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The pandemic has reiterated the significance of digitization in
EVERYTHING we do, but more significantly in health care.
It is indeed survival of the digital fittest. Ed and Paddy are
expert practitioners in digital transformation who have synthe-
sized several key trends and this book is a compelling narra-
tive that defines the future of healthcare as we know it.
CP Gurnani
CEO, Tech Mahindra

The future of healthcare is now, as response to COVID-19 has

shown us. Virtual, always available, and at home. Now it’s up
to us to make a new normal of care delivery liberating, highly
efficient and effective. This book shows us a clear path for-
ward in the midst of crisis.
Ashish Atreja, MD
Chief Innovation Officer, Mount Sinai Medicine

I recognized Ed’s career potential when I hired him for his

very first healthcare job – and Ed proved me right!
Mike Gogola
President, Florida Guardian ad Litem Foundation
Retired Global CIO

Many people talk about digital transformation, but few can

actually make it a reality. It takes vision, courage and exper-
tise to change the course of an organization. Ed and Paddy
are practitioners of organizational digital transformation which
gives them the refreshing perspective of veterans. The sto-
ries in Healthcare Digital Transformation are steeped in wins,
losses and long hours of work with dedicated professionals
focused on making healthcare better. This book is a roadmap
for those who are ready to usher healthcare into the future.
Bill Russell
Managing Editor, This Week in Healthcare IT

Understanding digital is critical for any organization, espe-

cially as we move toward the post-pandemic era. This is a
great roadmap for any Leader, regardless of industry. As an
example, and what makes this book such a great tool/road-
map; is each chapter includes a high-level ‘consult’ – practical
ideas you can use to implement the concepts from the respec-
tive chapter.
Tom Hulsey
Author, The Winning Mindset that Saved my Life
Board Member, Mary Crowley Cancer Research

Can you embrace, then transcend what’s tragic to build new

opportunities for yourself, families, and networks leveraging
technical shifts. This is how healthcare can become more effi-
cient, precise, and physically distant – safe for clinicians and
patients. Ed and Paddy have the expertise, know-how, and
networks; Let them help light your path.
Sherrie Douville
CEO, Medigram, Inc.

A must read for all interested in digitalization and the future of

healthcare IT. Written by a nationally recognized leader with
professional integrity.
Arlene Anschel
Consultant, Witt Kieffer

Timely and inspiring! Our new digital world will require lead-
ership that is innovative, courageous, passionate and effective.
Ed and Paddy provide a roadmap that healthcare leaders must
embrace.
Britt Berrett, PhD
Past Executive Vice President, Texas Health Resources
Professor, University Texas Dallas

With Ed and Paddy’s depth and breadth of experience in the

realm of healthcare innovation, this book should be the de
facto handbook for any organization or leader that is on their
journey for healthcare digital transformation.
Bradley Dick
Vice President, Ellkay

The ideas in this book were time tested, successful strategies

that as the CEO of New York City Health & Hospitals and Ed,
as chief digital officer, implemented during our process of digi-
tal transformation. The framework is foundational for success
for any organization no matter where you are.
Ram Raju, MD
Former CEO, New York City Health & Hospitals
Senior Vice President, Northwell Health

The ability to combine experience and industry wisdom

with a willingness to learn and change makes the difference
between an organization that is on the leading edge and one
that is not. Digital offers unique and valuable insights that will
help technologists promote and support innovation and trans-
form processes and cultures.
Pamela Arora
Children’s Health, Senior Vice President and CIO
Board Member, HIMSS

This is a real-world practical playbook full of actionable

insights around were we are now as an industry given the
pandemic and what the next generation of Heath Care con-
sumption and delivery will look like infused with digital tech-
nology and analytics. A must read for anyone that wants to
lead transformation in the Healthcare industry.
Daniel Garrett
Retired PwC Partner
Board Member, Multiple Companies

An important book, at an important time. Highly recommend

for healthcare professionals and investors.
Jared Sender
Investment Banker

Digital medicine is now medicine. Technology should increase the

quality of the data available to physicians and enhance the con-
sumer experience for patients. Edward and Paddy identify why
healthcare is at an inflection point and how a digital transforma-
tion benefits all. This book outlines well why all providers should
embrace the change and accelerate their digital transformation.
Daniel Barchi
Senior Vice President and CIO, New York Presbyterian
The pandemic has pushed the healthcare industry into the
biggest disruption in decades forcing fundamental examination
of how business and services are provided. Healthcare Digital
Transformation is a forward-looking blueprint to navigate and
“create” the future state. Ed Marx and Paddy Padmanabhan are
uniquely positioned to write this timely and important book,
as each have had extensive and varied experiences within
large and complex healthcare organizations.
Matthew Hamlin
Vice President and General Manager, Quest Diagnostics

A man of tremendous faith, Ed Marx is an industry giant in

the field of innovative healthcare. His latest literary effort is
sure to be an excellent roadmap for leaders in all walks of life.
Thaddeus McCall
Pastor, Greater Love Mission Church

This is the timeliest book that not only provides the guidance
to alter the slow spiral diminish of our industry, but rather pre-
pares us with a roadmap and applies the intellectual capital to
accelerate our transformation and embraces the digital world
to exceed any other industry from the past.
Craig D. Richardville
Senior Vice President and Chief Information and
Digital Officer, SCL Health

Once again, Ed paints a vision of what’s possible coupled

with a roadmap to guide the journey into the unknown and
shifting sands of ‘digital transformation’ in healthcare. When
we worked together in an evolving health care system, I
found his ability to see into the future, and nudge those
around him to step into his vision to be just what was needed
to help us make tracks quickly. If you can’t work directly with
Ed, this is a close second best! Enjoy, Learn & Apply…and
watch what happens…
Cheryl Lynn Mobley
President, reCalibrate LLC
The authors of Voices of Innovation are not only well-known
innovators within the health technology industry, but they
also have hands on practical experience in delivering solu-
tions to some of the most prestigious healthcare organizations
in the world. Whether you are an IT professional or not, this
book will provide you with great insights into the complex
world of healthcare.
Ivo Nelson
Entrepreneur, Author, Consultant

“Healthcare Digital Transformation” is a breath of fresh air

for an industry that often keeps the windows closed. In their
excellent book, Ed Marx and Paddy Padmanabhan make the
case that for healthcare executives to grow, they must seek
both knowledge and talent from outside the domain, looking
to other industries for novel ways forward.
Anthony Guerra
Editor-in-Chief, HealthsystemCIO Media

Transformations are never easy, digital or physical. Everyone

knows that the Healthcare industry needs a massive revamp. Ed
Marx and Paddy Padmanabhan’s book is a refreshing look at
how one engages in an enterprise transformation that is based
on a three-legged framework that sits on vast domain experi-
ence, process/method rigor and new age digital technology.
Dilip Keshu
CEO, BORN Group

The name Ed Marx is synonymous with healthcare information

technology. Assembled through years of experience at some
our nation’s most preeminent health systems, together with a
passion for the betterment of health and leadership, Ed and
Paddy take us on a journey of digital transformation. An essen-
tial handbook for those seeking a primer in digital health.
Gene Mannheimer
Senior Research Analyst, Digital Health,
Healthcare IT & Services at Colliers International
Moving beyond having a deployed EHR to extending it, along
with related technologies, to communicate and interoperate
with all extended care givers, to enable analytics and predic-
tive medicine and to truly Transform both your practice and
your patient’s lives is like moving from Ford’s Model A, and
rutted dirt roads to modern integrated, reliable transportation.
Use this book as your roadmap!
Peter S. Tippett, MD, PhD
CEO careMESH

