HABITS THAT HANDICAP

HABITS
THAT HANDICAP
The Menace of Opium, Alcohol, and Tobacco,
and the Remedy

BY
CHARLES B. TOWNS

NEW YORK
THE CENTURY CO.
1916

Copyright, 1915, by
The Century Co.
Published, August, 1915

PREFACE

It is interesting to note that a year or more ago a few deaths from bichlorid of mercury poisoning caused within a period of six months a general movement toward protective legislation. This movement was successful, and after the lapse of only a short time the public was thoroughly protected against this dangerous poison. It will be observed that the financial returns from the total sale of bichlorid of mercury tablets could be but small. Had the financial interests involved been of a magnitude comparable with those interested in the manufacture and promotion of habit-forming drugs, I have often wondered if the result would not have been less effective and as prompt. Bichlorid of mercury never threatened any large proportion of the public, and those falling victims to it merely die. Opium and its derivatives threaten the entire public, especially those who are sick and in pain, and with a fate far more terrible than death—a thraldom of misery, inefficiency, and disgrace.

Lest somewhere there be found within the pages of this book remarks that may lead the reader to suppose that I unduly criticize the doctor, and therefore that I am the doctor’s enemy, I feel that it behooves me to add that in the whole community he has not one admirer more whole-souled.

PREFACE

Some years ago, Mr. Charles B. Towns came to me with a letter from Dr. Alexander Lambert and claimed that he had a way of stopping the morphia habit. The claim seemed to me an entirely impossible statement, and I told Mr. Towns so; but at Dr. Lambert’s suggestion, I promised to look into the matter. Accordingly, I visited Mr. Towns’s hospital, and watched the course of treatment there at different times in the day and night. I became convinced that the withdrawal of morphine was accomplished under this treatment with vastly less suffering than that entailed by any other treatment or method I had ever seen. Subsequently, I sent Mr. Towns several patients, who easily and quickly were rid of their morphia addiction, and have now remained well for a number of years.

At that time I had the impression that the treatment was largely due to the force of Mr. Towns’s very vigorous and helpful personality, but when subsequently a similar institution was established near Boston, I became convinced by observation of cases treated in that hospital that Mr. Towns’s personality was not an essential element in that treatment. His skill, however, in the actual management of cases, from the medical point of view, was very hard to duplicate, and Mr. Towns generously came from New York, when called upon, and showed us what was wrong in the management of cases which were not doing well. I do not hesitate to say that he knows more about the alleviation and cure of drug addictions than any doctor that I have ever seen.

All the statements made in this book except those relating to tobacco I can verify from similar experiences of my own, since I have known and used Mr. Towns’s method of treatment.

I do not pretend to say how his treatment accomplishes the results which I have seen it accomplish, but I have yet to learn of any one who has given it a thorough trial who has obtained results differing in any considerable way from those to which Mr. Towns refers.

The wider applications and generalizations of the book seem to me very instructive. The shortcomings of the medical profession, of the druggists, and those who have to do with the management of alcoholics in courts of law seem to me well substantiated by the facts. Mr. Towns’s plans for legislative control of drug habits also seem to me wise and far-reaching. He is, I believe, one of the most public-spirited as well as one of the most honest and forceful men that I have ever known.

I am glad to have this opportunity of expressing my faith and confidence in him and my sense of the value of the book he has written.

Richard C. Cabot.

INTRODUCTION

There is only one way by means of which humanity can be relieved of the curse of drug using, and that is to adopt methods putting the entire responsibility upon the doctor. Until the present legislation was passed in New York State, no one had ever considered the doctor’s responsibility; this most valuable medical asset and most terrible potential curse had been virtually without safeguard of any effective kind. Discussion of the drug problem in the press dealt wholly with those phases which make themselves manifest in the underworld or among the Chinese. I am reasonably certain that until very recently the world had heard nothing of the blameless men and women who had become drug-users as the result of illness. This seems strange, since there are in the United States more victims of the drug habit than there are of tuberculosis. It is estimated that fifteen per cent, of the practising physicians in the country are addicted to the habit, and although I think this is an exaggeration, it is nevertheless true that habit-forming drugs demand a heavy toll from the medical profession, wrecking able practitioners in health and reputation, and of course seriously endangering the public.

I have elsewhere explained the fact that the medical man himself is ignorant of the length to which he can safely go in the administration of drugs to his patients. If he is ignorant of what quantity and manner of dosage constitutes a peril for the patient, is it not reasonable to suppose that similar ignorance exists in his mind with regard to his own relations with the drug habit? As a matter of fact, I know this to be the case; many physicians have come to me for help, and ninety-nine per cent. of them explained to me that their use of drugs was the direct outgrowth of their ignorance. If the man who practises medicine is unaware of what will bring about the habit, what can be expected of the medically uneducated citizen who is threatened by those in whom he has most confidence—his doctors?

The wide extent of the drug habit in this country has not been apparent. The man suffering from a physical disease either shows it or makes it known; the man suffering from the drug habit presents unfamiliar and unidentified symptoms, and far from being willing to make his affliction known, through shame he tries to conceal it at all hazards. Until legislation forced the victims of drug habits by hundreds into Bellevue Hospital in New York, this great institution rarely had one as a patient. The sufferer from tuberculosis would seek this hospital, feeling that there he might find measurable relief; the drug-user shunned it, for he was doubtful of receiving aid, and above all things he dreaded deprivation without relief. No man or woman will go to any institution for relief from the drug habit where the only treatment offered is that of enforced deprivation, for he or she knows perfectly well that deprivation means death. No human longing can compare in intensity with that of the drug-user for his drug. Unrelieved, he will let nothing stand between him and it; neither hunger, nakedness, starvation, arson, theft, nor murder will keep him from the substance that he craves. Clearly humanity must be protected against such an evil. And the physician must be saved from it, for saving him will fulfil in a large measure the demand for the protection of the public.

After the experience of the medical profession of New York State with the workings of the Boylan Act, it is scarcely probable that strong opposition to similar legislation will be made in other States. Even if other States delay in the enactment of right legislation, the Boylan Act may be considered not only a protective measure for the profession and the people of New York State, but it may be safely accepted as an educational pronouncement for the benefit of the medical profession everywhere. It establishes for the first time the danger-line.

CONTENTS

HABITS THAT HANDICAP

HABITS THAT HANDICAP

CHAPTER I

THE PERIL OF THE DRUG HABIT

It is human nature to wish to ease pain and to stimulate ebbing vitality. There is no normal adult who, experiencing severe pain or sorrow or fatigue, and thoroughly appreciating the immediate action of an easily accessible opiate, is not likely in a moment of least resistance to take it. Every one who has become addicted to a drug has started out with small occasional doses, and no one has expected to fall a victim to the habit; indeed, many have been totally unaware that the medicine they were taking contained any drug whatever. Thus, the danger being one that threatens us all, it is every man’s business to insist that the entire handling and sale of the drug be under as careful supervision as possible. It is not going too far to say that up to the present time most drug-takers have been unfairly treated by society. They have not been properly safeguarded from forming the habit or properly helped to overcome it.

It has been criminally easy for any one to acquire the drug habit. Few physicians have recognized that it is not safe for most persons to know what will ease pain. When an opiate is necessary, it should be given only on prescription, and its presence should then be thoroughly disguised. A patient goes to a physician to be cured; consequently, when his pain disappears, he naturally believes that this is due to the treatment he has received. If the physician has used morphine in a disguised form, the patient naturally believes that the cure was effected by some unknown medicine; but if, on the other hand, he has received morphine knowingly, he realizes at once that it is this drug which is responsible for easing his pain. If he has received it hypodermically, the idea is created in his mind that a hypodermic is a necessary part of the treatment. Thus it is clear that the physician who uses his syringe without extreme urgency is greatly to be censured, for the patient who has once seen his pain blunted by the use of a hypodermic eagerly resorts to this means when the pain returns. Conservative practitioners are keenly aware of this responsibility, and some go so far as never to carry a hypodermic on their visits, though daily observation shows that the average doctor regards it as indispensable. The conservative physician employs only a very small quantity of morphine in any form. One of the busiest and most successful doctors of my acquaintance has used as little as half a grain a year, and another told me he had never gone beyond two grains.

Both of these men know very well that only a small percentage of drug-takers have begun the practice in consequence of a serious ailment, and that even this small percentage might have been decreased by proper medical treatment directed at the cause rather than at its symptom, pain. An opiate, of course, never removes the cause of any physical trouble, but merely blunts the pain due to it; and it does this by tying up the functions of the body. It is perhaps a conservative estimate that only ten per cent. of the entire drug consumption in this country is applied to the purpose of blunting incurable pain. Thus ninety per cent. of the opiates used are, strictly speaking, unnecessary. In the innumerable cases that have come under my observation, seventy-five per cent. of the habitual users became such without reasonable excuse. Beginning with small occasional doses, they realized within a few weeks that they had lost self-control and could not discontinue the use of the drug.

FORMING THE HABIT

A very common source of this habit lies in the continued administration of an opiate in regular medical treatment without the patient’s knowledge or consent, or in the persistent use of a patent medicine, or of a headache or catarrh powder that contains such a drug.

The man who takes an opiate consciously or unconsciously, and receives from it a soothing or stimulating or pleasant effect, naturally turns to it again in case of the same need. The time soon arrives when the pleasurable part of the effect—if it was ever present—ceases to be obtained; and in order to get the soothing or stimulating effect, the dose must be constantly increased as tolerance increases. With those who take a drug to blunt a pain which can be removed in no other way, it is fulfilling its legitimate and supreme mission and admits of no substitute. Where it was ever physically necessary, and that necessity still continues, an opiate would seem inevitable. But the percentage of such sufferers, as I have said, is small. The rest are impelled simply by craving—that intolerable craving which arises from deprivation of the drug.

But whether a man has acquired the habit knowingly or unknowingly, its action is always the same. No matter how conscientiously he wishes to discharge his affairs, the drug at once begins to loosen his sense of moral obligation, until in the end it brings about absolute irresponsibility. Avoidance and neglect of customary duties, evasion of new ones, extraordinary resourcefulness in the discovery of the line of least resistance, and finally amazing cunning and treachery—this is the inevitable history.

The drug habit is no respecter of persons. I have had under my care exemplary mothers and wives who became indifferent to their families; clergymen of known sincerity and fervor who became shoplifters and forgers; shrewd, successful business men who became paupers, because the habit left them at the mercy of sharpers after mental deterioration had set in. But the immediate action of morphine by no means paralyzes the mental faculties. Though when once a man becomes addicted to the drug he is incapacitated to deal with himself, yet while he is under its brief influence his mind is sharpened and alert. Under the sway of opium a man does venturesome or immoderate things that he would never think of doing otherwise, simply because he has lost the sense of responsibility. I have had patients who took as much as sixty grains of morphine in a single dose, an overdose for about one hundred and fifty people, and about fifty grains more than the takers could possibly assimilate or needed to produce the required result—an excellent illustration of how the habit destroys all judgment and all sense of proportion.

Against this appalling habit, which can be acquired easily and naturally and the result of which is always complete demoralization, there is at present no effective safeguard except that provided by nature itself, and this is effective only in certain cases. It happens that in many people opium produces nausea, and this one thing alone has saved some from the habit; for this type of user never experiences any of the temporarily soothing sensations commonly attributed to the drug. Yet this pitiful natural safeguard, while rarely operative, is more efficacious than any other that up to the present has been provided by man in his heedlessness, indifference, and greed.

