Morphinum

Morphia, an alkaloid from opium, C„H,9N03.

Including the various salts, to which reference is made in the list of authorities.

Preparation, Triturations, or solutions in alcohol.

Authorities. 1, Sertiirner (the discoverer of M.), took ^ a grain, repeated after half an hour, and again after a quarter of an hour, Annali Univerz. di Med., xxvii (Buchner’s Toxicologic, 1827, p. 201); 2, Bally, experimental effect of moderate doses, and also of 2 grains of sulf. or acet., Med. du I’Acad. Roy. de Med. a Paris (from Wibmer) ; 3, Charvet, experiments on himself, with 1 grain of acetate, Wirkun des Op., p. 176 (Wibmer); 4, same, a man aged thirty-six, took 6 grains of acetate at one dose; 5, same, another took 6 grains of the acetate; 6, Chevalier, Rev. Med., 1824, took i grain of the acetate (Wibmer) ; 6 a, same, took next day, ^ grain ; Gb, same, took, the following day, ^ grain ; 6c, same, took, the following day, 1 grain ; 7, Wibmer, took grain of the acetate, repeated after one hour and a half; 7a, same, took ^ grain of M., repeated after one hour and a half; 8, Beraudi (experiments on several healthy persons, Horn’s Archiv, 1829, from Wibmer), a man named Albino took I- grain of the acetate, pulse before the dose 66; 8 a, same man, subsequently took I grain; 8b, same man, took 1 grain; 9, Beraudi on Crispo, aged twenty-one, effects of ^ grain of acetate ; 9 a, same man, took | grain; 96, same man, took I grain ; 10, Beraudi on Rabuni, aged nineteen, effects of grain of the acetate; 10«, same, man, effects of k grain ; 106, same man, grain ; 11, Beraudi on himself, effects of ^ grain of acetate; 11a, same, I grain ; 116, same, 1 grain ; 12, Beraudi on Sella, effects of ^ grain of acetate; 13, Bonnet and Trousseau, Bull. Gen. de Therap., 32 (Wibmer), general effects of the salts ; 14, Ronander, Hecker’s Annal. de Med., 1834 (Wibmer), effects of ^ to 1 grain of acetate ; 15, Fully, Bost. M. and S. J., 1832, effects of j grain of tbe sulphate, on himself; 16, same, effects of grain of the sulphate for pain in the stomach ; 17, Boujean, a man took 55 grains at once, Schm. Jahrb., 52, 156; 18, Lesser, effects of 33 to 36 grains of acetate, in a man, Journ. de Cann. Med., 1838 (A. H. Z., 18, 288) ; 19, Anderson, effects of j grain of sulphate, repeated in two hours, in a woman suffering from sleeplessness. Am. J. Med. Sc., 1848; 20, Anderson, effects of 2 ounces of a solution of the muriate during thirtysix hours, in a patient suffering from delirium tremens. Month. J. Med. Sc., 1854 ; 21, Shearman, effects of 3 grains in a woman, Med. Times and Gaz., 1857; 22, Kreisig, effects of a solution in a girl aged sixteen, Inaug. Diss. (S. J., 93, 175) ; 23, Salvia, effects of 2 grammes, in a man aged thirty. Union j\Ied. d. 1. Gironde, 1859 (from Tardieu, Empoison.) ; 24, Rogers, effects of 1 grain in a man, suffering from neuralgia of face (post-mortem showed kidneys diseased). Lancet, 1861; 25, Zepuder, effects of lith grain of the acetate in a child, eleven weeks old, When Med. Halle, 1861 (A. H. Z., Mbl., 3, 49) ; 26 and 27, omitted; 28, Dr. A. M. Cushing, provings. Mass. Horn. Med. Sac. Trans., vol. 3, p. 569, effects of 100 drops of 3d dil., evening first and second days, 1 drachm evening third day, 1^ drachms evening fourth day; 29, Alexander, When Med. Presse, 1865 (S. J. 128, p. 294), effects of grain, in a child ; 30, Am. Horn. Obs., 1864, p. 169, effects of 1^ grain of M., by mistake for quinine, for a slight indigestion; 31, Maschka, fatal effects of large doses, Prag. Vjs., 1867 (A. H. Z., Mbl., 16, p. 57); 32, omitted; 33, Brain, effects of injections of i grain of acetate, in a woman aged thirty-five, for pain in a tooth, Med. Times and Gaz., 1868; 34, Reyher, poisoning by M., Deutsche Arch. f. Clin. Med., 4, 602; 35, Pfister, effects of a solution, S. J., 15, p. 16 ; 36, Verdi, effects of 15 grains in a woman, Ohio M. and S. Rep., 3, 156 ; 37, Cattell, symptoms of muriate, Br. J. of Horn., 11, 337 ; 38, Goodno, effects of a solution of acetate (3 grains to 1 ounce), teaspoonful doses for dysmenorrhoea. Am. J. H. M. M., 4, 60 ; 39, Tellar, effects of injection of yyth grain, A. H. Z., 83, p. 40; 40, Gro.«s, effects of injections of muriate, in a girl aged twenty, suffering from chronic neuritis. Am. Horn. Obs., 1870, p. 420; 41, Model, effects of twelve doses of grain of acetate, for sleeplessness, .Urzt. lutell. Bl., 1871 (A. 41. Z., Mbl., 25, p. 2); 42, Oliver, effects in one case, Practitioner, 1871, p. 79; 43, Ferris, effects of a solution of muriate, for a cough and diarrhoea, Br. Med. J., 1871 ; 44, Schopf, Lehrhuch der Phai m., p. 515, general effects of small doses; 44a, same, larger doses, 14 to 36 milligramme; 446, same, doses up to 7 centigrammes; 45, Tardieu, poisoning by 2 grammes, Sur. I’Empoison., 1058; 46, Martin, effects of injection of muriate, Gaz. des Hop., 1874; 47, Trask, effects of 6 or 7 grains of the sulphate on self, and 2 grains to daughter, and 3 grains to another young lady, N. Y. Med. J., 1874; 48, Schein, effects of 7 grains of sulphate, in a healthy man, N. Y. Med. J., 1874 ; 49, Dr. Helen J. Underwood, effects of as much as could be put on a sixpence, in a girl, threatened with chorea, Med. Invest., 1875, p. 282; 50, C. B. Mitchell, effect of injecting ^ grain into his own arm, dose repeated after fifteen minutes, Med. Invest., 1875, p. 244; (51 to 59 Harley’s experiments. Old Veg. Neurotics) 51, Michael, aged forty-eight, “ strong but disabled by sciatica,” effects of injection of i grain of the acetate; 52, John L., aged fifty-four, with facial neuralgia, effects of i grain of the acetate ; 53, Samuel M., aged forty-nine, with facial neuralgia, effects of injections of ^ grain of acetate, afterwards \ grain, and again ^ grain; 54, John W., aged thirty-three, with lumbar neuralgia, injected ^ grain, and some weeks afterward ^ grain ; 55, Charles V., aged thirty-two, chronic lumbago, injected ^ grain of acetate ; 56, Mary B., aged forty-six, lame from sciatica, injected ^ grain of the acetate; 57, Mrs. N., aged forty, neuralgia in right shoulder, injected ^ grain Morph, acetate ; 58, Mrs. E. W., aged thirty-four, four months pregnant, hysterical and neuralgic, effects of gf^in of the acetate, afterward of the y’^ grain ; 59, Miss L., aged thirty-seven, effects of ^ grain, on alternate mornings; 60, Berridge, effect of injection of ^ grain, N. Am. J., 1872, p. 102; 61, Levinstein, effects of injections of M., 22 to 30 grains daily, for neuralgia, Berl. Kl. Woch., 1877; 62, same, effects on a woman of as much as 15 grains daily, injections for chronic rheumatic symptoms; 63, same, effects in a man, with rheumatism, of ^ to 1 gramme injections daily; 64, same, in a man, injections of 1 to IJ gramme daily (commenced its use in syphilitic “iritis ”); 65, Berridge, “ a man took Morph, acet. nine days after a proving of Cannabis indiea,” Hahn. Month., 3, 462; 66, Fiedler, general effects, Schmidt’s Jahrb., 172, 236 ; 67, same, fatal case, after stopping habitual use of M., in a woman; 68, same, effects of stopping habitual use, in a man, thirty-five years old; 69, same, another case reported by Kapp; 70, Roberts, effects of subcutaneous injection, in a man, Med. Times and Gaz., 1868 ; 71, Anstie, effects of 3 grains injected into rectum of a man, suffering from fistula, Med. Times and Gaz., 1863, p. 134; 72, Anstie, effects of prolonged use of M. in small grain daily) doses in a lady, suffering from sciatica. Practitioner, 1871, p. 153; 73, Levinstein, Die Morphinum-such, eine Monograph, Berlin, 1877, general effects.f

