THE SANATORIUM
There is no class of patients in the world to whom the physician, and especially the physician who conducts a sanatorium, can offer so good an excuse for long-continued treatment as to those addicted to the use of drugs. It is certain that the person who makes a weekly charge to such patients is rarely honest with them or tries to shorten their stay. Several years ago I freely and without reservation gave all the details of my treatment to the medical world, and though many institutions have endeavored to install it as a part of their own curative policy, most have failed. The failure may be attributed principally, if not wholly, to the fact that few have also adopted the necessary principle of a fixed charge, without regard to the length of time the patient is under treatment. The weekly charge, with its attendant temptation to keep the patient as long as possible, has invariably defeated all possibilities of success.
There is also a class of institutions in which the “cure” for the drug habit consists in the administration of the drug itself in a disguised form. In such surroundings a patient will contentedly stay indefinitely, for the chains of his habit bind him to the spot. The very fact that he wishes to stay may be accepted as a proof that he has not been benefited by it. For the man who has been freed from a drug habit desires a normal life in the world; indeed, only his reëntrance into its turmoil and bustle can set him surely on his feet.
The average sanatorium, accustomed to the time-honored and thoroughly established system of making its patients comfortable,—in other words, pampering and coddling them,—finds it difficult, if not impossible, to conform in every detail to the necessities of a system like mine.
Even if the institution is equipped with every possible facility, it is highly probable that the physicians in charge may be mentally unfitted to the work. Inured by every detail of their training to methods that make a successful treatment of drugs impossible, they find themselves incapable of changing when confronted by specific cases that demand a radically different treatment. The institutions themselves are equally inadaptable. The sanatorium, it must be remembered, is really a boarding-house or hotel, and the business of boarding-house or hotel, whether it presents an epicurean or “sanitary” bill of fare, or whether its staff is supplemented by trained nurses and physicians or not, remains a boarding-house or hotel. Its main province is to keep its paying guests and to make them comfortable.
The whole sanatorium situation so far as it relates to the “cure” of those addicted to the use of drugs and alcohol may be summed up in a few words. The average sanatorium is merely a small colony of drug-users. No one can deny that. Now, no man who has been freed from his desire for drugs and no one who is being made uncomfortable by deprivation will remain in such surroundings for any length of time. The natural conclusion is that such institutions are not accomplishing what they have promised to be able to accomplish. The inmates are still drug-users. This is not true of American institutions alone. Within a few months I have had as an eleven-day inmate of my own institution a very wealthy man who has made three European journeys to find relief from the drug habit, on each journey going the rounds of six or eight celebrated institutions, and taking the treatment of each without result. Successful treatment is brief treatment, and no establishment operating upon a system of a weekly charge to patients will make an earnest effort to release these patients as soon as possible. In their desire to make their patients comfortable, and so prolong their stay, their usual quantity of drugs is supplied to them, though of course in some disguised form. There is no other way of accomplishing this.
Moreover, so long as a patient is thus kept comfortable, he is unable to describe his symptoms, for he does not feel them. The drug, therefore, hides exactly those details of a man’s condition that it is essential for the attending physician to know. In a normal man the presence of pain is always a guide for a physician, but in a drugged case this is always absent. The constant drugging that conceals the symptoms of organic ailment may permit one of comparative insignificance at the time a patient entered a sanatorium to become incurable before he leaves. Thus the result of his stay may mean in the end a serious or even fatal deterioration.
And the prolonged stay becomes a means, intentional or unintentional, of mulcting the patient or his friends of money. The sum annually spent in the United States upon useless sanatorium treatment must certainly amount to millions. I have had patients come to me from such institutions to which they had paid sums as large as $10,000. Wealthy people are specially likely to become victims of this form of rapacity, and a mere glance at some of the receipted bills that I have seen in their possession is enough to stagger a modest financial imagination. The ingenuity with which a sanatorium manager devises “extras” is worthy of the name of genius. And the physically incurable patient is often retained in the sanatorium till his money or the money of his friends is exhausted in a needless sacrifice to greed.
