated desire or unsatisfied longing was transformed into a desire for narcotics. Some had a craving for narcotics when they were hungry, and others when they wanted to smoke. The craving would be completely relieved by food or tobacco. In some, certain unsatisfied social impulses were directed into the narcotic channel. The craving produced by social longing is more serious than that which is purely physical in origin because it is not so easily appeased. The longing for companionship, for the good will of others, the desire for a position the salary from which would insure the ordinary comforts of life and relieve financial worry, would, when frustrated be directed into the channel that experience had shown would resolve all longings by dulling the faculties that gave rise to them. The cured addict is advised to abandon his old associates, but he too often has no others who look upon him with understanding sympathy. When this is the case, he inevitably gravitates back to them to relieve the tension of his social impulses. This, in itself, is good for him, but the environment arouses memory associations connected with the use of narcotics and affords opportunity to return to them when his resistance is weakened. Without a social environment that satisfies certain emotional impulses and an occupation that diverts the mind while it absorbs the physical energy that is seeking for an avenue of expression, the continued abstinence from narcotics by a former addict is extremely difficult.
"Relapse was precipitated in some cases of this series by emotional disturbances incident to financial difficulties that could only be made worse by the return to narcotics; by the nagging influence of a suspicious wife, who, to protect her husband from relapse, watched every move he made; by a loss of position, by a deserved rebuke, and by other seemingly inadequate causes. One man, abstinent for ten years, relapsed because of an injury that kept him in bed for a week. Such relapses, of course, occur in unstable persons, who are in constant danger of falling under the depressing influence of some cause that would impel them to seek relief in narcotics. They know that the remedy will in the end increase that difficulty, but for the time being the relief promised overshadows, in importance, all other considerations.
"In addition to the various pathological strivings and impelling memory associations that act independently of the patient's will to bring about a resumption of the use of narcotics, some account has to be taken of the pleasurable physical thrill that large doses of these drugs give to certain addicts. This thrill has been discussed in another paper. It is sufficient here to say that striving for a repetition of it causes some psychopaths to inject narcotics directly into their veins, and its intensity may be judged by the fact that a few of them link it with sexual feeling. Some of these cases seem to return to narcotics purely for the physical pleasure the drugs give them aside from a negative feeling of mental relief that is also obtained.
*    *    *    *    *
"SUMMARY

"The relapse of drug addicts is mainly due to the same cause that is responsible for their original addiction, namely, a pathological nervous constitution with its inferiorities, pathological strivings, etc., from which narcotics give an unusual sense of relief and ease.
"The inebriate impulse is one of the most important causes of relapse. "Relapse is more common than formerly because the addiction of more normal and therefore more easily curable persons is less common.
"Nearly all addicts make sincere efforts to be cured during the early period of their addiction. Many of the cures taken later on are mere matters of expediency and are insincere in effort.
"The hope for cure wanes as time passes and the force of habit, numerous impelling memory associations, and increasing physical dependence upon opiates is added to the original nervous pathology.
"Physical dependence upon opiates is unimportant as a cause for relapse during the first two or three years of addiction in those addicts who have been off the drug for two weeks or more.
"In some very nervous persons who have been addicted to an opiate for many years, withdrawal of the drug may produce hysterical symptoms or hypomania lasting several months."
Resume
The most apparent conclusion to be reached from the material reviewed is that, for the most part,*the treatment of this condition has not emerged from the stage of empiricism. The various methods described in general indicate that the basis of the majority of them is merely the separation of the patient from the drug. Very few of those who have described the details of treatment have given a rationale for their procedures, but rather have outlined dogmatically the adoption of certain measures, whose primary object is the withdrawal of the drug and have stated or left the reader to infer that the completion of the procedure brings about cure.
If the separation of the patient from the drug is all that is signifled by "cure," it is evident that the modus operandi and the underlying rationale mean little or nothing and it is readily understood how any treatment with this object in view may result in "cure." The word "cure" should imply the return of the patient, insofar as is possible, to somatic and psychic integrity. In the literature dealing with treatment there is little to indicate that this desirable state of affairs commonly is accomplished.
In a few instances, however, the authors have developed their procedures in accordance with definite concepts of the morbid changes involved; they have pointed out the wide individual variations of physical and mental reactions both to the chronic poisoning and to therapeutic measures, and whether right or wrong in their conceptions of mechanism their claims deserve serious study and careful evaluation.
For the present, therefore, in view of the many unsettled questions as to the mechanism involved in this condition, it would seem more desirable to employ tentatively methods of treatment that appear to be based on such pathologic changes as are at present recognized in individual cases than to advocate, as too often has been done in the past, the employment of arbitrary procedures for general application.