Mind p. 381

Emotional, Conscious of a certain amount of stimulating influence upon the brain ; a sensation not unlike the early physiological effects of Quinine (almost immediately)

General condition of excitement ; the patient seems exceedingly lively and wide awake, with a certain uneasiness, unsteadiness, and haste, and glistening of the eyes

Great excitement, without sleepiness

Violent cerebral excitement, so that the patient had to be isolated

Delirium; (after two hours)

Hallucinations for many days

Hallucination and delirium

There is great similarity in the intoxication of Morphine and that of alcohol; but the delirium of alcohol is more joyous; that of Morphine is almost gloomy and melancholy

When she tried to describe her sym})toms, and ask for an explanation from her friends, she could not for her tears and sobs, which she could not repress

(Since she has used it she enjoys a great deal of calm happiness, her mind is active and clear, though her emotions are still very easily excited)

Low-spirited (after two hours, eighteen minutes)

Complete melancholy, so that he desired to commit suicide

Some patients sit in mute despair, casting about for some opportunity to free themselves from their suffering

Some individuals endure their troubles with resignation ; they remain quietly in bed, scarcely speaking a word, others, but very few, pass the time in a soporous condition; others have no rest at all, get out of bed, anxiously run about the room, howl and cry; they either gradually become quiet or rarely their excitement increases

Anxious condition, with hallucinations and illusions of almost all the organs of sense, seeming to comprise the whole, somewhat excitement that occurs during the period of abstinence, especially after the exhibition of Chloral hydrate; if the patient, during the first two to four days of abstinence, is given a dose of 3 or 4 grammes for sleeplessness, the individual is seized a few hours after the dose with a high degree of excitement; he has to rise in bed, leaves It and runs around the room weeping, laughing, singing, crying, and knocking against doors and windows, throwing over the furniture, and at last becomes aggressive to those about him ; he becomes quiet only towards morning, and has a very transient sleep, from which he wakes without remembrance of the occurrences of the night, or he can recall them only with difficulty. The differential diagnosis between the delirium tremens of Morphine and other forms of delirium, is only difficult when the physician is ignorant of the cause, and when the patient is in the later stage of Morphine intoxication (when there is tremor, sleeplessness, some disturbances of speech, restlessness, anxiety, mental illusions), then it is almost identical with chronic alcoholism. Moreover, it is not easy to recognize when the person intoxicated by Morphine has been in the habit of partaking freely of alcoholic drinks, and has communicated only the latter fact to the physician. The acute delirium tremens of Morphine ma}’ be distinguished from the acute delirium tremens potatorum, by the following:

1st Delirium potatorum occurs spontaneously, or after tremors, or during the progress of acute diseases; the acute delirium of Morphine occurs only during the partial or total abstinence from Morphine.

2d. In the height of delirium potatorum the delirium mostly disappears, while in the delirium of Morphine it increases.

3d. Alcoholic drinks, which are frequently craved by the patient, mostly aggravate the paroxysm, never arrest or obliterate it. The Morphine patient longs for Morphine, and is for a time quieted by a large dose of it.

4th. Delirium potatorum continues for days or weeks, while the duration of the delirium tremens of Morphine rarely exceeds forty-eight hours.

5th. The delirium potatorum ends in a collapse, which is frequently fatal; in the delirium tremens of Morphine there is no collapse. The delirium of Morphine can scarcely be confounded with that of lead (delirium saturninum), since in the latter the lead line on the gum, extensor paralysis, and the alternating conditions of excitement and stupefaction are sufficiently distinctive. analogous to that caused by alcohol

A few hours after the last injection the patient begins to feel uncomfortable and restless, and becomes exceedingly depressed ; slight paroxysms of cough, with a condition of anxiety

Anxiety

Internal anxiety and restlessness

Felt strangely, a kind of terror overpowering her (before half an hour)

The patient cried out with an expression of great alarm (immediately)

Ill-humor

Intellectual. There is a certain similarity in Morphine poisoning and cerebral paralysis, especially as regards the motor symptoms ; the essential difference consists in that Morphine poisoning has complete consciousness of the condition and memory, and the ability to concentrate the mind is unimpaired, at least as long as there is not a condition of actual mania

Flow of ideas became more rapid and pleasant

While engaged in undressing my mind was very active, but seemingly without control of the will; thoughts followed each other in quick succession, and the mind jumped rapidly from one subject to another; the condition seemed to be analogous to that which exists when a dream, seeming to involve days and weeks, will be known to occupy but a few seconds or minutes of time

The clearness of mind and the memory suffered very greatly

Dulness of mind

Impossible to study or fix mind on any one subject (second morning)

She seemed incapable of thinking, or recognizing any one in the room (after four hours)

For an hour after rising, in talking, would have to stop in the midst of the simplest sentence to think what word to say next (second morning)

Loss of consciousness

Flagellation, pinching, etc., failed to elicit signs of cognition

Stupefaction; (after twenty minutes)

Stupefaction, bordering on faintness

In a half comatose state (after eight hours)

Complete comatose insensibility (after two hours)

Profound coma; (after nine hours and a half)

Head p. 382

Confusion and Vertigo. After a nap, the head continued dull and confused for some time, as from a disordered stomach ; he then took a swallow of vinegar, after which the nausea and headache increased, and after eating, the heaviness and stupefaction of the head increased, so that he was obliged to lie down

Feru^'o,® ** *’, etc.

Much vertigo, on rising (second morning)

Excessive vertigo

Violent vertigo

Disagreeable vertigo and nausea (after six hours

Spells of dizziness and loss of sight, all day (third day)

Frequent dizzy spells, with momentary loss of sight (second day)

Felt giddy, and walked cautiously (after two hours and a half)

Some giddiness and drowsiness (fifty minutes after grain)

Giddy and drowsy (one hour after y’^^th grain); giddiness and drowsiness passed off (two hours after j'^-th grain)

Giddiness and somnolency (after ten minutes); complained of being very giddy, and said that everything was turning round (after one hour)

Slight giddiness

Felt a little giddy (after one hour and twenty minutes)

Felt “dreadfully tipsy (after forty minutes)

General Head, Head drawn backward

Congestion of the head

Began to feel light-headed a,ud sleepy (one hour and a quarter after

Aggravation p. 382

Dulness of the head

Dulness and heat of the head

Dulness of the head, for several days

Some dulness of the head, with difficult thought (after half an hour)

General dulness of the head (after one hour)

Dulness in the head, especially in the frontal region (after ten minutes)

Heaviness of the head; (after first day grain); (after fifty minutes)

Head heavy, hot

Head heavy, with a tensive sensation in it, like a pressing asunder at both parietal bones; this sensation made thinking and writing difficult

Something shot to the head like lightning, the instant the injection took place,Pain in the head (after seven hours)

Dull pain in the head, with stupefaction

Head painful on waking, disappearing on moving about

Headache,® ** ®*, etc.

