One hundred and twenty-seven pounds. He was under treatment two and one-half months. On the day he took his last dose of morphin he weighed one hundred and forty-nine pounds. He remained with me. two weeks after the morphin was entirely discontinued and at the end of that time weighed one hundred and fifty-four pounds

-a total gain of twenty-seven pounds, and he never felt better in his life. The other was a man fifty-one years of age, who had taken morphin for fifteen years, and for a number of years had taken as much as twenty-five or thirty grains per day. There was only one night during his treatment that he did not sleep well. He ate well after the first week's treatment. He was with me four months and had increased in weight twenty-four pounds.

These are exceptional cases, but the majority will improve more or less in weight during the stage of withdrawal, and four out of five patients say that they feel better during the treatment than while taking morphin ad libitum.

Perhaps there is no way in which I can better illustrate the method than by giving a condenst report of a case. Mr. T. B., aged twenty-six years, married, general health fairly good, bowels badly constipated and appetite poor, had used opiates six years. The first three years he smokt opium; the last three he had used morphin, and was using from twenty to thirty grains per day hypodermically when he came to me for treatment. ordered

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I also prepared a solution of morphin containing thirty-two grains to the ounce, or one grain in fifteen minims, of this solution I gave him thirty minims, or two grains four times a day. Finding that he was very comfortable on this amount, I quite rapidly reduced the quantity of morphin until, twelve days after commencing treatment, he was taking fifteen drops at a time, or one grain four times a day. Seventeen days later he was taking ten drops or two-thirds of a grain. Up to this

time I had reduced the amount of the solution given, one drop at a time whenever a reduction was made, but to reduce one drop now would mean one-tenth of the whole, and he would feel quite perceptibly the loss of that proportion, so I prepared another solution of one-half the quantity of morphin-one grain to thirty minims

and gave him nineteen minims, nearly twice the quantity of the solution. I then very gradually reduced this quantity one minim at a time, and only as that could be done without his knowledge, for no progress can be made while he is suffering for the want of morphin. March 1st he was taking four minims, when the morphin solution was again reduced to one grain to sixty minims, and of this seven minims given at a time. Again the quantity was reduced as before until March 14th, when he was taking three minims at a time. A solution was then made containing one grain to 120 of water, and five minims given. The quantity was then reduced to three minims on March 17th, when a solution containing one grain to 240 of water was made and five minims given; and reduced to three minims on March 20th. At this time a solution of one grain to the ounce was made, and on March 25th he was taking four minims or 1-120 grain. This was the last day that he took any morphin, three months from the day that he came for treatment. improvement in flesh and appearance was constant while being treated. He was uncomfortable only a few times during the entire period; at such times I always gave him enuf extra morphin to relieve him.

His

This I consider an important factor. The physician must have the confidence of his patient. Unless the patient can feel sure that he can get morphin when he asks for it, he is sure to imagine that he is badly in need of it much of the time, when otherwise he will feel fairly comfortable until the regular hour for taking it. Many times a patient imagines that he requires morphin when a syringe of water will do as well. One has to study each case and be constantly on guard that he does not give morphin when water would do as well. Some patients are continually asking for extra hypodermics, and water will satisfy perfectly.

One who treats morphin has no time for other practice. He must devote his entire time to his patients. I never leave my patients with a nurse for a few hours that some or all of them do not require more

morphin than they would if I were with them. On the other hand, be as careful as possible not to make mistakes and give water when morphin is required. The patient gets nervous, becomes irritable, does not eat and loses sleep, unless the error is rectified in time. There is no disease with which I am acquainted that requires the constant study and watchfulness that morphinism does. Patients can seldom be treated successfully at their homes; general hospitals or sanitariums, for obvious reasons, are not good places to treat this class of patients. The most suitable place to care for them is in institutions devoted exclusively to that class of work, where physicians and attendants can constantly have an eye on each patient in the institution. So far as medicine is concerned, no fixt formulæ can be given; every case is a law unto itself and must be treated according to its particular condition and requirements. The one thing that is to be done in every case is to build the patient up physically, improve the general health just as much as possible. Give general tonics, heart tonics, nerve tonics, according to indications. Keep all the secretions in a condition as nearly normal as possible, and look well after the condition of the stomach. When the quantity of morphin has been reduced to a very small amount, or, in some cases after it has been entirely discontinued, the patient will have a better appetite than digestion. A little care should then be exercised that easily digested food is used. Baths and massage are beneficial in many cases. Often a hot bath at bedtime will secure a good night's sleep. In others dry heat will be more successful. The more exercise one takes, the more morphin he will require; therefore, where it is desirable to get rid of the morphin as soon as possible, the patient should take little or no exercise. In the treatment of about 200 cases upon the above plan, my experience has been that in direct proportion to the success that I have had in recuperation previous to the reduction of morphin, has been the lessened amount of discomfort to the patient, and in the cases, only, that have shown little tendency to recuperation in spite of all efforts, has there been sufficient discomfort to be worth mentioning.-AUSTIN J. PRESSEY, M. D., Cleveland, Ohio, in Jour. of Amer. Med. Assc.