Never has a focus on innovation, transformation, and disrup-

tion been more relevant for healthcare than today. In the Keanu
Reeves sci-fi “The Day The Earth Stood Still”, his alien character
postulates that “humans don’t change until they are standing
at the precipice”. Right or wrong, Covid has brought us to that
place, and has forced us to alter our course overnight, more
than any pilot, experiment, or regulatory change has done in a
decade or more. Leaders at CMS and insurance companies have
rolled back archaic policies and rules that have stood in the way
almost overnight, and I’ve heard from many physicians across
the country that are realizing for the first time that quality care
can be delivered digitally – in its variety of forms.
This book is a wonderful resource. Ed and Paddy have
created an excellent construct for organizing and prioritizing,
organizational planning, and moving forward. Based on their
own experiences, the viewpoints of highly respected peers, and
additional research and observation, it covers everything from
basic blocking and tackling to implementing for the new nor-
mal. You are sure to derive some new thinking as well as vali-
date and benchmark your goals and progress as a result of it!
Shelli Williamson
Senior Advisor, Scottsdale Institute
 Healthcare Digital
Transformation
How Consumerism, Technology
and Pandemic are Accelerating
the Future
 Healthcare Digital
Transformation
How Consumerism, Technology
and Pandemic are Accelerating
the Future

Edward W. Marx
and
Paddy Padmanabhan
First edition published 2021
by CRC Press
6000 Broken Sound Parkway NW, Suite 300, Boca Raton, FL 33487-2742

and by CRC Press

2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN

© 2021 Taylor & Francis Group, LLC

CRC Press is an imprint of Taylor & Francis Group, LLC

Reasonable efforts have been made to publish reliable data and information, but the author and pub-
lisher cannot assume responsibility for the validity of all materials or the consequences of their use.
The authors and publishers have attempted to trace the copyright holders of all material reproduced
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been obtained. If any copyright material has not been acknowledged please write and let us know so
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Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced,
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ISBN: 978-0-367-47657-1 (hbk)

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Typeset in Garamond
by Deanta Global Publishing Services, Chennai, India
 I dedicate this book to my five children who forced
me to be digital. From the early days of MySpace to
Instagram and beyond, you forced your Daddy to learn
and grow. You taught me everything digital. Love you.
—Edward

This book is dedicated to those who work at the

front lines of healthcare and save lives every day.
—Paddy
Contents

List of Figures and Tables............................................... xvii

Foreword............................................................................. xix
Acknowledgments...........................................................xxiii
About the Authors.......................................................... xxvii
Introduction.....................................................................xxix
1 How the Covid-19 Pandemic Reshaped
Healthcare with Technology.....................................1
Assessing the Current State of Digital Maturity in
Healthcare............................................................................ 6
How Big Tech Firms and Non-Traditional Players Are
Reshaping the Healthcare Market.......................................22
How Leading Health Systems Are Approaching
Digital Health......................................................................30
Key Takeaways and Action Steps.......................................37
2 The Future of Digital Health..................................39
Enabling Online Patient Experiences: Telehealth and
Digital Front Doors.............................................................40
Improving Caregiver Experiences: Beyond EHR...............45
Digitally Enabling Administrative Functions:
Automation......................................................................... 48

xiii
xiv ◾ Contents

Enhancing Wellness in Our Communities: Population

Health Management............................................................50
Creating New Lines of Revenue: Monetizing Digital
Platforms..............................................................................52
Key Takeaways and Action Steps.......................................61
3 Creating an Agile Digital Transformation
Blueprint.................................................................63
A Vision for a Digital Enterprise........................................ 64
Digital Strategy and Readiness Assessment.......................70
Agile Roadmap Development and Prioritization of
Initiatives............................................................................ 77
Agile Digital Transformation and Technology Partner
Selection..............................................................................83
Key Takeaways and Action Steps.......................................92
4 Ensuring Strong Foundations.................................95
Data Ownership and Data Management........................... 96
Data Integration and Interoperability ..............................104
Security and Privacy ........................................................ 114
Technical Debt and Infrastructure Readiness ................. 116
ITSM, Agile, and TBM......................................................120
Key Takeaways and Action Steps.....................................124
5 Leveraging Maturing and Emerging
Technologies.........................................................127
Analytics, Machine Learning, and AI...............................128
Maturing Technologies: Cloud, Voice, and Automation......139
Emerging Technologies: 5G, Blockchain..........................148
Key Takeaways and Action Steps..................................... 151
6 Building Technology Partnerships for Success.......153
Understanding the Technology Vendor Ecosystem:
ICEATM Framework............................................................ 154
Innovators: We Have a Whole New Way of Doing It...... 158
Custodians: We Have the Data and the Workflow..........168
Enablers: Rent It, Build on It............................................ 172
 Contents ◾ xv

Arbitrageurs: We Can Do It Cheaper, Faster,

and Better..........................................................................180
What Successful Technology Vendors Do Right..............185
Key Takeaways and Action Steps.....................................189
7 Getting Digital Transformation Right.................. 191
Setting the Stage for Success............................................ 192
Selecting and Managing Your Technology Partners........ 193
Harnessing Innovation: Straddling Two Canoes..............199
Funding Your Digital Transformation Journey.................204
Managing Governance, Culture, and Change..................208
Addressing Cultural Aspects of Transformational
Programs...........................................................................213
Key Takeaways and Action Steps..................................... 217

Index........................................................................... 219
List of Figures and Tables

Figures
Figure 1.1 M
 arket forces driving digital transformation
in healthcare.........................................................12
Figure 1.2 D
 igital transformation maturity models in
health systems......................................................14
Figure 1.3 Components of digital health .............................27
Figure 3.1  ey focus areas for healthcare’s digital
K
transformation..................................................... 68
Figure 3.2 A phased approach to digital transformation.....71
Figure 3.3 Digital innovation prioritization matrix...............81
Figure 3.4 Traditional versus agile digital transformation......85
Figure 6.1 Technology vendors: ICEATM framework........... 158
Figure 7.1 T
 he role of the chief digital officer in
healthcare organizations.....................................210

Tables

Table 2.1  op venture innovation funds by health

T
systems....................................................................60
Table 3.1 Digital transformation definitions..........................65
xvii
xviii ◾ List of Figures and Tables

Table 3.2 S ample questions for an internal survey on

digital initiatives.....................................................73
Table 3.3 Aligning digital enablers to improvement areas......75
Table 3.4  atient experience journeys and technology
P
components............................................................79
Table 6.1  valuation framework for health cloud
E
solutions................................................................ 178
Foreword

