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Advances in Intelligent Systems and Computing 721

Álvaro Rocha
Teresa Guarda Editors

Proceedings of the
International Conference
on Information
Technology & Systems
(ICITS 2018)
Advances in Intelligent Systems and Computing

Volume 721

Series editor
Janusz Kacprzyk, Polish Academy of Sciences, Warsaw, Poland
e-mail: kacprzyk@ibspan.waw.pl
About this Series
The series “Advances in Intelligent Systems and Computing” contains publications on theory,
applications, and design methods of Intelligent Systems and Intelligent Computing. Virtually
all disciplines such as engineering, natural sciences, computer and information science, ICT,
economics, business, e-commerce, environment, healthcare, life science are covered. The list
of topics spans all the areas of modern intelligent systems and computing.
The publications within “Advances in Intelligent Systems and Computing” are primarily
textbooks and proceedings of important conferences, symposia and congresses. They cover
significant recent developments in the field, both of a foundational and applicable character.
An important characteristic feature of the series is the short publication time and world-wide
distribution. This permits a rapid and broad dissemination of research results.
Advisory Board
Chairman
Nikhil R. Pal, Indian Statistical Institute, Kolkata, India
e-mail: nikhil@isical.ac.in
Members
Rafael Bello Perez, Universidad Central “Marta Abreu” de Las Villas, Santa Clara, Cuba
e-mail: rbellop@uclv.edu.cu
Emilio S. Corchado, University of Salamanca, Salamanca, Spain
e-mail: escorchado@usal.es
Hani Hagras, University of Essex, Colchester, UK
e-mail: hani@essex.ac.uk
László T. Kóczy, Széchenyi István University, Győr, Hungary
e-mail: koczy@sze.hu
Vladik Kreinovich, University of Texas at El Paso, El Paso, USA
e-mail: vladik@utep.edu
Chin-Teng Lin, National Chiao Tung University, Hsinchu, Taiwan
e-mail: ctlin@mail.nctu.edu.tw
Jie Lu, University of Technology, Sydney, Australia
e-mail: Jie.Lu@uts.edu.au
Patricia Melin, Tijuana Institute of Technology, Tijuana, Mexico
e-mail: epmelin@hafsamx.org
Nadia Nedjah, State University of Rio de Janeiro, Rio de Janeiro, Brazil
e-mail: nadia@eng.uerj.br
Ngoc Thanh Nguyen, Wroclaw University of Technology, Wroclaw, Poland
e-mail: Ngoc-Thanh.Nguyen@pwr.edu.pl
Jun Wang, The Chinese University of Hong Kong, Shatin, Hong Kong
e-mail: jwang@mae.cuhk.edu.hk

More information about this series at http://www.springer.com/series/11156

Álvaro Rocha Teresa Guarda
•

Editors

Proceedings of the
International Conference
on Information
Technology & Systems
(ICITS 2018)

123
Editors
Álvaro Rocha Teresa Guarda
DEI/FCT Systems Department
Universidade de Coimbra Universidad Estatal Península de Santa
Coimbra Elena
Portugal La Libertad
Ecuador

ISSN 2194-5357 ISSN 2194-5365 (electronic)

Advances in Intelligent Systems and Computing
ISBN 978-3-319-73449-1 ISBN 978-3-319-73450-7 (eBook)
https://doi.org/10.1007/978-3-319-73450-7
Library of Congress Control Number: 2017963760

© Springer International Publishing AG 2018

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part
of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations,
recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission
or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar
methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are exempt from
the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this
book are believed to be true and accurate at the date of publication. Neither the publisher nor the
authors or the editors give a warranty, express or implied, with respect to the material contained herein or
for any errors or omissions that may have been made. The publisher remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.

Printed on acid-free paper

This Springer imprint is published by Springer Nature

The registered company is Springer International Publishing AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Preface

This book contains a selection of papers accepted for presentation and discussion at
the 2018 International Conference on Information Technology & Systems
(ICITS’18). This conference had the support of the State University of Península de
Santa Elena, IEEE Systems, Man, and Cybernetics Society, and AISTI (Iberian
Association for Information Systems and Technologies). It took place at Libertad,
Península de Santa Elena, Ecuador, January 11–13, 2017.
The 2018 International Conference on Information Technology & Systems
(ICITS’18) is an international forum for researchers and practitioners to present and
discuss the most recent innovations, trends, results, experiences, and concerns in the
several perspectives of Information Technology & Systems.
The Program Committee of ICITS’18 was composed of a multidisciplinary
group of 110 experts and those who are intimately concerned with Information
Systems and Technologies. They have had the responsibility for evaluating, in a
“double-blind review” process, the papers received for each of the main themes
proposed for the conference: (A) Information and Knowledge Management;
(B) Organizational Models and Information Systems; (C) Software and Systems
Modeling; (D) Software Systems, Architectures, Applications, and Tools;
(E) Multimedia Systems and Applications; (F) Computer Networks, Mobility, and
Pervasive Systems; (G) Intelligent and Decision Support Systems; (H) Big Data
Analytics and Applications; (I) Human–Computer Interaction; (J) Ethics,
Computers & Security; (K) Health Informatics; (L) Information Technologies in
Education.
ICITS’18 also included several workshop sessions taking place in parallel with
the conference ones. They were sessions of the WMETACOM 2018—1st
Workshop on Media, Applied Technology and Communication.
ICITS’18 received about 200 contributions from 31 countries around the world.
The papers accepted for presentation and discussion at the conference are published
by Springer (this book) and by AISTI and will be submitted for indexing by ISI,
EI-Compendex, SCOPUS, DBLP, and/or Google Scholar, among others.

v
vi Preface

We acknowledge all of those that contributed to the staging of ICITS’18 (au-

thors, committees, workshop organizers, and sponsors). We deeply appreciate their
involvement and support that was crucial for the success of ICITS’18.