DANGERS OF THE HYPODERMIC SYRINGE

I have seen over six thousand cases of drug habit in various countries of the world. Ninety-five per cent. of the patients who have come to me taking morphine or other alkaloids of opium have taken the drug hypodermically. With few exceptions, I have found that the first knowledge of it came through the administration of a hypodermic by a physician. It is the instrument used that has shown the sufferer what was easing his pain. I consider that among those who have acquired the habit through sickness or injury this has been the chief creator of the drug habit. This statement does not apply to those who have acquired the habit through the taking of drugs otherwise. My work has been carried out almost entirely in coöperation with the physician, and I have not come in contact with the under-world drug-takers. I consider that the syringe has been the chief creator of the drug habit in this country. In 1911 I made this statement before the Ways and Means Committee of the United States Congress, then occupied with the matter of regulating the sale of habit-forming drugs, and I personally secured the act which was passed by the New York legislature in February, 1911, to restrict the sale of this instrument to buyers on a physician’s prescription. Before that time all drug stores and most department stores sold hypodermic instruments to any one who had the money. A boy of fifteen could buy a syringe as easily as he could buy a jack-knife. If a physician refused to give an injection, the patient could get an instrument anywhere and use it on himself. This bill has passed only a single legislature, but I am arranging to introduce a similar bill before all the others, and hope to have the State action confirmed by a Federal bill. At present in Jersey City, or anywhere out of New York, any one may still buy the instrument. It is inconceivable that the syringe should have gone so long without being considered the chief factor in the promotion of a habit which now alarms the world, and that as yet only one state legislature should have seen fit to regulate its sale. Restricting the sale of the syringe to physicians, or to buyers on a physician’s prescription, is the first step toward placing the grave responsibility for the drug habit on the shoulders of those to whom it belongs.

HABIT-FORMING DRUGS IN PATENT MEDICINES

The second step to be taken is to prevent by law the use of habit-forming drugs in patent and proprietary medicines which can be bought without a physician’s prescription. Prior to the Pure Food and Drugs Act, created and promoted by Dr. H. W. Wiley, druggists and patent-medicine venders were able, without announcing the fact, to sell vast quantities of habit-forming drugs in compounds prepared for physical ailments. When that act came into effect, these men were obliged to specify on the label the quantities of such drugs used in these compounds, and thus the purchaser was at least enabled to know that he was handling a dangerous tool. Except in a few States, however, the sale of these compounds was in no way restricted, and hence the act cannot be said to have done much toward checking the formation of the drug habit. Indeed, it has probably worked the other way, for there is perhaps not an adult living who does not know that certain drugs will alleviate pain, and people who have pains and aches are likely to resort to an accessible and generally accredited means of alleviation. Yet the difficulties in the way of passing the Pure Food and Drugs Act are a matter of scandalous history. What, then, would be the difficulties in passing a Federal bill to restrict the sale of patent medicines containing habit-forming drugs? It is of course to the interest of every druggist to create a lasting demand for his article. There is obviously not so much profit in a medicine that cures as in one that becomes indispensable. Hence arises the great inducement, from the druggist’s point of view, in soothing-syrups and the like. In this country all druggists, wholesale and retail, are organized, and the moment a bill is brought up anywhere to correct the evil in question, there is enormous pressure of business interests to secure its dismissal or satisfactory amendment.

To show the essential selfishness of their position, it is only necessary to quote a few of the arguments used against me before the Congressional Ways and Means Committee when I was making a plea for the regulation of the traffic in habit-forming drugs. They claimed that registration of the quantities of opiates in proprietary medicines would entail great bother and added expense, that these drugs are usually combined with others in such a way as to result in altering their effect on the user, and that, anyway, so small an amount of these drugs is used that it cannot create a habit. Now, as a matter of fact, the combination of medicines in these remedies makes not the slightest difference in the physiological action of the drug; further, it is found that, just as with the drug itself, the dose of these compounds must be constantly increased in order to confer the same apparent benefit as in the beginning; and finally, it is well known that what creates the craving is not the quantity of the drug, but the regularity with which it is taken. A taker of one eighth of a grain of morphine three times a day would acquire the habit just as surely as a man who took three grains three times a day, provided the latter could tolerate that quantity.

The average opium-smoker consuming twenty-five pills a day gets only the equivalent of about a quarter grain of morphine taken hypodermically or of a half grain taken by the mouth. A beginner could not smoke a quarter of that quantity, but still he acquires the habit. Any amount of the drug which is sufficient to alleviate pain or make the taker feel easier is sufficient to create a habit. A habit-forming drug having no curative properties whatever is put into a medicine merely for the purpose of making the taker feel easier. One wholesale house alone prepares and sells six hundred remedies containing some form of opiate. Most of the cases of the cocaine habit have been admittedly created by so-called catarrh cures, and these contain only from two to four per cent. of cocaine. In the end, the snuffer of catarrh powders comes to demand undiluted cocaine; the taker of morphine in patent medicines, once the habit is formed, must inevitably demand undiluted morphine.

This easy accessibility of drugs in medicinal form is more dangerous than moralists care to admit. The reason why opium-smoking has been, up to the present, less prevalent in the United States than in China and some other countries is probably that the preparation of it and the machinery for taking it are not convenient. If opium-smoking had been generally countenanced in America, if the sale of the pure drug had been for generations permitted here, as it has been in China, if houses for its sale and preparation had been found everywhere, if its social aspects had been considered agreeable, if society had put the stamp of approval upon it, opium-smoking would be as prevalent here as it has been in China. Our human nature is essentially little different from that of the Chinese, but lack of opportunity is everywhere recognized as a great preservative of virtue. Due allowance being made for the difference of moral concepts, our standards of morality and honesty and virtue are certainly no higher than those of the Chinese. Thus, were the conditions the same in both cases, there is no reason to suppose that opium would not be smoked here as much as there; but fortunately it has not yet become thus easy, convenient, and agreeable, and consequently that particular phase of the evil has not yet reached overwhelming proportions. On the other hand, the alkaloids of opium administered hypodermically or as ingredients in many patent medicines are thus convenient, and as a result this phase of the evil has reached overwhelming proportions. Nor have we any cause for congratulation upon our particular form of the vice, for opium-smoking is vastly less vicious than morphine-taking.

THE TRAFFIC IN OPIUM

Something more is needed, however, than mere restriction of the sale of hypodermic syringes and patent medicines by any one legislature or country. All persons who handle habit-forming drugs should be made to give a strict accounting for them, otherwise the traffic can never be properly regulated. Four years ago, by special act of Congress, all importation of prepared opium and of crude opium designed for smoking purposes was prohibited. In the ample interval between the passage of the bill and its going into effect the importation of opium was simply phenomenal. By the time it went into effect the American dealers had learned the secret process of preparing opium for smoking, which had hitherto been known only in the Orient. Thereafter it was found that since responsible importing houses were still at liberty to import crude opium in any quantity for general medicinal use, the retailers could buy and were buying from importers all the crude opium they wished and preparing it themselves without having in any way to account for the use they meant to make of it, although that use had now become illegal. The result was that the smoker could get opium more easily than before, since the secret process of preparing it had become known; and having no longer to pay the enormous tax on prepared opium, he got it much cheaper. In short, the only difference was that the Government lost about one million five hundred thousand dollars a year in revenue, while the vice was greatly increased. Thus the act had worked in precisely the opposite way from the intention of the framers, and all because men are permitted to handle opium without accounting for it. Until there is such an accounting, there can be no real regulation of the opium trade.

Congress has just passed a bill aiming to regulate the traffic in habit-forming drugs. I wish to go on record here as saying that this bill will not accomplish its purpose, and should be further amended to prove effective. But it will be only a matter of time when there will be amendments proposed, which, if adopted, will create legislation on this subject worth while.

The history of the Opium Commission appointed by Mr. Taft is sufficient to show how any less comprehensive regulation would act. When Mr. Taft was Governor-General of the Philippines, he found that an enormous quantity of opium was being smoked by the natives and the large Chinese settlement, of whom it was estimated that fifty-five thousand were smokers. He appointed a commission headed by Bishop Brent, now stationed at Manila, who has since headed two international opium conferences, at Shanghai in 1909 and at The Hague in 1911. Mr. Taft sent the commission into the most important opium-producing countries to find out how they were dealing with the problem and what progress was being made toward decreasing the use of the drug. The nearest approach they found to a reform was the method of the Japanese in their newly acquired island of Formosa. Japan, with the most stringent regulation of the sale of opium in the world, had made it a government monopoly in Formosa, had compelled the registration of all smokers, and was gradually lessening the amount which each smoker could buy. After the exhaustive report of the commission, our Government adopted the same tactics in the Philippines. To the surprise of the officials, they found that out of the fifty-five thousand opium-smokers they could obtain a registration of only from ten to twelve thousand, which meant that the great majority were getting smuggled opium. By special act of Congress the authorities at Manila were allowed to stop the importation of opium entirely. But this, while it meant a great loss of revenue to the local government, apparently did not lessen the amount smoked. After the sale was stopped, there were virtually no voluntary applications for opium treatment, as there must have been if anybody’s supply had been cut off, which conclusively showed that nobody had discontinued the habit merely because importation had been discontinued. Stopping importation, then, is a farce, unless at the same time there is rigid governmental control in those countries that produce or import the drug. And, therefore, unless there should be a coöperation of all governments, it is futile to try to regulate the traffic. As long as people can get opium, they will smuggle it.

It has been demonstrated to be quite practicable for all the opium-producing countries to make the drug a government monopoly; it would be equally practicable for them to sell directly to those governments that use it for governmental distribution. The only obstacle to an international understanding is that the producing countries know very well that government regulation would materially lessen the sale of the drug. Within the borders of our own country such a system would simplify rather than complicate present conditions. We have to-day along our frontier and in our ports inspectors trying to stop the illicit traffic in opium, and the money thus spent by our Government would be more than sufficient to handle and distribute all of the drug that is needed for legitimate purposes. Any druggist could of course continue to buy all that he wished, but he would have to account for what he bought. The drug would serve only its legitimate purpose, because the druggist could sell it only on prescription. This would at once eliminate the gravest feature of the case, the indiscriminate sale of proprietary and patent medicines containing small quantities of opium. The physician would thus have to shoulder the entire responsibility for the use of any habit-forming drug. With the Government as the first distributor and the physician as the last, the whole condition of affairs would assume a brighter aspect, for it would be a simple matter to get from the physician a proper accounting for what he had dispensed. Thus the new crop of users would be small, and less than ten per cent. of the opium at present brought into this country would be sufficient to meet every legitimate need.

THE HABIT-FORMING DRUGS

The important habit-forming drugs are opium, cocaine, and the small, but dangerous, group of hypnotics. These last—trional, veronal, sulphonal, medinal, etc.—are chiefly coal-tar products, and are not always classified as habit-forming drugs, but they are such, and there are many reasons why the sale of them should be scrupulously regulated. The opium derivatives go under the general head of narcotics. Morphine is the chief active principle, and codeine and heroin are the chief derivatives of morphine. Codeine is one eighth the strength of morphine; heroin is three times as strong as morphine.