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The Hippocratic Oath. The Hippocratic Oath was briefly as follows:

"I swear by Apollo, by Esculapius, by Hygeia and Panacea, by all the gods and goddesses of Olympia, whom I call upon as witnesses, to fulfil this vow according to my capacities and my power."

"I will regard as my father the one who has taught me medicin; I will share with him my goods and money if he shall be in need; I will consider and treat his children as if they were my brothers, and if they desire to study medicin I will teach them without reward of any kind.” "I will prescribe for my patients that which seems most useful and will reject everything harmful."

"I will maintain a pure life and exercise my art only for the good of man." "That which I have heard while in the exercise of my profession I will consider as a secret which ought not to be divulged."

"If I keep my oath, may my life be happy and my reputation honored; if I violate my oath, may I suffer the contrary."

This is an abbreviated form of the oath, but gives the general character of the vow. The licentiate further agreed not to give poison to any one asking it, and to abstain from giving a woman an abortifacient as well as cutting for stone. Regarding the latter clause, Mons Doctor Charpignon, who has written a monograph upon the subject, thinks that Hippocrates referred to castration and not cutting for stone.

Considering the licentiousness reigning at that time, and the fact that pederasty was prevalent, slaves and others being castrated that they might grow up emascu lated and therefore more feminine in aetions and appearance, it is probable that castration was the operation interdicted by the oath.-Leon Noel, in Phila. Med. Jour.

Effect of Coitus During Pregnancy. The importance of this subject leads me to remark that someone more competent than myself should have been selected to present it in the scientific spirit that it merits. I have been led to make a more or less exhaustive research of the literature of this subject, and, with the excep tion of a short abstract from a paper on a kindred topic, presented by me before the American Medical Association, at Denver.

namely, on the disturbances of lactation, my remarks will consist principally of a compilation of the literature on the effects of coitus during pregnancy and lactation. With but few exceptions, specialists are consulted by their married clientele in regard to these two points. There seems to be a wide difference of opinion prevailing among the laity, and, so far as I have been able to observe from conversation with my brother practitioners, among the profession, hence my quotations.

The points I will present are: 1. The effects of coitus during pregnancy are productive of abortion. 2. The aggravation of nausea and vomiting on part of the female. 3. Its relation to puerperal sepsis. 4. Its relation to labor, resulting in dystocia. 5. The possible effect on the mental development of the infant-idiocy, epilepsy and cerebral palsy. 6. Malnutrition of the infant from exhaustion of the nervous force of the mother. 7. During lactation there is a tendency to cause abortion. 8. Error of opinion on part of laity that conception does not occur during lactation. 9. Busey states that it deteriorates the nutritive qualities of milk, which may be demonstrated. Numerous cases of convulsions in a child after sexual intercourse have been reported, and Bouchut gives a case of convulsions in a child after each repetition of the sexual act, with death of the infant resulting.

Quoting in regard to the effect of coitus during pregnancy as a cause of abortion, John Burton, writing in 1751, page 282, says: "I took notice that whatever brings too much blood to the womb and stimulates the adjacent parts, may occasion abortion; whence, in some constitutions, coition, altho the woman be generally more desirous of it the first two or three months of pregnancy, is bad, especially if the woman menstruates during her being with child." Crosseris (Manual, 1853, "Treatment of Tendency to Abortion") requires abstinence from coitus. Bedford (Principles and Practice of Obstetrics, 1861, page 273), in speaking of habitual abortion, says: "I have found an excellent expedient in such cases is, as soon as gestation takes place, to interdict sexual intercourse until after the fifth month.” Gooch (Practical Midwifery, 1853, page 128) says that for the prevention of miscarriage, the separation of the wife from her husband is an indispensable measure. Frequent sexual connection alone will often excite the uterus to action, which

terminates in abortion. Hodge (Principles and Practice of Obstetrics, 1864, page 108), on the "Treatment of Disorders of Pregnancy," says, "Avoid all inordinate sexual gratification." Galabin (1886, page 133, Manual of Midwifery) says: "It is not usual to abstain from marital intercourse during pregnancy, altho in this respect the animals set an example to the human race. Coitus is, however, a frequent cause of abortion, and much moderation is desirable, especially during the first four months." Grandin (Cyclopedia of Obstetrics and Gynecology, 1887, page 309), on "Hygiene of Pregnancy,' says: "The question of conjugal relations has been differently answered by various authors.

