Etiology. All factors capable of bringing about rapid and profound exhaustion of the organism occur in the etiology of primary mental confusion: physical and mental stress, painful and prolonged emotions, but especially grave somatic affections. The puerperal state, through the exhaustion which it entails as well as through the nutritive disorders and infections by which it is sometimes complicated; the infectious diseases (typhoid fever, the eruptive fevers, influenza, cholera); profuse hemorrhages; inanition, etc., are among the causes frequently found in the history of the disease.

How is the action of these factors to be explained? Two hypotheses are possible.

According to one, that of Binswanger, the general exhaustion of the organism brings about deficient cerebral nutrition the clinical expression of which is primary mental confusion.

According to the other, advanced by Kraepelin, the causes enumerated above bring about disturbances in the nutritive changes and determine the production of toxic substances which, acting upon the cerebral cells, give rise to an intoxication psychosis: primary mental confusion.

Perhaps both causes are at work simultaneously. In either case exhaustion constitutes the essential cause of the affection and the term "Exhaustion Psychosis" is therefore perfectly applicable to it..

Treatment. During the entire acute period of the disease rest in bed should be rigorously enforced.

les lésions cellulaires corticales observées dans six cas de troubles mentaux toxi-infectieux. Rev. neurol., Dec. 1899.

Proper alimentation is of great importance. A reconstructive diet better than all medication sustains the patient's strength and even calms the agitation. Milk, eggs, chopped meat, and meat-juice should form the basis of the diet.

In cases of sitiophobia one must resort without hesitation to artificial feeding; these patients cannot with impunity be allowed to fast. Gastric lavage sometimes gives good results, even in cases of acute delirium.

Injections of artificial serum are of great service and easy of application. The necessary apparatus consists chiefly of a glass funnel, a soft-rubber tube, and a slender trochar.

Ordinarily 300-500 grams of Hayem's serum [or of normal saline solution] may be injected every day or every second day.

The most important results of this treatment are elevation of the blood pressure and diuresis.1

Moderate physical exercise, life in the open air, reading, and light mental work for brief periods at a time accelerate the course of convalescence.

1 Cullerre. De la transfusion séreuse sous-cutanée dans les psychoses aiguës avec auto-intoxication. Prog. méd., Sept. 30, 1899. Jacquin. Du sérum artificiel en Psychiatrie. Ann. méd. psych., May-June, 1900.

CHAPTER XVII.

MISCELLANEOUS GROUPS (Continued).

.CHRONIC INTOXICATION BY THE ALKALOIDS.

§ 1. MORPHINOMANIA.

CHRONIC intoxication by morphine brings about a condition known as morphinism. Morphinism constitutes morphinomania when the drug has become a necessity to the organism, so that its suppression causes a train of physical and psychical disturbances known as the symptoms of abstinence.

Etiology. The study of the etiology of morphinomania involves the consideration of two distinct questions: (1) What individuals are apt to become morphinomaniacs? (2) How does one become a morphinomaniac?

(1) What individuals are apt to become morphinomaniacs?

Morphine is no longer, as it was formerly, an aristocratic poison limited to the upper classes. "Even rural populations are no longer exempt from the contagion; and the fault is chiefly with the physicians.” 1

Morphinomania is especially frequent among those who, on account of their profession or surroundings,

1 Chambard. Les morphinomanes. Charcot-Debove.

Bibliothèque médicale

can readily procure the poison; such are physicians, their wives, medical students, pharmacists, nurses, and laboratory attendants.

As in the case of alcoholism, the character of the soil is here also an important factor. The less energetic and mentally stable the individual is the more likely he is to yield to the seductive influence of the poison. Thus we find that morphinomaniacs are often degenerates.

(2) How does one become a morphinomaniac?-In many ways, but chiefly:

(a) Through medication: many subjects receive their first injection for the relief of some painful affection as hepatic colic, neuralgia, or tabes.

(b) Through curiosity: this occurs especially among degenerates, idlers, individuals who are tired of all ordinary pleasures and are longing for new sensations, and whose unfortunate tendency is still farther stimulated by the example and proselytism of old morphinomaniacs.

(c) Through the craving for a sedative or for relief from mental suffering:, this occurs in the overworked (soldiers in time of war or young people during difficult examinations) and in those who are driven by some misfortune or ill-luck to seek in morphine a consolation for their sorrows and disappointments.

Doses. The action of the poison becoming less effective in time, the doses necessarily increase more or less rapidly. The maximum dose taken daily by different patients varies greatly. One morphinomaniac, reported by Pichon, was in the habit of taking nine grams daily. Most patients limit themselves to smaller doses. Of the one hundred and twenty subjects com

prised in the statistics of Pichon eighty-four took from 0.40 to 1.20 grams daily.

The methods of morphinomaniacs. -The places usually selected for the injections are the arms, forearms, thighs, or legs; the next in frequency are the abdomen and the chest. Very frequently these regions are covered with scars from abscesses caused by septic injections. These scars constitute, so to speak, the stigma of morphinomania and often enable the physician to establish the diagnosis in spite of denials on the part of the patient

Many morphinomaniacs take their injections without regularity or precaution and at any opportunity; others, in true epicurean fashion, select the moment and conditions when they can enjoy most profoundly their favorite pleasure. Some, again, have their hours regularly fixed, use only accurately prepared solutions of a certain strength, and take all antiseptic precautions; many take their daily quantity in divided doses; others take a single large dose daily in order to obtain the most intense effect.

SYMPTOMS AND EVOLUTION.

It has been aptly

According to Chambard four periods may be distinguished in the career of a morphinomaniac, which succeed each other by imperceptible transitions. First period: initiation or euphoria. called the honeymoon of the morphinomaniac. Under the influence of the morphine physical pains, if they exist, disappear or become abated, the organic functions become more active, and the mind lapses into a pleasant reverie; ideas form themselves without any effort and