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Discrimination: A Context and Practice

Casebook, Third Edition
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Contents

Table of Principal Cases

Series Editors' Preface

Preface and Acknowledgments

Chapter 1 • Introduction to Employment Discrimination Law
Core Concept: At-Will Employment
Howard v. Wolff Broadcasting Corp.
Further Discussion
Core Concept: Putting the Federal Discrimination Statutes in
Context
Core Concept: Practical Realities of Employment
Discrimination Claims
Beyond the Basics: Statutory Interpretation and
Administrative Deference
Chapter 2 • Coverage of Statutes
Core Concept: Protected Classes
Race and Color
McDonald v. Santa Fe Trail Transportation Co.
Notes
National Origin
Saint Francis College v. Al-Khazraji
Note
Espinoza v. Farah Manufacturing Co.
Notes
Religion
Sex
City of Los Angeles, Dept. of Water & Power v.
Manhart
Notes
Age
Hazen Paper Co. v. Biggins

7
 Note
Core Concept: The Proper Defendant
Employment Agencies and Labor Organizations
Private Employers
Individual Supervisors and Co-Workers
Government Employers
Major Exceptions
Core Concept: Protected Individuals
Hishon v. King & Spalding
Chapter 3 • Disparate Treatment
Core Concept: Individual Disparate Treatment
Core Concept: The McDonnell-Douglas Test
McDonnell Douglas Corp. v. Green
Subsequent Developments
Reeves v. Sanderson Plumbing Products, Inc.
Core Concept: Comparators—Similarly Situated Employees
Outside of Plaintiff's Protected Class
O'Connor v. Consolidated Coin Caterers Corp.
Further Discussion
Core Concept: Stray Remarks
Core Concept: Business Judgment
Core Concept: Same Decisionmaker and Same Class
Inferences
Core Concept: Direct vs. Circumstantial Evidence
Core Concept: Adverse Actions
Core Concept: Mixed Motive
Price Waterhouse v. Hopkins
Subsequent Developments
Desert Palace, Inc. v. Costa
Gross v. FBL Financial Services, Inc.
Beyond the Basics: Mixed Motive in the ADA Context
Subsequent Developments
Beyond the Basics: Intersectionality
Beyond the Basics: The Intersection of Mixed-Motive and
Single-Motive Cases
Core Concept: Pattern or Practice
International Broth. of Teamsters v. U.S.
Hazelwood School Dist. v. U.S.
Core Concept: Affirmative Action

8
 Core Concept: BFOQ
Western Air Lines, Inc. v. Criswell
Dothard v. Rawlinson
International Union, United Auto., Aerospace and
Agr. Implement Workers of America, UAW v. Johnson
Controls, Inc.
Notes
Core Concept: After-Acquired Evidence
McKennon v. Nashville Banner Pub. Co.
Core Concept: Intent
Staub v. Proctor Hosp.

Chapter 4 • Disparate Impact

Core Concept: Disparate Impact, Its Theory and Structure
Griggs v. Duke Power Co.
Subsequent Developments
Wards Cove Packing Co., Inc. v. Atonio
Subsequent Developments
Core Concept: Defining Disparity
Bottom-Line Defense
Core Concept: The Correct Comparison
Core Concept: Job-Related and Consistent with Business
Necessity
Dothard v. Rawlinson
Note
Further Exploration of “Job-Related” and “Consistent with
Business Necessity”
Other Considerations
Core Concept: Disparate Impact—ADEA
Smith v. City of Jackson, Miss.
Subsequent Developments
Beyond the Basics: Disparate Impact and the ADA
Core Concept: Choices Made to Avoid Disparate Impact
Liability May Lead to Disparate Treatment Claims
Ricci v. DeStefano
Core Concept: The Adequacy of the Frameworks
Wal-Mart Stores, Inc. v. Dukes

Chapter 5 • Discriminatory Harassment

Core Concept: Types of Harassment
Core Concept: Quid Pro Quo Harassment

9
 Core Concept: Hostile Work Environment Harassment
Meritor Savings Bank, FSB v. Vinson
Harris v. Forklift Systems, Inc.
Further Discussion
Core Concept: Because of a Protected Trait
Oncale v. Sundowner Offshore Services
Notes
Core Concept: Unwelcomeness
Core Concept: Severe or Pervasive
Tademy v. Union Pacific Corporation
Core Concept: Motive vs. Content of Harassment
Core Concept: Employer Liability for Harassment
Meritor Savings Bank, FSB v. Vinson
Subsequent Developments
Faragher v. City of Boca Raton
Notes
Vance v. Ball State University
Note
Lauderdale v. Texas Dept. of Criminal Justice
Core Concept: Tangible Employment Action
Beyond the Basics: Harassment