Headache, on waking from sleep

Headache, after eating,*”’. Headache, more on the right side than on the left, lasting half an hour, leaving behind a painful sensation

Sudden headache

Violent headache; (after half an hour)

Intense cephalalgia

Tensive sensation in the head, as if the skull were too small for the brain ; reading, writing, or thinking were very difficult; was obliged to stop at times (after half an hour)

Pressive headache, with inclination to sleep (after two hours and a half)

Pressive headache, with inclination to sleep; reading and thinking increased the headache (after two hours and a half)

Throbbing like a pulse; the head threatened to burst

Five- Jieod, Heaviness in the frontal region; (after one hour and a half)

Pain in the frontal region (after half an hour)

Pains in the frontal region, on waking from sleep; (after two hours and a half j

Violent pain in the forehead (after half an hour)

Violent pain in the right side of the forehead (second morning)

Violent pain in the forehead, as if the frontal bone would press outward

Dull pain in the frontal region, especially of the right side

Dull frontal headache, in the morning (fifth day)

Throbbing pain in the forehead (after fifty minutes)

Temples, Right temporal artery beating full and quick (after one hour and a half)

Parietals. Pain in the right side of the head (immediately)

Intolerable pain in the right side of the head (after thirty-five minutes)

Occiput, Pain in the occiput (after fifty minutes)

Eyes p. 383

Objective, Eyes staring

Eyes staring, and unaffected by light (after two hours)

Glistening eyes (after fifty minutes)

Eyes very glistening (after one hour)

Eyes sparkling

Eyes injected; (one hour after grain)

Membranes of eyes much injected (half an hour after grain)

Cornea injected (after half an hour)

Eyes sunken, especially the right

Eyes sunken, half open, not turned upward, but staring straight ahead, with the axes of vision parallel

Eyes fixed, and insensible to light (after two hours)

The eyes are frequently lustreless, having a look of weakness, exhaustion, and fear, becoming after a new injection lively, fiei’y, or like those of a person in delirium

* The look becomes unsteady

Subjective, Pain over and at side of left eye all day, with some pain in left ear (fifth day)

Eyes early in the course were hot and lame; bits of ice were laid on them with relief

Eyes felt small, too small for sockets (second morning)

Eroiv afld Orbit, Pressure above the eyes (after fifty minutes)

Paresis of the recti interni

Feeling of fulness in the orbits (after one hour)

Lids, Lids bluish, drooping

Slight ptosis

Upper lids paralyzed

Coujuuctivci, "^Conjunctiva injected,(after fifty minutes)

The coujuuctivie of both eyeballs were very red, much injected, especially the subconjunctival tissue, with a rosy red circle in the anterior ciliary region, like that frequently seen in iritis

Luchvymul A-ppuvcvtus, Eyes suffused (ten minutes after grain)

Vcill, The eyes looked as though they would protrude from their orbits

Eyeballs prominent (immediately)

Eyes protruding from their orbits; (after two hours)

Convulsive motions of the eyeballs

Eyes convulsively turned upward and outward

Eyes rigid, turned upward

Diverging strabismus of both eyes

Pupil, Pupils dilated ***’; (immediately); (after twenty minutes); (after half an hour); (after fifty minutes)

Pupils continued dilated through the night (first night)

Pupils somewhat dilated (soon)

Pupils greatly dilated (after twenty minutes)

Pupils greatly dilated, even on looking at the sun (soon)

Contraction of pupils,®'® etc.; (after eight hours); (second day)

Pupils contracted, insensible

Pupils contracted habitually

Very slight contraction of pupil observable during two or three hours after the injection

Strongly contracted pupils (after nine hours and a half); and insensible to light (after eleven hours and a half)

Pupil very much contracted (after four hours)

Pupils very much contracted ; would not respond to light (second morning)

Pupils very much contracted, not being as large as a pin’s head, and she saw red and black spots floating before the eyes (after four hours)

Pupils extremely contracted, insensible

Pupil of a minimum size; eyes imperfectly closed

Pupils contracted to mere points

Pupils contracted to such a degree as is only seen after large doses of Calabar; the pupils, indeed, showed but a minute point, and were entirely insensible

Pupils, unequal

Pupils at light aside, barely I (before the injection); at light aside i (after one hour); at light aside -f (after two hours)

Pupils (before the experiment); (after two hours and a half)

Pupils (before the injection) ; (after forty minutes)

Pupils at the light, towards the dark side of the room (before the injection) ; y'j at light, from the light i (three-quarters of an hour and two hours after y^th grain)

Pupils at light y'o", sideways y; at dark side of room i (before the injection); y'y, sideways; y at dark side of room; ^ (after thirty minutes and four hours)

Pupils y diameter at light, towards the dark side of the room dilating to i (before the experiment); dilate from y'y to i (after thirty minutes, and after two hours and eighteen minutes)

Pupils at light sideways i (before the injection); y'./' (two hours after i grain); y (thirty minutes after k grain); yL (three-quarters of an hour after graiir) ; y (two hours and a quarter after grain) ; y'y, sideways (ten minutes after 4 grain) ; sideways y (one hour after grain) ; y'^, sideways i (three hours after i grain)

Pupil i (before the experiments); 4" (one hour and a half after y grain) ; \ (three hours after grain); continued to read the newspapers for one hour and a quarter after the injection of grain; i; vision for near and distant objects unimpaired; in reading the newspapers he could detect no change in his vision, and he clearly discerned an inconspicuous lightning conductor, a rod of the thickness of the little finger, by the side of a chimney-pot, at a distance of about seventy yards (one hour and a quarter after grain )

Vision Weakness of vision

* Sight impaired and feeble

The eyes formerly only moderately far-sighted, became very hypermetropic

Vision at times seemed obscured by a fog

Could not see (after two hours)

Vision distorted and impaired

She can only distinguish one vertical half of the objects before her (as one eye, one arm, etc.)

Double vision and diminished range of accommodation are frequently observed ; the pupils are usually contracted, often unequally, seldom dilated

Double vision, disappeared at the end of a week, but the inequality of the pupils remained during the whole time she was under treatment; sometimes one, sometimes the other, pupil being dilated

Double vision and disturbance of accommodation, often accompanied by lachrymation

Head p. 384

Some pain in left ear, with pain over and at side of left eye all day (fifth day)

Ringing in the ears (after one hour)

Surring of the ears

Tinnitus aurium,®h

Roaring in the ears

Nose p. 385

Sneezing

Paroxysms of sneezing

Peculiar tickling sensation in the nose, oesophagus, and larynx, as when one has to sneeze, felt after every injection

Coryza

Face p. 385

Looked very heavy (after forty minutes)

Appeared very wild (after nine hours)

Wild, confused expression after sleep

Countenance looked haggard and eyes watery, like one who had been dissipating (second morning)

Face flushed (after two hours)

Face slightly flushed

Face intensely flushed (after a few minutes); followed by vomiting, and then a dead faint and struggling for breath, the pulse scarcely perceptible

Her face was reddened

Face red (soon)

Face and lips red (after half an hour)

Face red, lips pale

Face red, puffy

Face red, puffy, lips livid (after fifty minutes)

The usually pale face became red, with drops of perspiration on it (after thirty-five minutes)

Face very red (immediately)

Intense but evanescent redness of the face

The face became red, almost cyanotic

Face almost livid (after one hour)

Bluish look,®

Face of a dark-blue color

Face cyanotic

Face and extremities cyanotic

The face became violet

Pale face

Face and lips pale (after fifteen minutes)

Face pale and anxious (one hour and three-quarters after grain)

Face pale and sunken

Pale and cold, for four hours (after two hours)

Very pale, with contracted and painful expression of the face (after four hours)

Face swollen; (after two hours)

Face very much swollen (immediately)

Face somewhat puffy

Clieeh'S. Cheeks red

Circumscribed redness of the cheeks (after fifty minutes)

Lips discolored (after nine hours)

Lips livid; (after eleven hours and a half)

Lips pale

Chin. Mouth rigidly closed

Mouth closed, the jaws pressed together as in tetanus

Muscles of the jaw strongly contracted, so that the mouth could scarcely be opened at all (after eleven hours and a half)

Teeth clenched, so that he could not be made to swallow a drop (after two hours)

Slight trismus

Mouth and eyes wide open

Feeling as if the teeth of both sides of mouth were clenched

Feeling that teeth in both sides of mouth were clenched (after two hours); had a similar feeling from Cannabis indica, but at no other time

Mouth p. 385

Tongue. Dry brown tongue

Redness of the tongue; (after twenty minutes),®* ®*, etc.

