RELATION OF DRUGS AND ALCOHOL TO INSANITY
The habitual drug-taker and the confirmed alcoholic are puzzles that baffle the alienist. The man with the “wet brain” is a contradiction of all the rules of normality. In many criminal trials men have been adjudged insane who were merely in abnormal states due to the habitual use of drugs or alcohol, of which, without proper treatment, they have been suddenly deprived.
In one of the largest hospitals in the United States I once ran across an old woman crooning while she rocked an imaginary baby. She had been formally and legally adjudged insane by the State’s experts. As a matter of fact, she was suffering only from an hallucination due to alcoholic deprivation. I suggested definite medical treatment for this case when I discovered that she was about to be transferred from the alcoholic ward to the insane pavilion. In two days after the administration of this treatment she had lost all her hallucinations, and on the third day was dismissed from the institution. Not long ago I observed a similar case in a foreign hospital.
It is my belief that commitments for insanity in the United States might be decreased by one third if in every case where insanity was suspected, but where an alcoholic or drug history could be traced, the patient should be subjected to the necessary medical treatment before the final commitment was made. The sudden deprivation of drugs and alcohol which follows the imprisonment of alcoholics and drug-users upon disorderly or criminal charges has produced thousands of cases of apparent insanity sufficiently marked for the subjects to be placed in insane asylums. There, as in the prison, no intelligent note is made of their condition, nor is any proper treatment applied, the result being that they become really insane—insane and hopeless. If we had any means of securing accurate knowledge of the number of such incurable maniacs who are now confined in our asylums, we should find in it a startling evidence of the lack of knowledge on the part of the medical world of what deprivation means to the habitual victim of drugs or alcohol.
GENERAL IGNORANCE OF THE RELATION OF ADDICTION TO INSANITY
The necessity for educating the public in regard to the very definite relation between alcoholism and insanity should no longer be overlooked. There lies a public peril of unappreciated magnitude in the fact that mere deprivation, the only method so far followed, has been, and if it is not corrected, will continue to be, one of the principal feeders of our insane asylums. Alcoholism will lead to insanity eventually even without deprivation.
The case is somewhat different with drug victims. Ordinarily they will not become insane unless deprived of their drug, although in the final stages of the habit they are likely to become incompetent and subject to certain hallucinations, imagining the existence of plots against them, suspecting unfairness on every hand, taking easy offense, exhibiting, in fact, a general distorted mental condition. It is true, indeed, that in some instances the drug victim who is deprived of his drug may become definitely insane, but death is the more frequent result.
I have before me a clipping from a newspaper published in Columbus, Ohio. There, after the enforcement of restrictive legislation, the authorities found it necessary to ask the governor for some special procedure which would authorize them to supply drug victims with their drugs until proper medical treatment was provided. This did not relate to those victims who had come exclusively from the under-world, but referred specially to those habitual drug-users whose habits had been acquired through illness. It can scarcely be expected that restrictive legislation will entirely prevent the sale and use of drugs in the under-world any more than restrictive legislation has been able to prevent the practice of burglary or any other type of crime or lawlessness. It is highly probable that the under-world will always be able to get its drugs; but it is nevertheless true that the passage of restrictive legislation and the enforcement of such laws will tend to prevent the descent of many into the criminal class.
Even this is comparatively unimportant. Those who suffer most are those who have been given the habit by physicians. These are honest drug-users, and to them at this writing no helping hand is anywhere held out save in New York State. I have been somewhat disgusted—I am sure that is the word I wish to use—by the continual outpouring of sympathy and constant manifestations of anxiety on the part of good people in regard to the under-world, when these same good people regard with indifference or classify as criminal the involuntary victim toward whom the most intense and understanding sympathy should be extended.
MENTAL ATTITUDE OF THE DRUG-TAKER AND THE ALCOHOLIC
The victim of drugs psychologically differs very materially from the victim of drink. Until his trouble has reached an acute stage, the alcoholic feels little interest in any of the methods advertised as remedial for alcoholism. Many men deny to their friends and even to themselves that they are alcoholics until they have reached a point akin to hopelessness in their friends’ eyes and their own. The drug-user, on the other hand, knows that he is a victim as soon as he becomes one; in ninety-nine cases out of a hundred he is immediately filled with an intense longing to be relieved of his habit. Thousands of alcoholics will defend their vice. A library might be filled with books, fictional and other, glorifying alcohol and the good-fellowship and conviviality that it is supposed to promote. One might search a long time for a victim of any drug habit who would speak with affection of the material which has enthralled him. No poet has ever written any song glorifying morphine. There is no drug-user in the world who would not hail with joy any opportunity that might lead to his relief. The drug-victim investigates every hint of hope with eager interest, reading, intelligently questioning, experimenting. He shrinks from publicity with a horror that is backed by an acute consciousness of his condition, while the victim of alcohol becomes so mentally distorted or deadened that he takes no thought of consequences, cares nothing for publicity, and finds himself unable to avoid public exhibitions of a kind that put him into the hands of the police. Public hospitals do not tempt the drug-user for, having investigated them, he knows that they are not competent to give him real relief.