 

1 Wood, G. B.—A Treatise on Therapeutics and Pharmacology or Materia Medica. 1856.

2 This article was published in 1827.

3 Erlenmeyer, A.—Considerations sur la Morphinomanie et son TraitmentEncephale. 1886. Vol. 6. p. 677.

4 We have been unable to verify this reference.

5 Calkins, A.—Opium and the Opium Appetite-1871.

6 Day, H.—The Opium Habit. 1872.

7 Stifle, A.—Therapeutics and Materia Medica. 1874.

8 Mr. Little.—Month. Jour. of Med. Sci. June, 1850, p. 530.

9 Brit. Med. Jour. Feb. 15, 1868.

10 Levinstein, E. Die Morphiumsucht—Berl. Klin. Wchnschr. Nov. 29, 1875. Vol. 12. pp. 646-649.

11 Levinstein, E.—Morbid craving for Morphia, translated from the German "Die Morphiumsucht" by Charles Harrer, M.D. 1878.

12 Levinstein, E.—Die Morphiumsucht. 3rd Edition, 1883.

13 Mattison, J. B.—The modern and Humane Treatment of the Morphine Disease—Med. Rec., 1893. Vol. XLIV. pp. 804-806.

14 "Kane, H. H.—The Hypodermic Injection of Morphia. 1880.

15 Earle, C. W.—The Opium Habit. Chicago Med. Review. 1880. pp. 442-446; 493-498.

16 This is the earliest warning against the use of coca in the treatment of chronic opium users that we have discovered.

17 Jouet, D.—Etude sur le Morphinisme Chronique. 1883.

18 Pepper, William—System of Practical Medicine. Chapter on the Opium Habit by James C. Wilson. 1886.

19 Erlenmeyer, A.--1886. loc. cit.

20 Erlenmeyer, A.—Die Morphiumsucht-1883—Chapter on treatment translated by E. P. Hurd-1889.

21 Erlenmeyer, A.—Behandlung der chronischen Morphinismus and Cocainismus. In. Penzoldt and Stintzing. Vol. 1-1909.

22 Burkart, R.—Ueber Wesen and Behandlung der chronischen Morphium. Vergiftung-1884.

23 "Ball, B. and 0. Jennings—Considerations sur le Traitement de la Morphinomanie, Encephale-1887—VII. p. 295-301.

24 Ball, B.—The Morphine Habit. 1887.

25 Jennings, 0.—The Morphia Habit. 1909.

26 The authors open their article with the following : "For a long time there has been noted a distinction between `morphinism' and `morphinomania.' By morphinism we mean the sum total of phenomena resulting from chronic poisoning; by morphinomania we understand the vicious habit consisting of taking almost always increasing doses of a toxic stimulant regularly."

27 Ball, B.—Loc. cit.

28 Jennings, 0.—Loc. cit.

29 Sollier, P.—La Demorphinisation et le Traitement rationnel de la Morphinomanie. Sem.—Med. 1894. pp. 146-152.

30 Sollier, P.—Methode physiologique de demorphinisation rapide basee sur 357 cas de guerison (1890-1910). Jour. de Med. de Paris. Dec. 28, 1910.