Chapter 6 • Retaliation
Core Concept: Elements of the Statutory Claim for Retaliation
Core Concept: Protected Activity
Crawford v. Nashville
Notes
Core Concept: Reasonableness of Opposition Conduct
Core Concept: Reasonable Belief That the Act Has Been
Violated
Clark County School District v. Breeden
Note
Core Concept: Materially Adverse Employment Action
Burlington Northern & Santa Fe Railway Co. v. White
Notes
Core Concept: Causal Link
Clark County School District v. Breeden
University of Texas Southwestern Medical Center v.
Nassar
Notes

10
 Beyond the Basics: Third-Party Retaliation
Thompson v. North American Stainless, LP.
Notes
Beyond the Basics: Retaliation Protection under Section 1981
CBOCS West, Inc. v. Humphries
Beyond the Basics: Federal Employee Protections

Chapter 7 • Religion and Accommodation

Core Concept: The Differences of Religious Discrimination
Core Concept: Defining Religion
Core Concept: Proof Structures in Religion Cases
Chalmers v. Tulon Company of Richmond
E.E.O.C. v. Abercrombie & Fitch, Inc.,
Further Discussion
Core Concept: Reasonable Accommodation and Undue
Hardship
Trans World Airlines, Inc. v. Hardison
Further Discussion
Ansonia Board of Education v. Philbrook
Further Discussion
Chalmers v. Tulon Company of Richmond
Beyond the Basics: The Religious Employer Exemption
Beyond the Basics: The Ministerial Exception to Federal Anti-
Discrimination Statutes
Hosanna-Tabor Evangelical Lutheran Church and
School v. EEOC
Further Discussion
Beyond the Basics: Religious Discrimination and Public
Employers

Chapter 8 • Disability Discrimination

Core Concept: Disability, Individuals, and Social Policy
Core Concept: Definition of Disability
Core Concept: Actual Disability
Sutton v. United Air Lines, Inc.
Further Discussion
Mazzeo v. Color Resolutions International, LLC
Core Concept: Record of Disability
Core Concept: Regarded as Disabled
Adair v. City of Muskogee
Core Concept: Qualified Individual

11
 Hennagir v. Utah Department of Corrections
Core Concept: Reasonable Accommodation
Billups v. Emerald Coast Utilities Authority
Dewitt v. Southwestern Bell Telephone Co.
Further Discussion
Core Concept: Proof Structures
Core Concept: Direct Threat Defense
Chevron v. Echazabal
Beyond the Basics: Drug and Alcohol Use
Beyond the Basics: Medical Examinations and Inquiries
EEOC Guidance on Medical Examinations
Other Sources of Obligations Related to Exams and
Inquiries
Beyond the Basics: Burdens of Production and Persuasion in
Disability Cases
U.S. Airways v. Barnett
Notes

Chapter 9 • Protected Traits and Special Issues

Core Concept: Affirmative Action
Legal Challenges to Affirmative Action
Constitutional Challenges to Affirmative Action
Voluntary Affirmative Action under Title VII
Johnson v. Transportation Agency
Notes
Because of Sex
Because of Sex: Pregnancy, Childbirth, or Related Medical
Conditions
Young v. United Parcel Service, Inc.
Doe v. C.A.R.S. Protection Plus, Inc.
Notes
Back v. Hastings on Hudson Union Free School
District
Notes
Because of Sex: Sex-Based Pay Discrimination
Because of Sex: Comparable Worth
Because of Sex: Sexual Orientation or Transgender Status
Hively v. Ivy Tech Community College of Indiana
Note
Etsitty v. Utah Transit Authority

12
 Further Discussion
Macy v. Holder
Note
Because of Race/Color
What Constitutes Race?
Rogers v. American Airlines, Inc.
EEOC v. Catastrophe Management Solutions
Note
Color Discrimination
Salas v. Wisconsin Dept. of Corrections
Note
Race and Arrest Records
Because of Age
General Dynamics Land Systems, Inc. v. Cline
Grooming Codes
Jespersen v. Harrah's Operating Company, Inc.
Notes
Because of National Origin
Verification of Work Authorization Status and National Origin
Discrimination
Zamora v. Elite Logistics, Inc.
Notes
Undocumented Workers and Discrimination
Workplace Communication and National Origin