January 2017 Álvaro Rocha

Teresa Guarda
Organization

Conference

Organizing Committee

Datzania Villao State University of Santa Elena Peninsula, Ecuador

Shendry Rosero Vasquez State University of Santa Elena Peninsula, Ecuador
Teresa Guarda State University of Santa Elena Peninsula, Ecuador

Scientific Committee

Álvaro Rocha (Chair) University of Coimbra, Portugal

Abderrazak Sebaa Bejaia University, Algeria
Adefemi Falase Ajayi Crowther University, Nigeria
Abdulmotaleb El Saddik University of Ottawa, Canada
Alexandru Vulpe University Politehnica of Bucharest, Romania
Amal Al Ali University of Sharjah, United Arab Emirates
André da Silva IFSP and NIED/UNICAMP, Brazil
André Marcos Silva University Adventist of São Paulo, Brazil
Andrés Melgar Pontificia Universidad Católica del Perú, Peru
Angeles Quezada Universidad Autonoma de Baja California, Mexico
Ania Cravero University de La Frontera, Chile
Antonio Jara HES-SO, Switzerland
Antonio Osorio University of Minho, Portugal
Arnulfo Alanis Garza Tijuana Institute of Technology, Mexico
Anushia Inthiran University of Canterbury, New Zealand
Azeddine Chikh University of Tlemcen, Algeria
Borja Bordel Universidad Politécnica de Madrid, Spain
Carlos Carreto Polytechnic of Guarda, Portugal
Carlos Grilo Polytechnic of Leiria, Portugal
Dalila Durães Technical University of Madrid, Spain

vii
viii Organization

Dália Filipa Liberato ESHT/IPP, Portugal

Daniela Benalcázar Universidad Técnica de Ambato, Ecuador
Dante Carrizo Universidad de Atacama, Chile
Diego Marcillo Universidad de las Fuerzas Armadas ESPE, Ecuador
Diego Ordóñez-Camacho Universidad Tecnológica Equinoccial, Ecuador
Eddie Galarza Universidad de las Fuerzas Armadas, Ecuador
Edison Loza-Aguirre Escuela Politécnica Nacional, Ecuador
Eduardo Albuquerque Federal University of Goiás, Brazil
Efraín R. Fonseca C. Universidad de las Fuerzas Armadas ESPE, Ecuador
Egils Ginters Riga Technical University, Latvia
Enrique Carrera Universidad de las Fuerzas Armadas ESPE, Ecuador
Ewaryst Tkacz Silesian University of Technology, Poland
Fabio Gomes Rocha Tiradentes University, Brazil
Felix Blazquez Lozano University of A Coruña, Spain
Filipa Ferraz University of Minho, Portugal
Filipe Sá Câmara Municipal de Penacova, Portugal
Francisco Andrade University of Minho, Portugal
Franklim Silva Universidad de las Fuerzas Armadas, Ecuador
Gabriel Pestana Universidade Europeia, Portugal
George Suciu BEIA, Romania
Gregory O’Hare University College Dublin, Ireland
Hector Florez Universidad Distrital Francisco Jose de Caldas,
Colombia
Henrique Lopes Cardoso University of Porto, Portugal
Ildeberto Rodello University of São Paulo
Isabel Pedrosa Coimbra Business School - ISCAC, Portugal
Ivan Puentes Rivera University of Vigo, Spain
Jan Kubicek Faculty of Electrical Engineering and Computer
Science VŠB-TUO, Czech Republic
João Paulo Pereira Polytechnic of Bragança, Portugal
João Vidal de Carvalho ISCAP/IPP, Portugal
Jonathas Cruz IFPI, Brazil
José Araújo SAP, Portugal
Jose Ignacio Universidade Distrital Francisco Jose Caldas,
Rodrigues Molano Colombia
José Luís Silva ISCTE-IUL and Madeira-ITI, Portugal
Juan Jesus Ojeda University of Almeria, Spain
Juan M. Ferreira Senate, Paraguay
Júlio Menezes Jr. Federal University of Pernambuco, Brazil
Justyna Trojanowska Poznan University of Technology, Poland
Korhan Gunel Adnan Menderes University, Turkey
Laura Varela-Candamio University of A Coruña, Spain
Leandro Flórez Aristizábal Antonio Jose Camacho University Institute,
Colombia
Leonardo Botega UNIVEM, Brazil
Organization ix

Mafalda Teles Roxo INESC TEC, Portugal

Magdalena Diering Poznan University of Technology, Poland
Manuel Monteiro Hospital Particular São Lucas, Portugal
Marcelo Mendonça Federal Rural University of Pernambuco, Brazil
Teixeira
Marcia Bayas Universidad Estatal Peninsula de Santa Elena,
Ecuador
Marciele Berger University of Minho, Portugal
Maria José Sousa University of Coimbra, Portugal
Maria Koziri University of Thessaly, Greece
María Pilar Mareca López Universidad Politécnica de Madrid, Spain
María Teresa University of A Coruna, Spain
García-Álvarez
Maristela Holanda University of Brasilia, Brazil
Martin Kyselak University of Defence, Czech Republic
Michele Della Ventura Music Academy “Studio Musica,” Italy
Miguel Angel Universidad Politécnica de Madrid, Spain
Manso Callejo
Mohamed Abouzeid Innovations for High Performance
Microelectronics IHP, Germany
Monica Leba University of Petrosani, Romania
Nadjet Kamel University Ferhat Abbas Setif 1, Algeria
Nikolai Prokopyev Russian Academy of Sciences, Russia
Nikolaos Giannakeas Technology Educational Institute of Epirus, Greece
Niranjan S K JSS Science and Technology University, Mysore,
India
Nomusa Dlodlo Namibia University of Science and Technology,
Namibia
Pablo Alejandro Quezada Universidad Internacional del Ecuador, Ecuador
Sarmiento
Pedro Fernandes State University of Maringá, Brazil
de Oliveira Gomes
Pedro Liberato ESHT/IPP, Portugal
Pedro Nogueira LIACC, Portugal
Ramayah T. Universiti Sains Malaysia, Malaysia
Ramon Alcarria Universidad Politécnica de Madrid, Spain
Robson Lemos Federal University of Santa Catarina, Brazil
Prabhat Mahanti University of New Brunswick, Canada
Said Achchab Mohammed V University in Rabat, Morocco
Samanta Patricia Universidad Técnica Particular de Loja, Ecuador
Cueva Carrión
Sandra Patricia San Buenaventura Cali University, Colombia
Cano Mazuera
Sampsa Rauti University of Turku, Finland
Santoso Wibowo CQUniversity, Australia
x Organization