Though the general impression is otherwise, the users of heroin acquire the habit as quickly and as easily as if they took morphine. Many cough and asthma preparations contain heroin, simply for temporary alleviation, since, like opium, it has no curative power whatever. From time to time I have had to treat cases of heroin-taking in which the victims had thought to satisfy their need for an opiate without forming a habit. In the cases where it was given by prescription, it was so given by the physician in the sincere belief that it would not create a habit. All this despite the fact that heroin is three times stronger than morphine, and despite the fact that physicians know that anything which will do the work of an opiate is an opiate. Codeine, notwithstanding the fact that it is weaker than morphine, is likewise habit-forming; yet doctors prescribe it on account of its relative mildness, even though they know that it is the cumulative effect of continued doses, and not the quantity of morphine in the dose, which results in habit. As with morphine, to use either of these drugs effectively means in the long run the necessary increase of the dose up to the limit of physical tolerance.

The most harmful of all habit-forming drugs is cocaine. Nothing so quickly undermines its victim or provides so short a cut to the insane asylum. It differs from opium in two important ways. A man does not acquire a habit from cocaine in the sense that it is virtually impossible for him to leave it off without medical treatment. He can do so, although he rarely does. On withdrawal, he experiences only an intense and horrible depression, together with a physical languor which results in a sleepiness that cannot be shaken off. Opium withdrawal, on the other hand, results in sleeplessness and extreme nervous and physical disorder. In action, too, cocaine is exactly the opposite of opium, for cocaine is an extreme stimulant. Its stimulus wears off quickly and leaves a corresponding depression, but it confers half an hour of capability of intense effort. That is why bicycle-riders, prize-fighters, and race-horses are often doctored, or “doped,” with cocaine. When cocaine gives out, its victim invariably resorts to alcohol for stimulus; alcoholics, however, when deprived of alcohol, generally drift into the use of morphine.

The widespread use of cocaine in the comparatively short period of time since its discovery has been brought about among laymen entirely by patent-medicine preparations containing small quantities of it. These have been chiefly the so-called catarrh cures, which of course cure nothing. With only a two or four per cent. solution, they have created a craving, and in the end those who could do so have procured either stronger solutions or the plain crystal. As with the other drugs, in order to maintain the desired result the dose must be increased in proportion as tolerance increases. Wherever the sale of patent medicines has been restricted to those presenting a physician’s prescription, the consumption of cocaine has at once been lessened. A man cannot afford to get a physician’s prescription for a patent medicine; and even if he could, the reputable physician refuses to prescribe one that contains cocaine. When an overseer in the South will deliberately put cocaine into the rations of his negro laborers in order to get more work out of them to meet a sudden emergency, it is time to have some policy of accounting for the sale of a drug like cocaine.

It is also extremely important to regulate the sale of the hypnotic coal-tar derivatives. All the group of hypnotics should be buyable only on a physician’s prescription. They all disturb heart action and impoverish the blood, thereby producing neurotics. No physician, without making a careful examination, will assume the responsibility of prescribing for a man who comes to him in pain, yet a druggist does so constantly. He knows nothing of the customer’s idiosyncrasy; that, for instance, an amount of veronal which would not ordinarily affect a child may create an intense nervous disorder in a particular type of adult. To the average druggist a headache is only a headache; he does not know that what will alleviate one kind of headache is exceedingly bad for another kind, and furthermore it is not his business to warn the customer that a particular means of headache alleviation may perhaps make him a nervous wreck. The patient usually has the same ignorance. In a case which was once brought to my attention, a girl swallowed nine headache powders within one hour. Had there been ten minutes’ delay in summoning a doctor, she would have died; as it was, she was seriously ill for a long time.

These, then, the narcotics, cocaine, and the hypnotics, are the chief habit-forming drugs. They form habits because it is necessary to increase the dose in order to continue to derive the apparent benefit obtained from them in the beginning, and because, when once the habit is set up, it cannot be terminated without such acute discomfort that virtually no one is ever cured without medical help. In drug addictions the condition of the patient is not mental, as is generally supposed, but physical. Definite medical treatment to remove the effects of the drug itself is imperative, whether the victim be suffering from the drug habit alone or from that habit in a body otherwise physically disordered. With regard to the cure of the habit, as in the case of the conditions which permit of its being acquired, it may justly be said that the victims have been unfairly treated.

THE NEED OF CONTROL BY THE GOVERNMENT AND BY PHYSICIANS

The prevalence of the drug habit, the magnitude of which is now startling the whole civilized and uncivilized world, can be checked only in one way—by controlling the distribution of habit-forming drugs. With the Government as the first distributor and a physician as the last, drug-taking merely as a habit would cease to be. If physicians were made accountable, they would use narcotics, hypnotics, and cocaine only when absolutely necessary. Nobody should be permitted to procure these drugs or the means of using them or any medicines containing them without a doctor’s prescription. By such restriction the intense misery due to the drug habit would be decreased by nine tenths, indeed, by much more than this; for when a physician dares no longer to be content with the mere alleviation of pain, which is only nature’s way of announcing the presence of some diseased condition, he will seek the more zealously to discover and remove its cause.

CHAPTER II

THE NEED OF ADEQUATE SPECIFIC TREATMENT FOR THE DRUG-TAKER

The Internal Revenue Reports are the only index to the extent of the drug consumption in the United States. They show for years past an annual increase in the importation of opium and its derivatives and cocaine, and for last year a very marked increase over that of any preceding year. This is not due to the increase in population; our immigrants are not drug-takers. Among the thousands of drug-users that I have treated or known, I have never seen an Italian, a Hungarian, a Russian, or a Pole. Moreover, I have met with only four cases of drug-taking by Hebrews. Few Jews—except in the under-world—acquire the habit knowingly. It may become fastened upon them through the use of a medicine the danger of which they do not realize, but, once freed, they will not again come under its power. The practical sagacity of their race is their surest safeguard.

What is commonly spoken of as the “American type,” highly nervous, living under pressure, always going to the full limit, or beyond, is peculiarly liable to disorders that lead to the habitual use of drugs. We are all hypochondriacal by nature, prone to “take something” whenever we feel badly. Lack of opportunity alone, of knowledge of what to take and how to procure it, has saved many a person under severe physical or mental strain from recklessly resorting to drugs. Since the passage of the Pure Food and Drugs Act, which was intended to protect the public by requiring the express statement of any dangerous ingredients in a compound, the sale of preparations containing habit-forming drugs has preceptibly increased. It seems a just inference that the information given, instead of serving as a warning to the unwary, has been chiefly effective in pointing out a dangerous path to many who otherwise would not have known where to find it.

Women, it should be said, though constitutionally more liable than men to feel the need of medicines, form the lesser portion of the drug-taking class. In the beginning their addiction is due almost exclusively to a physician’s prescription, except in the under-world.

The habitual users of drugs in the United States come from every grade of society. Professional men of the highest responsibility and repute, laborers wearying of the dullness in a mining-camp, literary men, clergymen, newspaper men, wire-tappers, shoplifters, vagrants, and outcasts—all are among the number. Strangely assorted as they are, they become yet more strangely alike under the influence of the common habit. Shoplifting is not confined to the professional thief; it is noticeable in many a drug-user who has had every moral and worldly advantage.

The major part of the habit-forming drugs used in the United States is consumed by the under-world. It would be impossible to calculate the extent of their influence. Many a record of heinous crime tells of the stimulus of a drug. But when the school-children in some of our larger cities are found to be using cocaine, and able to buy it at will, the limit of tolerance has surely been reached.

THE DRUG-TAKING PHYSICIAN, NURSE, AND PHARMACIST

Among the widely varying classes of drug-users, three in particular are a source of the gravest danger: the drug-taking physician, nurse, and pharmacist. To realize this, one has merely to recall that the drug-taker is a confirmed evader of responsibility; and the physician, of all men, is in a responsible position. He must not forget or break his appointments; he must realize the effects of the medicines he is prescribing; if a surgeon, his work must never be below its best. But the proportion of physicians that I have treated, or consulted with, suggests one specially grave danger. It is a characteristic of the drug-taker, no matter who he is or how he acquired the habit, on the smallest excuse to advise others to take the drug whenever pain or fatigue gives the slightest occasion for it. While he grows callous to everything else, he has an abnormal sympathy with suffering. Thus it will readily be seen that there are few more dangerous members of society than the physician who is addicted to a drug.

The fact that there are not more drug-taking doctors speaks volumes for the high character of the profession. The physician has such drugs constantly at hand. The more a man knows of their insidious action and the more he handles them, the more cautious he feels himself to be, and the more confident that he can discontinue the use of them whenever he chooses. Any fear that the layman may have of them is due less to the dread of being personally overcome than to the mystery which surrounds them; but for the physician they have no such mystery. Furthermore, by the nature of his calling he is peculiarly exposed to the need of such drugs. He is often under excessive physical and nervous strain not only because he is unable to arrange his work so as to prevent periods of too great pressure upon his time and strength, but also because in a unique manner he puts his heart into it.

An even greater danger, in some respects, is the drug-taking professional nurse. Whatever has been said of physicians both in the way of extenuation and of warning may be repeated of nurses. They have the same exposure to the habit, and, once addicted, are likely to exhibit signs of irresponsibility. They are more dangerous in that their opportunity for mischief is greater, since they are closer to the patient and able to thwart the doctor’s orders with perfect freedom. “I have had several nurses on this drug case,” a doctor once said to me, “and I find that they have all smuggled morphine to my patient.” This was, no doubt, an exceptional case, but the fact remains that nurses, because of their close alliance with druggists and doctors, find it comparatively easy to purchase drugs and hypodermics at any drug store without causing the slightest suspicion or reproof. Nor should one censure them too severely for clandestine compliance with the demands of a patient. It should not be overlooked that the nurse, in being paid by the patient and not by the doctor, is ordinarily subjected to great pressure when the patient clamors for morphine. In such circumstances the protection of a physician’s monopoly of the drug would be most welcome. But how much worse is the pressure when the well-intentioned nurse also is a drug-taker! The morphinist has an abnormal sympathy with those who have undergone or are undergoing experiences similar to his own, and there is no stronger bond than that which unites two morphine victims. As a matter of the most elementary precaution for all concerned, no nurse should under any conditions be allowed to buy habit-forming drugs.

Another kind of drug-taker against whom physicians’ distribution would be a safeguard, and the only safeguard that can be devised, is the pharmacist. The contingency of a drug-taking pharmacist, perhaps more than anything else, will bring sharply home to the average man the menace of morphine when used by a professional person. By reason of closer and more personal observation one may feel rashly confident of his ability to detect when a doctor or a nurse is “queer,” but generally the patron of a drug store has no such opportunity for observation. Addiction to a drug incapacitates the pharmacist for filling prescriptions. Often the slightest deviation from a precise formula in either quantity or ingredient is of the gravest consequence, and hence the utmost care should be used to insure the scrupulousness of one on whom such responsibility rests. As long as he is accountable to no one, or even accountable to the Government only on a business basis, there can be no safety for the public. If he may sell to any purchaser other than a physician, he may always supply his own wants. But if he has to account to a physician for the entire amount of habit-forming drugs that he distributes, any leakage may quickly be detected by the man who more than any one else can be relied upon to stop such a leakage promptly and sternly. A pharmacist should be allowed to dispense habit-forming drugs only on a physician’s prescription.

The physician should be limited as to his authority not only for prescribing such drugs, but, as the Boylan Act provided, there must be a careful accounting on his part for all such drugs administered or given away. In other words, he must account for all such drugs which he buys for office use, and he cannot prescribe such drugs except under certain definite limitations.