Chapter 10 • Administrative and Litigation Procedures

The Administrative Process
Step 1: The employee files a charge with the EEOC.
What Constitutes a Charge under the Federal Anti-
Discrimination Statutes?
Federal Express Corp. v. Holowecki
Notes
The Location for Filing a Charge with the EEOC
The Deadline for Filing the Charge with the EEOC
Commencing the Charge-Filing Period
Discrete Discriminatory Acts
Continuing Violations
Discriminatory Compensation Decisions
Disparate Impact Claims
Lewis v. City of Chicago

13
 Consequences of Failing to File a Timely EEOC Charge
Step 2: The EEOC serves the notice of the charge on the
employer.
Step 3: The EEOC investigates the charge.
Step 4: The EEOC makes a determination on the charge.
EEOC v. Manville Sales Corp.
Notes
Step 5: The EEOC issues a right-to-sue letter.
The Time Frame for the EEOC's Issuance of the Right-to-
Sue Letter
The 90-Day Time Period to File a Lawsuit
Equitable Tolling, Estoppel, and Waiver
ADA, ADEA, and Section 1981 Claims and the
Administrative Process
State Antidiscrimination Claims and the Administrative
Process
Procedural Requirements for Public Sector Employees
The Court Process
Step 6: The plaintiff files the employment discrimination
claim in court.
The Lawsuit
Pleadings
Swierkiewicz v. Sorema
Notes
Sample Complaint in an Employment Discrimination Case
Sample Answer in an Employment Discrimination Case
Discovery
Summary Judgment
Trial
Further Discussion

Chapter 11 • Remedies
Core Concept: Introduction to Remedies
Core Concept: Equitable v. Legal Remedies under Title VII
Enforcing the Historical Law and Equity Divide
Title VII Remedial Provision—Title VII §706(g); 42
U.S.C. §2000e-5(g) [Equitable Relief]
Title VII Remedial Provision—42 U.S.C. §1981a [Legal
Relief]
Core Concept: Purpose of Remedies
Albemarle Paper Co. v. Moody

14
 Core Concept: Types of Title VII Remedies and Standards for
Awarding Title VII Remedies
Back Pay
Retroactive Seniority Relief
Reinstatement
Front Pay
Donlin v. Philips Lighting North America Corp.
Note
Declaratory and Injunctive Relief
EEOC v. DCP Midstream L.P.
Notes
Compensatory Damages
Punitive Damages
Core Concept: Title VII's Compensatory and Punitive
Damages Cap
Core Concept: Mitigation of Damages
Richardson v. Tricom Pictures & Productions, Inc.
Notes
Core Concept: Damages under the ADA
ADA Remedial Provision—ADA §107(a); 42 U.S.C.
§12117(a)
Core Concept: Damages under the ADEA
ADEA Remedial Provisions—ADEA §7; 29 U.S.C. §626
FLSA Remedies Provision—29 U.S.C. §216—Applicable
to ADEA Remedies
Core Concept: Damages under Section 1981
Core Concept: Recovery of Attorney's Fees
Beyond the Basics: Affirmative Action as a Remedy
Beyond the Basics: Job Offers as a Remedy
Beyond the Basics: Damages and Civil Procedure
Pleadings
Discovery
The Trial
Jury Instructions Example on Damages

Chapter 12 • Capstone Experience

Index

15
Table of Principal Cases

Adair v. City of Muskogee, 823 F.3d 1297 (10th Cir. 2016), 414
Albemarle Paper Co. v. Moody, 422 U.S. 405 (1975), 659
Ansonia Board of Education v. Philbrook, 479 U.S. 60 (1986), 365
Back v. Hastings on Hudson Union Free School District, 365 F.3d 107
(2d Cir. 2004), 500
Billups v. Emerald Coast Utilities Authority, 714 Fed. Appx. 929
(11th Cir. 2017), 427
Burlington Northern & Santa Fe Railway Co. v. White, 548 US. 53
(2006), 312
CBOCS West, Inc. v. Humphries, 553 U.S. 442 (2008), 336
Chalmers v. Tulon Company of Richmond, 101 F.3d 1012 (4th Cir.
1996), 349, 368
Chevron v. Echazabal, 536 U.S. 73 (2002), 442
City of Los Angeles, Dept. of Water & Power v. Manhart, 435 U.S.
702 (1978), 35
Clark County School District v. Breeden, 532 U.S. 268 (2001), 310,
318
Crawford v. Nashville, 555 U.S. 271 (2009), 304
Desert Palace, Inc. v. Costa, 539 U.S. 90 (2003), 100
Dewitt v. Southwestern Bell Telephone Co., 845 F.3d 1299 (10th Cir.
2017), 433
Doe v. C.A.R.S. Protection Plus, Inc., 527 F.3d 358 (3rd Cir. 2008),
493
Donlin v. Philips Lighting North America Corp., 564 F.3d 207 (3rd
Cir. 2009), 663
Dothard v. Rawlinson, 433 U.S. 321 (1977), 142, 194
EEOC v. Abercrombie & Fitch, Inc., 135 S.Ct. 2028 (2015), 350
EEOC v. Catastrophe Management Solutions, 876 F.3d 1273 (11th
Cir. 2017), 539