Tip and margins of the tongue red

Tip of the tongue red, palate scarlet-red, somewhat painful

Tongue red on the margin, violet in the middle

Tongue red at the tip and margins, and violet in the middle

Tongue livid

Tongue pale (second morning)

Tongue foul (second morning)

Tongue clean and moist (before the injection); moist, a slight whitish fur, indented (after tw’o hours)

Tongue heavy, pale (after fifteen minutes)

Tongue dry, with thick dirty mucus

Anterior part of the tongue dryish (three hours and a half after ■§■ grain)

(The tongue symptoms, for which Quinine was prescribed, a thickened feeling, and inability to articulate distinctly, disappeared entirely)

Cehievul 31outli. Dome mucus in the mouth

Dryness of the mouth and throat

Mouth dry, in the morning, and after eating (fifth day)

Mouth and fauces dry, after sleeping

Mouth pasty

The mucous membraneofthemouth is usually dry, the patient complains of thirst, nausea, vomiting, aversion to meat, loss of appetite. The tongue at times trembles on extending it. The stool is almost always retarded, diarrhoea is seldom

Saliva, Discharge of watery saliva from the mouth

Taste, Perverted taste

Mouth bitter, sticky (second day)

Speech. Made a strange noise in his mouth (after nine hours)

Speech hasty

Disturbances of speech, for example, stammering

Speech embarrassed and feeble

Muscles of tongue so much affected that articulation was almost impossible (after fourth dose)

Throat p. 386

Dryness and constriction in the throat (after half an hour)

Pain and obstruction (?) in the posterior portion of the throat (second morning)

Irritation in the throat

Peculiar sensation about the fauces (almost immediately)

Faaces ami Flutvyiix. Burning in the posterior portion of the fauces (after five minutes)

Paralysis of the pharynx

Muscles of fauces and glottis so much affected that deglutition was almost impossible (after fourth dose)

Swallotvhig, Complained that he could not swallow

External Throat. Jugular veins swollen

Violent pulsations in the cervical and temporal arteries

Stomach p. 386

Appetite, Diminished appetite

Loss of appetite; (second day)

Complete loss of appetite

Entire aversion to food (second day)

Thirst, Thirst

Much thirst

Great thirst; (after one hour)

Burning thirst; (second day)

Anic- tatioii and JIiccou(/h. Eructations and vomiting for two days

Frequent eructations and nausea, with uprisings of some acid mucus

Violent eructations

Hiccough; lasting three-quarters of an hour

Long-continuing singultus (frequently)

Nausea and Vomiting, Nausea,”*; (after four minutes); (after a quarter of an hour),®, etc.

Nausea and eructations (after two hours and a half)

Distressed with nausea, faintness, and constant retchings, with alternate flushes of heat and cold, for five hours (after two hours)

Nausea and inclination to vomit (after four hours)

Awakened from slumber by nausea and inclination to vomit

Nausea and inclination to vomit soon after eating

Constant nausea (after four hours)

Slight nausea, with increased warmth of the face

A little nausea (at first); gone (after one hour and twenty minutes); (between five and six hours after injection)

Sick and faint

Slight sickness (after seven hours)

Very sick, after a large quantity of warm water (after two hours)

Very sickish and drowsy (after two hours)

On rising in morning my stomach gave way and I was forced to throw myself on the bed to keep from vomiting; felt perfectly well in bed, but it was not till 4 p.m. that the stomach would suffer the head to remain erect (second day)

Inclination to vomit; (after a quarter of an hour)

Vomiting; rarely

Vomiting half an hour after fresh milk (second morning)

Nausea and vomiting,**; (after a few doses),”; (after two hours)

Retching and vomiting; for six hours (after gr.)

Vomiting for three days

Obstinate vomiting

Vomiting and diarrhoea

Had suffered constant nausea, and vomited twice (after two hours); continued in this state for four hours; did not recover from tendency to nausea for a week

Vomiting of coffee

Became nauseated and vomited a small amount of frothy liquid (after four hours)

Vomiting of green matter

Nausea and qualmishness; and, after some hours, actual vomiting of a sour, bright-green fluid, followed by transient relief of the nausea

Vomiting of bile

Stomach. Irregular digestion

Dyspepsia

Pain in stomach,**; immediately; for three days; aggravated by taking food

Pains in the stomach, umbilicus, and bladder, in the evening (first day)

Pain in the pit of the stomach; immediately,*****; (after five minutes); (after two hours)

Pain in the epigastric region,'“*’; (second day)

Pain in the epigastric region, and afterwards about the umbilicus, and then about the loins

Painful sensation in the pit of the stomach, extending as far down as the bladder (immediately)

Painful sensation in the stomach, navel, and bladder

Violent pain in the pit of the stomach (after four hours)

Violent pain in the pit of the stomach, or in the intestines

Violent pain in the pit of the stomach, and in the bladder, waking from sleep (after four hours)

Violent pain in the stomach after eating, so that he had to go to bed

Feeling of constriction and pressure in the stomach

Awoke with cramp in epigastrium, as if clenched by a hand (fourth day)

Coliclike pains in the stomach

Crawling in the stomach

Abdomen p. 387

ximhilical. Pain in the umbilical region; (after four hours)

Violent pain in the umbilical region

General Abdoinen. Moderate meteorismus

Rumbling in the abdomen (after twenty minutes)

Frequent rumbling in the abdomen (after half an hour)

Pain in the bowels (after half an hour)

Acute pain in the abdomen, and along the spinal column, on every inspiration

Colic; relieved by turning on back, in morning (fifth day)

Awoke with severe colic (third day)

Stool p. 387

Diarrhoea. i)<ar?7icea,®® ®*, etc.; (second morning),**; second and following days; (evening, first day)

The acetate generally produced diarrhoea

Watery diarrhoea (after two hours); (second morning)

Bowels had acted loosely twice (after two hours)

Two painful stools (second day)

Desire for stool for two hours, then small stool with great straining, in the morning ; soft, loose stool at 2 p.m., with horrid tenesmus, straining, and burning in the rectum, almost causing frenzy (fifth day)

Copious ev^evacuations of the bowels

Constipation. Constipation,® ® *®, etc.; (second day); (third day)

Morphia always caused constipation

Constipation for a long time

Constipation often followed by diarrhoea

Retention of stool

Almost complete stoppage of the evacuation of stool and urine

No stool, contrary to habit (second morning); but at 2 oclock there occurred a very indolent evacuation of a little fseces, with painful urging

Urinary Organs p. 387

Bladder. Paresis of the bladder

Slight paresis of the bladder

Pain in the region of the bladder (after one hour)

Pain in the bladder; (after two hours)

Micturition. Emission of scanty urine, with great urging (after four hours)

Passed very little urine, with great difficulty (first night)

Ineffectual efforts to urinate (after seven hours); he succeeded in urinating (nine hours later)

Constant desire to urinate, and inability to do so for twelve hours

Complete ischuria

Strangury is often caused

Retention of urine

Urine. Urine high-colored and scanty

Urine scanty

Diminished secretion of urine

Frequently the secretion is diminished, though at times it is increased

Suppression of urine (second day)

Suppression of urine and faeces

Complete suppression of urine

Urine turbid and slimy

The urine yielded albumen, without structural elements

Passed gix urine, sp. gr. 1010.4 (on rising, before injection) ; Jxviiiss. urine, alkaline, sp. gr. 1008.8 (after two hours); 5 vij, freely acid, sp. gr. 1009.2 (after four hours)

The kidneys excrete albuminous urine, in severe cases. The evacuation of urine is often difficult, and th& amount frequently scanty; the specific gravity varies within the most extreme limits; I have found urine of 1004 to 1038 ; generally the urine at first has the highest specific gravity ; towards the end of the cure the specific gravity diminishes; naturally this varies according to the amount of urine passed. The urine of nearly all suffering from Morphine intoxication reduces an alkaline solution of Cuprum sulphate without precipitating it as an oxide, at the same time the urine usually turns the polarization ray to the left

Urine acid, sp. gr. 1022, about ^ij in the hour (before the injection) ; during two hours and a quarter, ^iv of bright acid urine, sp. gr. 1029, was secreted (after 1 gr.); .Uj pale acid urine, sp. gr. 1009.2, in the hour (before gr.) ; §vss. of bright acid urine, sp. gr. 1022.0, during the three hours (after gi’.)

At first the specific gravity of the urine, although the quantity was only moderate, was 1000; and in three weeks it rose to 1014; during about three weeks the quantity of albumen was very abundant; it then slowly diminished, and disappeared in the fourth mouth ; no formed elements were found

The specific gravity of the urine varied from 1007 to 1012; the urine reduced alkaline solution of Sulphate of copper, turned the plane of polarization to the left, and showed a remarkable amount of albumen; microscopical examination, during the first fourteen days of her stay in the hospital, detected waxy cylinders and white blood-corpuscles; five weeks later, there were only a few traces of albumen

The specific gravity of the urine varied from 1026 to 1035; sugar was tested for, but was not found; albumen was distinctly present, but in small quantities; no structural elements were present; after the albumen had disappeared for some days, it was again observed for a short time

The urinary organs are generally more affected in men than in women

Urine diabetic, possessing reducing and levogyrating properties, in cases of chronic poisoning ; this fact had already been established, but its occurrence in acute poisoning now noticed, is new

