PREVENTIVE MEASURES FOR THE DRUG EVIL
Early in my investigations into the proper facilities for the medical treatment of drug-users it became apparent that this could not be properly carried out in the patient’s own environment, in a general hospital where new facilities had not been introduced, or in the usual sanatorium. It became necessary for me then to outline some system by which the medical profession might properly take up the work and to suggest some basis on which the medical men of various States might combine in an effort to remove the treatment of these sufferers from the hands of the irresponsible.
Some, if not the majority, of the worthiest subjects of the drug habit are people who cannot pay large sums or travel long distances in their search for relief. It seemed clear, therefore, that state institutions should be equipped with facilities and knowledge for dealing with this affliction.
THE NEED FOR PRACTICAL INSTRUCTION
At the present time there is in existence no clinic or other practical place of demonstration where a doctor can get competent instruction in this important branch of medical work. I hope the time will come when it may be possible for me to offer to the medical profession a clinic where the professional student may prepare for this line of effort as effectively as he may now prepare himself for any special work, like nose and throat diseases. This can come about only through some arrangement in which I have no financial interest.
SKEPTICISM OF THE MEDICAL PROFESSION
I am fully aware that I must first overcome a strong undercurrent of skepticism among the members of the medical profession. The efficacy of the treatment must be proved. Even among the best-informed physicians it is a popular belief that the treatment which I announce as simple is really an impossibility. No matter what the doctor has hoped that he might do, he has been told by text-books and articles in medical periodicals that it cannot be done. This fallacious teaching must be counteracted before much can be accomplished, and in the progress of the work many traditions of the profession must be violated. Before he can hope to accomplish anything of importance in the administration of my method of treatment, the physician must understand that the length of time a drug-user has been taking the drug, the quantity that he has taken, and the manner of its administration are matters of no consequence. Short histories and small amounts, long histories and large amounts, are all one when it comes to the administration of this treatment. I went to Dr. Richard C. Cabot of Boston with a letter of introduction from Dr. Alexander Lambert of New York, whom he knew well and admired. He listened to my statement of the facts which I have just set forth.
“I have heard what you say, but I shall not believe it until it has been demonstrated to me,” he declared.
I demonstrated it, and convinced him. A similar skepticism remains general throughout the medical profession.
The experience that the medical profession has already had in New York State as the result of prohibitive legislation indicates the many problems that arise immediately after the drug is put beyond the reach of those who have acquired the habit. It is only natural that the unscrupulous should seek to take advantage of the opportunities created by this situation. Without proper treatment, an habitual drug-user cannot endure the agony of deprivation until a definite physiological change has occurred; so that unless the medical profession is informed of this fact, and the community at large is provided with facilities for the administration of the required treatment, it is almost inevitable that restrictive measures will be followed immediately by the victimization of the unfortunate by the unscrupulous. One detail of the peril to society which may accrue from a general cessation of the drug traffic without the provision of proper facilities for the care of those who have been its victims is that those who are accustomed to drugs, on being suddenly deprived of them, almost invariably turn to alcohol for stimulation and, without being the least relieved of the drug habit, with abnormal speed become alcoholics. Modern society presents few spectacles of suffering more acute than that endured by the drunken drug-fiend. Few persons, moreover, are so dangerous to its welfare.
MEDICAL ETHICS
Constantly I must lay emphasis upon the responsibility of the physician in regard to drug habits. This phase of the subject must be an ever-recurring one, because the whole unpleasant situation has grown out of medical ignorance. While treatment for drug-users is at last making headway, for a long time experimentation had no chance save with a small number of broad-minded and bright-minded doctors who were able to shake off the shackles that held the less intelligent members of their profession.
When I made public the formulas of my treatment, I did not understand this phase of medical ethics. I assumed that certain dangers might arise from the probable activities of the omnipresent medical faker, who without any genuine effort to administer my treatment properly would advertise it widely, and thus victimize the innocent. I also assumed that the medical profession would eagerly grasp the idea, put the treatment into operation, to their own benefit and that of the world at large, and by the very beneficence of their work far more than offset the harm the charlatans would do.