Healthcare is experiencing a digital transformation that has

been decades in the making. Consumers are demanding con-
venience. COVID-19 responses exposed the need for further
automation, advanced analytics and rapid innovation. Big tech
players are moving in, intent on narrowing healthcare’s tech-
nology gaps by leveraging artificial intelligence (AI), machine
learning, and advanced tools that other industries have long
embraced. Non-traditional players are also entering the market,
making bold moves that are disrupting incumbents.
To successfully navigate the digital transformation, health-
care requires forward-thinking strategic leaders who are will-
ing to take charge, embrace technology-led innovation, and
boldly position their organizations for digital success. These
leaders must be passionate about their mission and commit-
ted to the development and execution of digital strategies that
position their enterprises for success and long-term relevance.
Healthcare Digital Transformation: How Consumerism,
Technology and Pandemic are Accelerating the Future is an
essential read for all healthcare leaders. While we have a
wealth of talented leaders, until now there’s been a shortage
of roadmaps to guide organizations through the process. This
book, however, provides an agile blueprint for digital transfor-
mation success. Leveraging agile methodologies, organizations
can accelerate responsiveness to the market and public health,

xix
xx ◾ Foreword

making rapid, incremental progress aligned with enterprise

strategy.
I can’t think of two individuals more qualified to write this
book than Edward W. Marx and Paddy Padmanabhan. Both
have spent their careers promoting technology-led innovation
in healthcare and have hands-on experience of developing
and executing digital strategies. Individually, they are two of
the industry’s most highly regarded experts on this topic.
I was CEO at the Cleveland Clinic when I met Ed Marx. Ed
was an experienced CIO who had held leadership positions at
Texas Health Resources, University Hospitals, and the Advisory
Board Company and had been recognized as the 2014 CHIME-
HIMSS John E. Gall Jr. CIO of the Year.
In 2017, I hired Ed as CIO for the Cleveland Clinic. Though
his title was CIO, Ed’s true mission was to lead the health
system’s digital transformation. Over the next two years,
Ed took charge, forged new trails, and worked to create a
digital transformation framework. Under his leadership, the
Cleveland Clinic developed its first digital strategy and began
its execution.
Paddy Padmanabhan is one of healthcare’s most widely
published and quoted thought leaders on digital transforma-
tion, with long experience in the technology sector. In addi-
tion to his prolific writing, he leads a digital transformation
and growth advisory firm and hosts The Big Unlock, a podcast
series based on his book of the same name, featuring insight-
ful conversations with some of the most prominent leaders in
healthcare and technology today. His podcast is an essential
resource for digital leaders in healthcare.
I first met Paddy when he asked me to be a guest on The
Big Unlock. I was struck by Paddy’s passion for the potential
of new digital technologies, including the possibilities for rei-
magining the patient and caregiver experience, driving opera-
tional efficiencies, and enhancing the quality of life in our
communities.
 Foreword  ◾ xxi

Together Ed and Paddy have created a handbook based on

their in-depth, hands-on experience of leading health systems
and technology firms. The book provides the specific “to-dos”
to enable digital transformation in organizations, from initiat-
ing the journey to picking technology partners, establishing
governance, preparing for future pandemics, and measuring
results. Healthcare’s digital transformation is in early stages.
The insights they share in this book will benefit both health-
care and technology executives and enable enterprises to suc-
cessfully navigate their digital transformation journeys.

Toby Cosgrove, MD
Former President and CEO of Cleveland Clinic
Acknowledgments

The idea for the book came together as the result of the work
that Ed and I did together while he was CIO of Cleveland
Clinic. I would like to start by acknowledging Ed for provid-
ing me that opportunity, and also to numerous other health-
care and technology executives with whom I have had the
privilege of working over the past several years. Many of
them have generously shared their insights with me through
a series of formal and informal conversations, in particular
as guests on my podcast, The Big Unlock. Their names are
everywhere in the book. I want to especially acknowledge
the support of Aaron Martin at Providence Health; Karen
Murphy and John Kravitz at Geisinger Health; David Quirke
at Inova Health; Daniel Barchi at New York Presbyterian;
John Halamka at Mayo Clinic; Manu Tandon at Beth Israel
Deaconess; Sylvia Romm at Atlantic Health System; Angela
Yochem at Novant Health; Steve Miff of the Parkland Center
for Clinical Innovation; and Dwight Raum at Johns Hopkins.
The technology community has been enormously influential
in accelerating the digital transformation of healthcare. I want
to make a special mention of the deep insights I received
from my conversations with Paul Black at Allscripts, Seth
Hain and Sean Bina from Epic, along with a number of digital
health entrepreneurs who are shaping the future of healthcare:
Graham Gardner of Kyruus, Mike McSherry of Xealth, Mudit
Garg of Qventus, Leah Sparks of Wildflower Health, and Drew

xxiii
xxiv ◾ Acknowledgments

Schiller of Validic. Giovanni Monti of Walgreens gave me deep

insights from the point of view of a non-traditional player in
the healthcare market. John Glaser, who has been a mentor
and an advisor, gave me a unique perspective from the point
of view of a former healthcare CIO as well as a former senior
executive with a major EHR company.
I want to thank the CHIME Foundation for supporting
my firm’s research which enabled us to interview dozens of
healthcare executives for their experiences, all of which are in
this book. Russ Branzel and his team deserve a special men-
tion for all the work they do to advance healthcare IT.
My team from Damo Consulting supported me for the
second time around with this book project, going above and
beyond their normal duties. Special thanks to Arpita Bose Das,
Kaushik Dutta, Bhawna Misra, and Sanjith Kumar for their
editorial and design work. Katie McCandless, once again my
manuscript editor, did a magnificent job of holding our feet to
the fire on tightening up and streamlining the narrative.
Kristine Mednansky from Taylor & Francis gave us the start
for this project and continued to support us through the inevi-
table ups and downs of writing and producing a book. We are
grateful for her guidance, advice, and patience.
Last but not least, I owe thanks to my family who put up
with my long absences during the writing of the book. They
inspire me every day to be better.
Paddy Padmanabhan

This book is dedicated to all the teams I have served with

throughout my healthcare journey. To the technicians and
specialists who encouraged me as a 16-year-old janitor at the
Peterson Air Force Base Medical Clinic. To my fellow Army
91B Combat Medic classmates who helped me learn our craft.
To Poudre Valley Hospital for hiring me and giving me my first
break. To Parkview Episcopal Medical Center for hiring me
into my first IT-based role and helping me grow. To HCA for
helping me develop enterprise vision. To University Hospitals
 Acknowledgments  ◾ xxv

of Cleveland for making a huge bet on me as a young CIO.

Texas Health Resources for allowing me to take risks with
innovation. To New York City Health & Hospitals via the
Advisory Board for helping me fulfill my desire for public
health. To Cleveland Clinic for the opportunity to be the first
to lead digital and to allow me to serve in the operating rooms
weekly as an anesthesia technician. Finally, to Tech Mahindra/
HCi for believing in me as the first global chief digital officer
for health and life sciences. In each of these companies there
was a team. All of the experiences and learnings that helped
create this book came from them. Team of Teams.
A special shout out to our publisher and editors who
helped shape the lumpy word clay into something readable to
push our industry forward. My co-author Paddy for the book
idea, his commitment to excellence, and a neverending supply
of “red-eye” coffee with conversation.
Edward W. Marx
About the Authors

Edward W. Marx is husband to Simran

and father of Brandon, Talitha, Nicholas,
Austin, and Shalani. He serves as the chief
digital officer for TechMahindra/HCi Health
& Life Sciences division. He has been
blessed to serve as a CIO in many progres-
sive organizations, namely, Cleveland Clinic,
New York City Health & Hospitals, Texas
Health Resources, and University Hospitals of Cleveland.
Simultaneously, Edward began his distinguished military
career starting as a combat medic and finishing as a combat
engineer officer. Edward has written many books, includ-
ing the bestselling Voices of Innovation (2019), Scenes from
an Early Morning Run (2019), and Extraordinary Tales of a
Rather Ordinary Man (2015). He is set to release a book on
sexuality in marriage co-written with Simran (2020). In his
spare time, Edward races for Team USA Duathlon and loves
to hike and climb mountains with Simran. Edward received
his bachelor’s in psychology and master’s in design, mer-
chandising, and consumer sciences, all from Colorado State
University.

xxvii
xxviii ◾ About the Authors

Paddy Padmanabhan is an award-winning

business leader and a trusted C-suite advisor
with a proven history of success in guid-
ing key strategies across the healthcare and
technology sectors. He is the CEO of Damo
Consulting, a digital transformation and
growth advisory firm focused on the health-
care sector. Both commercially astute and
entrepreneurially adept, Paddy has garnered a reputation for
driving growth and efficiencies in both large corporates and
start-ups within the healthcare technology industry. A vision-
ary leader and practitioner, he has worked at globally recog-
nized firms such as Accenture, GE, and Wipro where he built
large global technology businesses and spearheaded strategic
growth initiatives. He has also been in Silicon Valley start-ups
that went through successful exits. A respected and credible
voice in healthcare technology, Paddy is widely considered a
thought leader and expert practitioner in digital transforma-
tion and growth strategy. He is the author of The Big Unlock –
Harnessing Data and Growing Digital Health Businesses in a
Value-Based Care Era and hosts a widely acclaimed podcast
featuring C-suite executives from healthcare and technology.
He is widely published and quoted in industry publications
and has a long-running by-lined column in CIO magazine on
digital health technology trends. He lives in Chicago.
Another random document with
no related content on Scribd:
 BY JAMES C. WILSON, M.D.