Saulo Barbará Oliveira Universidade Federal Rural do Rio de Janeiro, Brazil

Sergio Luján-Mora University of Alicante, Spain
Shuai Zhao MediaTek Inc. USA, USA
Simona Riurean University of Petrosani, Romania
Songjie Wei Nanjing University of Science and Technology,
China
Stanley Lima Technische Universität Dresden, Germany
Sylvie Ratté École de Technologie Supérieure, Canada
Tariq Ahamed Ahanger Prince Sattam Bin Abdulaziz University,
Saudi Arabia
Teresa Guarda State University of Santa Elena Peninsula, Ecuador
Thanasis Loukopoulos University of Thessaly, Greece
Victor Georgiev Russian Academy of Sciences, Russia
Victor Villar Tiradentes University, Brazil
Ville Leppänen University of Turku, Finland
Vladislav Gorbunov Russian Academy of Sciences, Russia
WMETACOM 2018 – 1st Workshop on Media,
Applied Technology and Communication

Organizing Committee

Andrea Mila Maldonado Pontificia Universidad Católica del Ecuador Sede

Ibarra, Ecuador
Francisco Campos Freire Universidade de Santiago de Compostela, Spain
Iván Puentes Rivera Universidade de Vigo, Spain
María Fannery Directora Académica Pontificia Universidad
Suárez Berrío Católica del Ecuador Sede Ibarra, Ecuador
María Josefa Prorrectora Pontificia Universidad Católica del
Rubio Gómez Ecuador Sede Ibarra, Ecuador
Mónica López-Golán METACOM research group from Pontificia
Universidad Católica del Ecuador Sede Ibarra,
Ecuador
Nancy Ulloa Erazo METACOM research group from Pontificia
Universidad Católica del Ecuador Sede Ibarra,
Ecuador
Paulo Carlos López-López METACOM research group from Pontificia
Universidad Católica del Ecuador Sede Ibarra,
Ecuador
Tania Aguilera Bravo Pontificia Universidad Católica del Ecuador Sede
Ibarra, Ecuador
Xosé López García Universidad de Santiago de Compostela, Spain

Scientific Committee

Ana Belén Fernández Universidade de Vigo, Spain

Souto
Andrea Mila Pontificia Universidad Católica del Ecuador Sede
Ibarra, Ecuador
Alba Silva Rodríguez Universidade de Santiago de Compostela, Spain
Carlos Toural Bran Universidade de Santiago de Compostela, Spain

xi
xii WMETACOM 2018

Clide Rodríguez Vázquez Universidade de A Coruña, Spain

Eva Sánchez Amboage Universidade de A Coruña, Spain
Francisco Campos Freire Universidade de Santiago de Compostela, Spain
Félix Blázquez Lozano Universidade de A Coruña, Spain
Iván Puentes Rivera Universidade de Vigo, Spain
Magdalena Universidade de A Coruña, Spain
Rodríguez Fernández
Miguel Túñez López Universidade de Santiago de Compostela, Spain
Mónica López Golán Pontificia Universidad Católica del Ecuador Sede
Ibarra, Ecuador
Nancy Ulloa Erazo Pontificia Universidad Católica del Ecuador Sede
Ibarra, Ecuador
Óscar Juanatey Boga Universidade de A Coruña, Spain
Paulo Carlos López Pontificia Universidad Católica del Ecuador Sede
Ibarra, Ecuador
Tania Aguilera Bravo Pontificia Universidad Católica del Ecuador Sede
Ibarra, Ecuador
Valentín Alejandro Universidade de A Coruña, Spain
Martínez Fernández
Xosé Rúas Araújo Universidade de Vigo, Spain
Xosé López García Universidade de Santiago de Compostela, Spain
Contents

Organizational Models and Information Systems

Rationalization of Organizational Processes: The Case
of the Institute of Applied Social Sciences of
Rio de Janeiro Federal Rural University . . . . . . . . . . . . . . . . . . . . . . . . 3
Elisangela Costa, Saulo Barbará de Oliveira,
and Daniel Ribeiro de Oliveira
Benefits of Process Simulation Software – The Case of a Brazilian
Mixed Public-Private Company . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Ricardo Luiz Schiavo do Nascimento, Saulo Barbará de Oliveira,
and Aparecida Laino Entriel
IT Service Management Using COBIT Enablers: The Case
of Brazilian National Institute of Cancer . . . . . . . . . . . . . . . . . . . . . . . . 20
Sandro Luís Freire de Castro Silva, Saulo Barbará de Oliveira,
Marcos Azevedo Benac, Antônio Augusto Gonçalves,
and Carlos Henrique Fernandes Martins
Towards a Forensic Analysis of Mobile Devices Using Android . . . . . . . 30
Estevan Gomez-Torres, Oswaldo Moscoso-Zea, Nelson Herrera Herrera,
and Sergio Lujan-Mora
Process-Based Project Management for Implementation
of an ERP System at a Brazilian Teaching Institution . . . . . . . . . . . . . . 40
Ada Guagliardi Faria, Saulo Barbará de Oliveira,
and Fábio Carlos Macêdo
A Conceptual Framework for the Implantation of Enterprise
Applications in Small and Medium Enterprises (SMEs) . . . . . . . . . . . . . 50
Irving Reascos and João Alvaro Carvalho
Model for Selecting Software Development Methodology . . . . . . . . . . . . 62
Lizeth Chandi, Catarina Silva, Tatiana Gualotuña, and Danilo Martinez