16
EEOC v. DCP Midstream L.P., 608 F. Supp. 2d 107 (D. Maine 2009),
667
EEOC v. Manville Sales Corp., 27 F.3d 1089 (5th Cir. 1994), 613
Espinoza v. Farah Manufacturing Co., 414 U.S. 86 (1973), 29
Etsitty v. Utah Transit Authority, 502 F.3d 1215 (10th Cir. 2007), 523
Faragher v. City of Boca Raton, 524 U.S. 775 (1998), 270
Federal Express Corp. v. Holowecki, 552 U.S. 389 (2008), 589
General Dynamics Land Systems, Inc. v. Cline, 540 U.S. 581 (2004),
553
Griggs v. Duke Power Co., 401 U.S. 424 (1971), 176
Gross v. FBL Financial Services, Inc., 557 U.S. 167 (2009), 105
Harris v. Forklift Systems, Inc., 510 U.S. 17 (1993), 250
Hazelwood School Dist. v. U.S., 433 U.S. 299 (1977), 127
Hazen Paper Co. v. Biggins, 507 U.S. 604 (1993), 43
Hennagir v. Utah Department of Corrections, 587 F.3d 1255 (10th
Cir. 2009), 418
Hishon v. King & Spalding, 467 U.S. 69 (1984), 52
Hively v. Ivy Tech Community College of Indiana, 853 F.3d 339 (7th
Cir. 2017), 508
Hosanna-Tabor Evangelical Lutheran Church and School v. EEOC,
565 U.S. 171 (2012), 381
Howard v. Wolff Broadcasting Corp., 611 So. 2d 307 (Ala. 1992), 4
International Broth. of Teamsters v. U.S., 431 U.S. 324 (1977), 115
International Union, United Auto., Aerospace and Agr. Implement
Workers of America, UAW v. Johnson Controls, Inc., 499 U.S. 187
(1991), 148
Jespersen v. Harrah's Operating Company, Inc., 444 F.3d 1104 (9th
Cir. 2006), 561
Johnson v. Transportation Agency, 480 U.S. 616 (1987), 469
Lauderdale v. Texas Dept. of Criminal Justice, 512 F.3d 157 (5th Cir.
2007), 292
Lewis v. City of Chicago, 560 U.S. 205 (2010), 603
Macy v. Holder, EEOC Appeal No. 0120120821 (April 20, 2012), 531
Mazzeo v. Color Resolutions International, LLC, 746 F.3d 1264 (11th
Cir. 2014), 407

