According to Chambard four periods may be distinguished in the career of a morphine addict, which follow one another by imperceptible transitions.

First Period: Initiation Or Euphoria

It has been aptly called the honeymoon of the morphine addict. Under the influence of the morphine physical pains, if they exist, disappear or become abated, organic functions become active, and the mind lapses into a pleasant reverie; ideas arise without 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 re'enting 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 Hekatompylos; 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 patients, 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: Established Addiction

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

These consist in general reduction 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, bribery, swindling, falsehoods, violence, all seem to him permissible. Many morphine addicts obtain their drug from the druggist on false prescriptions, others sell their household articles to purchase morphine.

In the sphere of the reactions there is generally 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 morphine and other drug addictions.

Drug addicts, like criminals, make much use in conversation of a special variety of slang, like the expressions in the following vocabulary.

Toy, a small jar of opium sold for smoking, constituting a sort of standard of measure in the illicit opium traffic.

Blowing, snuffing heroin.

Jabbing, using heroin, morphine, or cocaine by hypodermic injection.

Deck or Package, a portion containing one or two doses sold for snuffing.

Quill, a piece of paper curled to be used in snuffing.

An eighth, one drachm (an eighth of an ounce).

A quarter-eighth, half an eighth, two eighths, etc., derived from the expression an eighth.

Snow, cocaine.

Snow-bird, cocaine user, a more or less derisive term used by other drug addicts.

(C) Physical

The general nutrition suffers: loss of flesh, pallor of the skin, etc.

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

The temperature is often subnormal.

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." 2

The pupils are frequently myotic.

The tendon reflexes are occasionally diminished.

In cases in which the drug is taken by hypodermic injection there are at the sites of injection characteristic puncture points, spots of pigmentation, indurations, and scars which constitute great aids in diagnosis in cases in which a trustworthy history is not to be had.

(B) Symptoms Of Abstinence

When the hour for his injection has passed the drug addict becomes restless, his expression anxious, respirations accelerated. A state of anxiety soon appears, accompanied by marked inhibition of all 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 appear pathognomonic somatic symptoms: pallor of the face, acceleration and weakening of the pulse, general prostration, cold sweats, sleeplessness, abdominal cramps, vomiting and spells of yawning. If abstinence continues the condition may become alarming: obstinate diarrhoea appears and collapse is threatened.

1 Jouet. Quoted by Chambard, loc. cit.

2 Pichon. Le morphinisme, 1890.

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, 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. Craving for the drug is greater than ever. Loss of flesh reduces the patient almost to a skeleton; the stomach rejects all food and intractable diarrhoea sets in; blood pressure becomes low, the cardiac impulse grows weak, 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.

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 demorphimzation cannot be carried out outside of an institution for the following reasons: (1) because the patient should be, in case of threatened collapse, within immediate reach of medical aid; (2) because only strict control 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 drug addiction, that rapid suppression is the best method of treatment." 1 The period of demorphini-zation 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 1 gram or more to several centigrams experience grave disturbances when they are deprived of this minute allowance.