THE PHYSICIAN’S ATTITUDE TOWARD THE DRUG-USER
It is also necessary to direct attention to some of the errors of the general medical practitioner who deals with cases of this sort. It is not unnatural for a doctor to hesitate at the thought of surrendering his patient into strange hands. There may be unselfish as well as purely mercenary reasons for this hesitation. The doctor may hope that he himself can aid the sufferer, and may therefore endeavor to administer this treatment either in the patient’s home or possibly in his own residence or private hospital. The patient is likely to be as much inclined to this course as the doctor, for the doctor is his friend and confidant, and he dislikes intensely the idea of revealing what he regards as the shameful secret of his enslaved soul to strangers’ ears. Treatment in the doctor’s or the patient’s own environment must of necessity be an expensive matter, but if the patient can afford it, he is likely to desire it. This is most natural, especially if the patient is one of the tens of thousands who have tried the treatment offered by a sanatorium and found it not only valueless, but horrifying. There are, too, many patients who from sheer lack of funds naturally desire a home administration of the treatment as a means of saving expense. Of course many of the most worthy cases are to be found among people of moderate or small means. The drug habit is itself impoverishing.
Even so I find myself irresistibly impelled to advise against any attempt to treat such cases in their own environment, or in any environment improvised by a local doctor. This I do only because I have known so many cases of utter failure, so many cases where the sufferer’s final hope has been destroyed by such experiments.
PRIVATE ADMINISTRATION OF TREATMENT NOT SUCCESSFUL
The friendship existing between a physician and his patient must often disarm the former and incapacitate him for the strict dealing that is required in a treatment like mine. The mere fact that in caring for a friend or one of his regular patients the doctor feels unwilling to exact a definite charge in advance is a certain handicap here, as is also the fact that each patient needs continual watching, and no doctor can afford to devote his entire time and constant medical attention to one patient. The average doctor in private practice, moreover, finds it impossible to secure upon demand nurses of sufficient moral responsibility and medical assistants of sufficient technical training to coöperate with him in the work. Above all, I find that only when the patient is on premises other than his own, in unfamiliar surroundings where he is subject to a strict and inviolable discipline, can the best results be obtained. The doctor who administers this treatment, if he is to win, must have every advantage. Hospital surroundings, unfamiliar nurses, and strange assistant doctors are of great value; but payment in advance may be regarded as the most effective means for inducing the patient to complete the necessary course. An amazing number of people have come to me who have confessed that while they have from time to time tried other treatments, they have never completed one of them. Others come in a skeptical frame of mind. I can mention one such who had been three times to Europe, each time on the advice of the very doctor who, as the patient was aware, had been responsible for his forming the habit.
No physician in private practice should ever attempt to relieve a patient from a drug habit in a manner incidental to the conduct of his practice, though it is nevertheless true that the temptation for doctors to attempt this are extraordinary. A patient who becomes aware that his physician knows of a treatment which will bring relief is likely to bring to bear upon the physician every possible pressure in the effort to induce him to administer it. The doctor must be liberal indeed who, having made such an attempt and failed to achieve good results with it, will acknowledge that he was mistaken at the start.
THE NECESSITY OF A FIXED CHARGE FOR TREATMENT
The advantage of a definite charge, paid in advance, was a discovery that I made early in my work. With a large proportion of my patients it would otherwise have been impossible for me to obtain the definite medical result which has characterized my work.
It is quite impossible to make an intelligently satisfactory mental or physical diagnosis of any patient brought to me until he has been entirely freed from the drug which he has been taking. As soon as this has been fully accomplished, it is possible to consider the case carefully. It is also necessary to make an invariable rule that no person entering my institution for treatment shall be permitted to come into contact with any other person who is there for treatment, for there can be nothing psychologically worse than the discussion of symptoms and the exchange of experiences among people under treatment. It is also a rule that in the institution physicians employed in the establishment shall not become intimate with the patients or spend with them any time not necessarily devoted to professional investigation and attendance.
Nurses also must be as businesslike as possible in all their relationships with patients, and must do as little hand-holding and sympathizing as possible even in the cases of ultra-nervous women patients. It is a principle of the average sanatorium to encourage the “sympathetic” nurse. Wittingly or unwittingly, the old-time sanatorium made a practice of manufacturing habitual sanatorium inmates. The most hopeless cases I have ever seen have been those who have become inured to wearing sanatorium stripes. Such will never change their tailor till their pocket-book becomes empty.