xiii
xiv Contents

Information and Knowledge Management

Smart Cities Semantics and Data Models . . . . . . . . . . . . . . . . . . . . . . . . 77
Antonio J. Jara, Martin Serrano, Andrea Gómez, David Fernández,
Germán Molina, Yann Bocchi, and Ramon Alcarria
The Information Technologies in the Competitiveness
of the Tourism Sector . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Pedro Liberato, Dália Liberato, António Abreu, Elisa Alén-González,
and Álvaro Rocha
A Fuzzy Classifier-Based Penetration Testing
for Web Applications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
J. K. Alhassan, Sanjay Misra, A. Umar, Rytis Maskeliūnas,
Robertas Damaševičius, and Adewole Adewumi
Comparative Evaluation of Mobile Forensic Tools . . . . . . . . . . . . . . . . . 105
J. K. Alhassan, R. T. Oguntoye, Sanjay Misra, Adewole Adewumi,
Rytis Maskeliūnas, and Robertas Damaševičius
Cloud Based Simple Employee Management Information System:
A Model for African Small and Medium Enterprises . . . . . . . . . . . . . . . 115
Isaac U. Oduh, Sanjay Misra, Robertas Damaševičius,
and Rytis Maskeliūnas
Inexpensive Marketing Tools for SMEs . . . . . . . . . . . . . . . . . . . . . . . . . 129
José Avelino Vitor, Teresa Guarda, Maria Fernanda Augusto,
Marcelo Leon, Datzania Villao, Luis Mazon,
and Yovany Salazar Estrada
Big Data, the Next Step in the Evolution
of Educational Data Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
W. Villegas-Ch, Sergio Luján-Mora, Diego Buenaño-Fernandez,
and X. Palacios-Pacheco
Method for Emotion Corpus Validation from the Consensual
Identification of Patterns in Alzheimer’s Patients . . . . . . . . . . . . . . . . . . 148
Pablo Gómez, Alexandra González-Eras, and Pablo Torres Carrión
Web Prosumers: The Intangible Wealth of Education
and Economics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
Emanuel Bohórquez, Teresa Guarda, Humberto Peña, Marcelo León,
William Caiche, and José Villao
Analysis of Correspondences Applied to Vehicle Plates
Using Descriptors in Visible Spectrum . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Shendry Rosero and Alberto Jimenez
Contents xv

Alignment of Software Project Management with the Business

Strategy in VSEs: Model and Evaluation . . . . . . . . . . . . . . . . . . . . . . . . 178
Carlos Montenegro and Geovani Barragán
Proposal to Implementation Time-Driven Activity Based Costing
(TDABC) for Calculation of Surgical Procedure Costs
of a Medium-Sized Teaching Hospital . . . . . . . . . . . . . . . . . . . . . . . . . . 191
Michele Mendes Hiath Silva and Saulo Barbará de Oliveira
Best Practices and Pitfalls in Open Source Hardware . . . . . . . . . . . . . . 200
Manuel Moritz, Tobias Redlich, and Jens Wulfsberg
Best Practice in Advanced Enterprise Knowledge Engineering . . . . . . . 211
Matteo Sasgratella and Alberto Polzonetti
Production Flow Improvement in a Textile Industry . . . . . . . . . . . . . . . 224
Jose J. Lopes, Maria L. R. Varela, Justyna Trojanowska,
and Jose Machado
Marketing Knowledge Management Model . . . . . . . . . . . . . . . . . . . . . . 234
Teresa Guarda, Maria Fernanda Augusto, Marcelo León,
Hugo Pérez, Washington Torres, Walter Orozco,
and Jacqueline Bacilio
Participative Sensing in Noise Mapping: An Environmental
Management System Model for the Province of Santa Elena . . . . . . . . . 242
Teresa Guarda, Marcelo León, Maria Fernanda Augusto, Hugo Pérez,
Johnny Chavarria, Walter Orozco, and Jaime Orozco
Using Experimental Material Management Tools in Experimental
Replication: A Systematic Mapping Study . . . . . . . . . . . . . . . . . . . . . . . 252
Edison Espinosa, Juan M. Ferreira, and Henry Chanatasig
Unveiling Unbalance on Sustainable Supply Chain Research:
Did We Forget Something? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264
Edison Loza-Aguirre, Marco Segura Morales, Henry N. Roa,
and Carlos Montenegro Armas
Industry Knowledge Management Model 4.0 . . . . . . . . . . . . . . . . . . . . . 275
José Ignacio Rodríguez-Molano, Leonardo Emiro Contreras-Bravo,
and Edwin Rivas-Trujillo
Smartphone-Based Vehicle Emission Estimation . . . . . . . . . . . . . . . . . . 284
M. Cerón, M. Fernández-Carmona, C. Urdiales, and F. Sandoval
An Information Visualization Engine for Situational-Awareness
in Health Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294
Flávio Epifânio and Gabriel Pestana
xvi Contents

ECOPPA: Extensible Context Ontology for Persuasive

Physical-Activity Applications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
Mohamad Hoda, Valeh Montaghami, Hussein Al Osman,
and Abdulmotaleb El Saddik
Creating Predictive Models for Forecasting the Accident Rate
in Mountain Roads Using VANETs . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319
Borja Bordel, Ramón Alcarria, Gianluca Rizzo, and Antonio Jara