EXPEDIENTS OF DRUG-TAKERS
Nothing but really enforced restrictive legislation, fashioned after the model of the present New York State law, will bring to light the drug-victims in any community. The New York law uncovered thousands of them, and within two weeks forced Bellevue and other hospitals to devote many beds to sufferers from drug-deprivation. Similar restrictive legislation would uncover every sufferer from drugs in the country and thus accomplish more good than could be achieved by any other similarly simple means. No man on earth is more pitiably affected than the drug-taker; no suffering is more intense than his when deprived of his drug. The fact that rather than undergo such suffering men and women will resort to the most desperate expedients has been proved a thousand times. When confronted by the terrible prospect of deprivation, they invented plans worthy of the mental agility of the most famous fictionist. Drugs were smuggled into prison hidden in the heels of visitors’ shoes. One wife who knew the agony her husband must endure if deprived of his regular morphine dosage took to him clean linen which was admitted to the prison without question, but which, as an accident revealed, had been “starched” with morphine. Another ingenious wife or sweetheart devised the expedient of sending in to a prisoner oranges from which the juice had been cleverly extracted and which had been filled hypodermically with a morphine solution.
If there is no length to which a drug victim will not go rather than find himself deprived of his drug, there is no length to which he will not go in order to obtain relief from a habit the existence of which fills him with horror. This has often been illustrated in the course of my practice, but perhaps never more strikingly than when I learned of the experiences of a certain judge in Jacksonville, Florida. This far-sighted, merciful, and progressive jurist had come in contact with one or more pitiable cases of the drug habit to which he wished to give relief. He communicated with me, and I was very glad to coöperate in aiding with definite medical relief several drug-victims taken before him. This procedure was commented upon in the public press, and presently the judge found himself importuned for help by those who had committed no crime, but expressed themselves as quite willing to be sent to prison as the only way in which they could get the treatment that was being administered under his auspices.
DRUG-TAKING MORE OFTEN THE CAUSE THAN THE RESULT OF CRIMINALITY
A careful study of the histories of drug-takers who upon one charge or another find themselves caught in the meshes of the law will reveal that in most cases, or at least in many cases, the drug habit has led to crime rather than the reverse. If an efficient treatment for the drug habit were established in a prison almost anywhere in the United States where such a treatment did not elsewhere exist, it would result, I am sure, in the actual commission of crimes by a certain number of people willing to endure the misery and disgrace of incarceration for the mere sake of securing treatment for their affliction. Any drug-user will tell you that no punishment recorded in the course of human history, no torture visualized by the most inventive imagination, can compare with the unspeakable agony of deprivation.
FALLACY OF IMPRISONING DRUG-TAKERS
That imprisonment should rarely, if ever, result in freeing a person from the drug habit can mean only one thing: that drugs are obtainable in every prison. Guards and other employees in such institutions are of a low class, for men and women of a high type are unlikely to seek such employment. I fear that this fact will prove one of the most serious stumbling-blocks in the path of those who are endeavoring to make a success of inebriety-farm experiments. In the first place, they will not be able to find men of a high type anxious to serve in the subordinate positions provided at such places; and in the second place, even if such men can be found, they will be unlikely to obtain positions because persons of an inferior type will be certain to be pushed forward by political influence. Such places would be used as means wherewith to pay political debts, and this would be more or less complacently tolerated, because society has always underrated and still underrates the terrific complications of the task of working for the reclamation of, or even caring for, the down-and-out. Such work is not employment for the saloon-keeper, the ward heeler, or the ex-prize-fighter, and of such is the personnel of most prison staffs made up. The reclamation of the alcoholic wreck means far more than physical rehabilitation. It means moral and psychological regeneration, and such work can be done only by people of understanding and delicate sensibility. The alcoholic from the city who has been perhaps an office employee or a professional man and who is sent to an inebriate farm will find there nothing curative save deprivation. Even if outdoor work will harden his muscles, it must be admitted that the surroundings in which this is accomplished may well ossify his brain.
PSYCHOLOGY OF THE DRUG HABIT
Nothing could more clearly indicate the popular ignorance concerning the drug habit than the general belief that it is usually accompanied by moral deterioration. Where the habit is an accompaniment of life in the under-world, moral deterioration of course exists, though this is due rather to the under-world than to the drug habit. In the thousands of histories where the habit has been acquired by the administration of drugs by physicians it results in moral deterioration no more than drinking tea does. As a matter of fact, that portion of society which holds a drug victim blamable is woefully mistaken and inhumanely unmerciful, the truth being that the man or woman who is not taking drugs is lucky.