METHODS OF TREATMENT: “THE HOME CURE”

For many years only two methods of dealing with the drug habit were known. They continue to be the only ones in general use to-day. They are the “home cure” and the sanatorium method. Neither is in any proper sense a treatment or anything more than a process of substitution and deprivation.

In many of the periodicals and daily papers are carefully worded advertisements setting forth that a man may be cured of a drug habit quickly, secretly, painlessly, and inexpensively. These are written by people who thoroughly understand the mental and physical condition of the drug-taker. In almost all cases he wishes to be freed from the habit, but at the same time to avoid the disgrace of being classed with “drug-fiends”; he is unwilling that even his family or his intimates should know of his condition. He has an exaggerated sensitiveness to pain, upon which also the advertisement relies. Furthermore, attention is directed to the fact that the patient may take the alleged remedy without spending much more money than he has been spending for the drug itself, naturally a powerful appeal to a man of limited means. Moreover, the people who take these “cures” are generally those who are unable to consider the expense of leaving home. That the advertisement is very alluring to the average drug-taker is shown by the fact that in my entire practice I have encountered few patients who have not at some time or other taken a home cure.

A minister wrote to me the other day begging me to cure a fellow-minister of the cure habit. His friend had had occasional attacks of renal colic, and a physician had eased their acuteness with a hypodermic. The patient of course knew what he was taking, and since he was forced to consider the cost of the physician’s visits for the mere administration of the hypodermic, he naturally procured his own outfit, and in a short time was using it regularly upon himself. When he found that he could not leave off the practice he entered into correspondence with a succession of “home-cure” advertisers, whose clever use of the word “privacy” offered a hope that his condition might be concealed from his congregation. For ten years he had been undergoing the cures, and during all this time had been forced to take a regular dosage of the so-called remedies.

Before the passage of the Pure Food and Drugs Act the ingredients of such remedies were not stated. The patient seems never to have suspected the truth—that the bottle contained the very drug he had been taking, its presence disguised by added medicines. In certain instances the makers boldly advertised that a trial bottle would be sufficient to prove clearly that the taker could not get along without using his drug. Now that the law compels a list of dangerous drugs on the label, the cures proceed admittedly by a reductive principle. The patient graduates from a number one bottle to a number two, containing less opium, and so on, until finally he is supposed to be cured. The proprietors of these cures make a great deal of capital out of the fact that the reduction is so gradual that the taker experiences no discomfort. This consideration is highly effective, for while it irresistibly appeals to the morbidly sensitive morphinist, it also makes him comprehend, as time goes on, why the process of cure is so slow. It is hardly necessary to state that the final stage is almost never reached.

Almost without exception, the basis of restoration to health is the perfect elimination of the effects of the drug. It should go without saying that it is impossible to eliminate the effects of opium with opium or to find any substitute for opium that is not itself opium. At the International Opium Conference in China I exhibited seventy-six opium-cures which I had had analyzed and found to contain opium; and as a consequence of the Pure Food and Drugs Act all the American “cures” announced on their labels that they also contained it. Thus it is easy to see why the sale of these cures had always greatly increased wherever the rigid enforcement of anti-opium enactments had closed up the customary sources of habit-forming drugs.

Up to the passage of the act, however, the presence of opium in the American cures was concealed, and their formulas were kept secret; and hence all of them, by the very nature of the case, were put forth either by irresponsible persons or by persons outside the pale of the profession; for one of the pledges given by a physician is that he will not patronize or employ any secret treatment, and that he will give to the profession whatever he finds to be of benefit to his fellow-men.

In very rare cases these home cures have been able to relieve a man of strong will power, with the added assistance of a regimen for building up his bodily tone. But these cases have been so infrequent as to be virtually negligible, for to administer the treatment successfully demands from the patient the exercise of precisely that power of self-control the loss of which drove him to the cure in the first place. If there ever was any curative property in one of these so-called cures, a man could not be benefited unless he were under constant supervision. A treatment of this sort must, except in case of a miracle, be administered by another and under continuous medical surveillance. A man addicted to a drug, be he physician or longshoreman, in a short time becomes utterly unable to deal justly with himself, for it is the nature of the drug to destroy his sense of responsibility.

THE SANATORIUM TREATMENT

Besides the home cure there was, and is, the sanatorium treatment. Unlike the former, this was first established and carried on by trustworthy medical men, who depended for their support upon the patients of reputable doctors. A physician who had a morphine patient was obliged to send him to a sanatorium because there was nothing else to be done with him; elsewhere no course of treatment under constant surveillance could be given. It afforded the only opportunity of carrying the patient through the long period of gradual reduction which was then the only known treatment. Thus there was nothing optional about the matter; the physician could not recommend a home cure, and the only means of approximating systematic treatment was the sanatorium. Furthermore, those relatives and friends who knew of the patient’s condition were anxious that he should go to one, since they realized the increasing awkwardness of keeping him at home. In many cases, indeed, they even went so far as to resort to means of commitment, if they failed to get his voluntary coöperation. It is due to the ease with which this type of patient can be committed that the State of Connecticut, for instance, abounds in sanatoriums. In that State, when a patient has entered one of them, he can often be detained there virtually at the pleasure of his relatives and friends.

The method of treatment at most of the sanatoriums is like the home cure, except that it is under surveillance; that is, it is merely one of gradual reduction accompanied by an upbuilding of bodily tone. The morphine-taker with means and time at his disposal will stay in a sanatorium as long as he can be made comfortable. This shows that whatever reduction he has undergone is extremely slight; for gradual reduction, when it is carried to any extent, sets up a highly nervous state, together with insomnia and physical disturbance. The patient, as is often said, has an exaggerated dread of discomfort, and will not, if he can help it, endure it at all. Unless he is committed, he transfers himself to another sanatorium the moment he ceases to be made comfortable. I had one patient whose life had been a continuous round of sanatoriums. He would stay in one place until the point was reached where discomfort was in sight, and then remove to another, remaining there for a similar period, and then to another, and so on, until he had finished a long round of sanatoriums to his taste in America and Europe. Then he would begin all over again.

A patient of mine who had visited eight different sanatoriums in the vicinity of New York told me that in America the sanatorium treatment of neurological patients was divided into three great schools: the “forget-it” system, the “don’t-worry” system, and the “brace-up” system. Any nervous invalid who has stayed much at sanatoriums will appreciate the humor of this classification.

The gravest aspect of these long stays at a sanatorium is the unavoidable colonization. Picture to yourself a group of from half a dozen to fifty morphine patients, eating together, walking together, sitting on the veranda together, day in and day out. In this group are represented many different temperaments and many different stations of life, from the gambler to the clergyman. All the more on this account is there a general and eager discussion of previous history and present situation. For where the alcoholic is quite indifferent, the morphine victim has an insatiable interest in symptoms. He has also an excessive sympathy with all who have been through the same mill with himself. Thus, in a matter where individual and isolated treatment is imperative, most sanatoriums deal with patients collectively. Furthermore, these are peculiarly a class of unfortunates who ought never to become acquainted. Whatever moral restraint the habit has left in a man is completely relaxed when he hears constant bragging of trickery and evasion and has learned to envy the cleverness and resource so exhibited. The self-respect and pride which must be the main factors in his restoration are sometimes fatally weakened. Colonization should be restricted to the hopeless cases, and to them only because it is unhappily necessary.

FAILURE OF THE REDUCTION METHOD

All this, moreover, is never, or almost never, to any purpose. As the uncomfortable patient will move if possible, it is naturally the business of the sanatorium to keep him from being uncomfortable. The method of reduction, therefore, is rarely carried out to the point where it would do any good, even if good were thus possible. But it is not possible. In the first place, lessening the dose is of little avail; there is as much suffering in the final deprivation of a customary quarter of a grain as of twenty grains. In the second place, it cannot be ascertained by gradual reduction whether there is any disability which makes morphine necessary, since no intelligent diagnosis can be made so long as a patient is under the influence of the smallest quantity of the drug. Obviously, the first step in taking up a case should be to discover whether any such disability is present, and, if so, whether it is one that can be corrected; otherwise it may be a waste of time to try to correct it. The true physical condition of the patient, which should be considered before a long course of treatment is undertaken, can seldom be discovered by the reduction method.

The best doctors have always felt that they could not afford to lend their names to any institutions or sanatoriums except those which restricted themselves to mental cases. Yet these home cures and sanatoriums, unscientific and ineffective as they were, have offered to the victims of the drug habit the only hope they could find. The investigations begun by Mr. Taft in the Philippines extended over considerable time and cost two hundred and fifty thousand dollars, but, although furthered in every way by the whole world, they failed to discover a definite treatment for the drug habit. It was generally believed by physicians that there was no hope for the victims of it.

COST OF THE DRUG HABIT

It may be noted that I have not dwelt upon the expense of the habit. This consideration may be omitted from the case. To the average victim, the cost of his drugs, no matter what he may have to pay for them, seems moderate. He is buying something which he deems a vital necessity, and which, moreover, he places, if a choice be required, before food, drink, family, sleep, pleasures, tobacco—every necessity or indulgence of the ordinary man.

The real cost is not to the drug-taker, but to the world. If a human life be considered merely as a thing of economic value, an estimate may perhaps be made of the total loss due to the habit.

But the loss should not be reckoned in any such way. It should rather be reckoned by the great amount of moral usefulness and good that might be rendered to the world if these unfortunates could be freed from their slavery, and by the actual harm being done by them, especially by those that are now loosely classed as criminals and degenerates.

The retrieving of much of the waste of humanity may be accomplished by adequate treatment of the drug habit.

CHAPTER III

THE DRUG-TAKER AND THE PHYSICIAN

The doctor who begins to take the drug in order to whip his flagging energies into new effort finds the habit fastened on him before he realizes what has occurred. His endeavors to reduce his daily dosage fail, and he becomes thoroughly enmeshed. His acquired tolerance for the drug has brought about so great a physical change that deprivation or even reduction of dosage is intolerable. Hundreds of cases where physicians had experimented with the drug with these disastrous results have been brought to my attention.

No one shows less foresight, less appreciation of the danger of tampering with drugs, than the physician himself. I am constantly amazed by the fact that any doctor will take even the slightest risk of becoming a drug-user. That many voluntarily incur the peril passes my understanding.

I have seen an astonishing number of physicians who for various physical reasons other than exhaustion and the need of stimulant considered themselves eligible to experiment with drugs. It is a curious thing that, as a class, physicians and surgeons are themselves singularly averse to submitting to surgical operation, even when symptomatic indications strongly urge it. Why surgeons, in particular, should so generally dread the application of the knife in their own cases is a puzzle, for of course no class more thoroughly understands the need of surgery. I could mention many cases of this sort, but one in particular recurs to my memory. He was one of the most careful and best-informed doctors in the country, and he was not without a certain special knowledge of the peril involved in habit-forming drugs; but he suffered from a painful rectal trouble, and although he considered himself too intelligent a man to go too far with a dangerous substance, he did go too far. He had thought that he could leave drugs off whenever he desired; he found that he could not.