31 Osler, W.—The Principles and Practice of Medicine. 1894.

32 Tyson, J_ Practice of Medicine. 1900.

33 Lott, M. K.—The Drug Habit: Its Treatment—Texas Med. Jour. Nov., 1901. Vol. XVII. No. 5, p. 157-162.

34 Pettey, G. E.—The Narcotic Drug Habits and their Treatment. Therap. Gaz. 1901. Vol. 17. p. 655-662.

35 Pettey, G. E.—Narcotic Drug Diseases and Allied Ailments. 1913.

36 Morel-Lavallee, A.—Les alcaloides de l'opium, morphine, heroin, dionin. Notes pour la cure de demorphinisation. Emploi de l'Heroine. Rev. de Therap. Paris, 1902. LXIX. 109-119.

37 Paton, S.—Psychiatry. 1905.

38 Lambert, A.—Chapter on Opium and Morphine in Osler and McCrae's Modem Medicine-1907. Vol. 1.

39 Lambert, A.—Chapter on Opium and Morphine in Osler and McCrae's Modem Medicine-1914.

40 Lambert, A.—Chapter on Intoxicants and Narcotics in Nelson's Loose-leaf Medicine-1920.

41 The "belladonna mixture" of the Towns-Lambert treatment is the same mixture as that given in the third edition, 1904, of "The General Practitioner as a Specialist," first published in 1900 by J. D. Albright, M.D., of Philadelphia. The following formula is given as Formula No. 1 of one of several methods of treatment described by the author.
Tr. Belladonna lvs.    fl. 3. VIII-XII.
Fl. Ext. Hyoscyamus    fl. 3. VII.
Fl. Ext. Prickly Ash bark fl. 3. IV
Glycerine C. P.    fl. 3. III.
Syr. Simple q. s. ad.    fl. 3. IX.
According to Albright a drachm of this mixture should be given every three hours, night and day. After sixty hours, each dose should be reduced by ten minims until none is taken.
This treatment, according to Albright, is to be preceded for three or four days by a reduction of the drug to the lowest amount that will sustain without suffering. During this time as well as later when necessary Formula No. 2, a sedative and tonic mixture, is to be given, followed by a ten grain dose of calomel which should act before No. 1 is begun.

42 Loc. cit.

43 Butler, G. F.—A Text-book of Materia Medica, Pharmacology and Therapeutics. 1908.

44 " Bishop, E. S.—Morphinism and Its Treatment. Jour. Amer. Med. Assn. May 18, 1912. Vol. LVIII. pp. 1499-1504.

45 Bishop, E. S.—The Narcotic Drug Problem. 1920.

46 McIver, J. and G. E. Price—Drug Addiction—Analysis of 147 cases at the Philadelphia General Hospital. Jour. Amer. Med. Assn.. Feb. 12, 1916—Vol 66. pp. 476-480.

47 Sceleth, C. E.—A Rational Treatment of the Morphin Habit. Jour. Amer. Med. Assn. Mar. 18, 1916. Vol. 66. pp. 860-862.

48 Dercum, F. X.—Rest, Suggestion, and other Therapeutic Measures in Nervous and Mental Diseases. Second edition. 1917.

49 Bastedo, Walter A.—Materia Medica: Pharmacology : Therapeutics Prescription Writing. 1918.

50 Jelliffe, S. E. and White, W. A.—Diseases of the Nervous System. 1919.

51 White, W. A.—Outlines of Psychiatry. 6th ed. 1918.

52 Joyce, Thomas F.—The Treatment of Drug Addiction. New York Med. Jour. Aug. 14, 1920. Vol. 112. p. 220-222.

53 Biberfeld, J.—Entwohnungsversuche. Biochem. Ztschr. 1921. Vol. 122. p. 260-268.

54 Dupouy, M. Roget—Quelques reflexions sur la morphinomanie. Annales Medico-Psychologiques. 1922. p. 453-466.

55 Dupouy, R.—Traitement de la morphinomanie. Bull. Med. Oct. 25, 1924. Vol. 38. pp. 11934197.

56 From unpublished material supplied by Dr. Wholey.

57 Willcox, Sir W. H.—Norman Kerr Memorial Lecture on Drug Addiction. British Med. J. Dec. 1, 1923. No. 3283. pp. 1013-1018.