Both of these assumptions proved incorrect. The fakers avoided even counterfeiting my treatment, because the articles which had announced it in the medical and lay press had made its brevity clear to the public; they did not care to promote any treatment in which their victims would be justified in demanding immediate relief. From that real peril the community was thus saved. But the general indifference of the medical profession was equally surprising and at first somewhat discouraging. I have since decided, however, that this was perhaps fortunate; for as the work develops, it becomes more and more apparent that it is a strictly hospital treatment, and cannot often be successfully administered in the environment of the home or in the regular course of a general practitioner’s daily work.
In another part of this book I shall have more to say about the medical buzzards who, working outside of medical ethics and in defiance of the usually admirable spirit of the profession as a whole, without regard to financial or ethical honesty, indulge in whatever practices seem to promise them the greatest profit. How dangerous these men are not only to the patient, but to the profession has many times been illustrated. Various medical discoveries imported from abroad or achieved and announced by eminent American medical men have brought flocks of unscrupulous practitioners to New York, not with the progressive desire to study and honestly apply these new theories for the benefit of their patients, but with the idea of learning barely enough about them to enable them to offer credulous sufferers cheap and worthless counterfeits at exorbitant rates. Where secret methods have been heralded, they have bid against one another frantically to secure locality privileges, working to this end with all the fierce competitive enthusiasm shown by eager commercialists seeking county rights to a practical and popular patent flat-iron. It is my earnest hope that the wave of reform which has begun in New York State, and which undoubtedly will carry new and effective drug legislation into every State of the Union before it loses its forward impulse, may not revitalize these unworthy schemers. It was partly the hope of preventing this evil that led to the writing of this book.
The progress of intelligent legislation will fill the land with much suffering from the tortures of drug deprivation. Therefore events have placed a solemn obligation upon the medical profession to satisfy itself of the efficacy of my treatment, even though a new organization for that purpose should be necessary. After the profession is assured of the value of the treatment, many should achieve competence in its administration. Then it will become a matter of duty to see that every community is provided with facilities and a staff of experts sufficient to meet the special needs that may arise there. If such an organization should be formed, I should be glad to devote my services to it.
THE AUTHOR’S EXPERIENCE WITH THE DRUG HABIT
My opportunities for observation in this field have extended over fourteen years of constant study. They have included investigations in the Orient and Europe as well as in the United States, and have dealt with patients of every class. Early in my work I found it difficult to secure subjects, and presently saw that I could do so only by personally searching the under-world for them.
It was a complicated task, full of unexpected problems. As I could not engage salaried people for the carrying out of the details of the treatment, it became necessary for me to do everything except the medical work, and to assume all except the medical responsibility. But what I at first deemed a hardship proved in the end to be an advantage, for if I had had plenty of money with which to carry on my work, I should never have mastered its details.
It may be that the need for making the work strictly self-supporting from the start led to one of my first important psychological discoveries: that any person worth saving is either able to pay a reasonable amount for treatment or can make the price of it a deferred obligation of such a character that it will certainly be met. The experience from which this and other statements in this book have been deduced is not an experience gained from casual or even regular daily calls of a few minutes or a few hours upon the patients under treatment, but is due to years in which I have frequently spent twenty-two hours out of every twenty-four in the same building with them, and subject to their constant call.
After having proved the efficacy of treatment at home it seemed advisable to make a journey to the Orient, where drug habits were notoriously more common than elsewhere. It was the desire to study them at first hand and literally by wholesale which led me to China, where I opened three hospitals, and in the course of eleven months supervised the treatment for the opium habit of over four thousand Chinese. During this period I treated all who presented themselves, the ages of those to whom relief was given ranging from eighteen to seventy-six. Among the four thousand patients not one fatality occurred, although many of them were extreme cases, and I was able to obtain the assistance of only one foreign physician who could be considered responsible. The rest of the work was done by untrained Chinese boys, who administered the capsules at stated hours, and not one of whom was capable of intelligently counting a patient’s pulse.
I have said that not one fatality occurred. It is pleasant for me to add that during the whole fourteen years of my practice, although I have had thousands under treatment, many of them in exceedingly bad physical condition at the time the treatment was begun, with their drug symptoms complicated by various and serious physical ailments and often accented by alcoholism, only four cases have died.
SUCCESSFUL ACHIEVEMENTS IN THE CURE OF DRUG-USERS
A new precedent has been established with cases of this character in the course of my hospital experience. For the first time the treatment has been reduced to a definite hospital system, during which the resident physician is never divorced from his patient, and in the course of which complete and elaborate bedside histories and charts are kept. I have in my possession at the present moment the complete bedside notes of every patient to whom my treatment has ever been administered. I call attention to this fact because it shows that the work has not been hit or miss, but has been as carefully systematized and made as highly scientific as it has been possible to make it.