Albumen is frequently found in the urine in cases of Morphine intoxication, both during the continued use of Morphine and the period of abstinence. This albumen, which appears during the long-continued use of Morphine, either as a transient symptom that occurs irregularly, often lasting only a few days, or as a constant symptom that only disappears after weeks or months following the total withdrawal of the drug. Albumen is much more frequently found during the period of abstinence than during the continued use of Morphine, as observed in nearly all cases; it makes its appearance in three to six days after the beginning of the abstinence, and disappears in two to four days. It varies from the slightest turbidity to a flocculent sediment. Before I had observed cases of the latter character, I had considered the slight turbidity as accidental, dependent upon a slight catarrhal condition ot the uro-genital organs; the presence of the deposit leaves no doubt that we have here to deal with pathological changes in the uropoietic system. In the chemical action of the urine, all the reagents (Nitric acid. Acetic acid. Carbolic acid. Potassium ferrocyanide, and Sodium sulphate) promptly indicate albumen. In some cases the action of Nitric acid was noteworthy, and called to mind the case of Hence Jones and his acid albuminate. When the Nitric acid was used freely, and the urine heated, no albumen was precipitated while hot, but after the urine became cold, and it was again dissolved by heat

Sexual Organs p. 388

Kale, Impotency; the testimony of all men suffering from Morphine intoxication is uniform in that their sexual power is affected by the drug. Sometimes th6 sexual excitement, voluptuous sensations, and in part erections are incomplete, less energetic, and of shorter duration, or they do not occur at all. So in this case all grades may be found, from simple sexual weakness to complete impotency. The great majority refrain from sexual intercourse, either from lack of interest or from inability, owing to the fact that erections are incomplete or wanting altogether. Unmarried men become impotent sooner than married men. In many men the first effect of Morphine is excitement of the sexual sphere, afterwards the usual paralysis. Many unmarried men make use of this fact to smother their sexual desires when they become aroused during the interval free from Morphine. The question arises whether there may not be other causes than that of Morphine for the impotency. The condition of depression which is induced in many persons might be supposed to be a psychical impotency, but there are also cases in which there was a condition of eutropia, and also still others upon whose emotional nature Morphine has no influence whatever, that are more or less impotent. M hether the power of erection ceases sooner, or since the emissions are not of a frequent occurrence the function of the seminiferous organs ceases sooner, is uncertain from want of sufficient data. The testimony of men is usually not clear; many dislike to speak of their impotency ; many healthy men are, indeed, unaware of this condition, or pass it over lightly, or are silent about it. In the register of the Morphine poisonings in Maison de Saute, it is found that the wives of none of the men who had injected large doses of Morphine have had a normal pregnancy during the last two years, although they were young women, and, previous to the use of Morphine by their husbands, had had children every year

Impotence

He: had become impotent since he used Morphia

Pain in the genitals and urinary organs, especially in the right spermatic cord (after one hour aud a half)

Diminished sexual desire

Fetnale. Amenorrhoea. In all the women treated by me for Morphine intoxication, menstruation had been irregular, or suppressed for months or years. These women varied in age from twenty-five to thirty-five, and had used subcutaneous injections of Morphine for a long time. The symptoms noticed at the commencement and during the course of the amenorrhoea, such as headache, vertigo, disinclination to work, loss of appetite, vomiting, constipation, palpitation, hysterical attacks, etc., coincide with those of Morphine intoxication, so that it is often difficult to distinguish whether they are caused by the toxication of Morphine, or are the consequence of the amenorrhoea. I have never observed swelling of the breasts or vicarious haemorrhages in my cases. The amenorrhoea of Morphine is gradually developed from dysmenorrhoea, or it occurs suddenly. Conception has never been noticed in amenorrhceic women, while some of the women have been repeatedly pregnant previous to the use of Morphine. Therefore, it seems probable that the cessation of menstruation is dependent upon anomalies of the ovaries, in that they seem inactive. According to Pfliiger’s theory, in the amenorrhoea of Morphine, the growth of the cells of the ovaries ceases from one period to another, and in consequence, the irritability that is transmitted by the ovarian cells and causes, on the one hand, bursting of the Graafian follicles, and on the other, determines the reflex condition of congestion of the sexual organs, is wanting. As a consequence. Morphine affects the ovaries as it does other secretory glands, namely, it renders them unable to perform their functions. It is most probable that menstruation ceases because ovulation ceases, and this also explains the sterility. The supposition that Morphine injection causes the arrest of the function of the organs of generation is justified by the fact that, after the cessation of Morphine, these organs recover their activity. The sexual desire is at first increased by the habitual use of Morphine, but after the graver symptoms of poisoning have been developed it almost entirely disappears, as in men. It is also noteworthy that women who have suffered from fluor albus, are generally free from it during the prolonged use of Morphine; this reappears only after the withdrawal of the drug, often with laborlike pains. Women suffering from Morphine intoxication, in whom menstruation continues normal, may conceive; but I have noticed that the pregnancy runs a normal course only when the women use small doses; they abort from large doses

Menstruation too early

Menstruation generally more profuse and too early

Respiratory Organs p. 390

Slight rattling of mucus in the trachea,®b

Voice. More or less hoarseness

Frequently hoarseness when speaking for any length of time, whereas her voice is usually extremely clear

Speech indistinct (inaudible), (soon, after fifteen minutes)

Respiration. Breathing loud and rattling (after eleven hours and a half)

Respiration stertorous

Breathing stertorous, amounting to no more than 4 or 5 per minute

Respirations increased, with acute pains in the chest

Respiration IS, 20 (before the injection); 15, regular (three-quarters of an hour after gr.); 16, regular (ten minutes after j gr.) ; 14, regular (three hours and a half after i gr.)

Respiration 9 and 10 all day (second day)

Respiration rattling, slow, 8 to the minute

Respiration very superficial, occurring only every twelve or fifteen seconds

Respiration short and irregular

Respiration irregular, with frequent sighs (one hour and three-quarters after gr.)

Respiration indescribable, thoracic respiration being apparently entirely suspended

Respiration difficult; (after five minutes); (after fifteen minutes)

Respiration slow and difficult (after four hours)

[390<] Slight difficulty in breathing (after third dose); respiration greatly obstructed (after fourth dose)

Very difficult respiration

Struggling for breath,™.

Chest p. 390

Tightness of the chest and difficulty in breathing, and she asked to be raised, saying she felt as if she were dying (after fifteen minutes)

Great pain in the chest, and could not take a long breath (after half an hour); pain principally in the middle of the sternum, the breathing was short and quick, and she sighed often (after four hours)

Felt very ill, with an indescribable sensation, worse to bear than any pain behind the lower half of the sternum (after one hour)

Heart and Pulse p. 390

Heart’s Action. Palpitations

Violent throbbing in the heart and carotids

The beat of the heart could not be felt; with the ear could be indistinctly heard only at times

Congestions of the head, palpitations of the heart, with tense pulse; the latter often suddenly disappears and gives place to a scarcely perceptible, thready, slow, and intermittent pulse, that marks the beginning of a serious collapse ; increased reflex irritability; the patient has frequent attacks of sneezing and yawning; he starts up in fright if one approaches him; touch of the skin causes cramp and twitchings

Pulse. 1%00.] Pulse full and slightly accelerated (after two hours)

Pulse strong and frequent

The pulse in severe cases is small, at times tense or thready. In some cases oppression of respiration and palpitation are observed

Pulse strong, rapid; (after half an hour)

Pulse small and rapid

Pulse small, contracted, rapid

Pulse scarcely perceptible, rapid, weak, fluttering, about 140 or 150

Pulse feverish

The pulse at first sinks. aud then rises several beats/^®.