Next in order to alcohol, opium and morphine are habitually abused

to a greater extent than any other narcotic. Chloral is used in the
same way by a large number of individuals. Paraldehyde, cannabis
indica, ether, chloroform, and cocaine are also used to a less extent.
The scope of this article does not include the consideration of acute
poisoning by these drugs.

The habit of taking narcotics, whether medicinally or as a mere

matter of indulgence, is apt speedily to become confirmed. The
physiological dose more or less rapidly loses its power to affect the
nervous system in the ordinary way. Tolerance increases with
increasing doses, and in a comparatively short space of time
poisonous doses are taken with impunity as far as immediate danger
to life is concerned. The toxic effects of the poison are shown in
characteristic perversion of the functions of the nervous system and
of the mind. A condition is established in which the ordinary functions
of life are properly performed only under the influence of the habitual
narcotic, and in which its absence results in languor, depression, and
derangement of bodily and mental processes. The habit, once
established, thus makes for itself a constantly recurring plea for its
continuance. Especially is this true of opium and morphia.

Opium and Morphine.

Opium-eating is chiefly practised in Asia Minor, Persia, and India. It

is also prevalent in Turkey. It has been practised in India from very
ancient times. The prevalence of this habit in the East is probably
largely due to the restrictions placed upon the use of alcoholic
beverages among the Mohammedans, and to some extent also to
the long religious fasts observed by the Buddhists, Hindoos, and
Moslems, during which opium is often used to allay the pangs of
hunger. The prevalence of the opium habit in India is shown by the
fact that the license fees for a single year amounted to nearly five
hundred thousand pounds sterling. It is stated that in Samarang, a
town of 1,254,000 inhabitants, the average quantity of opium
consumed monthly is 7980 pounds. The town of Japava, with
671,000 inhabitants, consumed in fifteen days 5389 pounds of
opium. In 1850, 576,000 pounds of opium were imported into Java,
besides an unknown quantity smuggled.1
1 Archiv für Pharmazie, 1873, cited by Von Beck, Ziemssen's Cyclopædia, vol. xvii.

The habit is not confined to Oriental countries, but is also practised

in various forms in the West. It is by no means rare on the continent
of Europe. In certain districts of England, especially in Lincolnshire
and Norfolk, more opium is consumed than in all the rest of the
United Kingdom. Shearer2 states that the increase in the practice of
opium-eating among the workpeople of Manchester is such that on
Saturday afternoons the druggists' counters are strewed with pills of
opium of one, two, and three grains, in preparation for the known
demand of the evening. The immediate occasion is said to be the
lowness of wages, opium being used as a cheap substitute for
alcohol or as a food substitute, or with the view of removing the
effects of disease and depression. According to the same observer,
laudanum is more or less in use as a narcotic stimulant in the cotton-
spinning towns, where female labor is in requisition and is well paid.
Children are accustomed to it from their earliest infancy. Their
parents drug them with daily potions of Godfrey's cordial, Dalby's
carminative, soothing syrup, and laudanum itself, during the long
hours of their absence from home. While the habit of opium-eating
cannot be said to be generally prevalent in any part of the United
States, instances of it are frequently encountered in all classes of
society, and particularly among people of means and refinement.
The preparations employed in this country are crude opium, tincture
of opium or laudanum, camphorated tincture of opium or paregoric,
McMunn's elixir, Dover's powder, and the salts of morphia. All of
these preparations are used by the mouth; opium is very frequently,
especially among women of the better classes of society, habitually
taken in the form of suppositories; finally, the acetate and sulphate of
morphine are used by means of the hypodermic syringe. While it will
be necessary to point out some differences in the effects of these
drugs due to the preparation used or to the method in which it is
employed, the distinction between the opium habit and the morphine
habit, in itself an artificial one, will not be regarded in the course of
the present article.
2 Opium-smoking and Opium-eating, their Treatment and Cure, by George Shearer,
M.D., F. R. S.

Opium-smoking is chiefly practised by the inhabitants of China and

of the islands of the Indian Archipelago. It has been imported into
those countries where Chinese labor is largely employed. The
Chinese have transmitted it, to an extent which is fortunately very
limited, to the inhabitants of certain of our cities. Opium-smoking is
habitually practised in this country only among the more debased
orders of society.

SYNONYMS.—Opiophagia, Morphiopathy, Morphinism,

Morphinomania, Morphiomania, Morpheomania, are terms
occasionally employed to designate the opium or morphia habit.3
Landowski, Levinstein, Jouet, and others use the term morphinism to
denote the condition of the body; morphinomania, the condition of
the mind in chronic morphine-poisoning. This distinction may be
misleading. In effect, the pathological condition is complex, including
derangements both somatic and psychical.
3 The word morphiomania, used by writers, is contrary to all etymological rule
(Zambaco, De la Morphéomania, Paris, 1883).

ETIOLOGY.—A. Predisposing Influences.—Pain holds the chief place

among the influences which predispose to the formation of the opium
habit. By far the greater number of cases have taken origin either in
acute sickness, in which opium administered for the relief of pain has
been prolonged into convalescence until the habit has become
confirmed, or in chronic sicknesses, in which recurring pain has
called for constantly repeated and steadily increasing doses of
opiates. In view of the frequency and prominence of pain as a
symptom of disease, and the ease and efficiency with which opium
and its preparations control it, the remote dangers attending the
guarded therapeutic use of these preparations are indeed slight.
Were this not so, the number of the victims of the opium habit would
be lamentably greater than it is. In a considerable proportion of
cases of painful illness the relief afforded by opiates is attended by at
least some degree of malaise, nausea, vomiting, and vertigo—
symptoms which render the speedy discontinuance of the remedy
scarcely less desirable than the control of the pain for which it was
administered. Occasionally these symptoms are so distressing as to
render opium wholly inadmissible. In other instances each
successive dose is attended by an aggravation of the distress. More
commonly, especially in acute illnesses, decreasing pain may be
controlled by diminishing doses, thus rendering practicable entire
discontinuance of the drug before those modifications of the nervous
system, and especially before that tolerance for large doses, which
constitutes the beginning of the opium habit, are established. For
these reasons the use of opiates in acute sickness, if properly
regulated, is attended with but little danger. Far different is it,
however, in chronic painful illnesses. Here to procure relief by opium
is too often to pave the way not only to an aggravation of the existing
evils, but also to others which are often of a more serious kind.
Opium is at once an anodyne and a stimulant. The temptations to its
use are of a most seductive character. To the overworked and
underfed mill-operator it is a snare more tempting than alcohol, and
less expensive. It allays the pangs of hunger, it increases the power
of endurance, it brings forgetfulness and sleep. If there be myalgia or
rheumatism or neuralgia, and especially the dispiriting visceral
neuralgias so common and so often unrecognized among the poorer
classes of workpeople, opium affords temporary relief. The medical
man suffering from some painful affection, the worst symptoms of
which are relieved by the hypodermic injection of morphine, falls an
easy prey to the temptation to continue it—a danger increased by
the fact that he is too often obliged to resume his work before
convalescence is complete. Indeed, the self-administered daily
doses of physicians sometimes reach almost incredible amounts. To
women of the higher classes, ennuyée and tormented with
neuralgias or the vague pains of hysteria and hypochondriasis,
opium brings tranquillity and self-forgetfulness.