Intelligent and Decision Support Systems

Improving Game Modeling for the Quoridor Game State
Using Graph Databases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333
Daniel Sanchez and Hector Florez
A Model of Self-oscillations in Relay Outputs Control Systems
with Elements of Artificial Intelligence . . . . . . . . . . . . . . . . . . . . . . . . . . 343
R. H. Rovira, V. M. Duvoboi, M. S. Yukhimchuk, M. M. Bayas,
and W. D. Torres
Computer Vision-Based Method for Automatic Detection of Crop
Rows in Potato Fields . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355
Iván García-Santillán, Diego Peluffo-Ordoñez, Víctor Caranqui,
Marco Pusdá, Fernando Garrido, and Pedro Granda
A Finger-vein Biometric System Based on Textural Features . . . . . . . . . 367
Enrique V. Carrera, Santiago Izurieta, and Ricardo Carrera
Multi-level Skew Correction Approach for Hand Written
Kannada Documents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376
H. C. Vinod and S. K. Niranjan
Semi-automatic Determination of Geometrical Properties of Short
Natural Fibers in Biocomposites by Digital Image Processing . . . . . . . . 387
Victoria Mera-Moya, Jorge I. Fajardo, Iális C. de Paula Junior,
Leslie Bustamante, Luis J. Cruz, and Thiago Barros
ExperTI: A Knowledge Based System for Intelligent Service Desks
Using Free Text . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397
Alejandro Bello, Andrés Melgar, and Daniel Pizarro
Mapping the Global Offshoring Network Through
the Panama Papers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407
David Dominguez, Odette Pantoja, and Mario González
Comparing Different Data Fusion Strategies for
Cancer Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417
Katarzyna Pojda, Michał Jakubczak, Sebastian Student,
Andrzej Świerniak, and Krzysztof Fujarewicz
Contents xvii

A Recommender System Based on Cognitive Map

for Smart Classrooms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427
Jose Aguilar, Priscila Valdiviezo-Diaz, and Guido Riofrio
Strategy to Develop a Digital Public Health Observatory
Integrating Business Intelligence and Visual Analytics . . . . . . . . . . . . . . 443
Leidy Alexandra Lozano and Maria del Pilar Villamil
Using Machine Learning for Sentiment and Social Influence Analysis
in Text . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 453
Emmanuel Awuni Kolog, Calkin Suero Montero, and Tapani Toivonen

Big Data Analytics and Applications

Big Data Applications in Cancer Research: A Case Study
at the Brazilian National Cancer Institute . . . . . . . . . . . . . . . . . . . . . . . 467
Antônio Augusto Gonçalves, Carlos Henrique Fernandes Martins,
José Geraldo Pereira Barbosa, and Sandro Luís Freire de Castro Silva
New Diagnostic Tool for Patients Suffering from Noncommunicable
Diseases (NCDs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 476
Wojciech Oleksy, Zbigniew Budzianowski, Ewaryst Tkacz,
and Małgorzata Garbacik
Detection of Genetic Aberrations in Cancer Driving Signaling
Pathways Based on Joint Analysis of Heterogeneous
Genomics Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 484
Roman Jaksik and Krzysztof Fujarewicz

Ethics, Computers and Security

Cookie Scout: An Analytic Model for Prevention of Cross-Site
Scripting (XSS) Using a Cookie Classifier . . . . . . . . . . . . . . . . . . . . . . . 497
Germán Eduardo Rodríguez, Diego Eduardo Benavides, Jenny Torres,
Pamela Flores, and Walter Fuertes
An Empirical Evaluation of Open Source in Telecommunications
Software Development: The Good, the Bad, and the Ugly . . . . . . . . . . . 508
Rolando P. Reyes Ch., Efraín R. Fonseca C., John W. Castro,
Hugo Pérez Vaca, and Manolo Paredes Calderón
Wearable Technology, Privacy Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . 518
Pablo Saa, Oswaldo Moscoso-Zea, and Sergio Lujan-Mora

Human-Computer Interaction
Older Adults’ Perception of Online Health Webpages Using Eye
Tracking Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 531
Anushia Inthiran and Robert D. Macredie
xviii Contents

Method for Accessibility Assessment of Online Content Editors . . . . . . . 538

Tania Acosta, Patricia Acosta-Vargas, Luis Salvador-Ullauri,
and Sergio Luján-Mora
An Approach to Mobile Serious Games Accessibility Assessment
for People with Hearing Impairments . . . . . . . . . . . . . . . . . . . . . . . . . . 552
Angel Jaramillo-Alcázar and Sergio Luján-Mora
Real Time Driver Drowsiness Detection Based on Driver’s Face
Image Behavior Using a System of Human Computer Interaction
Implemented in a Smartphone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 563
Eddie E. Galarza, Fabricio D. Egas, Franklin M. Silva, Paola M. Velasco,
and Eddie D. Galarza
Interactive System Using Beaglebone Black with LINUX Debian
for Its Application in Industrial Processes . . . . . . . . . . . . . . . . . . . . . . . 573
Marco Pilatásig, Franklin Silva, Galo Chacón, Víctor Tapia,
John Espinoza, Esteban X. Castellanos, Lucia Guerrero,
and Jessy Espinosa
Interactive System for Monitoring and Control of a Flow Station
Using LabVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 583
Jorge Buele, John Espinoza, Marco Pilatásig, Franklin Silva,
Alexandra Chuquitarco, Jenny Tigse, Jessy Espinosa,
and Lucía Guerrero
Interactive System for Hands and Wrist Rehabilitation . . . . . . . . . . . . . 593
Marco Pilatásig, Jenny Tigse, Alexandra Chuquitarco, Pablo Pilatásig,
Edwin Pruna, Andrés Acurio, Jorge Buele, and Ivón Escobar
Toward a Combined Method for Evaluation of Web Accessibility . . . . . 602
Patricia Acosta-Vargas, Sergio Luján-Mora, Tania Acosta,
and Luis Salvador-Ullauri
Educational Math Game for Stimulation of Children
with Dyscalculia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 614
Pablo Torres-Carrión, Christian Sarmiento-Guerrero,
Juan Carlos Torres-Diaz, and Luis Barba-Guamán
Intelligent Tutoring Based on a Context-Aware Dialogue
in a Procedural Training Environment . . . . . . . . . . . . . . . . . . . . . . . . . 624
José Paladines and Jaime Ramírez
Communities of Language Learners: Mobility, Usability
and Learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 631
Fernanda Maria Pereira Freire, André Constantino da Silva,
and Isaque Miguel Pires
Contents xix