Pulse 79 (after twenty minutes)

Pulse ranging from 140 to 160, extremely non-resistant, feeble, fluttering

Pulse 63 (before taking) ; 108 (after half an hour)

Pulse 66 (before taking) ; 94 (after twenty minutes)

Pulse rose from 68 to 78 (immediately) ; to 8'< (after one hour)

Pulse rose from 84 to 94 (after half an hour)

Pulse rose from 61 to 86 (after a few minutes)

Pulse rose from 66 to 82 (after half an hour) ; to 90 (after one hour and a half),’‘’b

Pulse 60 (before taking); 80 (after half an hour)

Pulse 65 (before taking); 68 aud irregular (after twenty-five minutes)

Pulse 66 (before taking) ; 80 (after half an hour)

Pulse 80 (before injections) ; accelerated 6 beats (three-quarters of an hour and one hour after ,’3^ grain); 80, regular, of good volume and power (two hours after y grain) ; weaker (three-quarters of an hour after grain) ; feeble, decreased 4 beats (one hour and three-quarters after y grain) ; very small, weak, intermittent, accelerated 6 beats (three hours and a half after y grain)

Pulse 74, of fair volume and power (before the experiment) ; 70, a little fuller and stronger (two hours after grain) ; accelerated 6 beats, unchanged in volume and power, intermitted thrice in two minutes (thirty minutes after 4 grain) ; accelerated 8 beats (three-quarters of an hour after grain) ; accelerated only 1 beat, of diminished volume (one hour after grain); decreased 8 beats, and of less volume aud power than before the injection (two hours and a quarter after 3 grain) ; accelerated 16 beats (ten minutes after grain); accelerated 20 beats, increased in power (half an hour after 4 grain) ; attained its maximum acceleration of 26 beats, strong and regular, and of good volume; a pulse indicative of strong stimulation (one hour after grain) ; the maximum acceleration remained unchanged (two hours after 3 grain) ; fallen from 100 to 96, and had nearly returned to its original volume and power (three hours after grain); 94, still a little fuller and stronger (three hours and a half after grain)

Diminished rapidity of the pulse (immediately ),*b

Pulse excessively weak, and rather slow

The pulse sinks during the first hour several beats

Pulse lowered 4 to 8 beats, but only in healthy subjects, or those laboring under simple neuralgic complaints (after half an hour)

Pulse about 60 (after four hours)

Normal pulse 60 ; all day was 49 and 50 (second day)

Pulse 65, regular (before taking) ; 90 (after twenty-five minutes) ; 80 (after forty minutes); 62 (after three hours)

Pulse 75 (before taking); 72 (after a quarter of an hour); 75 (after three-quarters of an hour) ; 68 (after one hour and a half) ; 66 (after two hours); 70 (after three hours)

Pulse 80 (before the injection) ; increased in volume and power, evidently under the influence of strong stimulation (after one hour) ; 74, regular, of the same volume and power as before the injection (after two hours)

Pulse 74, regular, good volume and power (before the experiment); reduced 19 beats, being now 55, unchanged in volume and power (after two hours aud a half)

Pulse 100 (before the injection); decreased 4 beats, regular (after one hour); decreased 30 beats, feeble, aud slightly irregular (after two hours)

Pulse 76 (before the injection); decreased 16 beats, regular, of unchanged volume and power (after one hour and a half); decreased 20 beats (after two hours); decreased 22 beats, being now 54, regular, aud of good volume and power (after four hours)

Pulse 78 (before the experiments); decreased 4 beats (fifty minutes after j grain); decreased 10 beats, unchanged in volume and power (one hour and a half after grain); 60, decreased 16 beats, of normal volume and power (three hours after grain) ; decreased 4 beats, unchanged in volume and power (one hour and a quarter after grain)

Pulse irregular (soon, after fifteen minutes) ; afterwards not to be felt,®l

Pulse slow, full, intermitting

Pulse small, contracted, intermitting

Pulse hard

Pulse greatly contracted

Pulse exceedingly weak (after eleven hours and a half),’h

Pulse small

Pulse very small (after four hours)

Pulse extremely small (immediately)

Pulse scarcely perceptible

Very great diminution in the strength of the pulse, and a considerably reduced arterial tension

The increase or diminution in arterial tension does not take place in accordance with the quantity injected, and the largest dose only prolongs the lowering effect

Tracing almost a straight line, representing the maximum effect on the arterial tension, which thereafter began to increase (half an hour after 1 centigramme); marked increase in the swell corresponding to the arterial diastole; but the smaller prominence, caused by dicrotism, is not yet visible (one hour and ten minutes after 1 centigramme); tracing returned to normal outline (two hours and ten minutes after 1 centigramme)

Neck and Back p. 392

Stiff neck (second morning)

Great pain in the back (after two hours)

Pains extending along the spine

Pain and twitchings all down her spine (after four hours)

Weakness of the loins, for several days

Extremities in General p. 392

Ohjeetive. Tremor of the hands

Trembling of the limbs

Trembling of the limbs, and general oppression

Twitching of the limbs

Her fingers were involuntarily contracted and extended ; she experienced some uneasiness about the elbows and knees (after third dose) ; the muscles of the hands and feet became rigidly contracted; the legs were drawn upon the thighs, and they upon the abdomen; the arms were alternately flexed, extended, and then contracted across the thorax (after fourth dose); in fact, the spasmodic action of all the voluntary muscles was so great as to simulate a genuine case of traumatic tetanus; alcohol, ammonia, coffee, cold and hot ablutions, and constant frictions were resorted to with no effect; the spasmodic action commenced at 2 p.m., and continued till 5.30 p.m.,®

Slight stiffness or heaviness of the limbs (after one hour)

Limbs paralyzed (after two hours)

Limbs weak

Weakness and some trembling of the limbs

Weakness of the joints

Sabjeetive. Her arms and legs felt as if they were alive, and as if they were going to jump up (after twenty honrsj

Feeling of great weariness, in the limbs, with inclination of the right lids to close; great longing for rest (after one hour)

Abnormal sensations in the extremities associated with salivation

Heaviness of the limbs; (after half an hour)

Pains in the joints

Violent pain in the joints

Superior Extremities p. 392

Stiffness and pain in the arms, after sleep

Heaviness of arms (after first grain)

A peculiar drawing, almost painful sensation in the wrist

Trembling of the hands

Hands somewhat tremulous, after sleeping

Slight trembling and unsteadiness of the hands, while writing

Fingers numb, and both thumbs firmly drawn into the palms of the hands

Inferior Extremities p. 392

Gait insecure and tottering

Gait irregular; staggered like a drunken man (second morning)

Her legs were twitched up, and she begged that they might be held, as she could not keep them quiet, and said it felt as if there were worms in them (after four hours)

A few twitches of left leg (after one hour)

Legs swollen, so that he could not put on boots (second day)

Cramp)s of the several muscles

Geiievnl Syniptonm

Ohjective. Emaciation

He lost about 15 pounds of body weight

General cachexia

Trembling

Whole body trembles

Twitching of the muscles

Twitching of the muscles of the face and limbs, at times

Both sides of her mouth were twitching; the arms were bent and moved backwards and forwards convulsively ; the motions soon ceased but returned (after two hours)

Jerking in the whole body

Violent jerking in the arms, head, and especially in the face

Convulsive motions; (second day)

Convulsive and tetanic spasms

Convulsions

Convulsions of the extremities and face, with partial opisthotonos; convulsions renewed by tickling or pressure upon the skin, without any loss of consciousness

Partial opisthotonos (after two hours)

Eclampsia

Drawing and stiffness of the muscles

Patient rigid, absolutely immovable; extremities exhibited no flexibility whatever, and the transient contraction seemed like rigor mortis; indeed, it was with difficulty that the joints could be moved

Muscular system very much relaxed (after four hours)

The sensory nerves had almost ceased to act, and the motor portion was also materially affected by the drug (after four hours)

Phrenic and pneumogastric nerves considerably narcotized (after four hours)

Great weariness (after thirty six hours)

TPeaykness,® ®’’®*, etc.

Mental and physical weakness and laxity

Weakness of the limbs, small of the back, neck, and joints (after twenty-five minutes)

Great weakness

Great weakness of the body, so that he could with difficulty get into bed

Almost unable to walk, for four hours (after two hours) ; did not recover from weakness for a week

Could not get up, in morning (second day)

Prostration,®*®®®®, etc.