Another detail of my treatment not easily compassed in the average sanatorium is to consider every case as an individual case, to be dealt with individually. In private practice this is often overlooked, and to this I also attribute many failures in treatment. The individuality of every case must be borne in mind not only throughout the treatment itself, but afterward, during the period of recuperation. The case itself is sure to indicate in some measure the further treatment which should be followed in the period immediately succeeding the patient’s discharge from my institution, and very frequently indicates, in fact, the necessity for consultation with other specialists and for a surgical operation. After the patient has been relieved of drugs comes the time to begin the necessary physical upbuilding by means of exercise. Although I may have seemed to condemn the sanatorium, I must add now that some institutions are specially qualified to assist in this building-up process. Some health-building institutions that devote their entire attention to strengthening their patients by means of physical exercise are doing wonderfully good work.
The fact that my methods in treating these cases have prevented me, and will prevent me, from becoming directly or indirectly interested in any institution other than my own, in New York City, gives me a freedom in offering advice to patients concerning what they should do after they have left my care that I should not feel if my institution were operated upon the old-time keep-them-as-long-as-you-can plan. I find it possible to suggest physical exercise and even professional training to those who especially need it with entire disinterestedness, just as I find it possible to suggest to some an investigation of some religious influence.
It must be laid down as an axiom that the patient must have a mental as well as a physical change before the treatment can accomplish all the good of which it is capable. Such a mental change is highly improbable in the comfortable surroundings of the average sanatorium. No man or woman ever achieved it by sitting on a pleasant veranda in an easy-chair exchanging tales of symptoms with other invalids.
THE REASON FOR THE FIXED CHARGE
The principal consideration which has influenced me in shaping my policy of a definite charge and limiting the length of stay of my patients has been the fact that I find it impossible when the effect of the drug has been perfectly eliminated to hold most of the patients under restraint. The man who has won freedom from his habit feels sure of himself; he desires to get away, and he is not afraid to go out into the world, where it may be possible for him to get the drug again. He will not yield to the temptation to get it, partly because he will not want it, and partly because he knows the horror of the habit and does not wish to become involved in it again. As a matter of fact, one of the hardest tasks I have is that of inducing people to stay as long with us as we think necessary, although their prolonged stay means no additional payment to us and no additional expense to them.
That is one of the principal arguments against colonization; and it is as much an argument against the average municipal or state institution as it is against the average sanatorium. The theory of colonization in this matter is all wrong.
The question of a definite charge has as much influence on my own attitude as on that of the patient. From the fact that I know when a patient enters my house that I can get no further money from him or her beyond the advance payment I gain a distinct advantage. I do not feel it necessary to cater to my patient’s whims, nor do I feel it necessary to sacrifice any portion of the necessary routine of the treatment because the patient may be rich or influential and may make extraordinary demands upon me. All that I have to do is to go ahead along those lines which I know are effective and which will gain results.
The effect of this system is equally admirable upon the members of my medical staff, for our efforts are devoted not to keeping the patient as long as possible for the purpose of increasing revenue but to getting rid of him as quickly as possible, so that the profit will be relatively large. That it is to his advantage as well as to mine to see that the treatment is complete and effective before the patient leaves is obvious.
These methods take into consideration my own and my patient’s psychology. A man who deals with this type of patient needs every advantage which he can get, for invariably he is dealing with abnormalities.
PHYSICAL DEFECTS REVEALED BY TREATMENT
The treatment itself is certain to uncover these abnormalities, revealing whether or not they are due to physical causes. It becomes very quickly evident if there is any real physical reason why a patient is not eligible for treatment, as in the case of an incurable and painful physical ailment. No matter how careful and frank a patient’s statements may be or how elaborate the diagnosis that his physician has transmitted to me, no matter how elaborately careful are the preliminary examinations made by my own physician, it is not until the drug has been entirely eliminated that we find it possible to make a really intelligent diagnosis. The symptoms of disease, however, are sure to appear before the first part of the treatment is completed. It is a standard policy of my hospital at once to inform a patient who has proved to be physically ineligible, and to return to him his fee.