Moving Beyond Limitations: Evaluating the Quality

of Android Apps in Spanish for People with Disability . . . . . . . . . . . . . 640
Andrés Larco, Cesar Yanez, Carlos Montenegro,
and Sergio Luján-Mora

Software Systems, Architectures, Applications and Tools

Analysis and Implementation of ETL System for Unmanned
Aerial Vehicles (UAV) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 653
Wilson Medina-Pazmiño, Aníbal Jara-Olmedo, Cristian Tasiguano-Pozo,
and José M. Lavín
Analysis of the Interaction on the Web Through Social Networks
(Twitter, Facebook, Instagram) Case Study: Economic Sectors
with Higher Incomes in Ecuador . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 663
Mariuxi Tejada-Castro, Maritza Aguirre-Munizaga,
Vanessa Vergara-Lozano, Mayra Garzon-Goya, and Evelyn Solís-Avilés
Proposal of a Supply Chain Architecture Immersed
in the Industry 4.0 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 677
Jose Ignacio Rodriguez, Monica Blanco, and Karen Gonzalez
Open Source Web Software Architecture Components for Geographic
Information Systems in the Last 5 Years: A Systematic
Mapping Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 688
Alvaro Uyaguari, Edison Espinosa-Gallardo,
Santiago P. Jácome-Guerrero, Patricio Espinel, Cristian F. Cabezas,
Gloria I. Arias Almeida, and Frankz Alberto Carrera Calderón
Ethnographic Study on Practices of the Software Development
Industry in Chile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 700
Dante Carrizo and Andrés Alfaro
Geolocation Applied to Emergency Care Systems
for Priority Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 710
A. José Sánchez, L. Lídice Haz, B. Datzania Villao,
and G. Washington Torres
MORPHY: A Multiobjective Software Tool for Phylogenetic
Inference of Protein Coded Sequences . . . . . . . . . . . . . . . . . . . . . . . . . . 719
Cristian Zambrano-Vega, Antonio J. Nebro, José F. Aldana Montes,
and Byron Oviedo
Adaptive Harris Corner Detector Evaluated
with Cross-Spectral Images . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 732
Patricia L. Suárez, Angel D. Sappa, and Boris X. Vintimilla
xx Contents

JavaScript Middleware for Mobile Agents Support on Desktop

and Mobile Platforms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 745
Carlos Silva, Nuno Costa, Carlos Grilo, and Jorge Veloz
Analyzing UAV-Based Remote Sensing and WSN Support
for Data Fusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 756
Ramón Alcarria, Borja Bordel, Miguel Ángel Manso, Teresa Iturrioz,
and Marina Pérez
Continuous Speech Recognition and Identification
of the Speaker System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 767
Diego Guffanti, Danilo Martínez, José Paladines, and Andrea Sarmiento
Competitive Intelligence Using Domain Ontologies on Facebook
of Telecommunications Companies of Peru . . . . . . . . . . . . . . . . . . . . . . 777
Geraldo Colchado and Andrés Melgar
Sustainability Performance Evaluation of Groundwater
Remediation Technologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 788
Santoso Wibowo and Srimannarayana Grandhi
Mobile Application to Encourage Local Tourism
with Context-Aware Computing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 796
Carlos A. Silva, Renato Toasa, Juan Guevara, H. David Martinez,
and Javier Vargas
Modelled Testbeds: Visualizing and Augmenting Physical
Testbeds with Virtual Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 804
Stephane Kundig, Constantinos Marios Angelopoulos, and Jose Rolim
Proposal for an Integrated Framework for Mobile
Applications Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 813
Danilo Martínez, Xavier Ferré, and Diego Marcillo

Computer Networks, Mobility and Pervasive Systems

An Adaptive-Bounds Band-Pass Moving-Average Filter
to Increase Precision on Distance Estimation from Bluetooth RSSI . . . . 823
Diego Ordóñez-Camacho and Edwin Cabrera-Goyes

Health Informatics
Towards a Framework to Enable Semantic Interoperability of Data
in Heterogeneous Health Information Systems in Namibian Public
Hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 835
Nikodemus Angula and Nomusa Dlodlo
Contents xxi