General prostration

Weakness and general prostration

Muscular prostration complete

Sudden prostration ; she had not strength to stand up

Fell suddenly to the ground, as if struck by lightning (after a quarter of an hour)

General weakness and loss of power

Some spasms of the facial muscles took place, and she fell back to all appearance dead ; face blanched, pulse not to be felt, aud respiration not to be perceived ; insensibility continued about three minutes

Insensible (after nine hours); (after nine hours and a half)

Collapse; on the second or third day after the withdrawal of Morphine there occurs in consequence of the previous slight nutrition diarrhoea, sleeplessness, and yawning, a condition of weakness in almost all patients, the pulse becomes small, the face sunken, the patients cannot leave the bed, and have an expression of complete exhaustion ; this simple collapse is not dangerous; it either disappears as soon as the patient begins to take regular nourishment or it passes into a more serious form ; this latter commences often with alteration of the voice and articulation ; the patients are hoarse, they stammer or hesitate in speech ; the facial muscles jerk, the tremor of the hands increases ; sometimes this serious collapse appears suddenly, even at a time when the results of abstinence, as vomiting and diarrhoea, seem to have subsided, and when it is least expected. Even while the patients are sitting in bed busy with their surroundings they fall back unconscious, and can at first be awakened only by most energetic means; the face becomes sunken or deathly pale, the nose pointed, eyes turned upward and sunken, respiration difficult, sighing, and slow, pulse perceptible only at the heart, or the face becomes deeply red, the eyes shining, pulse 44 and 40, and after a transient nausea aud a deathly sensation the patient becomes again unconscious; when raised up the head sinks forward on the chest. No response can be obtained either by shouting or irritating the skin ; this condition lasting from fifteen minutes to nearly an hour is repeated three or four times at short intervals in twenty-four hours, during which the patient remains only partly conscious, or consciousness returns completely, or the patient may die with symptoms of paralysis of the brain

She retired at 8 p.m., feeling as she said quite drunk;” in about one hour after she was found perfectly insensible; she was lying upon her back, her eyes open, a delicate flush in the cheeks, and the lower extremities paralyzed, very cold, and doughy ; the extremities were violently pinched, pricked with needles, even after consciousness returned, but with no result; consciousness partly returned in an hour, when the right arm and leg were paralyzed, with violent trembling or shaking; Nux 200 relieved (after a few doses)

The patient was found to be apoplectic, unconscious, with stertorous respiration and bluish congestion of the face

Faintness, nausea, and constant retchings, with alternate flushes of heat and cold, for five hours (after two hours)

Two attacks of faintness, with dilated pupils (second morning)

Faint and almost ready to drop (after two hours and eighteen minutes) ; recovered in about half an hour after taking a cup of tea, but still felt poorly and sleepy

So much faintness and nausea as to confine her to the bed for the remainder of the day, which was for seven or eight hours (after three hours)

Dead faint

Fainted several times, so that she was thought to be dead (after two hours)

When rising suddenly from stool, he fainted and was soon dead (after three days)

Restlessness '* ®^ ®®.

General hyperesthesia

Slibjectire. Increase of reflex irritability

Relex irritability appeared to be entirely gone; the finger, and subsequently a feather, applied to the fauces and upper portion of the oesophagus, failed to call forth any reflex action whatever

(She has comparative, though not complete, immunity from pain)

At first, an agreeable sensation

A sort of pleasant weariness

Walked three miles, felt very weak going along (after two hours and eighteen minutes)

Had felt faint, tremulous, and sick for fifteen minutes (three-quarters of an hour after grain)

Heaviness of the whole body

An indescribable sensation of sickness and discomfort, and a condition bordering on delirium

The nervous system in general is affected; uneasiness, sleeplessness, hallucinations, alternating moods, hyperesthesia, neuralgia, paresthesia, trembling of the hands, and increased reflex irritability, and other symptoms of this kind occur

Towards 3 oclock in the afternoon (about two hours before the usual time for injection), the beneficial influence of the Morphia has usually given way, not (save exceptionally) to positive pain, but to the indescribable sense of depression which Niemeyer’s patients so graphically represented to him by the phrase katzenjammer;” this feeling disappears almost immediately after the injection

Very ill after the return of sensibility

Oppression

Neuralgia

Neuralgia in various parts of the body, forehead, occiput, and stomach

“ Sore all over (second morning)

Sensation as if the flesh were trembling on the bones

Crawling and trembling in the tips of the fingers and in the whole body

After the severe symptoms of the period of abstinence have disappeared, and the patients seem to be convalescent, the whole of the symptoms suddenly break out again ; this renewed outbreak has, however, no further influence on the course of the case, and generally lasts only one or two days ; in this patient, the relapse was severe, it lasted thirty-six hours

Distinct intervals of two or three minutes between the paroxysms of pain and convulsions/

SlviH. Ohjecfive. Skin deathly pale

The skin lost its elasticity

Eruption over the whole body (second morning)

Eruptions of red pimples

Numerous dark bluish spots on the back and thigh

Eruption over the face and large portion of the body (second day)

Eruption in the eighth intercostal space, which, except for the absence of pain, resembled herpes zoster

The skin loses its turgescence, color, and tension The subcutaneous cellular tissue atrophies (though, in some cases, especially in women, it contains fat). The face is mostly pale, ashy gray, seldom deep red, sometimes of a normal color; the perspiration is usually much more profuse than normal, exanthema is very seldom observed. Inflammation of the sebaceous glands, zoster, affecting especially the chin, cheeks, intercostal spaces, occurs from time to time, disappearing and returning, or in some cases persistent. At the point of injection of Morphine abscesses form and infiltrate in the skin, sometimes of a very large size. The patient complains of coldness or even chilliness

Arms and legs covered with red pimples

Subjective. Biting in the skin ; this biting is sometimes accompanied by small round elevations

Crawling, tickling, and itching over the whole body

Formications

Formication all over (second day)

Itching in the skin; (after thirty-five minutes),"; (after half an hour)

Soon wakened by an itching sensation over the whole body, which induced vigorous and constant scratching ; this sensation was felt in every part of the body, from the crown of the head to the soles of the feet; head itched as though innumerable insects were crawling through my hair; face felt as though covered with cobwebs, which I would try to wipeotf; bottom of feet felt as if I had chilblains; the legs, arms, abdomen, chest, and back, all itched as though being tickled with feathers, and I was kept busy scratching from head to feet; this lasted till morning, and I should be afraid to say how many times I raked over my entire body with my ten finger-nails; I think that after giving myself a thorough going over, I would drop asleep, but soon be awakened by the itching, and have to scratch more vigorously than ever. I expected to find my body covered with blotches, but my skin was as white and smooth as ever; at intervals all next day and evening, feel here and there, on body, slight itching; and if I were on the sand-beach of Carolina would think it suggested fleas

Constant itching, especially in the face, frequently obliging him to scratch

Violent itching over the whole body, in the evening (first day)

Sometimes it produces a troublesome itching of the skin, which in some cases is universal, but in others confined to the nose, neck, loins, and inside of the thighs

Disagreeable itching on the skin, especially on the anus (after half an hour)

“ Tingling or prickling sensation in the extremities (soon after third dose)

Tingling in feet (after first grain)

Sleep and Dreams p. 395

SleepinefiH. Yawning

Inclination to sleep (after five minutes)

Sleepiness; (after half an hour)

Occasionally slight excess of sleepiness, making it rather difficult for the patient to rouse herself in the morning

So sleepy that it was with much difficulty that I was able to reach my room and undress (soon after second injection)

Heaviness and sleepiness throughout the day

Continued heavy and sleepy (after one hour and twenty minutes)

Drowsiness (after fifteen minutes); since then sleep (after thirty minutes) ; had continued drowsy and still remained so (after two hours and eighteen minutes); slept about two hours (later)

Drowsiness (fifteen minutes after gr.); felt drowsy and giddy (after one hour); the drowsiness and giddiness now passed off (two hours after y'^- gr.); had napped for twenty minutes (one hour and three-quarters after yV gr.); slept half an hour more (three hours and a half after y'y gr.) ; drowsiness continued for a short time, after walking home

Occasional drowsiness (second day)

Some drowsiness and giddiness (fifty minutes after i gr-)! sleepy and lightheaded (one hour and a quarter after 4 gi’.); dozed and had some sound sleep (from one hour and a half to three hours after f gr.); slept soundly for half an hour, and was now very sleepy and giddy (one hour and a quarter after J gr.)