THE PHYSICIAN WHO TAKES DRUGS

It is impossible to make even an approximately accurate guess at the proportion of physicians who are drug-users. Everywhere except in New York State physicians can obtain as many drugs as they desire without publicity and without laying themselves open to any penalty whatsoever, even if their purchases are brought to official attention. No medical organization takes any cognizance of drug-taking physicians or provides any medical help for them. It is highly probable that the New York State legislation may uncover some of the drug-taking doctors in that commonwealth, though this is by no means certain, since legislation in force in only one State cannot effectively put a stop to the illegal importation of habit-forming drugs from other States and countries. Proper restrictive legislation of sufficiently wide scope would very quickly disclose every drug-taking doctor in the nation, and either force him to correct his physical condition or drive him from the profession. Proper general regulation of the traffic and consumption of habit-forming drugs will aid tremendously in freeing the medical profession from drug-takers. Until this general regulation exists no general reform will be possible. An exact accounting for every grain of habit-forming drugs which he purchases, possesses, or administers, must be demanded of every physician in the United States before this evil can be entirely abated; and this accounting among physicians will be impossible until a similar accounting is demanded of every grain imported, manufactured, and dispensed by wholesale and retail druggists.

Concerning the extent of the hold which the drug habit has upon physicians I have had a rare opportunity to judge. Not only has my dealing with the drug habit been as exclusively as possible through the physician rather than through the patient, but the brevity of my treatment and the privacy that my patients are assured make it possible for many physicians who have become afflicted to come to me for relief without arousing in the mind of any one a suspicion of the real cause for their brief absence. I therefore feel that I have a firm basis for accuracy.

It is the fear of disgrace which has driven hundreds of physicians from bad to worse with the drug habit: they have become apprehensive that any effort tending to their relief will uncover their position to their families, associates, or patients, and thus bring ruin; so they have drifted on from bad to worse. Many who have not taken steps in time have reached the irresponsible and hopeless stage. To the medical profession in general, as well as to the public, these men are a dreadful menace.

ATTITUDE OF THE PROFESSION

I, a layman, have been greatly surprised that the medical world shows so little sympathy for these unfortunates. This seems to me to be specially reprehensible, since by this neglect they imperil the public. No greater service could be rendered to mankind by the medical profession than a concerted movement of the medical organizations toward the care and relief of those among their drug-taking members who are still susceptible to help, and the exclusion from medical practice of those who have already gone too far to be reclaimed. Physicians of this class who are without means are specially entitled to sympathy and help, and this service will be of double value, for it will not only give them necessary aid, but will notably safeguard the public. No physician should be permitted to practise who is addicted to the use of habit-forming drugs or who uses alcoholic stimulants to excess; but whatever is done in regard to these men should be accomplished without publicity and without any loss of pride or standing. A doctor who has used either drugs or alcohol is much more to be pitied than blamed.

The worthy practitioners—and there are many—who must resort to the use of drugs in order to enable them to practise despite some physical disability which cannot be eliminated, are no less numerous in proportion to the total number of physicians than similar cases are in relation to the total number of lawyers, merchants, or journalists, but because of the nature of their work, they are far more dangerous to the general public. It seems to me that there is in this fact—the existent, non-elimination of such perilous characters from the practice of medicine, and the obvious, very real necessity for such an elimination—a suggestion for some person of philanthropic mind. If the medical profession will not care for its own, then some one else must care for them. It occurs to me that among the people whose naturally fine impulses are leading them toward the endowment of institutions for the care of the aged maiden lady, or superannuated teachers, or others to whom fate has been unkind, there are many who might well consider this great need for the establishment of a comfortable institution in this country for the care of physicians who through no fault of their own have become unable to practise their profession with profit and efficiency.

HOW THE DOCTOR BECOMES A DRUG-TAKER

The doctor’s yielding to the drug habit is a simple process, in ninety-nine cases out of a hundred unaccompanied by any unworthy tendency toward dissipation. In another part of this book I make extensive reference to the fact that nowhere in the text-books by means of which the medical students of the world receive their education is any proper attention paid to the psychology of the drug habit. We may assume that a doctor, having lost sleep because of a difficult case, is confronted on his return to his office by another that demands immediate and skilful attention. He is tired and very likely he himself is ill. He cannot yield to his worries or illness, as he would demand one of his patients to yield. He must “brace up.” He knows that in the stock of habit-forming drugs that he uses in his profession lies the material which will brace him up. He tries it; it succeeds.

This doctor has begun to nibble at the habit, and he does not know his danger. He himself does not believe that one or two or a few doses will fasten that habit upon him. He finds that a certain dosage produces the necessary desired result upon the first day; he is stimulated to new efforts in behalf of his patients, and because those new efforts are the result of stimulation, they produce abnormal weariness. This exhaustion must be overcome, and the result is another dosage of the drug; and this time the dosage must be larger than the first, for both his toleration for the drug and his weariness have increased. Only a few days of such experiences are necessary to fasten the habit upon him.

I have often endeavored to imagine the thrill of horror which must chill a doctor’s soul when he finds that this has happened. His position is a dreadful one. He has lost control. He must tell no one, for if he tells, disgrace and the loss of his means of livelihood will be but matters of a short time. He knows nothing of any means of real relief; he cannot help himself; he is familiar with the dangers attendant on the fake cures which are widely advertised. He is confronted by a stone wall. He must either continue his dosage, thus enabling him to keep on with his practice, or he must accept ruin and defeat; and to continue his dosage is the easiest thing imaginable, for the drug has been by law intrusted to his keeping and is close at hand.

Another doctor who is specially susceptible to drug addictions is the one who has been accustomed to alcoholic stimulation. Any doctor who drinks alcohol, when he finds himself beset by arduous labor involving loss of sleep, or is confronted by cases of such a complex nature that they involve a great deal of mental worry on his part, is likely to drink more than usual. Thus work and worry, the two things which make him most liable to the evil effects of any stimulation, are likely to drive him directly into over-stimulation.

Over-stimulation results in super-nervous excitation. The victim finds himself unable to sleep, he finds his hand tremulous, he finds his thoughts wool-gathering when they should be concentrating with intensity upon his work. In his pocket case there is his little morphine bottle; he knows its action, and when called to see a patient while under the influence of alcoholic stimulants he attempts to steady himself by the administration of a small dosage. The result is virtually instantaneous and at first marvelously effective. He finds himself enabled to do better work than he has done for years, and more of it. The remedy seems magical; he tries it again and again. The man is lost.

Such instances as these have produced the most utterly hopeless of the many cases of drug addictions among physicians with which I have come into contact.

TYPES OF DRUG-USERS

Specially numerous among drug victims are physicians in nose and throat work, where they make daily employment of cocaine solution. Some of the most desperate cases of drug habit that I have ever seen among physicians have come from this class, made familiar with the constant use of the drug by the necessity for continually administering it to their patients.

Another physician who is specially liable is the man who suffers severe pain from a physical cause that he knows can be removed only by resorting to surgery. The average doctor will postpone a surgical operation upon himself until his condition has long passed the stage that he would consider perilous to any of his patients. While he postpones it he is suffering, and while he suffers he may be more than likely to continue his practice through reliance upon the stimulation and pain-deadening qualities of habit-forming drugs, concerning the true and insidious nature of which he usually knows no more than the average layman.

There have been a few cases of physicians who have yielded unworthily to drugs and opiates as a means of dissipation. I have known some physicians, for example, who have been opium-smokers. In the United States the opium-smoker is invariably unworthy. Not long ago the New York police raided the apartment of a physician where were found thirty or forty opium-pipes and more than a hundred pounds of opium, either crude or prepared for smoking. I have known fewer than half a dozen physicians whose drug vice was purely social, however. The victims of drag habit who achieved it through a tendency toward dissipation are almost invariably denizens of the under-world; and if it were not for the fact that the contagion of their vice may spread, they might well be permitted by society to drug themselves to death as speedily as possible.

We shall entirely disregard the physician who becomes addicted to the use of drugs through unworthy tendencies, and consider only the dangers to the profession and the public latent in the case of the physician who becomes addicted in the less reprehensible, but more dangerous, manner that I have indicated. Not only will such a drug addiction injure the doctor’s practice and threaten his career, but it will surely constitute a threat against the welfare of his patients not included in the possibility that through it he may miss engagements, write improper prescriptions, and make mistakes of many kinds.

THE DRUG-TAKING PHYSICIAN A MENACE

A very serious danger lies in the psychology of drug addictions. The person who has taken a habit-forming drug for the purpose of relieving his own pain, and through it has found that relief which he sought, is almost certain to become abnormally sympathetic to the suffering of others. It is a curious fact that this doctor will be more than likely to administer the drug he uses to his patients, not with malicious, but with probably friendly, intent, and that he will feel no scruples whatsoever in acting as a go-between for drug-users in general who find themselves unable to obtain supplies easily. He will do what he can to help confirmed users to obtain their drugs, even if he makes no profit out of it. He will write prescriptions for them in evasion, if not in violation, of the law. It is a curious and tragic fact that the drug-taking doctor will spread the habit in his own family.

There have been many instances in my hospital when I have had a physician and his wife as patients at the same time and on the same floor. In every one of these instances the drug addiction of a wife has been the direct result of constant association with the drug-addicted husband. No more dangerous detail exists in the psychology of drug-users than their almost invariable tolerance for the habit in others and their sympathetic willingness to promote its spread among those who suffer pain. In the under-world the drug habit never travels alone. Through it the woman who is a drug-user holds the man whom she desires; through it the male drug-taker holds the woman whose companionship he finds agreeable. It is a curious fact that while in the under-world the drug habit has become a social vice, especially in the case of cocaine, and is frequently a proof of mixed sex-relations, in the upper-world it is accompanied by a secrecy of method and sequestration of administration that characterizes no other form of vice.

The difference between the psychology of the doctor’s relation to the drug habit and that of the layman to it may be summed up in the statement that while the layman does not at all know what he is getting, the doctor knows what he is taking, but thinks that he can stop taking it whenever he feels ready. It is probable, therefore, that the doctor’s primary danger is as great as the layman’s, and it is certainly true that his secondary danger—that growing out of the fact that he has drugs and the instrument for their administration always ready to his hand—is very much greater.

The unnecessary administration of habit-forming drugs to the sick must be legally prevented as far as possible. No affliction which can be added to an already existing physical trouble can compare in horror with that of a drug habit. Numbers of cases have come under my observation in which physicians have accomplished exactly this addition to the ruin of their patients’ health, to the incalculable distress of the sufferers’ families, and to the vast loss of society. In the recent legislation written upon the statute-books of New York State the first definite effort is made to provide against this catastrophe.

CHAPTER IV

PSYCHOLOGY AND DRUGS

Drug habits may be classified in three groups: the first and largest is created by the doctor, the second is created by the druggist and the manufacturer of proprietary and patent medicines, and the third, and smallest, is due to the tendency of certain persons toward dissipation.

The major importance of the first two groups is due to the fact that they include by far the greater number of cases, and to the pitiful fact that such victims are always innocent. Speaking generally, and happily omitting New York State from our statement, it is safe to say that the manufacturer, the druggist, and the physician are without legal restraint despite their importance as promoters of drug habits, while the comparatively unimportant drug-purveyor in the under-world is held more or less strictly in control by the police, and is subject to severe punishment by the courts in case of a conviction.

With few exceptions, the part which the doctor plays in the creation of drug habits is due to lack of knowledge; but the druggist’s part in the spread of this national curse is purely commercial, and may justly be designated as premeditated. He always has gone and always will go as far as is permissible toward creating markets for any of the wares that he sells.