Automatic Extraction and Aggregation of Diseases

from Clinical Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 846
Ruth Reátegui and Sylvie Ratté
eHealth Applications in Portuguese Hospitals: A Continuous
Benchmarking with European Hospitals . . . . . . . . . . . . . . . . . . . . . . . . 856
João Vidal Carvalho, Álvaro Rocha, and António Abreu
Innovation Process in Cancer Treatment: The Implementation
of Picture Archiving and Communication System (PACS)
at Brazilian National Cancer Institute . . . . . . . . . . . . . . . . . . . . . . . . . . 867
Antônio Augusto Gonçalves, Carlos Henrique Fernandes Martins,
José Geraldo Pereira Barbosa, and Sandro Luís Freire de Castro Silva
The Higher-Order Spectra as a Tool for Assessing the Progress
in Rehabilitation of Patients After Ischemic Brain Stroke . . . . . . . . . . . 874
Ewaryst Tkacz, Zbigniew Budzianowski, and Wojciech Oleksy
Developing and Testing an Application to Assess the Impact
of Smartphone Usage on Well-Being and Performance Outcomes
of Student-Athletes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 883
Poppy DesClouds, Fedwa Laamarti, Natalie Durand-Bush,
and Abdulmotaleb El Saddik
Multisensory Virtual Game with Use of the Device Leap Motion
to Improve the Lack of Attention in Children of 7–12 Years
with ADHD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 897
David Chilcañán Capelo, Milton Escobar Sánchez,
Jhonatan Salazar Hurtado, and Daniela Benalcázar Chicaiza
Development and Improvement of the Visomotriz Coordination:
Virtual Game of Learning and Using the Sphero Haptic Device
for Alpha Generation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 907
David Chilcañán Capelo, Milton Escobar Sánchez,
Chrystian López Hidalgo, and Daniela Benalcázar Chicaiza

Information Technologies in Education

Experiential Education: Creation of a Business Game to Enhance
Learning of Business Administration Students . . . . . . . . . . . . . . . . . . . . 919
Eduardo de Oliveira Ormond, Gustavo Olivares,
and Saulo Barbará de Oliveira
Educational Computing Resources Applied to the Teaching
of Manufacturing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 927
Leonardo Emiro Contreras Bravo, Jose Ignacio Rodriguez Molano,
and Edwin Rivas Trujillo
xxii Contents

Recommendation Systems in Education: A Systematic

Mapping Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 937
Abdon Carrera Rivera, Mariela Tapia-Leon, and Sergio Lujan-Mora
Looking for Usability and Functionality Issues: A Case Study . . . . . . . . 948
Karina Jiménes, Jhonny Pincay, Mónica Villavicencio,
and Alberto Jiménez
Determinants of ICT Integration in Teaching Secondary School
Agriculture: Experience of Southern Africa (Swaziland) . . . . . . . . . . . . 959
Nomsa M. Mndzebele, Mzomba Nelson Dludlu,
and Comfort B. S. Mndebele

Media, Applied Technology and Communication

Design of a Recommender System for Intelligent Classrooms Based
on Multiagent Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 973
Dulce Rivero-Albarrán, Francklin Rivas-Echeverria, Laura Guerra,
Brian Arellano, and Stalin Arciniegas
The Visual Speech and Creativity in Advertising Impressed
in Ecuador in Daily “El Comercio” Between 1908 and 1950 . . . . . . . . . 983
Marco López-Paredes
Influence of Social Networks from Cellphones to Choose
Restaurants, Salinas – 2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 992
Homero Rodríguez, Jeyco Macías, Néstor Montalván,
and René Garzozi
Digital Feedback and Academic Resilience . . . . . . . . . . . . . . . . . . . . . . . 1004
Laura Guerra, Dulce Rivero, Stalin Arciniegas, and Santiago Quishpe
Mobile Learning: Challenging the Current Educational Model
of Communication Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1014
Verónica Yépez-Reyes
Competencies and Indicators for a Productive
Digital Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1022
Laura Guerra, Stalin Arciniegas, Luis David Narváez,
and Francisca Grimon
Transparency and Participation in Public Service Television
Broadcasters: The American Southern Cone . . . . . . . . . . . . . . . . . . . . . 1033
Paulo Carlos López-López, Mónica López-Golán,
and Iván Puentes-Rivera
Contents xxiii

Knowledge Based of an Expert System Using the Horizontal

Analysis for Financial Statements of National, Private TV Companies
in Ecuador . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1044
Ana Cecilia Vaca-Tapia, Francisco Campos Freire,
Francklin Iván Rivas-Echeverría, and Johnny Alejandro Aragón-Puetate
The Use of Facebook in Community Radio: A Quantitative
Analysis of the Andean Community of Nations . . . . . . . . . . . . . . . . . . . 1055
Viviana Galarza-Ligña, Amparo Reascos-Trujillo,
and Stalin Rivera-Imbaquingo
The Interaction Gap: From the Bit to the Resurgence of a New
Information and Communication System . . . . . . . . . . . . . . . . . . . . . . . . 1065
Carmelo Márquez-Domínguez, Nancy Ulloa-Erazo,
and Yalitza Therly Ramos-Gil
The Influence of New Technologies on University
Radio in Ecuador . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1076
Ana Culqui Medina and Elizabeth Granda Sánchez
The Press in the Context of the Andean Community
of Nations (CAN): Without Sustainable Monetization
in the Digital Economy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1084
Yalitza Ramos-Gil, Carmelo Márquez-Domínguez,
and Aldo Romero-Ortega
Ecuador, the Non-communication: Postdrama or Performance? . . . . . . 1094
Miguel Ángel Orosa and Aldo Romero-Ortega
Media Processes of Communicational Management, Information
Transparency and the Incidence of TIC . . . . . . . . . . . . . . . . . . . . . . . . . 1104
Nancy Ulloa-Erazo and Álvaro Cevallos Ramírez
Radio: A Didactic Meaningful Strategy, for Strengthening
the Oral Communicative Competence in the English Language . . . . . . . 1115
María Fernanda Ibadango-Tabango,
Armida Mariela Montenegro-Cevallos,
and Luz Marina Rodríguez-Cisneros
The Communication in English from an Educational Perspective
and Its Relationship with the Competence-Based Teaching Profile . . . . 1125
Brenda Gutierrez-Franco, Armida Mariela Montenegro-Cevallos,
and Hazel Machado-Rosales
The Diffusion of Public Policies on Technical Training
for the Textile and Clothing Industry in Ecuador . . . . . . . . . . . . . . . . . 1135
Tania Aguilera, Andrea Mila, Daniela Batallas, and Giovannina Torres
xxiv Contents

