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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

combine "to form ingenious conceptions, elaborate resolutions, vast projects which, alas, are never likely to last through the day"; depressing thoughts disappear and life assumes a smiling aspect.

This euphoria is identical with that which is produced by opium and of which Thomas De Quincey has given such an enthusiastic description:

"O just, subtle, and all-conquering opium! that, to the hearts of rich and poor alike, for the wounds that will never heal, and for the pangs of grief that 'tempt the spirit to rebel,' brings an assuaging balm; eloquent opium! that with thy potent rhetoric stealest away the purposes of wrath, pleadest effectually for relenting pity, and through one night's heavenly sleep callest back to the guilty man the visions of his infancy, and hands washed pure from blood; -O just and righteous opium! that to the chancery of dreams summonest, for the triumphs of despairing innocence, false witnesses, and confoundest perjury, and dost reverse the sentences of unrighteous judges; thou buildest upon the bosom of darkness, out of the fantastic imagery of the brain, cities and temples, beyond the art of Phidias and Praxiteles, beyond the splendours of Babylon and Hekatómpylos; and, from the anarchy of dreaming sleep,' callest into sunny light the faces of long-buried beauties, and the blessed household countenances, cleansed from the 'dishonours of the grave.' Thou only givest these gifts to man; and thou hast the keys of Paradise, O just, subtle, and mighty opium!"

Second period: hesitation. Many subjects, conscious of their danger, make efforts to escape from it. They diminish the doses, reduce the number of injections, etc. Some even completely discontinue the use of the drug permanently or temporarily.

The period of hesitation is not constantly present; many patients by reason of their ignorance or lack of determination pass directly from the first period to the third.

Third period: morphinomania proper. The poison

has now impressed its stamp upon the organism and has established certain permanent symptoms. Moreover, its suppression gives rise to a series of characteristic phenomena, the symptoms of abstinence.

(A) Permanent symptoms. — (a) Psychic phenomena. These consist in a general weakening of psychic activity, and are manifested in the intellectual sphere by sluggishness of association and impairment of attention contrasting with intact orientation and perfect lucidity, and by retrograde amnesia of reproduction; representations are in some way inhibited but not destroyed.

In the emotional sphere there are indifference and atrophy of the moral sense. All the aspirations of the patient reduce themselves to a single idea, that of procuring morphine by any possible means; disregard for conventionalities, swindling, falsehoods, violence, all seem to him permissible. Many morphinomaniacs obtain their morphine from the druggist on false prescriptions, others sell their household articles to purchase morphine for the money.

In the sphere of the reactions there is always very marked aboulia. The patient is conscious of the ruinous results of his inactivity, but has not the power to overcome it. This symptom appears early and together with the indifference forms a characteristic feature of the mental state in morphinomania.

(b) Physical symptoms. — The general nutrition always suffers: loss of flesh, pallor of the skin, etc.

The circulatory apparatus shows general atony. The cardiac impulse is weak; the peripheral circulation is sluggish; there are transient oedemas.

The temperature is often subnormal. A case of morphine fever has, however, been reported (Levinstein).

Motility: general muscular asthenia; a tendency to fatigue; tremors: "slow, regular oscillations resulting from a twisting movement of the limb upon itself." 1 Sensibility: slight hyperesthesia which is at times unilateral; diminution of the acuteness of vision, often dependent upon "pallor of the optic disc, which may advance to atrophy."

The pupils are frequently myotic.

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The tendon reflexes are occasionally diminished. (B) Symptoms of abstinence. When the hour for his injection has passed the morphinomaniac becomes restless, his expression becomes anxious, and his respirations accelerated. A state of anxiety soon appears, accompanied by a very marked inhibition of all the psychic functions. The patient abandons his unfinished work or conversation and leaves, complaining that he is unable to bear the tortures of which he is a victim. At the same time there is the appearance of the pathognomonic somatic symptoms: extreme pallor of the face, acceleration and weakening of the pulse, general prostration, cold sweats, and spells of yawning. If abstinence continues the condition may become alarming: obstinate diarrhoea appears and collapse is threatened.

No matter how grave the symptoms become an injection of morphine always affords instantaneous relief.

Occasionally the mental symptoms present all the features of a veritable acute psychosis: agitation, anxiety, persecutory ideas, psycho-sensory disorders,

1 Jouet. Quoted by Chambard, loc. cit.

2 Pichon. Le morphinisme, 1890.

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