Regulation of the upper-world in regard to the distribution of habit-forming drugs will automatically regulate the under-world in its similar activities. The amount which will be smuggled by those of criminal tendencies always will be small as compared with the amount improperly distributed through channels now recognized as legitimate until all the States have passed restrictive legislation founded upon, modeled after, and coöperative with New York State’s legislation; and all this must be backed and buttressed by Federal legislation of a special kind before real and general good can be accomplished in the United States. Illicit drugs rarely find their way into the possession of users who have acquired drug habits through illness or pain. So it must be admitted that most of the effort that in the past has been made toward restrictive legislation has really been devoted to the interests of the unworthy rather than to those of the worthy. Save in New York State, the man or woman with a sheep-skin—the doctor, the druggist, or the nurse—remains virtually a free-lance, permitted to create the drug habit in others or in himself or herself at will.

THE DOCTOR A MEANS OF SPREADING THE DRUG HABIT

The man in severe pain is immediately exposed, by the very reason of his misfortune, to the physician with a hypodermic or the druggist with a headache powder; the man who cannot sleep may at any moment be made a victim by the physician whom in confidence he consults, or by the druggist to whom he may foolishly apply for “something” which will help him to secure the necessary rest. Save in New York State, the druggist’s shelves are crowded with jars and bottles holding dangerous compounds which he may dispense at will, his drawers are crowded with neat pasteboard boxes containing powders which are potent of great peril. The public will have made a long step toward real safety when it realizes that any drug which brings immediate relief from pain or which will artificially produce sleep is an exceedingly dangerous thing.

The sick man’s confidence in his doctor is one of the doctor’s greatest assets; it has saved innumerable lives. It is of the same general nature as the mysterious mental phenomena which frequently control physical conditions, and which have been capitalized by various bodies, such as Faith Cure and Christian Science; but if this is an asset to the physician, the general public knowledge that he carries in his case or in his pocket drugs which he can use without restraint of law for the relief of pain may become a general peril. In the old days when the doctor’s work was a mysterious process, operating by methods of which he alone was cognizant, this peril was less well defined; but now that the spread of education has made everybody a reader and periodical literature of the times has given even children a smattering of knowledge concerning medical matters, the nature of the means by which the doctor works his miracles is well known, and his unrestraint may become a public peril.

Of one thousand patients who may consult the average physician, nine hundred and ninety-nine know perfectly well that he can stop their pain if he desires to do so. Pain is unpleasant; naturally their demands that he use his power are insistent. If he refuses, they are likely to call in another and less scrupulous physician. The medical profession is overcrowded, and perhaps the doctor needs the money. Even if he is swayed by nothing but financial need, he is likely to be tempted into the administration of pain-deadening substances when his patient urges him.

There is another powerful influence which works upon the most admirable of men—the pity of the temperamental physician for the human sufferer. Most men who choose the medical profession as the avenue for their life-work have the qualities of mercy, pity, and sympathy notably developed in their psychology. This is likely to induce them to stretch points in favor of relieving suffering patients. Even when their previous experience has proved to them the danger lying in narcotics, they are likely to forget it, or to take a chance if a special emergency arises. This may be done without great peril to the patient.

DANGER OF THE KNOWLEDGE OF PAIN-RELIEVING DRUGS

The physician should exhaust every means known to medical science to prevent his patient from knowing what it is that eases pain when his practice makes it absolutely necessary that a substance of the sort should be administered, and this is very much less frequent than the average doctor realizes, as will be shown in another passage of this book. It is in this necessity for concealment that the great danger of using the hypodermic syringe as an administrating instrument principally lies. The moment the hypodermic syringe is taken from the doctor’s or the nurse’s kit, the sufferer is made aware of the means which will be used to give him ease. He remembers it, forming a respect and admiration, almost an affection, for the mere instrument, and with the most intense interest gathers such information as he may find it possible to acquire about this wonder-working little tool and the material which is its ammunition of relief. He knows absolutely that the relief which he has found is not due to medical skill, but to the potency of a special drug administered in a special way. He stops guessing as to whether he has been soothed by an opiate; he knows he has been.

It is not only those of weak psychology or mental characteristics who are affected by this knowledge and who through it become drug-takers, though it is the general impression that this is the case. No impression was ever more inaccurate. The mentally strong and the morally lofty are as much averse to suffering physical pain as the mentally weak and the morally degenerate. All are in the same class when the drug has been administered until that point of tolerance is reached where its administration cannot be neglected without the indignant protest of the physical body. That this fact should be impressed upon the medical profession as a whole is one of the most needful things I know.

Another hazard which the doctor runs, if he passes the point of extreme caution in the administration of drugs to patients, is the possibility, even the probability, that through such an administration he will lose control of his patients. From the moment the patient becomes cognizant of the means which the doctor has successfully used to alleviate his pain, he begins to dictate to the doctor rather than to accept dictation from him. No doctor can control a case successfully unless his judgment is accepted as the supreme law of treatment. A patient who is not susceptible to the doctor’s dictation cannot be expected to get the full advantage of the doctor’s skill or knowledge. If diagnosis shows that a patient requires some operation, as in certain uterine troubles, or more especially in the case of bladder affections or gall-stones,—cases in which frequently only an operation can give relief,—and if that patient is aware that even if the operation is not performed, the doctor can still ease all suffering, that patient, loath to run the risk of the surgeon’s knife, horrified by the thought of hospitals and operating theaters, is likely to demand the relief which opiates offer, and refuse to risk the cure which surgical procedure alone would certainly afford.

The conscientious doctor who insists upon the proper course in such a case is seriously handicapped by the presence in the medical profession of many men who are less conscientious, and who may yield more readily to the urgings of the patient. Thus the possibility of unrestricted use of habit-forming drugs by the medical profession becomes a handicap to the conscientious man and a commercial advantage to the unscrupulous practitioner.

UNCONSCIOUS VICTIMS OF THE DRUG HABIT

Episodes occurring continually in the course of my work add to the strength of my conviction of the physician’s responsibility. For years not a week has passed which has not brought me patients with stories of the manner in which they have become victims of drug addiction through the treatment of their physicians. Lying before me as I write is a communication from a young man in Pennsylvania. He had been hurt, and through improper surgical attention a healing fracture had been left intensely painful. The attending doctor, unable to correct his imperfect work, had left with him a box of tablets to be taken when the pain became severe. Promptly and inevitably the youth achieved the drug habit. He felt disgraced, he would not tell his father, his wife, or his sister. His doctor could give him no relief. By some accident he saw an article of mine which was published in the “Century Magazine,” and made a pitiful appeal to me. I have received many such communications.

A pathetic letter comes to me from a woman suffering with fistula. Having achieved the morphine habit as the direct and inevitable result of taking pain-killing drugs given to her by her family physician, she now feels herself disgraced. Like many sensitive women who in this or some other way become victims of the drug habit, she is obsessed, as her letter clearly shows, with the conviction that her achievement of the habit has been a personal sin, and that her continued yielding to it puts her beyond the pale of righteousness. She writes that she finds herself incapable of going to her church for Sunday services or to prayer meetings because she feels ashamed when in the imminent presence of her Maker. Another woman, evidently animated by a similar psychological phenomenon, writes that having acquired the drug habit, although blamelessly, since it was through the administration of narcotics by her doctor, she finds it a psychological impossibility to kneel at her bedside and offer that prayer to God which it had been her nightly practice to deliver.

I could multiply such instances indefinitely. It is impossible to conceive any episodes more pitiful than the cases of this sort which have been detailed to me by drug victims, doctor-made. That feeling of disgrace, that unjustified conviction of sin on the part of absolutely innocent women victims of the drug habit, is apparently among the most terrible of humanity’s psychological experiences. If I had the pen of a Zola and the imagination of a Maupassant, I might properly impress the medical world with a sense of its responsibility in this matter. Without it I fear that I may fail to do so; but could I accomplish only this one thing, I should feel that my life had been of use to that humanity which I desire above all things to serve.

No work could be of more importance to the world of sufferers than one which would put the use of these potentially beneficent, but, alas! often injurious, drugs upon a respectable basis, so that the man who must be given the relief which they alone can offer may no more hesitate to tell his neighbor that he is taking morphine than he now will hesitate to tell his neighbor that he is taking blue mass pills or citrate of magnesia.

RESPONSIBILITY OF THE TRAINED NURSE

That the medical world should ever have been so lax in its realization of its proper responsibility as to allow trained nurses to carry hypodermic syringes and to administer habit-forming drugs seems to me to be one of the most amazing things in the world. No physician who has had an extensive experience with drug addiction and who has any conscientious scruples whatsoever will fail to make sure before he leaves a nurse in charge of a patient that the attendant possesses no habit-forming drugs and is without any instrument with which they may be hypodermically administered. If such drugs are to be used, they should be kept in the physician’s possession until they are used, and should be administered by means of an instrument which he carries with him. When such drugs are left, the nurse should give an accounting for every fraction of a grain.

I have no desire to convey the impression that in my opinion all nurses are untrustworthy or unscrupulous, but it must be remembered of them, as it must be remembered of the doctor, that they are in the employ of the patient, that their income depends upon giving satisfaction to their employer, and that they are likely to make almost any kind of concession and resort to almost any practice in order to make comfortable and profitable assignments last as long as possible. It is impossible not to admit the truth of this statement, and it must be recognized that if it is true, a nurse is under too great a responsibility when she is in possession of a hypodermic kit, particularly if the patient knows that it is her kit, her hypodermic, her drug, and that she will not be called to account by the physician for such drugs as she may administer. It must be rather disconcerting for a physician to reflect upon the fact that a nurse whom he has left in charge of a critical case, through greed or even through the general and admirable quality of mercy, is equipped for, and ignorantly may yield to the temptation of, resorting to a practice that may not only undo all the good his treatment has accomplished, but, in addition, may afflict the patient with suffering more terrible than any which disease could give. This element of mercy, soft-heartedness, and readiness to pity must specially be remembered in considering the relation of the trained nurse to the patient. If men are often induced to enter the medical profession because of its presence in their soul, even more frequently are women led by it to become trained nurses. The sympathetic woman is even more likely to yield to the pleadings of suffering patients than is the sympathetic male doctor.

It must also be remembered that, like the doctor, the nurse is human, and neither iron-nerved nor iron-muscled. She is frequently under terrific strain, which makes her tend toward the use of stimulants of any kind. That which she can administer to herself by means of the hypodermic is closest to her hand, is easiest to take, and is least likely to be discovered. Again, too, it must be remembered that the nurse is as susceptible to pain as are the rest of us. Suffering, with the means of alleviation at her hand, and, like the doctor, ignorant of its true peril, what is more natural than that she herself should use the hypodermic for her own relief? Thus it comes about that probably a larger proportion of trained nurses than of doctors are habitual drug-users. This is not a statement which is critical of the profession, for if all mankind knew of drugs, had hypodermics, and knew how to use them, a very large proportion of the human race would resort to this quick and effective, if inevitably perilous, means of finding comfort when agony assailed them.

The world does not, the world cannot, understand that while to the normal human being the worst that can come is pain, the worst pain is vastly less terrible than the horrors which at intervals inevitably afflict the habitual drug-user. Not one human being who has become a victim of a drug habit through its use for the alleviation of pain but will voluntarily cry after he has come to realization of the new affliction which possesses him, “save me from this drug habit, and I will cheerfully endure the pain which will ensue.” The horror of pain is not so great as the horror of the drug habit.