Of 100 cases collected by Jouet,4 the habit followed the therapeutic

use of morphine in 32 cases of ataxia, 24 of sciatica and other
neuralgias, 8 of asthma, 2 of dyspepsia, 4 of hypochondriasis, 2 of
madness, 9 of painful tumors, 2 of prostatic inflammation, 7 of
nervous conditions (not specified), 1 of peritonitis, 2 of periostitis, 1
of gastro-enteralgia, 4 of pleuritic pains, 1 of contracture, and 1 case
of hæmoptysis.
4 Étude sur le Morphinism chemique, Thèse de Paris, 1883.

The responsibility of the physician to his patient becomes apparent

when we reflect that with very few exceptions the opium habit is the
direct outcome of the use of the drug as a medicine.

The decade of life at which the opium habit is most common is

between thirty and forty. But it may be developed at any age. Even
infants are not rarely made the subjects of chronic opium narcotism
by the use of soothing syrups and other poisonous nostrums.

Sex in itself exerts very little influence as a predisposing cause.

Owing to collateral circumstances, the number of women addicted to
opium is greater than the number of men. Kane5 states that females
more frequently fall victims to these drugs than males, in the
proportion of three to one, and attributes this excess to the fact that
women more often than men are afflicted with diseases of a nervous
character in which narcotic remedies are used for long periods. This
observer suggests as an additional explanation the occasional
preference on the part of women for opium as a stimulant in place of
alcohol, its effects being less noticeable and degrading. On the other
hand, Levinstein observed in 110 cases 82 men and 28 women. He
does not, however, regard the conclusion that the use is more
common among men as warranted by these figures. The habit
resulted in these 110 cases from the following causes: In 20 men
and 6 women after acute affections; in 46 men and 17 women after
chronic affections, these diseases being in each instance
accompanied by great pain. One man began to use morphine as an
antiaphrodisiac. Either to produce mental excitement simply or to
cause forgetfulness of the ordinary cares of daily life, 15 men and 5
women indulged to an uncontrollable extent.
5 Drugs that Enslave, Philadelphia, 1881. I refer with pleasure to the early labors of
this observer. His later publications tell their own story.

Occupation has in some respects much to do in favoring the

development of the opium habit. Familiarity with the use of drugs
exerts a powerful influence. Of Levinstein's 110 cases, 47 occurred
in persons belonging to the medical profession or dependent upon it;
thus, 32 physicians, 8 wives of physicians, 1 son of a physician, 4
nurses, 1 midwife, and 1 student of medicine.

A predisposing influence of more importance than would at first sight

appear is found in sensational popular writings upon the subject. As
Kane has well said, “At the time in which De Quincey, Coleridge, and
Southey lived the people and the profession knew little of the opium
habit save among foreign nations. The habitués were few in number,
and consequently when De Quincey's article appeared it created a
most decided impression upon the popular mind—an impression not
yet effaced, and one which bore with it an incalculable amount of
harm. Men and women who had never heard of such a thing,
stimulated by curiosity, their minds filled with the vivid pictures of a
state of dreamy bliss and feeling of full content with the world and all
about, tried the experiment, and gradually wound themselves in the
silken meshes of the fascinating net, which only too soon proved too
strong to admit of breaking.” There can be no question that a
percentage of cases of the opium habit, small though it be, is even in
our day to be attributed to this cause.

Somewhat analogous in its etiological importance is the influence of

example upon persons of idle and luxurious habits. Nowhere in
Western countries, with the exception of the opium-smoking dens of
the Chinese and their depraved associates, are there public places
of resort devoted to the practice of the opium and morphine habits,
as there are in Turkey and the East. According to Jouet—whose
statements are corroborated by occasional statements in French
newspapers—the habitual injection of morphine is to-day, in France
at least, almost a matter of fashion. Landowski states that friendship
is occasionally pushed to the extent of the exchange of pretty
syringes in silver cases as presents, and that a patient received
upon his birthday a hypodermic syringe as a present from his sister.
Zambaco, whose observations were made at Constantinople, states
that among the Moslems the opium habitués prefer the crude drug,
either alone or associated with certain aromatic substances, such as
ambergris, canella, or saffron, which are used for their aphrodisiac
effect. These mixtures are prepared openly in the family, and carried
upon the person in the form of pills in rich boxes of gold and enamel
among the better classes. This observer further says that the ladies
of the better classes carry jewelled cases containing hypodermic
syringes and artistic flaçons for the seductive solution, and that they
avail themselves of favorable opportunities to take an injection of
morphine even when together.

In addition to the predisposing influences already mentioned, it has

been customary to regard insanity as a cause of the opium habit.
Laehr6 and Fidler7 have gone so far as to class the morphine habit
among the psychoses. This view appears to be no longer tenable.
The opium habit must be classed with the taste for alcohol,
gambling, avarice, and lust as among human passions. That nervous
subjects, invalids, and individuals wanting in moral and physical tone
are specially prone to it is obvious. It constitutes in these cases,
however, an expression of the morbid constitution rather than a
substantive affection in itself. In the same manner, the opium habit in
insane persons must be looked upon as an epiphenomenon of the
morbid mental condition.
6 Allgemeine Zeitschrift für Psychiatrie, 1872.
 7 Jahresb. der Gesellschaft für Natur und Heilkunde, Dresden, 1876.

Levinstein has with reason insisted upon the essential difference

between the disturbances resulting from chronic poisoning by
alcohol, lead, arsenic, etc., and that produced by morphine. In the
former group the mental conditions are expressions of physical and
chemical alterations of the central nervous system, which, once
established, persist for an indefinite period, whereas in
morphinomania the troubles of the nervous system are chiefly
functional and of a transitory character. He regards the nervous
disorders developed from the prolonged use of morphine as the
result simply of depression of the nervous system, and the extreme
suffering experienced on the withdrawal of the regular dose to which
the subject has been accustomed as a trouble of innervation rather
than as a psychical derangement. This physical suffering and the
mental depression which accompanies it have their analogues in the
angina occasionally seen in paroxysmal affections of the heart, the
blood-vessels, and the respiratory organs. Certain it is that
individuals addicted to opium and morphine excesses in a high
degree not only frequently retain full possession of their intellect, but
occasionally achieve and maintain great distinction in professional
and scientific life. Furthermore, subjects of the opium habit,
notwithstanding the gravest mental disturbance manifested during
the continuance or upon the cessation of the habit, usually exhibit
when cured no further indication of mental disorder.