Open Government and Citizen Participation in the Web Portals

of Ecuador GADM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1146
Patricia Henríquez-Coronel, Jennifer Bravo-Loor, Enrique Díaz-Barrera,
and Yosselin Vélez-Romero
Author Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1157
Organizational Models and Information
Systems
 Rationalization of Organizational Processes:
The Case of the Institute of Applied Social
Sciences of Rio de Janeiro Federal
Rural University

Elisangela Costa(&), Saulo Barbará de Oliveira,

and Daniel Ribeiro de Oliveira

Universidade Federal Rural do Rio de Janeiro, Rodovia BR 465

KM7-Seropédica, Rio de Janeiro 23890-000, Brazil
egcostaufrrj@gmail.com

Abstract. Processes are instruments for systematization of working activities

that facilitate management and add value to the organization. This study
describes results of mapping the processes of the Institute of Applied Social
Sciences of Rio de Janeiro Federal Rural University (UFRRJ). The study is
qualitative, exploratory and interventionist in nature. The data were collected by
consulting the literature and documents and conducting interviews. We sought
to ascertain the most suitable techniques and methods for the objectives of the
study, and through interviews with managers and other staff members it was
possible to assess the initial situation of the organization, its bottlenecks and
critical points, and from the knowledge obtained, to implement improvements in
the process. The results allow concluding that the mapping of processes con-
tributed by enabling the sector to identify and better visualize the processes,
identify failures, standardize activities and improve the quality of the services
rendered.

Keywords: Mapping
Processes
Performance improvement

Public organization

1 Introduction

A process is a set of activities carried out to generate a result, product or service. The
processes in organizations of any type or size are means to rationalize activities, guide
strategic actions and implement improvements in working routines. The objective of a
process is to facilitate aggregation of value to the tangible and intangible assets of the
organization.
In studying process management, modeling reveals the operational flow and its
interplay with processes, allowing the organization to clearly see the strong and weak
points, gain a better understanding of processes and increase performance, be it in
business or any other sector [1]. In general, mapping consists of the graphical repre-
sentation of a process, to allow clearer visualization and more detailed analysis. This, in

© Springer International Publishing AG 2018

Á. Rocha and T. Guarda (eds.), Proceedings of the International Conference on Information
Technology & Systems (ICITS 2018), Advances in Intelligent Systems and Computing 721,
https://doi.org/10.1007/978-3-319-73450-7_1
4 E. Costa et al.

turn, facilitates identification of failures and application of measures to rectify them and
improve overall performance.
The Institute of Applied Social Sciences of Rio de Janeiro Federal Rural University,
covered by this study, faced a critical situation due to lack of a standardized adminis-
trative routine and duly mapped business processes for hiring new professor, one of its
most important processes. In this respect, in 2015, 30% of the public examinations
realized were annulled due to appeals by candidates regarding flaws.
The entire process is executed by the academic departments, which indicate to the
human resources sector the members of the board of examiners, and together with an
administrative secretary, define the steps of the selective process. However, the absence
of standardization of the administrative routine and appointment of the secretary wound
up generating a bottleneck in the process, since other administrative routines exist that
must be concluded before, during and after the competitive exam. In this respect, the
failure to name a secretary undermined the whole process, contributing to the occur-
rence of failures and the respective nullification of the selection process in many cases.
Another factor that interfered in the progress of the process occurred after all the
selection steps, because paperwork was sent to sectors that no longer had any say over
the outcome of the process, generating unnecessary bureaucracy and delaying the
conclusion of the process, thus compromising the hiring of new professors.
The objective of the article can be synthesized by the following question: How does
the Process Management contribute to the improvement of the quality of the selection
process for professors of an institute inside a university? In this article, a specific
educational institute known as the Institute of Applied Social Sciences (ICSA) was
studied aiming at the improvement of its services.
The article is structured in four sections besides this introduction: theoretical
framework; methodology; case study (process and post-mapping benefits); and final
considerations.

2 Theoretical Framework

2.1 Process Management

Process Management can be defined as a “system or model for organizational man-
agement”, with the aim of managing organizations with focus on processes [2].
Organizations try to work with focus on processes when they need to execute a
sequence of activities that consume time and resources in the production of goods or
provision of services, to create value for clients and the organization. However, only
recently, with popularization of business process management (BPM), have organi-
zations started to explicitly systematize and formalize their processes [3].
An organization managed according to processes no longer operates through a
vertical hierarchical structure, but instead by means of matrix structures and multi-
functional teams, with focus on business processes [4]. Seen in this light, process
management is a management model that strives to manage the organization with focus
on the processes that generate value for clients [5]. It also contributes to ongoing
improvement of the organizational performance. Therefore, an organization that wants
 Rationalization of Organizational Processes 5

to pursue continuous improvement should first identify and then classify its processes,
seeking to learn which are the most important and which are the most critical. The
classification can be done by applying a reference model, such as the process classi-
fication framework (PCF) – an architecture developed by the American Productivity &
Quality Center (APQC) [5] that also enables subsequent benchmarking.
Although various PCF formats exist, all of them are decomposed into: (a) process
categories; (b) process groups; (c) processes; (d) activities. The PCFs are divided into
two process levels: operating processes, which are the most important to the company,
also called business processes; and management and support processes, which as the
name indicates provide support to the operating processes, as shown in Fig. 1.

Fig. 1. PCF architecture Source: [6]

By adopting this type of architecture, organizations can gain a horizontal view of

their activities, in place of the traditional vertical hierarchical vision. This allows them
to optimize the entire decision-making process, since the horizontal vision of the
processes reduces the power islands within organizations [7].
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