A second precedent has been set, as is proved by the fact that within a brief time any case of drug or alcoholic habit that is not complicated by physical disabilities due to other causes can be successfully treated in a few days without heroic methods and without risk.
This has at once proved the fallacy of old methods. It has demonstrated how false, for instance, is the principle of colonization. As I have said, drug cases should never be colonized, and among alcoholics only the absolutely hopeless inebriate should be subjected to this method of treatment. With the latter, of course, there is no chance of real relief, so that here colonization offers a means of relieving society of all of the burden upon the police which the inebriate’s freedom necessarily implies, and from a large part of the economic burden which his existence entails upon the community.
MAKING SANATORIUM CONVICTS
For drug-users colonization is the worst possible treatment that can be followed. From what I know of the conduct of the average sanatorium at this time in the United States, I feel absolutely certain that no person could possibly be helped if sent there, and I am convinced that definite and virtually incalculable harm would be the almost inevitable result of following such a course. Drug-users, as well as alcoholics, who are sent officially or otherwise to institutions of this character become what are called “sanatorium convicts.” These cases are virtually hopeless, and are little less pitiable than that of the “lifer” in a prison. There are in the United States many people of the better class who through no fault of their own have became afflicted with the drug-habit, and who have drifted from bad to worse until a sanatorium has been the only recourse left.
Treatment for drug and alcoholic habits and treatment tending toward the recuperation of the patient cannot be carried out together with one patient or even simultaneously with several patients in the same institution. An understanding of this fact has placed me in an advantageous position for giving advice about whatever remains to be done when a patient is ready to leave my hospital. I have always worked in the closest and most perfect harmony with physicians who have sent cases to me and have never permitted any of the doctors employed in my institution to visit a patient who has left my care. On the other hand, no physician who has brought a patient to my hospital has ever been divorced from him as a result of his stay with us.
ACCURATE DIAGNOSIS POSSIBLE AFTER TREATMENT
Physical revelations which follow the unpoisoning of patients frequently startle the patients themselves as well as the physicians who have their well-being in charge for long periods. Nor are the mental revelations less astonishing. There have been many cases, after the unpoisoning was complete, in which a man or woman has been found to be as seriously ailing mentally as others have been found ailing physically. Drugs and alcohol, especially drugs, have frequently been responsible for extraordinary mental and moral twists. But it must be maintained that the use of drug or liquor is usually the result rather than the cause of such conditions. There are many cases in which no type of medical help will bring about satisfactory permanent results, though other victims, after the elimination of alcohol or narcotics, quickly take their places as useful and admirable members of society.
The problem confronting the physiologist after a patient has been relieved of a drug or drink habit is comparatively simple. If this relief makes diagnosis possible and reveals the existence of an unsuspected, but curable, ailment, the course to follow is obvious. With the psychologist the problem is frequently far more complicated. The useless citizen who becomes a drug- or drink-user will remain a useless citizen after the drug or drink habit has been eliminated.
To this class belong most of those who readily relapse into their old habits after their systems have been thoroughly cleared of the physiological demand for the substance of their habit. Thus perhaps the most important query the psychologist interested in this work must ask after the treatment of a patient is, What is left of value, and what can be done with it? It is a curious fact that usually more is left in the case of a poor than in the case of a rich patient. No one is so hopeless as the vagrant rich. No man will ever make a reputation in work of this character who deals wholly or even principally with people to whom money has no value.
UNPOISONING THE USER IS ONLY THE FIRST STEP
My work has brought me to the conclusion that few physicians seem able accurately to classify their own patients. Even the specialist in psychology, who should be able to weigh all the details of men’s mental and moral as well as physical being, seems likely to go astray when he considers a psychology that has been affected either by drink or drugs. Many physicians seem to be imbued with the idea that after a patient has once been through the process of treatment for a drug or drink habit he will be entirely made over; but the fact is that the elimination of drugs or drink from a degenerate will not eliminate degeneracy. Nothing, in fact, will eliminate it except stopping the breeding of degenerates.