This method of procedure has made us careful before accepting patients to study their histories, for, naturally, we do not wish to do even preliminary work and then return the fee in full. We accept no patient for treatment until we are provided with a careful and detailed history of his case, and it is upon a large collection of such histories that I have based many of the theories embodied in the subject matter of this book. It is especially these detailed histories which have enabled me to fix with some accuracy of judgment the circumstances leading up to the formation of most drug habits. In our invariable practice of returning the fee and discharging the patient whom we find ineligible for treatment we have surely taken a step in advance. There is scarcely an institution of this sort in the United States to which a patient might write, “I am taking drugs,” without receiving in reply the invitation, “Come to us, and we will treat you,” implying that they will give the treatment whether or not an examination of the patient shows that he is one who can benefit from it.
THE DUTY OF THE MEDICAL PROFESSION
The victim of drugs, whether he is rich or poor, old or young, good or bad, deserves the public sympathy in a measure scarcely equaled by any other class. These folk are sick folk in every way I can possibly think of. I am attempting to see to it that they are protected by every safeguard from being victimized. It is my hope that through continual and untiring education I may force the state medical institutions throughout the country to assume their rightful responsibility in providing proper care for drug victims who have slight means or none. I purpose to work toward the awakening of the medical profession to its responsibility not only in regard to the growth of new crops of drug-users, but to the care and relief or sequestration from medical practice of those among its own members whose condition warrants action.
Perhaps this last step should be the first one to be taken. I have given it much thought, and can see only one way out of the veritably infernal tangle in which the medical profession has enmeshed itself. That would involve a conference between delegates from the medical societies of the various States to form a plan whereby the medical profession as a whole or in groups might establish and support an institution or a number of institutions. These should be backed by the most eminent and conscientious men in the profession. They should be managed by men fully competent, and should be open not only to physicians who need treatment and are unable to pay for it at a private institution, but to all patients, in the certainty that there they will receive the proper treatment, properly administered, and at a reasonable charge. I purpose furthermore that every institution under private management in the United States shall by law be held responsible for its methods of treatment.
LEGISLATION TO REGULATE SANATORIUMS
There should be the most drastic legislation compelling all physicians and institutions accepting this class of patients for treatment to report periodically to the board of health which has jurisdiction in their district whenever, after a three weeks’ medical supervision, they still require the administration of habit-forming drugs. It is only reasonable that any institution accepting a patient for this treatment, and failing to secure favorable results within a period of twenty-one days, should report the case to the authorities, giving detailed reasons for the failure of the patient to respond to treatment.
The general adoption of this rule of procedure would mean that a class of unfortunates who have never had any protection from any source would be immediately provided with definite medical help. An accompanying provision would insist that patients who for physical reasons are found to be ineligible for treatment—unable, that is, to exist in comfort without regular doses of their drug—will be relieved of all sense of disgrace arising from this necessity, and will be preserved from victimization, and will find it possible to get the drug without difficulty and at reasonable prices, if necessary, from the boards of health themselves. If this plan accomplished nothing more than to prevent the operation of medical fraud against sufferers for a period longer than three weeks, it would even then have accomplished an extraordinary good.
I have in my present hospital only fifty beds, and as a rule I receive and discharge about four patients a day. Were my institution operated along the colonization lines which are common in the United States, the volume of business which I handle in a year, running well above a thousand patients, would require not fifty, but at least five hundred beds, and rooms in proportion. This statement of the exact situation in my own institution may possibly explain existing conditions in some others.
It must not be understood that I attribute all the efforts at colonizing drug-users to unworthy motives. Much of it has been due to the complete ignorance of the medical profession in regard to this form of affliction. Finding itself unable intelligently to cope with conditions, it seeks the line of least resistance and adopts the colonizing sanatorium, with all its evils, as the best plan that can be found. When I first took up this work I went for information and assistance not to the humble members of the medical profession, but to the most eminent men whom I could find. Even these men invariably admitted their ignorance of the nature of the drug habit and the means for its relief. I was told by some of the best-known neurologists in the world that out of thousands of patients whom they and their confrères had sent to the best-known and most conscientiously operated institutions in the country not one had really been helped. They assured me that if I had found something which would give actual and material aid in any degree to even five per cent. of the drug victims who were sent to me for treatment, I would be doing more than any man had ever done before.