Another very serious reason for extreme caution on the part of the medical profession in regard to the use of habit-forming drugs is that the effect of such drugs upon a patient must almost certainly make accurate diagnosis of his case difficult or even impossible. A patient whose consciousness of pain is dulled or eliminated by the use of drugs cannot accurately describe to a physician the most important symptoms of his ailment. Without the assistance of such a description the physician is so handicapped that all the skill which he has acquired in practice and all the knowledge he has gained from study are apt to be of no avail. Indeed, in the case of habitual drug-users accurate diagnosis of any physical ailment is impossible until the effect of the drug has been so completely eliminated that not one vestige of it remains.

CHAPTER V

ALCOHOLICS

I am not specially familiar with the statistics of insanity, but I am inclined to believe that an appreciable contribution to the total—indeed, one of its largest parts—has arisen from the improper diagnosis of drug and alcoholic cases, followed naturally by improper medical treatment. Lack of definite medical help in cases of chronic alcoholism is likely to bring about brain lesions, which eventually mean hopeless insanity.

For that special reason, the chronic alcoholic has been the chief contributor to the army of the insane, and in the asylums his presence is notably frequent among the violent cases. The head of one of the greatest institutions in the United States for the care of the insane assures me that this seems to occur among women to a greater degree than with men.

One of the most difficult problems of my work has been to discover ways by which the medical profession can be made to understand the really serious meaning of chronic alcoholism. Most delirium, the primary cause of which lies in alcoholism, is amenable to treatment.

EFFECTS OF DEPRIVATION IN CHRONIC ALCOHOLISM

It is exhaustion or lack of alcohol which first produces delirium in an alcoholic case, whether that exhaustion is due to the patient’s inability to assimilate food or alcohol or whether it is due to the fact that, being under restraint, alcohol is denied him.

In most cases there is no form of medication which can be successfully substituted for alcohol, and unless definite medical help is provided for the purpose of bringing about a physical change and thus avoiding delirium, no course remains safe except a long and very gradual process of reduction of alcoholic poisoning. Such a measure as this cannot be successfully applied in the wards of the general hospital, as the mere fact that alcohol was there administered, even in slowly diminishing doses, would make such a ward the chosen haven of innumerable “old stagers,” who, having reached that stage of worthlessness which would make it impossible for them to obtain the narcotic elsewhere, would take the treatment for the mere sake of getting the alcohol of which it principally consists.

Many friends of alcoholic subjects and many physicians in private practice have believed that they were doing the alcoholic a great service when they put him where he could not get alcohol, and helped him over the first acute stages of the period of deprivation by the administration of bromide and other sedatives. This usually means delirium first and then a “wet brain”; if the patient survives this, his next development is more than likely to be prolonged psychosis, or, in the end, permanent insanity. It is because of this that I consider the chronic alcoholic more clearly entitled to prompt and intelligent medical treatment than most other sick persons. With the alcoholic, as with the drug-taker, the first thing to be accomplished is the unpoisoning of the body. In order to accomplish this, it is first necessary to keep up the alcoholic medication, with ample sedatives, using great care lest the patient drift into that extreme nervous condition which leads to delirium. If delirium does occur, nothing but sleep can bring about an improvement in the patient’s condition. This is the point of development at which physicians not properly informed in regard to such cases are likely to employ large quantities of hypnotics, and frequently this course is followed until the patient is finally “knocked out.” In many instances an accumulation of hypnotics in the systems of persons thus under treatment has proved fatal. I am rather proud of my ability to state that from delirium tremens I have never lost a single case.

NECESSITY OF CLASSIFICATION OF ALCOHOLICS

The records show that to-day about forty per cent. of the insane in the asylums of New York State have a definite alcoholic history. In this condition lies one of the greatest opportunities ever offered to the medical profession. Even now a proper classification of the patients thus immured, and their appropriate treatment, would in many instances result in the return to the normal of those affected; proper classification and treatment at the time when the symptoms of mental disorder first appeared would have resulted in the salvation of innumerable cases. As a matter of fact, I earnestly believe that if this course was followed, the number of supposedly permanent cases of insanity arising from alcoholic and drug addictions might be decreased by seventy-five per cent.

Certain general rules may be laid down. There are no circumstances in which it is advisable for a physician in private practice to attempt to handle a case of chronic alcoholism in the patient’s own environment. Efforts to do this are constantly made, with the result that many needlessly die from lack of alcohol, while an even more tragic result is the unnecessary entrance, first into the psychopathic wards of our hospitals and thence into our asylums for the insane, of innumerable cases which needed intelligent treatment only for alcoholism or drug addiction. If this treatment is neglected, the incarceration of these unfortunates in asylums becomes necessary, for without question their insanity is real enough.

UNSCIENTIFIC METHODS IN THE TREATMENT OF ALCOHOLISM

During the summer of 1913 I visited a large hospital in Edinburgh and discussed alcoholism and its treatment with the visiting physician.

“We do not have many alcoholics here,” said he.

“Why?” I inquired.

“All our hospital work is supported by private subscription,” he answered.

“Then there is no place whatever in Scotland for the care of the acute alcoholic case?”

“No. If an intoxicated person is locked up by the police and develops delirium, he is sent here, and we do what we can for him by the old methods.”

“You offer no definite medical help along special lines?”

“No; we have none to offer.”

He showed me two cases in the general ward; one man in a strait-jacket was in the midst of delirium tremens, his face terribly suffused. He was in a pitiable state, and nothing was being done for him.

“What course shall we follow?” the physician inquired.

“Let me see his chart,” I requested. After I examined it, it became immediately apparent that the patient’s condition was due to lack of his usual drug. It was his third day in the ward.

“Nothing but sleep will save him,” I said, and suggested medication which was administered.

In three or four minutes the patient was relaxed and taken out of the strait-jacket. I made certain suggestions regarding general stimulation for the bowels and the kidneys, and diet. On the next day I found the patient improved after twelve or fifteen hours of sleep, and wholly free from delirium. His case had now become simply a matter of recuperation.

Another case had lived through several days of delirium tremens, which had been followed by a “wet brain”; the visiting physician considered this patient a fit subject for the psychopathic ward. I asked the patient questions about himself. He was sure that he had been out the night before and pointed out one of the internes as his companion during the hours of dissipation. His case was regarded at the hospital as almost certain to end in an asylum. I suggested treatment and within two days the man’s mind had entirely cleared up.

These instances of successful and prompt relief occasioned considerable surprise among the hospital physicians, who frankly admitted that they knew nothing to do except to keep the patients there under restraint, and, if necessary, feed them according to existing rules, to keep their bowels open and their bladders free, and hope for the best.

This was an institution which is supposed to represent the best medical learning in the United Kingdom. I found similar conditions existing in the great hospitals of London, Paris, and Berlin, so that the Scotch institution is not an exception to the general European rule. Everywhere I was frankly informed that the medical staff knew of nothing to be done in alcoholic cases beyond deprivation and penalization.

Nor have we been more scientifically progressive in the United States. We are following virtually the same unenlightened methods, and it has even been suggested that chronic alcoholism be added to the conditions which in the minds of some sociological thinkers justify sterilization. How important our shortcoming is may be strikingly illustrated by the statement that alcoholic patients comprise one third of all the cases admitted to Bellevue Hospital in New York.

THE DIFFICULTY OF TREATMENT IN SOME ALCOHOLIC CASES

The alcoholic differs notably from the person addicted to drugs. A drug-taker, deprived of his drug, will experience in the early stages only acute discomfort and a natural longing for the drug of which he has been deprived. His unfavorable symptoms can always be relieved by the administration of the drug. The chronic alcoholic, however, deprived of the stimulant, often drifts into a delirium which cannot be relieved by the administration of his accustomed tipple. No more terrible spectacle can be imagined by the human mind than that of an acute case of delirium tremens; no patient needs more careful watching in order that unfavorable developments may be avoided; once delirium sets in, no type of case is medically so difficult to handle. The man who for long periods has been saturated with alcohol, and who is suddenly deprived of it, is, I think, more to be pitied than almost any one I know; yet relatives, friends, and physicians frequently follow exactly this course, and think that by so doing they are rendering the patient a kindly service.

CAUSES OF INSANITY

In mentioning the causes of insanity, it is, however, impossible to permit the impression to be recorded that alcohol is the only offender. My statement of the part which alcohol plays in supplying the population of our mad-houses has never been denied; but it is also true that the use of headache powders and other preparations commonly sold at our drug stores and as yet slightly or not at all restricted by law, and the use of coffee, tea, and tobacco in unrestricted quantity, also contribute their quota to the insane. A letter from the superintendent of a certain state asylum tells me that he has seen many improvements, sometimes even amounting to cures, result from ten days of fasting. That fasting really was a process of unpoisoning. In such a case the symptoms of insanity may be attributed to auto-intoxication, coming from any one of many causes, of which alcohol, tobacco, or even food improperly selected or unreasonably eaten may be one. The physician can have no means of learning just what method to pursue in any case of auto-intoxication until the patient has been unpoisoned. If any one of the great general hospitals would secure careful histories of one hundred of its patients and apply the proper methods to those who are found to have been poisoned by their habits, surprising results would be achieved. It is specially true that no intelligent mental diagnosis can be made of any patient who has had an unfavorable drug, alcoholic, or even tobacco, tea, or coffee history until he has been freed from the effects of these drugs or stimulants. The first thing that a physician must do when confronted by a case of alcoholic or drug addiction is to learn whether it is acute or chronic. If the case is chronic, the patient must not be suddenly deprived of his stimulants.

CHAPTER VI

HELP FOR THE HARD DRINKER

The people of the world in general, and especially the people of the United States, are asking more questions about the cost of alcohol—not its cost in money, but its cost in men. These are questions which statistics cannot answer, which, indeed, can never be definitely answered; but we know enough to be assured that if answers could be given, they would be appalling. With increasing unanimity the thinkers of the whole world are saying that in alcohol is found the greatest of humanity’s curses. It does no good whatever; it does incalculable harm. A dozen substitutes may be found for it in every useful purpose which it serves in medicine, mechanics, and the arts; its food value, of which much has recently been said, is not needed; and it has worked greater havoc in the aggregate than all the plagues. If not another drop of it should ever be distilled, the world would be the gainer, not the loser, through the circumstance. Yet the use of alcohol as a beverage is continually increasing. The number of its victims sums up a growing total. Sentimentalists have failed to cope with it, and the law has failed to cope with it. In combating it, the world must now find some method more effective than any it has yet employed.

When we consider excessive drinkers as a class, we find that a large number of alcoholics are born with tendencies which make alcohol their natural and almost inevitable recourse. As a rule they are naturally highly nervous, or, through some systemic defect, crave abnormally the excitation which alcohol confers. For these reasons, granting favorable opportunity and no great counterbalancing check, they are foredoomed to drink to excess. Some are predisposed to alcoholism by an unstable nervous organism bequeathed to them by intemperate parents or other ancestors; others are drinkers because they do not get enough to eat, or fail, for other reasons than poverty, to be sufficiently nourished; and others, possessing just the favorable type of physique, become alcoholics through worry or grief. All these kinds of people are victims of a habit which, properly speaking, they did not initiate, and of which, therefore, censure must be very largely tempered. Yet they are generally treated as though they had perversely brought about their own disease, a course not more reasonable than the punishment of people for developing nephritis or cancer.