THE NECESSITY OF DEFINITE MEDICAL TREATMENT IN DEALING WITH ANY FORM OF ADDICTION
It is impossible for me to conclude this book without discussing further the question of treatment for those afflicted with habits or addictions.
My taking up this work in 1901 was due almost entirely to an investigation into the methods employed to restore those who had lost control through the use of habit-forming drugs, whether they had acquired the habit through dissipation or from the administration of the drug by a physician on account of illness or injury. At that time such cases were supposed to be hopelessly incurable, and the victims only drifted from bad to worse until they had been accounted for either in a mad-house or in the morgue.
I found, on making inquiries from some of the leading medical men who had been dealing with the various types of mental and nervous diseases, that they were virtually unable to name any case of a confirmed drug-user who had been permanently benefited by institutional or any other means of treatment. This was very difficult to understand, particularly in the case of drug-users who had acquired the habit through the administration of the drug by a physician, and who earnestly desired to be freed from the habit. It seemed incredible that a skilled physician could not eliminate the craving or desire for the drug, or restore these unfortunates to the point where their systems would not demand or feel the need of it.
I soon found out why this was so. My investigation showed me that the drug habit is a mental as well as a physical condition; that the physiological action of an opiate is to tie up the functions, resulting in a deterioration of the vital organs when the victim has taken the drug sufficiently long to set up a definite tolerance.
The medical world had apparently been unable or had not attempted to bring about a definite physiological change, and to place such patients where they would not crave drugs and where their systems would not demand them. To my further surprise, I found that the medical world had been depending entirely on deprivation as a means of treating such cases. They would immediately send patients to an institution where they were put under surveillance and guarded by attendants, or they would attempt by gradual reduction of the dosage to eliminate the habit.
CURE BY DEPRIVATION IMPOSSIBLE
This investigation led me into some very interesting discoveries. I found that old, confirmed subjects of the drug habit were sent to such institutions. Where they were taking large daily doses of opiates the institutions were able to reduce these people, when there was no underlying physical disability, within a few weeks or a few months, according to the temperament of the patient, to a very small daily dosage, often as low as one half or one eighth of a grain a day. When they had reached this dosage it was often found absolutely impossible to limit them further. In some cases where the patient was confined and finally deprived of the drug entirely I found that when he had reached this minimum dosage he would suffer just as much physical discomfort in the end as if he had been suddenly deprived of a very much larger quantity of the drug taken daily. This led up to the further interesting fact that even where patients were finally deprived of the drug and lived through the horrible suffering inevitably accompanying the deprivation, although they outlived the tremendous depression and lassitude which followed, and for long periods of weeks and months after that time had the best of care and attention until they showed marked improvement in their physical condition, nevertheless, with too few exceptions, they never lost the desire for the drug. Always the need of some stimulant returned, and on the slightest excuse or opportunity they were taking their drug again. My investigation finally proved to me that deprivation did not remove the cause of the drug habit, because it did not remove the physical craving for the drug. No matter how long a period the deprivation had been, the needed physical and mental change had never taken place.
EFFICACY OF THE AUTHOR’S TREATMENT
During the first two years of my work, after finding in various ways patients from the under-world to use as subjects for demonstration, I was finally able to treat any case of drug habit which came to me unless it was complicated by underlying physical disability. After a period of from three to four days these patients would not feel the slightest craving or desire for any form of opiate, whether their addiction had been cocaine, alcoholic stimulants, or tobacco.
When the efficacy of this treatment was assured, it began to attract the attention of some of the best-known medical men in the country—men who were interested in this line of study. They followed carefully the medical administration of the new treatment of these cases.
It was only a matter of time before the value of the work was thoroughly established and became a medical fact. After hundreds of definite clinical histories had been recorded, the formula was publicly announced, first, at the International Opium Conference at Shanghai in 1909, and a month later to the medical world. Since the complete information concerning my work has been given to the medical profession, and after all these years of study and investigation and medical comment, I have never yet had from any physician an entirely satisfactory explanation as to why or how we were able successfully to unpoison these cases in this short period. At present this treatment is, so far as I know, the only one known to medical science that will bring about this definite physiological change.
The intelligent beginning of help in these cases is to unpoison the patient, put him physically on his feet, where he does not want drugs or drink, and where he does not feel the slightest desire or craving for them, and has no dread of ever drifting into these habits again. When you have brought about this definite physical change, you are invariably able to get a definite mental change. You cannot hope to get the mental change until you have first cleared the system of poison, for in this state the patient is in a most responsive condition to deal with. If physical building up, change of environment, change of surroundings in any way whatever are necessary, they can then be taken up intelligently.