17
McDonald v. Santa Fe Trail Transportation Co., 427 U.S. 273 (1976),
22
McDonnell Douglas Corp. v. Green, 411 U.S. 792 (1973), 65
McKennon v. Nashville Banner Pub. Co., 513 U.S. 352 (1995), 160
Meritor Savings Bank, FSB v. Vinson, 477 U.S. 57 (1986), 247, 269
O'Connor v. Consolidated Coin Caterers Corp., 517 U.S. 308 (1996),
79
Oncale v. Sundowner Offshore Services, 523 U.S. 75 (1998), 254
Price Waterhouse v. Hopkins, 490 U.S. 228 (1989), 87
Reeves v. Sanderson Plumbing Products, Inc., 530 U.S. 133 (2000),
72
Ricci v. DeStefano, 557 U.S. 557 (2009), 212
Richardson v. Tricom Pictures & Productions, Inc., 344 F. Supp. 2d
1303 (S.D. Fla. 2004), 679
Rogers v. American Airlines, Inc., 527 F. Supp. 229 (D.C.N.Y. 1981),
537
Saint Francis College v. Al-Khazraji, 481 U.S. 604 (1987), 25
Salas v. Wisconsin Dept. of Corrections, 2006 U.S. Dist. LEXIS
21140 (W.D. Wis. April 17, 2006), 546
Smith v. City of Jackson, Miss., 544 U.S. 228 (2005), 202
Staub v. Proctor Hosp., 562 U.S. 411 (2011), 166
Sutton v. United Air Lines, Inc., 527 U.S. 471 (1999), 398
Swierkiewicz v. Sorema, 534 U.S. 506 (2002), 631
Tademy v. Union Pacific Corporation, 520 F.3d 1149 (10th Cir. 2008),
263
Thompson v. North American Stainless, L.P., 562 U.S. 170 (2011),
333
Trans World Airlines, Inc. v. Hardison, 432 U.S. 63 (1977), 358
U.S. Airways v. Barnett, 535 U.S. 391 (2002), 455
University of Texas Southwestern Medical Center v. Nassar, 570 U.S.
338 (2013), 320
Vance v. Ball State University, 570 U.S. 421 (2013), 280
Wal-Mart Stores, Inc. v. Dukes, 564 U.S. 338 (2011), 228
Wards Cove Packing Co., Inc. v. Atonio, 490 U.S. 642 (1989), 180
Western Air Lines, Inc. v. Criswell, 472 U.S. 400 (1985), 134

18
Young v. United Parcel Service, Inc., 135 S.Ct. 1338 (2015), 479
Zamora v. Elite Logistics, Inc., 478 F.3d 1160 (10th Cir. 2007) (en
banc), 570

19
Series Editor's Preface

Welcome to a new type of casebook. Designed by leading experts in

law school teaching and learning, Context and Practice casebooks assist
law professors and their students to work together to learn, minimize
stress, and prepare for the rigors and joys of practicing law. Student
learning and preparation for law practice are the guiding ethics of
these books.
Why would we depart from the tried and true? Why have we
abandoned the legal education model by which we were trained?
Because legal education can and must improve.
In Spring 2007, the Carnegie Foundation published Educating
Lawyers: Preparation for the Practice of Law and the Clinical Legal
Education Association published Best Practices for Legal Education.
Both works reflect in-depth efforts to assess the effectiveness of modern
legal education, and both conclude that legal education, as presently
practiced, falls quite short of what it can and should be. Both works
criticize law professors' rigid adherence to a single teaching technique,
the inadequacies of law school assessment mechanisms, and the dearth
of law school instruction aimed at teaching law practice skills and
inculcating professional values. Finally, the authors of both books
express concern that legal education may be harming law students.
Recent studies show that law students, in comparison to all other
graduate students, have the highest levels of depression, anxiety and
substance abuse.
The problems with traditional law school instruction begin with
the textbooks law teachers use. Law professors cannot implement
Educating Lawyers and Best Practices using texts designed for the
traditional model of legal education. Moreover, even though our
understanding of how people learn has grown exponentially in the past
100 years, no law school text to date even purports to have been
designed with educational research in mind.
The Context and Practice Series is an effort to offer a genuine
alternative. Grounded in learning theory and instructional design and

20
written with Educating Lawyers and Best Practices in mind, Context
and Practice casebooks make it easy for law professors to change.
I welcome reactions, criticisms, and suggestions; my e-mail address is
mschwartz@pacific.edu. Knowing the author(s) of these books, I know
they, too, would appreciate your input; we share a common commitment
to student learning. In fact, students, if your professor cares enough
about your learning to have adopted this book, I bet s/he would welcome
your input, too!

Michael Hunter Schwartz, Series Designer and Editor

Consultant, Institute for Law Teaching and Learning
Dean and Professor of Law, University of the Pacific,
McGeorge School of Law

21
Preface and Acknowledgments

The Context and Practice Series

This book is part of the Context and Practice (“CAP”) series, the
mission of which is to support law professors' goals of becoming more
effective teachers and law students' goals of becoming more effective at
learning. An essential aspect of this mission is to engage students in
active learning, challenging students to integrate doctrine, theory, and
skills. The book uses the contextual learning emphasis of the Carnegie
Foundation's EDUCATING LAWYERS (2007) and the Clinical Legal
Education Association's BEST PRACTICES IN LEGAL EDUCATION
(2007).

