excitement simulating that of mania; these may be associated with hysteriform or epileptiform attacks.

Fourth period: cachexia. The symptoms of the preceding period become more marked. The psychic disaggregation in some cases resembles true dementia. The craving for the drug is greater than ever. Loss of flesh reduces the patient almost to a skeleton; the stomach rejects all food and a permanent and intractable diarrhoea sets in; the blood pressure becomes low, the cardiac impulse grows weaker and weaker, the pulse becomes small, thready, and irregular; renal changes, which are frequent, give rise to albuminuria.

Numerous complications are apt to appear, rendering the prognosis still more serious: pulmonary tuberculosis, furunculosis, phlegmons hasten the fatal termination, which occurs at the end of the fourth period.

Associated intoxications. The intoxicants, the abuse of which is often associated with morphine, are chiefly ether and cocaine. Cocainomania will be made the subject of a special section. Ether, absorbed from the respiratory tract or from the digestive passages, brings about a state of euphoria analogous to that produced by morphine. In certain cases there is a period of excitement which may reach the intensity of delirium and which is followed by comatose sleep.

Treatment. Its aim is discontinuance of the morphine. This may be attained by three methods: the sudden method (Levinstein), the rapid method (Erlenmeyer), and the gradual method (the so-called French method).

The suppression of morphine or demorphinization cannot be carried out outside of a sanitarium for the following two reasons: (1) because the patient should be, in case of threatened collapse, within immediate reach of medical aid; (2) because only strict supervision can prevent the patient from procuring the drug clandestinely.

The method of choice is rapid suppression. "It is a fact, recognized to-day by all physicians experienced in the treatment of morphinomania, that rapid suppression is the best method of treatment." 1 The period of demorphinization lasts from five to twelve days. The principle consists in diminishing the dose each day by one half of that administered on the preceding day, and finally, on reaching a minute ration, completely suppressing the drug. It is in the latter days of the suppression that the symptoms of abstinence appear with the greatest intensity. Patients who descend without much difficulty from one gram or more to several centigrams experience grave disturbances when they are deprived of this minute allowance.

Adjuvant therapy. The diet should be tonic and reconstructive. In the cases of marked cachexia it is advisable to improve the state of the general nutrition before complete demorphinization.2

The digestive tract and the heart demand special attention.

Gastro-intestinal disorders may be prevented by the

1 Sollier.

July 6, 1898.

La démorphinization. Presse médicale, April 23 and

2 Joffroy. Traitement de la morphinomanie. Gaz. hebd. de Méd. et de Chirurgie, 1899 and 1900.

use of bicarbonate of soda (2-6 grams daily), and cardiac failure by heart stimulants, such as caffein, strophanthus, and, if necessary, digitalis.

A morphinomaniac cannot be considered recovered until a long time has elapsed after the suppression of the drug. The return to ordinary life is for him a critical moment; for this reason isolation in a sanitarium should be continued for several weeks after the last injection.

This prolonged detention is further justifiable by the grave complications, notably fatal epileptiform attacks, which may occur long after complete demorphinization.

In spite of all these precautions permanent cures are the exception and relapses are the rule.

§ 2. COCAINOMANIA.

It seems that cocainomania first appeared in 1878, when Bentley made the fatal suggestion of treating morphinomania by means of injections of cocaine.

Like morphine, cocaine produces immediately after its absorption a peculiar state of euphoria characterized chiefly by a sense of vigor and energy. The craving becomes established after the first few injections, much sooner than in the case of morphine.

I shall describe successively the habitual mental state of the cocainomaniac and cocaine delirium.

Habitual state. - Normal activity is replaced by indolence, and affectivity by indifference. All the faculties are dulled. The memory is paralyzed, there being both anterograde amnesia by default of fixation and retrograde amnesia by default of reproduction.

The mood is usually sad, gloomy, and pessimistic, the will power is nil.

This state of general enfeeblement is interrupted by sudden outbreaks of gaiety and feverish activity, which disappear very soon, leaving behind them an intensified psychasthenia.

The sensory organs are the seat of hyperesthesia, so that even slight excitation produces pain. At intervals hallucinations appear, which constitute the germ of the delirium proper. Conscious in the beginning, the hallucinations are later accepted by the subject as real sensations.

The general nutrition is poor. The skin assumes an earthy color; the weight is reduced; the process of digestion is sluggish and painful; and there is diarrhaa alternating with constipation.

Cocaine delirium.—It is a delirium of a painful character associated with delusional interpretations; its main features consist in psycho-sensory disorders which, in spite of their extraordinary distinctness, are coexistent with perfect lucidity. The illusions and hallucinations may affect all the senses, but especially vision, touch, and the muscular sense.

1

Objects change their shapes and are constantly moving. A patient of Saury's felt himself assailed by a swarm of bees which he could see and feel. Many cocainomaniacs feel worms creeping over their bodies or coming out of their flesh; they see them, seize them with their fingers, and crush them under their feet. Many also perceive imaginary movements: the ground

1 Saury. Cocaïnomanie. Ann. méd. psych., 1889.

shakes beneath them, their bed is upset, or the house they are in, swept by a flood, floats upon the waves. Hallucinations of hearing, taste, and smell, though not rare, occur less frequently than the preceding and present no special characteristics.

Sometimes the delusions assume the form of morbid jealousy, as in alcoholic insanity.

The reactions of the patient are governed by the delusions and are often violent.

The duration of the attack is brief, several weeks at the longest, and in some cases but a few days. I have seen a typical case of cocaine delirium terminate in forty-eight hours.

The treatment consists in suppression of the poison, which can in the great majority of cases be accomplished by the sudden method without serious inconvenience.