LEGISLATIVE EFFORTS
The knowledge I gained from dealing medically with those afflicted with habits and addictions led me to take up personally the movement to bring about definite legislation with a view to subordinating as much as possible the traffic and consumption of drugs to legitimate medical needs; and to put an end to the criminal negligence by which such drugs have been permitted to be imported, manufactured, and distributed.
In contact with the afflicted of this class, I discovered the laxity with which drugs were dealt in, and began in 1912 to try and bring about some restrictive legislation with regard to the evil before the New York legislature. I had first found that in the medical use of the drug the principal evil had sprung from the knowledge of what would ease pain, and that the principal means used for this purpose was the hypodermic syringe. At that time there was no restriction placed upon the sale of this instrument; it could be bought in any drug store just as easily as a package of chewing-gum. The department stores that carried drug supplies advertised hypodermic outfits as low as twenty-five cents. A physician’s instrument permitted to be manufactured and sold in this way! Through the bill which was introduced in the New York legislature in 1912, for the first time in the history of the medical world it became possible to purchase this instrument only on a physician’s prescription.
In 1913 I was the author of a drastic law regulating the sale of habit-forming drugs in New York State, but because of severe pressure brought by physicians and druggists, I was unable to put it through. In 1914 I tried again, and after a hard fight I was able to have enacted a bill, which was introduced by Senator John J. Boylan, and which bears his name. For the first time there was put upon the statute-books of a State real restrictive drug legislation. Other States are taking up this matter, and, as the intention was, the New York bill has been the means of establishing a legislative precedent.
I regret very much that the aim and purpose of Federal legislation has been largely defeated by the powerful drug interests, but I predict that it is only a matter of time before public sentiment will defeat this powerful drug lobby, as it has always defeated other lobbies of a similar kind, and that the country will be largely freed from the illegal habit-forming drug traffic.
Until there is some international understanding between the countries that produce these drugs and the countries that consume them, we shall have to submit to more or less smuggling of these drugs into our country. Smuggled goods rarely, if ever, find their way into channels for legitimate medical needs, and for that reason it is only the under-world that would be affected by their use and abuse.
It is only a matter of time before the commissioners of health for the various States will be given authority enabling them to issue rules and regulations governing the health of the people that will wipe out the quacks and charlatan venders of all common advertised fake medicine cures.
THE NEED FOR REGULATING THE ADMINISTRATION OF DRUGS
I have been told that to require a consultation of physicians before the administration of a habit-forming drug would put upon the patient a financial burden which he should not be asked to bear. No fallacy could be more complete. There is in the United States to-day not one victim of the drug habit who, knowing as he does the intense suffering it entails, would not rather have given up ten years of his life and been forced to put a mortgage on his soul than to have had this habit fastened on him. Money? Money is nothing! The cost of a consultation is a small price to pay for the possible difference between life-long thralldom and free manhood or womanhood. And let me add in regard to the physician who objects to the legal establishment of a danger-point in drug administration that the physician who feels big enough to accept personally the responsibility of creating a drug habit is too small to be intrusted with that power.
PERCENTAGE OF THOSE TO WHOM THE PERMANENT ADMINISTRATION OF DRUGS IS A NECESSITY
The percentage of sick people to whom the administration of habit-forming drugs is a necessity for the preservation of life or comfort is smaller than is generally supposed even by the medical profession. When I was drafting my restrictive bill to be introduced into the New York legislature, I was asked by my lawyer to enumerate those physical troubles which demanded the constant use of habit-forming drugs. I found this to be impossible. I have known many instances in which to deprive of drugs patients suffering incurable illness would have been little less than criminal. This alone enabled them to live in comparative comfort.
I have known of many cases of drug habit which have grown out of the administration of morphine for recurring troubles, such as renal colic. Such a disorder as this, however, should never give rise to a drug habit, because those suffering from it are subject to such brief periods of pain that a physician could administer the necessary drug without their knowledge. I have had many cases of women who, acquiring the habit through the administration of drugs at the time of their monthly periods, became habitual users, although each recurrence of the pain lasted only three or four days. When this problem is thoroughly understood, such cases will be impossible, for legislation will not only prevent the layman from securing habit-forming drugs, but will prevent the doctor from the indiscriminate administration of them.
Of course the general reader may think this book merely a clever advertisement. In it I state that it is wrong to stop the use of morphine and alcohol unless the victims can be treated for the habit, and next I condemn doctors and sanatoriums for their useless methods of treatment, while lauding my own. Naturally, my reader may assume that my only motive is the selfish one of money.
Well, one may suppose what he likes, but the truth is that I urge every city and State to establish places that will drive me out of business. I urge physicians to take up this treatment and cure their own colleagues. I have no secrets. My methods have been published, and I am now devoting most of my time to legislative work from which I do not profit a cent.
APPENDIX