B. The Exciting Cause.—In addition to the usual constituents of

vegetable substances, mucilage, albumen, proteids, fat, volatile
substances, and salts of ammonium, calcium, and magnesium,
opium contains a number of alkaloids, two neutral substances, and
meconic acid. Some of the alkaloids are probably derivatives from
morphia. The three most important alkaloids are morphine, codeine,
and thebaine. The neutral substances are meconin and meconiasin.
Morphinæ hydrochloras, acetas, and sulphas, codeina, and
apomorphinæ hydrochloras are officinal in the United States
Pharmacopœia. Opium and its alkaloids act principally on the central
nervous system, and in mammals on the brain. The functions of the
nervous system, as Brunton has pointed out, are abolished in the
order of their development, the highest centres being the first
affected. In man the action of opium is chiefly manifested upon the
brain. With small doses a stage of excitement, attended by increased
activity of the circulation, augmented nervous energy, and under
favorable circumstances an agreeable languor, followed by quiet
sleep, constitute the effects of the drug; with larger doses, of from
one to two grains, the transient stage of excitement is followed by
deep sleep, the awakening from which is marked by headache,
nausea, and evidences of gastro-intestinal catarrh; with still larger
doses, of three grains or more, deep sleep is produced, which
speedily passes into coma. The drug has an especial action on the
vaso-motor system, which is manifested in its power to diminish
congestion and relieve inflammation. With the exception of the urine
and the sweat, the secretions of the body are diminished by opium.
The action of the drug upon the intestines varies with the dose. In
moderate doses it diminishes peristalsis and causes constipation; in
very small doses it increases peristalsis; in large doses peristaltic
action ceases. Morphine is eliminated unchanged by the kidneys. It
is eliminated also by the gastro-intestinal mucous membrane, having
been found in the stomach after hypodermic injection. The action of
opium and its derivatives, as that of other narcotics, is much
influenced by habit. In those accustomed to the drug large (and
sometimes enormous) quantities are required to induce the
characteristic manifestations. Not rarely these manifestations are
much retarded. The enormous amount of two pints of tincture of
opium has been taken in the course of a day; a female patient
afterward successfully treated by the writer took habitually for a long
period of time from ten to twelve grains of morphine per diem,
hypodermically. Diedriech8 assumes that a portion of the morphine
introduced into the organism is converted into oxydimorphine or
other analogous substances which have the property of
counteracting to some extent the toxic effects of the morphine.
8 Ueber oxydimorphine, Inaug. Diss., Göttingen, 1883.
Levinstein concludes as a result of experiments upon animals that
morphine, besides its influence upon the nervous system, exerts an
especial action upon two sets of organs: first, upon the digestive
tube; and second, upon the sudoriferous glands. Taken by the
mouth, it irritated the gastric mucous membrane. Whether taken by
the mouth or hypodermically, it diminishes the secretion of gastric
juice and the peristaltic movements of the intestine. These
disturbances serve to explain not only certain of the phenomena of
the opium habit itself, but even more fully some of the symptoms
manifested upon its discontinuance. The nausea, vomiting, and
constipation occurring during the continuance of the habit must be
looked upon as a result of the derangement of function of the gastro-
intestinal glandular apparatus and the chronic catarrh which
accompanies it. The abrupt discontinuance of the drug is followed by
the sudden return of functional activity, hence salivation, persistent
vomiting, anorexia, and diarrhœa.

The effects of habitual excesses in opium and morphine upon the

nervous system are in essential particulars the same. Upon the
functions of the digestive system and upon nutrition they differ to a
considerable extent. Opium, as a rule, soon produces gastro-
intestinal derangements of a marked kind. These derangements
consist in loss of appetite, enfeebled digestion, nausea, vomiting,
and constipation alternating with occasional diarrhœa. The anorexia
is usually persistent and of a high degree, and has much to do with
the development of the wasting which is so common and so marked.
The occasional excessive appetite for food manifested by opium-
eaters is of brief duration. Its gratification aggravates the functional
disturbances, provokes gastro-intestinal catarrh, and thus tends to
increase the general malnutrition. On the other hand, morphine is
much better borne. At the present time almost all morphine habitués
use the hypodermic syringe, and, notwithstanding the elimination of
the drug in part by the gastric mucous membrane, thus escape in
part its evil effects upon the organs of digestion, and remain for a
long time, often despite enormous excesses, free from the nutritive
disturbances which are almost characteristic of the habitual abuse of
crude opium.
SYMPTOMATOLOGY.—The symptoms of the confirmed opium habit may
be divided into two principal groups: first, the symptoms of chronic
opium- or morphine-poisoning; and second, the symptoms due to the
withdrawal of the drug.

I. Symptoms of Chronic Poisoning.—A considerable percentage of

the individuals addicted to the opium habit preserve for a longer or
shorter period of time the appearance of health; indeed, it is possible
for very large doses of opium to be occasionally taken by certain
individuals without appreciable impairment of the functions either of
the body or the mind. These cases must, however, be looked upon
as exceptional. It is estimated that from one-fourth to three-tenths of
the entire population of China are addicted to the habit of opium-
smoking. The statements of travellers concerning the effect of this
habit are somewhat conflicting. When practised within bounds it
appears to resemble in its effects the moderate use of alcoholic
stimulants, increasing the ability to endure fatigue and diminishing
for a time the necessity for food. In moderation it appears to have
little injurious effect upon the general health. On the other hand, in
the greater number of individuals the confirmed opium habit causes
in a variable period of time symptoms of the most decided character;
the appetite and general nutrition fail; emaciation is often rapid,
commonly marked, and sometimes extreme. There are thirst and
anorexia; a little later the patient begins to suffer from nausea with
occasional vomiting. At this time a loathing for food alternates with
boulimia. These occasional excesses in food are followed by
epigastric distress, heartburn, and great mental depression. The skin
becomes relaxed, inelastic, and dull. Exceptionally, especially in
women who use morphine hypodermically, embonpoint is preserved
and the skin retains its normal tension and appearance. The
countenance is pale, muddy, and sometimes slightly cyanotic. There
is increased tendency to perspiration. Acne and urticaria are
common. Herpes zoster is encountered with considerable frequency
among opium subjects. In cases in which morphine is administered
by means of the hypodermic syringe the resulting lesions of the skin
are of importance. If the habit be concealed or denied, they are of
diagnostic value. Not rarely they constitute serious affections in
themselves. They are of all grades, from mere inflammatory points to
coarse infiltration and ulceration. The wounds are frequently so thick
set over the greater part of a limb as to present the appearance of a
continuous eruption. In other cases scattered points of ulceration
occur or extensive surfaces are occupied by a series of ulcerations
varying in size from a split pea to an inch or more in diameter.
Purulent inflammation of the subcutaneous tissues, with burrowing,
also occurs. Numerous scars bear witness to the duration and extent
of the habit. These lesions are usually due to unclean needles and
impure solutions; in certain cases they are to be explained by the
peculiarities of the individual as regards the tendency to
inflammation of the integumentary structures; finally, instances are
related in which immunity from skin lesions has existed in spite of
rusty needles and carelessly kept solutions.

The expression of the countenance is sometimes dull, much more

frequently furtive and timid. The repetition of the dose renders it
eager and bright. The pupils are commonly contracted, sometimes
enlarged, and occasionally unequal. Diminished power of
accommodation is common, and diplopia has been occasionally
observed.

The action of the heart is often irregular and weak. Disturbances of

the vaso-motor system give rise to flushing of the face, irregular
sensations of heat over the body, and sweating. It is probable that
the albuminuria hereafter to be described is due to disturbance of the
circulation in the kidneys. The pulse is variable; it is sometimes tense
and full, sometimes small and thready, often irregular. The volume,
tension, and rhythm of the pulse depend largely upon the state of the
vaso-motor and general nervous systems. They vary according to
the periods of stimulation, following doses or the periods of
depression characterizing the intervals between the doses.
Palpitations occasionally occur. Respiration is, as a rule, normal.
Transient dyspnœa sometimes occurs after doses a little larger than
usual. Subacute bronchitis is common. The urine is often diminished
in quantity. Its specific gravity varies within extreme limits, being
influenced rather by collateral circumstances than by the dose of
opium or morphine consumed. In grave cases albuminuria occurs.
Casts of various kinds are also encountered. As Levinstein9 has
pointed out, these changes in the urine are often transitory,
disappearing upon the suppression of the opium habit.
9 La Morphiomanie, 2d ed., Paris, 1880.