Goals of This Casebook

This book combines traditional methodologies with an active learning
approach. The traditional model of legal education centers on learning to
think like a lawyer. The model tends to focus on a narrow skill set,
having students derive rules of law and learn about legal reasoning by
reading appellate court decisions. It is an effective approach—as far as it
goes. Legal reading and analysis skills are essential to the competent
lawyer, and this book, like other casebooks, challenges students to
become experts at both.
At the same time, the book recognizes that students will be better
prepared for professional life if they leave law school with a larger skill
set, an ability to conceptualize legal theory, a sensitivity to the contexts
in which legal rules operate and a concrete understanding of the lawyer's
role as a professional problem solver. The casebook has been designed
to give students the tools they need to understand the law and the cases,
providing background reading on the history, theory, policy, and
practical considerations that may impact the law's development and the
outcome of particular cases. This background reading is important to
help students place the cases and statutory language in their broader
context. This text also reminds students that statutory interpretation is an

22
important legal reasoning device and provides them with the tools to
undertake such statutory interpretation.
The book's exercises go beyond the realm of traditional legal
reasoning, providing opportunities to see how lawyers might use
concepts in practice. The book asks students to view legal problems
through different lenses, from the perspective of a plaintiff's lawyer, a
judge, an in-house counsel, a defense attorney, a victim of
discrimination, a person accused of discrimination, a human resources
professional, and an employer. It tries to help students gain an
understanding of what each of these individuals might consider in
resolving a legal problem.
In creating the exercises for this text, special consideration was given
to the skill set that a new employment discrimination attorney should
possess. The authors of the book, in consultation with practitioners and
professors, developed a list of skills critical to attorneys within the
employment discrimination field. The following is a list highlighting
those skills and identifying the exercises within the book designed to
develop them:

Initial Case Evaluation—Exercises 1.1, 2.4, 3.5, 5.3, 5.6, 5.9,

Capstone Exercises 1 & 2
Client counseling—Exercises 1.1, 1.3, 2.3, 5.8, 5.9, 5.10, 6.2, 7.4,
Capstone Exercises 1 & 2
Forum choice—Exercise 10.3, Capstone Exercise 1
Drafting a complaint or answer—Exercises 3.8, 3.9
Discovery and evidence development—Exercises 3.9, 3.12, 5.7,
Capstone Exercise 3
Recognizing problems with statistical evidence—Exercises 4.2,
4.3
Summary judgment—Capstone Exercise 4
Mediation/determining value of claim—Exercises 11.1, 11.2,
11.3, 11.4
Predicting the likely outcome of cases—Exercises 3.3, 3.4, 3.5,
3.6, 4.5, 5.9, 5.10, 6.1
Jury instructions—Exercises 10.1, 10.4
Drafting and evaluating policies—Exercises 1.3, 2.3, 4.4, 5.11,
9.4
Resolution of employee complaints, employee requests, and
client questions—Exercises 1.3, 2.2, 5.8, 5.11, 7.3, 7.4, 8.5, 8.6,

23
 8.10, Capstone Exercise 5
Engagement in the ADA accommodation interactive process—
Capstone Exercise 5
Providing training—Exercises 5.1, 5.12, 6.3
Statutory Construction—Exercise 3.1
Ethics—Exercise 1.1 (Rule 11, lawyer as advisor), Exercise 2.3
(lawyer as advisor), Exercise 3.9 (Rule 11), Exercise 3.11, Capstone
Exercises 1 & 2 (lawyer as advisor, speaking with represented
parties, lawyer as a witness).

The exercises' fact patterns involve both litigation and transactional

contexts to help students understand the multi-faceted roles of
employment discrimination attorneys. When a particular exercise
requires knowledge of another substantive or procedural area, the
exercise provides appropriate information and direction to allow the
student to practice the required skills.
Certain exercises also try to help students think about how best to
learn the law. These exercises ask students to think about how they can
organize material so that it is useful to them, both as students and in
practice. These exercises also challenge students to synthesize material
and to conceptualize it in different ways than the way the material was
originally presented. The following exercises are explicitly designed to
engage students in this way: Exercises 1.2, 3.2, 3.15, 4.6, 6.4, 8.13, 11.4,
and 11.5.
Perhaps most importantly, this book also tries to help students
understand how the policy and theory underlying discrimination law
affect the doctrine. The book contains numerous problems challenging
students to question the underlying theory of American employment
discrimination law and to consider how the law might work differently if
it were based on a different set of theoretical assumptions.
The following theoretical and policy discussions are included in
Exercises:

Whether the employment discrimination statutes should

promote race-neutral decisionmaking—Exercise 2.1
Formal v. substantive equality—Exercise 3.1
Intersectionality—Exercise 3.7
Whether intent should be required to prove discrimination—
Exercise 3.13

24
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