58 Wuth, O.—Ueber Morphinismus. II. Bemerkungen zur Therapie. Miinchen. med. Wchnschr. July 4, 1924. Vol. 71. pp. 893-894.

59 Meyer, E.—Ueber Morphinismus, Kokainismus and den Missbrauch anderer Narkotika. Med. Klinik. 1924. Vol. 20. pp. 403-407.

60 Mignard, M.—Psychologie et psychotherapie des Toxicomanes. Bulletin Medical. 1924. Vol. 38. pp. 1190-1203.

61 Romer, C.—Die Behandlung des Morphinismus. Klin. Wochenschr. 1925. Vol. 4. No. 8. pp. 364-66.

62 David, Erich.—Ueber die Ursachen der so hilufigen Rtickfiilligkeit nach der Morphiumentwohnung. Zeitschr. f. d. g. Neurol. u. Psychiat. 1925. Vol. 99. pp. 475-484.

63 Klee, Ph. and 0. Grossman —Ueber die klinische Brauchbarkeit des Cholins. Munch. med. Wchnschr. Feb. 13, 1925. Vol. 72. pp. 251-254.

64 Krauss, R.—Morphinismus and Homosexualititit. Ztschr. f. d. g. Neurologie u. Psychiatrie. Vol. 101. 1928. pp. 271-277.

65 Rojas, Nerio and Belbey, Jose C.—La Adrenalina en la Desmorfinizacion. Semana Medica. 1926. Vol. 33. Part 2. pp. 705-707.

66 Bogolow, T. M.—Die Heilung von Narkomanen durch subkutane Zufuhr von Sauerstoff. Moscow Med. Journal, 1925, No. 10. Abstracted in Munchen. med. Wchnschr., 1926. Vol. 73. p. 132.

67 Lambert, Alexander, and Tilney, Frederick.—The treatment of narcotic addiction by Narcosan. Medical Journal and Record. Dec. 15, 1926. Vol. CXXIV. No. 12. pp. 764-768.

68 Erlenmeyer, A.—Zur Theorie and Therapie des Morphinismus. Zeitschr. f. d. ges. Neurol. and Psychiatrie. 1926. Vol. 103. pp. 705-718.

69 A decomposition product of the labile phosphatides (lecithins) found in all the organs of the body.

70 In the jargon of the morphinists, those who inject more than 1 g. daily.

71 Obersteiner had established even in 1883 that rabbits which had been habituated to morphin by injections (up to 0.4 daily) administered through a period of 3 months, never displayed abstinence symptoms on sudden withdrawal. (Wien. Klinik, March, 1883.)

72 These are according to Schmiedeberg, among others, the antipyretics like antipyrin, phenacetin, pyramidon, etc.

73 Italics are mine. (E.)

74 The sphygmograms are published in the 3rd edition of my book: Die Morphiumsucht und ihre Behandlung.

75 Ministry of Health. Departmental Committee on Morphin and Heroin Addiction. Report. His Majesty's Stationery Office. London, 1926.

76 For the membership of this Committee see page 131, footnote.

77 Johnson, George S.—The use of Narcosan in the treatment of drug addiction, Colorado Medicine, Vol. 24, No. 11, November, 1927.

78 Carter, M. G., Orbison, T. J. Steele, E. H., Wright, C. A., and Williams, E. H.—The proteal treatment of drug addiction. Medical Journal and Record. New York. September 7, 1927. pp. 282-284.

79 "Kolb, Lawrence—Clinical contribution to drug addiction: The struggle for cure and the conscious reasons for relapse. Journal of Nervous and Mental Disease. Vol. 66. No. 1. July 1927.

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