In confirmed cases uric acid is increased and urea diminished. The

chlorides are also diminished in amount. Vesical irritation is likewise
common. It is apt to be accompanied by neuralgia of the urethra and
of the rectum. Strangury and retention of urine also occur in old
cases. These complications are often followed by vesical catarrh.

Derangements of the central nervous system are constant and

serious. The disorders which originally led to the use of opiates are
in many instances intensified. The temper is capricious, fanciful, and
discontented. There are giddiness, headache, and vertigo. Disturbed
sleep, irregular flying neuralgic pains, and hyperæsthesia also occur.
Spinal tenderness is occasionally encountered, with characteristic
painful spots. Reflex excitability is augmented, but in aggravated
cases the tendon reflexes are often impaired. Itching is common and
troublesome. It may be local or general. Trembling of the hands and
of the tongue also occurs. This tremor resembles in all particulars
the tremor of chronic alcoholism, and, as many individuals addicted
to the opium habit also abuse alcohol, it is not always easy to say to
which of these poisons the symptom in question is to be referred: it
may be due to their combined action. Disturbances of speech are not
very uncommon. Sleeplessness is troublesome, but absolute
insomnia is rare. The sleep which is obtained is late, irregular, and
unrefreshing. In several cases that have occurred under the
observation of the writer there has been habitual inability to sleep
during the night, the patients wandering about, occupying
themselves in attempts to read or write until toward morning, and
then, under the influence of repeated doses, falling into a more or
less profound slumber, which has often been prolonged till after
midday. The effects of the dose upon the mind are in the early
periods of the habit agreeable exhilaration, increased activity of
imagination, and stimulation of the powers of conversation. These
effects are sometimes manifested for a long period, and in many
instances the most brilliant conversation, and among professional
men and public speakers the ablest efforts, have followed the taking
of large doses of opiates, and been followed in turn by periods of the
most profound physical and mental depression. In the absence of
the necessity for intellectual effort, and in individuals incapable of it,
the mental condition produced by the dose is one of profound revery,
largely influenced by the mental organization of the subject. This
state is described, and in many particulars much exaggerated, in the
writings of De Quincey, Coleridge, and others.

The voluptuous play of the imagination ascribed to the action of the

drug by Orientals is for the most part absent among opium-takers in
this country. If present at all, it occurs only to a limited degree. The
corresponding fact is also worthy of note—namely, so long as the
habit is continued the depression between the doses is less
profound than that described as occurring in the East. One of the
mental peculiarities of individuals addicted to the opium habit is
secretiveness concerning their vice. Not infrequently, the real cause
of the grave derangements of health thus produced is wholly
unsuspected by the family or friends of the patient. When the habit is
suspected or admitted, the amount and frequency of the dose are
rarely fully known, patients almost invariably deceiving their friends
in regard to the particulars of their indulgence. Individuals above
reproach in other matters, and previously of unquestioned veracity,
lie without any hesitation in this matter. A patient under my care who
had secreted in her room a quantity of morphine when about to
undergo treatment, denied either having taken or then having in her
possession any opium or morphine whatever, using the expression,
“I call God to witness that I neither now have, nor have had since I
began the treatment, any preparation of opium or morphine
whatever.” Within ten minutes sixty quarter-grain pills of morphine
were discovered secreted under the bolster. This patient was a
devout, refined, and, in regard to other matters, a trustworthy person.
The functions of the reproductive organs both in the male and in the
female are seriously deranged. In the male sex enfeeblement of the
sexual function is manifested in all degrees, even to complete loss of
sexual desire and sexual power. In certain individuals opium and
morphine in moderate doses produce some increase of sexual
desire and power, which is, however, speedily lost on the
continuance of the habit. Some doubt exists whether this is of
psychical or physical origin—a question at once difficult to decide by
reason of the reticence of opium-habitués upon this subject, and
unimportant in itself. Levinstein makes the interesting statement that
in no cases coming under his observation did the wives of
morphomaniacs who had injected as high as fifteen grains of
morphine a day reach the full term of pregnancy for two years prior
to the treatment, notwithstanding the fact that they were still young,
that they had borne children before their husbands had become
addicted to morphine, and that they had not, up to the time of the
formation of the habit by their husbands, suffered from premature
accouchements.

Among women the morphine habit invariably produces derangement

of the menstrual function. Menstrual irregularity, both as regards time
and amount, is succeeded after a time by amenorrhœa. Vicarious
hemorrhages do not occur. Complete amenorrhœa is sometimes
established abruptly, and married women not infrequently suspect for
this reason that they have conceived. In several cases of this kind
under the observation of the writer the absence of enlargement of
the breasts, of alteration of the areola, and of softening of the os
after several months, indicated the improbability of these fears,
notwithstanding the irregular appetite, the morning vomiting, the
occasional palpitations and faintness, the hysterical condition, and
the mental peculiarities of the individuals—phenomena
unquestionably due to the action of the morphine itself. The
amenorrhœa of the morphine habit is associated with sterility—a fact
that renders probable the supposition that it is dependent upon
absence of ovulation. Women addicted to the opium habit are
capable of conceiving so long as menstruation persists, those only,
however, going to full term who use very moderate quantities. In
women using large doses abortion invariably occurs. The functional
integrity of the reproductive system is re-established upon the
permanent cessation of the habit. Women who are cured may again
menstruate regularly and may again bear children. Morphine in
women, as in men, is said to increase, when first habitually taken,
the capacity for sexual pleasure.

Levinstein and others have described certain febrile conditions

observed in individuals addicted to morphine. First, a form of
intermittent fever closely resembling malarial fever. This fever of
intermittent type occurs in individuals neither living in malarious
regions nor previously exposed to malaria. In addition to periodicity,
it presents other points of resemblance to malarial intermittent. The
earlier paroxysms cease after the administration of quinine. They are
favorably influenced by change of residence, and recur with intensity
after over-exertion, exposure, and upon the occurrence of acute
maladies. The favorable influence of quinine is only transient; the
febrile paroxysms recur after a time, notwithstanding the continued
use of the medicament. This fever disappears without special
treatment upon the discontinuance of the habit. It is more frequently
of the tertian than of the quotidian type. Its paroxysms are marked by
the symptoms of paludal intermittent. Neuralgias of various kinds,
especially supraorbital, intercostal, and præcordial neuralgias, are
apt to occur. The temperature during the paroxysm ranges from
102.5° to 104°. The area of splenic dulness is increased. More or
less mental and physical depression follows the paroxysm,
continuing in most cases through the period of apyrexia. These
observations require further confirmation. Secondly, confirmed
opium-habitués are peculiarly liable to transient febrile disturbances
from slight causes. Finally, ephemeral fever, ushered in by chills or
rigors and accompanied by headache, vertigo, thirst, malaise,
restlessness, and even mild delirium, and terminating with profuse
perspiration, occasionally occurs immediately after the injection of
large doses of morphine.

The course of the opium habit, when once established, is,

notwithstanding its occasional transient interruptions, gradual and
progressive. Certain individuals endure enormous doses of opium or
morphine for years without serious symptoms. In others moderate
doses give rise in the course of a few months to anorexia,
disturbances of nutrition, neuralgias, fitful and difficult sleep, and
serious mental derangement. These symptoms are usually
controlled by increasing doses and diminution of the intervals.
Finally, however, the drug fails to produce either excitement or
repose, and enormous doses are taken with but insignificant relief.
This is the period of grave derangement of the mental and physical
functions and of nutrition amounting to a true dyscrasia. The
phenomena are analogous to those produced by the withdrawal of
the dose. They are the symptoms of inanition, which in the absence
of well-directed and energetic treatment speedily terminates in
death.