Drowsiness gone off (after one hour),®h

Somnolency ; he fell asleep and had a short nap (half an hour after i gr.) ; somnolency had continued and he still felt a little sleepy (two hours after i gr.); great somnolency (fifteen minutes after gr.); somnolency continued (two hours and a quarter after I gr.); at no time so great that he could not prevent sleep, and when he gave way to it, he passed into a gentle slumber from which a slight noise awoke him (after 4 gr.); began to feel very sleepy (ten minutes after -g- gr.); unchanged (two hours after gr.) ; less, but continued very sleepy (three hours after k gr.); had slept throughout comfortably and a little more soundly than in ordinary sleep; was not conscious of dreaming, but muttered a good deal (three hours and a half after gr.) ; a little sleepiness during the next forty-eight hours

Somnolency and giddiness (after ten minutes); then fell asleep for threequarters of an hour; had felt very drowsy and sickish (after two hours)

Great somnolency (after fifteen minutes); had continued very drowsy, and slept at intervals (after two hours and a half) ; walked home, and continued sleepy for two or three hours

Light slumber, during which he was conscious of jerking in the limbs, lasting ten minutes (after two hours and a half),b

He lay in a half waking, half stupid condition, but with perfect ability to think of different things, though at the same time he was busy with confused fantasies; during this slumber the limbs lay as if stiff and immovable, and could only be moved by great exertion of tbe will

During the first night the patient slept, and did not wake in the morning

Fell asleep (after four hours); his wife could not succeed in waking him until after five houi’s more

Almost constant sleep for five hours and a half (after one hour), in which he dreamed different things, heard everything that was going on about him, and was almost always conscious of his condition

Long, quiet sleep

Quiet sleep, lasting five hours, after waking from which he had headache on the right side

Sound sleep, lasting five hours, from which he awoke with a dull sensation in the forehead (after ten hours)

Deep sleep, at times interrupted by convulsive cramps

Sleep profound and calm, and with pleasant dreams

Heavy sleep, with red cheeks

Sopor

Sleeplessness. No disposition to sleep; slept Only an hour next night

Most of the Morphine patients sleep too little

Unable to sleep till about 2 oclock in the morning, though the sleep obtained during the remainder of the night has seemed to refresh me as much as if I had slept the whole time

Uneasy sleep, with frequent starting up, lasting six hours

Sleep unsound and frequently interrupted by lively imagining; became wakeful early in the morning

Fell into a troubled, delirious sleep, from which she awoke in a few moments, feeling that she had slept weeks; this kind of sleeping and waking was repeated all day

Sleeplessness

Sleeplessness, followed by sopor

Night, restless; (first night)

Restless sleep, with frequent starting up

Sleep restless, with fever and headache, and itching on the skin (first night)

Sleep restless, interrupted; lasting three hours (after one hour)

Very restless all night; no sleep

Frightful dreams

Fever p. 397

Ch illiiiess. Skin cool; the feet warm,"k

Surface rapidly becoming cold (after nine hours and a half),’k

The skin of the whole body was somewhat livid, especially the lips and nails, and, with the extremities which were covered, it was very cold, and covered with cold, clammy perspiration

Cold and pale, for four hours (after two hours)

Generally cold and tremulous (one hour and three-quarters after gr.)

Skin icy cold

Diminished temperature (immediately)

Temperature lowered from a quarter to half a degree (after half an hour)

Temperature at first falls and afterwards rises

Chilliness

Chills creeping over her, especially from the hips to the knees, and back again to hips

Violent shudderings

Rigors

The warmth of the face diminished, and it became paler than usual; with general weakness (consequence of nausea), (after two hours)

Extremities cool

Head, face, and hands cool (two hours and a quarter after i gr.),^-

Extremities cold (after fifteen or twenty minutes)

Extremities cold, nails blue (after four hours)

All the extremities and hands cold and livid

Hands and feet became cold (after third dose)

Lower extremities cold

Heat. Skin hot and dry

Burning heat of the skin (after half an hour)

Temperature rises (Centigrade)

General diffusion of warmth throughout the body (one hour after gr.)

General increase of warmth, especially in the face (after half an hour)

Heat over the whole body, at night

Heat and itching over the whole body

Alternate flushes of heat and cold, with nausea, faintness, and constant retchings, for five hours (after two hours)

Fever

The intermittent fever of morphinism, which assumed first a tertian and then a quotidian character

The intermittent fever of Morphine intoxication seems to depend upon a peculiar neuropathic predisposition, since many persons develop no paroxysms of intermittent fever in spite of large doses and longcontinued use of Morphine. No other cause, however, can be assigned for the development of the intermittent than the use of the Morphine, for patients are attacked by it who live in regions free from malaria, and similar symptoms are not observed in other members of the family who have been living under the same conditions. Mild and severe forms of the intermittent fever of Morphine may be distinguished. Both have, in common with malarial fever, beside the rhythmical type, the fact, first, that the paroxysms apparently disappear after Chinin., though in spite of the continued exhibition of the latter, they sooner or later reappear; second, they are benefited by change of locality, and are brought on again by any imprudence (a voyage on the water, errors of diet). The characteristics of intermittent fever of Morphine, are those of malarial fever, chilliness, amounting to a shaking chill, headache, oppression, heat, and sweat. They are distinguished in the tact that after abstinence from Morphine, the paroxysms of fever, though they had existed for a long time, disappeared without treatment; in some cases the intermittent fever appears like a febris arthritic; there occur, at indefinite times, attacks with chilliness, heat, and sweat. These attacks are repeated three to six times, at increasing intervals, and then generally no longer recur. Usually the intermittent of Morphine has a tertian or sometimes a quotidian type; it is sometimes anticipating, sometimes postponing; the attacks last from four to ten hours, followed by a normal condition ; the paroxysms are only exceptionally relieved by withdrawal of Morphine. In such cases the patient complains that, at the time when the fever usually occurs, he feels uncomfortable, especially that he is exhausted. With the febrile paroxysms are associated neuralgia in various nerve-areas, supraorbital, intercostal, and cardiac pains; the temperature rises in all cases and varies from 38.5° to 40° (C.). The spleen is usually enlarged. After the paroxysm, a sediment is noticed in the urine. In the more violent form of Morphine intermittent, delirium occurs during the height of the fever; in this delirium the patient cannot be kept in bed, and is excited even to raving. Great exhaustion and prostration follow the fever, and continue into the apyrexia

Tertian intermittent fever, with delirium during the paroxysms; this fever was a puzzle to the then physician, as malarious diseases do not occur in the district, and treatment with quinine was without effect; it was intermittent fever from morphinism

The lower extremities had a somewhat higher temperature than the portions that are usually uncovered, though the temperature of these was far below the normal

Warmth in the face (after three-quarters of an hour)

Head hotter than usual

A little heat and flushing of the face

Face and head hot and flushed (one hour after gr.)

Cheeks hot and flushed ; scalp a little less so (half an hour after gr.)

Cheeks and forehead hot and flushed, hands hot, “felt hot all over (after one hour)

Sweat, Skin very moist

Sweats

Perspiration

General perspiration

Perspiration over the whole body, with increased warmth and redness; more frequently in men than in women

Excessive sweating

Copious perspiration; all over (after twenty minutes)

Profuse sweats; (second day)

General profuse perspiration (after five minutes)

Profuse perspiration, so that he changed his clothes nineteen times in one night

Bathed in perspiration (after two hours)

Exhausting sweats

Cold sweat

Broke out into a cold perspiration, on walking three miles (after two hours and eighteen minutes)

Cold perspiration over the bo*dy (after fifty minutes)

Clammy sweat over the whole body

Skin dry, itching (first night)

Colliquative sweats, with deep redness of the face

Face covered with perspiration (after one hour)

Upper part of the body covered with a viscid perspiration

Cold sweat on the back (second morning)

Conditions p. 398

Aggravation.

(Morning), On waking, disappearing on moving about; head painful.

(After eating), Heaviness, etc., of head ; pain in stomach.

(After sleep).

Stiffness in arms ; hands tremulous.

Footnotes p. 380

† The delirium of Morphine intoxication consists of a series of symptoms that possess nearly all the characteristics of alcoholic delirium. From my observation two forms of Morphine delirium may be distinguished, the acute and chronic. The chronic develops during the course of Morphine intoxication, continues during the period of abstinence, and runs its course without excitement. The acute form appears as a consequence of the withdrawal of the drug, and breaks out with violent symptoms. In the chronic form the depression is variable; most of the patients exhibit a certain joyfulness, only for a short time interrupted by anxiety; in some individuals during the day the mood is depressed, in the evening there is some excitement. and at times illusions of the senses. Trembling of the hands and twitchings of the muscles are constant forms of the disease. In spite of the alternations the patients are perfectly lucid and self-possessed. They are able to ward off for a longer or shorter time their depressed or excited moods, and they can mingle with society. The acute delirium tremens of Morphine develops in the course of six to twelve hours after the withdrawal of the drug. The patients at first become excited and restless, run constantly about the room, weep and cry, and at last become delirious, under the action of painful sensations and hallucinations. The attacks, which last onh' a few hours, are followed by a quiet stage, during which the patients have hallucinations which involve all the organs of sense except that of taste. They see brilliantly colored birds, hear voices, have a sensation of sitting in wet, and perceive the most various odors. These illusions are associated with a hypochondriac mood ; the patient thinks he will die ; thinks he has seen his own burial; seems to see persons by him constantly growing larger and larger, etc. ; also frequently talks with himself and with absent people. Tremor of the hands increases, and is associated with muscular twitches, nystatrmus, and trembling of the whole body. At the commencement of the acute delirium, the voice and speech became changed. This delirium tremens of Morphine must not be confounded with the condition of