Altho intercourse has often caused abortion, it has in other cases been quite harmless. Its effect depends on the health of the woman. In the beginning of pregnancy the woman needs absolute repose, particularly at the time corresponding to the catamenial period. In the interval the separation of the sexes is less necessary. Toward the end of pregnancy intercourse becomes more and more difficult, and we have the statement of many women that premature rupture of the membranes had been brought about by conjugal relations. Altho we, therefore, do not absolutely forbid intercourse, we recommend that it be indulged in only after careful consideration of the duration of pregnancy and of the woman's state of health." Hirst (1889, American System of Obstetrics, page 394): "With respect to sexual intercourse during gestation, it is necessary to give advice with an extreme degree of circumspection. The physician's counsel is not often requested, and when gratuitously offered, it is still more seldom acted upon. Spiegelburg remarks: "It is preaching in the wilderness."

During the first three months and the latter weeks of gestation, it is wiser for husband and wife to occupy different beds, as the danger of abortion and premature labor is considerable. In any case in which the tendency to abortion is at all evident, sexual intercourse must be forbidden thruout. During the interval between the end of the third month and latter weeks, in perfectly healthy women, contact ought to depend upon the desire of the female. Roederer speaks of the viri fastidium; Stoltz of the horreaur du mari (abhorence of husband) sometimes evinced by the pregnant woman. On the other hand, the weight of opinion is very much

in favor of the view that in the majority of healthy pregnant women desire is greatly increast, even to the point of nymphomania. Item: History of Obstetrics, by Engelmann, page 4: "In Mexico, as the old histories tell us, the pregnant woman was forbidden to yield too freely to the desire of the husband, altho coitus was indeed ordered to a certain extent, so that the offspring might not prove weakly. In Loango coitus is not forbidden. Some regulation with regard to the act exists among other tribes, and the too free exercise of matrimonial rights is often cautioned against." W. B. Dewees, of Kansas (Journal American Medical Association," 1894), on the "Care of Pregnant Women," writes: "The family physician must be fully aroused to the conscious realization of the fact that it lies within his power very largely to prevent many of the diseases among the women of the family intrusted to his care. When this obtains, his moral obligation will impel him to promptly do his full duty, by giving adequate instruction concerning the ill effects of improper posture, dress, food, drink and erroneous habits of living, including the non-forbearance of indiscriminate, excessive and impure sensual indulgences. Then it will come to pass that the wholesome forbearance of coitus during the entire period of gestation, the puerperium, and three months thereafter, will be insisted on." Landis (Compend of Obstetrics, page 42, Pregnancy), says: "Locally, the hyperemia of the pelvic organs will cause, at first, an increase in the sexual desire." Page 40 (Causes of Abortion): "Hyperemia of the pelvic organs from over exercise, coitus, lifting, etc."

Lusk (Management of Pregnancy, page 113): "Marital relations, though not absolutely to be prohibited, should be of infrequent occurrence. Excesses in the newly married are a common cause of abortion." Page 317 (Prophylaxis of Abortion): Rapid succession. In such cases, curetting is often of service, and a six-weeks' abstention from sexual intercourse may be usefully enjoined.

Palmer (American Text-book of Obstetrics, 1895, page 181): "Sexual intercourse is to be regulated carefully, for very often it is found to be injurious to pregnant women. While especially enjoyed by some pregnant women, coitus is distasteful to most women at this period, and it becomes the source of much pelvic discomfort to not a few; it may create an abortion.

Even

uncivilized nations have condemned the privilege of sexual intercourse during the period of pregnancy, and have visited punishment on the offender. During the first months, when so many abortions occur, and toward the last of pregnancy, it is best for husband and wife to occupy separate beds."

In regard to the effects, Palmer also says that it is aggravated by unpalatable food, by sexual excitement and by emotional excitement. Play fair, Churchill, Cazeaux and Tarnier, Baudelocque, Dewees and John Burns agree as to both abortion and vomiting. Lusk says that coitus often increases the sickness.

Garrigues (American Text-book. page 693): When we take into consideration that at least the staphylococcus pyogenes abounds on human hands, it can hardly be doubted that it is found also on the skin of the penis. Since women often have sexual intercourse up to the day of their confinement, there is no difficulty in supposing that they have, at the time of their confinement, such cocci in the vagina, and that, in a certain sense, they may infect themselves, not only with saprophytes, but also with pathogenic cocci."