II. Symptoms Due to the Withdrawal of the Drug.—Opium-habitués,

differing as they do among themselves in the manifestations of the
effects of the drug so long as it is freely taken, all alike develop
characteristic symptoms upon its speedy or gradual withdrawal. The
apparent immunity exceptionally observed now comes to an abrupt
termination. The nervous system, whether it has been accustomed
for months merely or for years to the influence of opiates, is upon
their withdrawal forthwith thrown into derangement of the most
serious and widespread kind. In the course of a few hours after the
last dose the steadying influence of the drug disappears. General
malaise is associated with progressive restlessness; the ability to
perform the ordinary duties of life gives way to profound depression
and indifference; præcordial distress, accompanied by cough, is
followed by insomnia, hallucinations, and sometimes by mania. The
habitual pallor of the face is replaced by deep flushing or cyanosis.
The heart's action becomes excited and irregular, then feeble; the
pulse, at first tense, becomes slow, thready, and irregular.
Colliquative sweats appear. Attacks of yawning and sneezing are
followed by convulsive twitching and trembling of the hands. Speech
becomes hesitating, drawling, and stuttering. Troubles of the
accommodation and even diplopia occur, often accompanied by
excessive lachrymation. Transient and varying differences in the
pupils are very frequent. Retinal hyperæsthesia may occur. In the
amblyopia occasionally observed in subjects of the opium habit the
ophthalmoscope reveals persistent anæmia of the retina. These
phenomena are associated with a sense of perfect prostration which
obliges the patient to take himself to his bed. Pain in the back and
limbs, followed by neuralgias, now occurs. Complete anorexia, with
easily-provoked or even causeless vomiting and persistent nausea
and diarrhœa difficult to control, adds to the gravity of the condition.
The abrupt discontinuance of the drug is followed in many individuals
by mental phenomena of a marked character: hallucinations,
illusions, and delirium continue for several days. The hallucinations
relate to all of the senses, but especially to those of sight and
hearing. The sense of smell is also occasionally affected, that of
taste rarely. Syncopal attacks occur. These are usually transient;
occasionally, however, profound syncope calls for the active
interference of the physician. Epileptiform seizures also take place.
Women who have previously suffered from hystero-epilepsy are
prone to the recurrence of severe paroxysms. Trembling of the limbs,
and especially of the lower extremities, rhythmical in time and often
violent, must be ranked among the more characteristic phenomena
produced by the abstinence from the drug. Sweating, although by no
means constant, is among the earlier and more persistent
phenomena. Urticaria occurs. Dyspnœa is common. Sometimes it is
provoked by exertion; sometimes paroxysmal shortness of breath
occurs spontaneously. Irritable cough is frequent. It is in many cases
unattended by râles. Pre-existing bronchitis is of course
accompanied by its characteristic signs and symptoms. Præcordial
distress, with palpitation and a sense of oppression, is common.
During the earlier days of abstinence the evidences of cardiac failure
are marked. Enfeeblement of the first sound, irregularity of the
heart's action, and intermission are common. The pulse phenomena
correspond to the heart's action. Thirst is a very frequent symptom. It
is often out of proportion to the loss of fluid by perspiration and
diarrhœa. The urine does not contain sugar. Salivation is rare and of
moderate degree. Nausea is persistent. Œsophageal spasm,
provoked by every effort to swallow, occasionally occurs and
constitutes a distressing symptom. Many patients also complain of
spasmodic contraction of the anus. Neuralgia of the testicles also
occurs. The cure of the opium habit is followed by rehabilitation of
the sexual power in the male and by menstrual regularity and
fecundity in the female. Levinstein has observed sexual
hyperæsthesia during the first weeks of abstinence in both sexes.
Albuminuria occurs in a large proportion of the cases. The albumen
shows itself, as a rule, from the third to the sixth day after the
discontinuance of the morphine, and disappears in the course of a
very few days. It is usually of slight amount.

The behavior of patients undergoing the suffering attendant upon the

abrupt, or even the gradual, withdrawal of the drug is variable. It
depends upon the mental and physical organization of the different
individuals and upon their ability to endure pain. Some rest quietly in
bed, enduring with fortitude suffering from which there is no escape;
others, silent, uncomplaining, and apathetic, present the appearance
of utter despair; a few, more fortunate than their fellows, lapse into a
condition of almost continuous drowsiness. In the greater number of
cases, however, these states of repose are but momentary or absent
altogether. Restlessness is continuous, and very often intense; the
patients are with difficulty kept in bed; if left to themselves they move
frantically about the room, moaning, bewailing their condition, and
begging the attendants for that which alone is capable of relieving
their distress. This condition gradually subsides, giving way to a
state of the most profound exhaustion. The exhaustion due to the
reaction of the nervous system deprived of the stimulus of the drug
is, on the one hand, favored by pre-existent derangement of the
nutritive processes, and on the other increased by the pain,
wakefulness, diarrhœa, and vomiting which accompany it. The
appearance of the patient is now most pitiable; the countenance is
blanched and pinched, the body occasionally drenched with sweat;
the heart's action is feeble, and the pulse thready and irregular. This
condition of collapse is usually of short duration, disappearing in
favorable cases under the influence of appropriate nourishment
administered in small quantities and with regularity. Where, however,
the gastric irritability is unmanageable, an increasing tendency to
collapse may threaten life. In rare cases suddenly-developed fatal
collapse has occurred at a later period in the treatment, even after
the patient has become able to take and retain food. The
restlessness does not, however, always subside in this manner. In a
considerable proportion of cases it increases. Hallucinations and
delusions occur, and a condition of delirium tremens, scarcely
differing from the delirium tremens of chronic alcoholism, is
established. Tremor is a constant phenomenon of this condition.
Sometimes the gravest symptoms of the suppression of the drug are
developed with great rapidity. Jouet relates a case of a patient at the
Salpêtrière who during a temporary absence from the hospital forgot
her syringe and solution; her return being delayed from some cause,
she, notwithstanding her struggles against the symptoms caused by
the want of her habitual dose, suddenly fell in the street, her
countenance haggard and anxious, her hands shrivelled, and her
whole body bathed in drenching sweat. She immediately became
maniacal, and demolished the glass and lamps of the coupé in which
she was taken to the hospital. No sooner had she received her
ordinary hypodermic dose than she recovered her usual quietude.
This patient was neither hysterical nor had she previously suffered
from nervous paroxysms. She was, however, accustomed to
administer to herself at four o'clock every day a large hypodermic
dose of morphine, and it was at a few minutes past four that the
above-described seizure occurred.

DIAGNOSIS.—The diagnosis of the opium habit is in many cases

attended with considerable difficulty. Many habitués, it is true, do not
hesitate to admit the real cause of their symptoms; others, while
seeking to conceal it, do so in such an indifferent manner that
detection is not difficult; but the greater number for a long time
sedulously conceal their passion, not only from their friends, but also
from the physician whom they consult voluntarily or at the solicitation
of those interested in them. If inquiries be made upon the subject,
they deny the habit altogether, often with vehement protestations. If
forced to admit it, they are very apt to misstate the amount employed
or the frequency of the repetition of the dose. As a rule—to which
there are, however, not infrequent exceptions—emaciation is
marked, appetite is diminished and variable, the pulse is small, the