In my work I have found it necessary sometimes to seek advice from as many as half a dozen physical and psychological specialists in connection with one case. While instances have been very numerous in which several specialists have been really required for the welfare of the patient, the need had been so thoroughly concealed by the patient’s drug habit that it was not apparent until the effect of the drugs was thoroughly eliminated.
NECESSITY FOR CAREFUL PSYCHOLOGICAL STUDY
In most instances expert treatment for the mental condition after drug or drink elimination is as essential as expert attention from the doctor of medicine, and if success is to be achieved, must be regarded as an entirely separate task. Habitual users of drugs or drink are literally human derelicts. The symptoms of their true condition are submerged, and to clear them of their concealed weaknesses it is necessary to lift them like a barnacle-ridden hulk into the dry-dock for investigation and repair.
I regard as a preferred risk among the victims of the drug habits those who have acquired it through the administration of a narcotic by physicians in time of pain or illness. Such a case, if treated before too great a deterioration has taken place, may be considered almost certain of relief, provided no other ailment discloses itself.
On the other hand, where the drug habit is the direct or indirect result of alcoholic dissipation or sexual excesses, or is a social vice, the case is extra-hazardous. Here the lack of moral standards and the loss of pride are serious handicaps. These matters are of extreme importance to the physician who is considering the care or treatment of cases of a drug habit. That he should classify his subjects of investigation, recognizing the hopeful ones and admitting the hopeless to be hopeless, is essential to successful work. He must know the material with which he has to work; familiarity with his material is as necessary to him as it is to the carpenter. Many cases have been brought to us that we have declined to accept because we could hope to accomplish nothing with them. Not long after I began my work I tried to help a man against my better judgment; I felt reasonably sure that he lacked the worthy qualities that would make him cling to and appreciate whatever advantages the treatment might afford. My estimate of his character proved to be correct; the man relapsed, and became a traveling liability on me, a reproach against my institution and my treatment.
THE HOPELESS CASE
I have already said that the idle rich to whom money has no value cannot usually be classed among hopeful subjects for treatment. The same may be said of those for whom others take financial responsibility, paying the cost of their treatment. If such cases do not already belong in the human scrap-heap, this mistaken kindness is very likely to place them there.
However, I believe that those among this class who have become public charges and refuse to work should be forced to do so by state or municipal authority. Society or their own families should not bear the burden of their useless existence. They should be segregated in some place where they will be physically comfortable, where they may be made industrious and useful, and where a separation of the sexes will prevent the increase of their worthless kind. My judgment is that the man or woman who through the vagaries of his or her own disposition has once been forced to wear the stripes of disgrace is likely to employ the same tailor during the rest of his or her life. Such persons will become permanent boarders at one or another of the places provided for the seclusion of the worthless. It is well that where they are first sequestrated there they should be permanently kept. Through this course alone society will be spared the periodical havoc they will be sure to work during their intervals of freedom.
IMPERSONAL RELATIONS BETWEEN PHYSICIAN AND PATIENT NECESSARY
Certain dangers inevitably arise where an intimacy exists between doctor and patient, since few physicians are morally so constituted that they will order a prosperous patient to do this or that or find another physician. In other words, instances have not been uncommon where the toleration of physicians for unfortunate practices among their patients has had its basis, and perhaps one not entirely inexcusable in these days of high pressure from professional competition, in self-interest. Social relations also have often led physicians to tolerate practices that they knew to be harmful to their patients and to the community. A patient who is a member of an influential club or a fashionable church is likely to be an asset of exceptional value to the physician whom he patronizes, for he is likely to recommend him to his friends. Good business management on the physician’s part leads him to keep such a patient good natured and comfortable, and to keep him comfortable means, among other things, to keep him free from pain. Where the patient suffers from an incurable malady, the use of drugs is not only excusable, but commendable; but instances are all too frequent where the malady is not incurable, but only puzzling and beyond the average practitioner’s power of diagnosis, so that he covers up his ignorance by the administration of pain-deadening substances. Patients who invariably and promptly pay their bills are sometimes in a position where they can tell a doctor what to do; whereas it should be the doctor’s unalterable resolution to retain the upper hand. Instances of this kind are far less grave in connection with the use of alcohol than in connection with the use of drugs; the physician may be said almost never to play any part in the establishment of an alcoholic habit among his patients, while he has surely played a most important part in the spread of drug habits.