William E. Ground (“ Times and Register," Philadelphia, 1896), in the Transactions of the Medical Society of the state of Wisconsin, criticises, among other things, the condition surrounding the women of the middle and lower classes. He states that the husband, as a factor in the production of puerperal sepsis, has not received the consideration he deserves. Gonococeus has been talkt of; when she is near the end of pregnancy, he comes home with a soft chancre and continues his septic and sexual relations with her. However dirty his occupation may be, he handles the penis in urinating, but never thinks of bathing before copulation. Men sometimes have sexual relations with their wives within a week or two after confinement; the woman develops symptoms of puerperal fever, and the doctor is puzzled to explain the cause. and perhaps lays it to the breasts, or to catching cold, or to auto-infection. During lactation I find that Galen, quoted by Bouchut, says: "I order all women who are nursing children to abstain from sexual relations." Further, he says, " If mother begins to menstruate from the possibility of conception she should refrain from sexual intercourse."

Out of about 200 journal articles and of 125 authorities examined, I found but lit

tle on the subject of the effect of coitus upon lactation. It is a subject fraught with great importance to-day, and I was surprised to find such a paucity of literature on the subject. I believe this matter will be forced upon our attention more and more every day until we make it our business to inquire into the disorders of infancy, and to know what the sexual relations of the nurse may be. Platner, quoted by Bouchut, says that "Certain it is that unsatisfied desires are worse and more harmful than a rare and moderate use."

Routh (Treatment of Defective Lactation) refers to great sympathy between breasts and genitalia, and states that proper functional use of the one will influence the other, and advises occasional reunion to improve and excite the flow of milk. Hartman says that "Sexual intercourse may be allowed the mothers in moderation." Trousseau remarks that "conjugal intercourse is not injurious to nurse or nursling, provided it is regulated by great

moderation."

Some four or five other authorities, consulted by me, counsel moderation in sexual intercourse between the husband and the nursing mother. Some go to the lower animals for the purpose of citing an analogy and quote the practice of some dealers in cattle, especially in milch cows and goats, in the southern part of Europe, where it is customary to gently irritate the genitals of the female in order to stimulate the secretion of milk, and place the animals on the market in order that they may find ready purchasers.

Speaking of the uncertainty of effects, Vogel states that "Whether a coitus upon which no gestation follows is in itself injurious, I am unable to say, but it does not seem probable, however." Bouchut states that Nothing positive is known concerning the influence of coitus." He relates the case of a young woman whose child fell into violent convulsions each time she gave herself up to coitus.

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"But numerous examples,on the other hand, demonstrate that the influence is not always so injurious." Routh, in an article on galactorrhea, says that "There can be no doubt that irritation of the womb itself, or its immediate appendages, cause profuse secretion. Undue excitement has been known to produce a jet of milk from both breasts, which has only subsided with the cessation of the stimulus."

Busey, of Washington, D. C., says that "Excessive sexual indulgence during the

period of lactation seriously deteriorates the nutritive qualities of the milk. The unwholesome and sometimes pernicious changes produced in the mother's milk are too well establisht by clinical observations, if not by chemical analysis, to be considered mere coincidence unworthy of the attention and careful scrutiny of the scientific physician. Woman is the highest type of the breeding female, yet she is the only one not exempt from the approach of the male by a natural periodic interval of aestus. It is a law of the physical economy that excessive indulgence of any animal passion, or the overwork of any function or organ, is detrimental to the whole organism."

Among the legendary and ethnological examples, Engelmann furnishes the greatest number, and states that the negroes of Loango of Central Africa are a fair type of the black race. With them woman are prohibited from sexual indulgence during lactation, which averages from twelve to fourteen months. Among the Northern tribes of Russia the mothers dwell apart for several months after confinement. On the slave coast, when women become mothers they are sent away for three years to nurse their infants and to prevent cohabitation. If the act should be accomplisht, they believe the evil spirit takes away the milk and the child dies. In several of these cases the wife selects a substitute for her husband, and in Japan they are called or known as "by wives." Natives of Africa, Asia and many of our western territories are not only kept apart from husbands during confinement, but for weeks afterward. With them, as with Hebrews, there is the idea of uncleanliness, but by this isolation, rest and non-exposure, women escape numerous uterine troubles. Arabs do not deprive themselves of sexual intercourse during the course of lactation. The prophet, however, without expressly forbidding this practice, lets it be understood that it must not be an injury to the nursling.

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Dr. G. J. Witkowski, in "Curiosities of Breast and Lactation," says that "It is a law of nature that the woman who is nursing ought rarely to become pregnant. One can compare the uterus to the earth. the lands which are not allowed to rest become exhausted and produce little, even so the women who are pregnant all the years without interruption, the uterus nourishes poorly its fruit." poorly its fruit." Jacobi (Transactions New York Obstetrical Society, 1876-78),