The demand for a more effective as well as a more logical treatment of alcoholism has even greater urgency than comes out of this injustice. Much of our best material falls victim to this disease. By general admission the alcoholic often possesses many qualities of mind and temperament which the world admires and pronounces of the utmost value when rightly developed. Even the careless weakling who drinks to excess is proverbially likely to be generous, magnanimous, warmly impulsive, even quixotic. The finest sensibilities, the most delicate perceptions, and the most enthusiastic temperaments—from all of which qualities great constructive results may be expected—are notably the most exposed to alcoholism. A far greater number of its victims than the offhand moralist is inclined to concede have admirable sturdiness of will and dogged persistence. With less, perhaps, they would not have become excessive drinkers. They are alcoholics because with the help of stimulants they have habitually forced themselves to overwork, to bear burdens of responsibility beyond their normal strength, or to overcome physical obstacles, like poor health, eye-strain, and insufficient nourishment. The man who drinks is not necessarily depraved; but under the influence of stimulant he is very likely to drift into associations and environments which will lower his standards until he becomes irresponsible, unadmirable, or even criminal.

ARE ALCOHOLICS GETTING A FAIR CHANCE?

It is perhaps not going too far to say that most alcoholics have not been given a fair chance by their bodies, their temperaments, or the actual conditions of their lives. The question is, Are they getting a fair chance from society—society whose experience has demonstrated that it must in some way protect itself from them?

At present the only public recognition of the alcoholic is manifested through some form of penalization. He loses his employment, he is excluded from respectable society, in extreme cases he is taken into court and subjected to reprimand, fine, or imprisonment. Nothing is done to bring about his reform except as the moral weight of the non-remedial punishment may arouse him to his peril and set his own will at work. Instances where this occurs are rare, because the crisis always comes when, through the influence which alcohol has wrought upon him, his brain has been befogged and his will weakened. Society does virtually nothing to awaken that will or to assist its operation. The man whose drinking has so disarranged him physically or mentally that he is obviously ill is, it is true, taken to the alcoholic ward of some hospital, but even there no effort is made to treat the definite disease of alcoholism. For example, Bellevue and Kings County hospitals, where New York’s two “alcoholic wards” exist, are institutions devoted specially to the treatment of emergency cases. As a matter of course, the alcoholics taken to them are merely “sobered up.” As soon as they are sobered and have achieved sufficient steadiness of nerve to make their discharge possible, they are turned out again into the liquor-ridden city, with their craving for the alcohol which has just mastered them no weaker, with their resolution to resist its urging no whit stronger, than they were before the crisis in their alcoholic history engulfed them. There is as yet no public institution in New York City where a man, either as a paying or as a charity patient, may go for medical treatment designed to alleviate the craving for liquor; no organized charity makes provision for the medical treatment of the alcoholic. Only three States in the Union attempt to provide more competently than New York State does for this class of unfortunates. The provision they make progressively treats men convicted of drunkenness in the courts with surveillance, threat, colonization, and finally perpetual exclusion from society. Massachusetts has a colony for inebriates, New York is developing one, and Iowa has had one for several years.

This, then, is at present the treatment accorded by the public to the victims of this serious disease. There are no clinics devoted to the study of alcoholism, although it is the ailment of probably one third of the sick people in the world to-day. Those who feel disposed to question this statement will be convinced that it is reasonable if they but make a count of the private sanatoriums dealing exclusively with alcoholics in and near New York, and, indeed, dotting and surrounding all our large cities. Connecticut, New Jersey, and Illinois will show a startling number. And it must also be remembered that many of the cases of disease other than inebriety treated in all public hospitals have histories more or less alcoholic, and that the insane asylums are crowded with those gone mad through drink. It is the demand of common sense, not of sentiment alone, that this situation should be altered.

Provision never has been made really to help even the man who, having lost control, is anxious to regain it. Inquire of the United Charities in New York and of similar organizations in other cities, and you will learn that they are doing most intelligent work in the treatment of tuberculosis, but that alcoholism is getting only condemnation and punishment, not curative methods; yet there probably are forty alcoholics to every consumptive. Neglect is almost universal, and where that charge cannot be brought, there the errors are incredible and continual. Many are charitable toward the drunkard, giving him their dimes when he begs for them, and thus promoting his inebriety; but society as a whole ignores him until he forces its attention through his helplessness or often through some sin, which might be more rightly charged to alcohol rather than to any natural criminal tendency in the man’s nature.

ALCOHOLICS SHOULD BE TREATED AS INVALIDS

The physician, as things are, can do little with the sufferer from any ailment if his system at the time is impregnated with alcohol, for the alcohol may very likely prove an antidote to the medicines, or, if it does not, may prevent the patient from taking them. An alcoholic does not keep engagements; he cannot be expected to take doses as prescribed by his physician. An alcoholic who is also ill of something else is doubly ill, but he usually gets treatment only for his secondary illness. No man who has lost control through stimulants is well, and until he has been definitely treated, he cannot be expected to act normally. The world does not yet know how to deal with him. Sequestration as it is usually practised—trips round Cape Horn, weeks spent in the woods where liquor cannot be obtained—will never do it. Not only must the physical yearning be eliminated, but the mental willingness to drink must be destroyed before reform can be accomplished. It is at this point that the sentimentalists are wont to fail. A promise made by one in whom the craving for the stimulant exists cannot properly be considered binding, for such a one is not responsible for what he promises. If body proves stronger than the mind in such a battle, he is merely an unfortunate, not really a liar or a weakling. The world’s loss through alcohol has been incalculable. No community ever existed which could afford to relinquish the services of all its citizens who drink to excess or even of those who frequently get drunk. Yet society has continually maintained that when encountering the alcoholic it has crime, not disease, to deal with. Hence the crudely ineffective idea of penalization as a preventive.

In general the nearest approach which has been made toward physiological treatment—beyond, of course, the mere “sobering up” in an occasional hospital of patients made delirious by drink—has not been through medicine, but regimen, and this regimen has invariably included sudden enforced abstinence. This remedy is worse than the disease. It rarely helps and sometimes kills. I have seen many men who had been pronounced insane after they had been deprived of alcoholic beverages, without proper treatment, but whose minds became perfectly clear as the result of the definite medical care their cases really required. Numbers of far from hopeless alcoholics are yearly being sent to our insane asylums, where there is little chance of their recovery, I think. Furthermore, by merely depriving an alcoholic of alcohol without eliminating his desire for it, we are likely to force him into something worse. Thus the attempt to enforce abstinence upon the man who wants to drink is not only ineffective, but destructive. In making this statement I do not wish to be understood as being opposed to the prohibition of the sale of alcoholic beverages; indeed, I should favor the most drastic restrictions prohibiting the sale of alcohol. If there was never another ounce of alcohol manufactured, the world would be none the loser either medicinally or commercially. My reason for making this statement is that prohibition of the sale of alcoholic beverages has been largely defeated because there have not been the proper safeguards thrown about the manufacture and sale of drug-store concoctions that can be had in any quantity as substitutes for alcoholic stimulants; and I think the most drastic legislation that could possibly be created on this subject should be enacted and enforced against the druggists selling over their counters such concoctions.

The late Dr. Ashbel P. Grinnell, for seventeen years dean of the Vermont Medical College, studied this phase of the subject, gathering interesting statistics.

After Vermont’s adoption of prohibitory legislation, he sent out to wholesale and retail drug stores, general stores, and groceries that carried drugs as a part of their stock a letter in which were inclosed blanks calling for specific information concerning the sale of habit-forming drugs. Such was his personal standing in the State that he received responses from all but two or three of those whom he addressed, and these indicated that such sales had swelled rapidly until they indicated a daily consumption equal to one and one half grains of opium or its alkaloids for every man, woman, and child in the State. This vast increase in the use of dangerous drugs he attributed solely to the prohibition of the sale of liquor. Thus it must be argued that the attempt to enforce abstinence upon the man who wants to drink is not only ineffective, but destructive. Society may thus save itself from a few drunkards, but is likely to get lunatics or “drug-fiends” in their places.

REFORM CANNOT BE ATTAINED BY PUNISHMENT

At the foundation of the present treatment of the alcoholic is usually the idea that threatening with punishment can be effective. Actual experience and the slightest examination prove this to be preposterous. Many a man who drinks when he knows he should not, does so because he cannot control himself, and he who has lost his self-control is obviously irresponsible. A threat, or the remembrance of a threat, cannot restrain him. A man who had committed a crime while drunk, but whose whole career had otherwise been reputable, was sentenced to life imprisonment. After he had served six years his friends presented so strong a case to the governor that he was pardoned, but with the warning that if he took one drink he might be returned to prison to complete his sentence. An excellent illustration of the slight influence of fear upon the alcoholic is furnished by the fact that within a very short time he was arrested for public drunkenness. Punishment breeds rebellion, and when you make a man rebellious you are most unlikely to reform him. Punishment has never yet cured a disease. The inflamed brain not only carries grudges, but is almost sure to intensify them. If a man is discharged from his employment or arrested at a time when he is in the abnormal alcoholic state, the effect on him cannot be reformatory; it must be to arouse his resentment, not his repentance. The employer who discharges a good man from his position because of drunkenness not only fails to deal intelligently with the man or with the subject, but may very likely be committing a crime against society by robbing it of a useful citizen and at the same time forcing a useless one upon it. A man taken to court for drunkenness should with great care be properly classified. It should be determined whether he is an habitual drunkard, an occasional drunkard, or an accidental drunkard. There may be hope for the occasional drunkard, there is invariably hope for the accidental drunkard. If one of these is found to have employment at the time of his arrest, great care should be exercised not to let the fact that he has been arrested prejudice his employer against him, and as far as possible he should be spared humiliation. Nothing will more quickly unfit a man for anything worth while than humiliation. To punish such a man with a prison term will help no one.

Neither should he be sent back to his liberty without some recognition of the fact that he has been drunk and irresponsible. Any police officer, and more especially any police-court reporter, will testify that almost every man who, having been arrested for drunkenness, is discharged from custody without penalty, for one reason or another, social position, political importance, or previous good character record, will find a saloon within two blocks of the court and take a drink on the way home. He will probably not get drunk,—the impression made by his arrest will remain too strong to permit that,—but he will take a drink. And that and other drinks will help time drive from his mind the memory of the arrest, the cell, the court. And what is true of him who has been arrested and discharged is also true of him who has been arrested and imprisoned. Punishment fails utterly to “reform” the alcoholic.

Nor is colonization more effective, except for the hopeless cases. It means segregation. A man once said to me: “I want to be helped, but not at the cost of compulsory association with others seeking help. I know that to be thrown into unavoidable contact with those worse than myself would hopelessly degrade me. I should not be willing to risk that, no matter how much good the treatment might do me.” Colonization of the occasional alcoholic stamps him only a little less deeply than his stripes are sure to stamp the criminal who is sent to prison, and its effects upon him and his family are not more desirable than they would be if the process made exactly that of him. He is likely to be barred from employment after his discharge from the colony, and thus find it impossible to reëstablish himself. Moreover, during the period of sequestration it is difficult to devise a plan for the care of the wives and children of those sent into seclusion. At a time when nothing in the way of betterment can be expected of him unless he regains confidence in himself, such treatment does not strengthen, but cripples, a man’s spirit. Surveillance after his return will work on his imagination, cowing him into morbidness, until that alone will first weaken his will and then break it down. Too great emphasis, therefore, cannot be placed upon the viciousness of colonization for any but the first of the three classes into which I have said that all men charged in court with drunkenness should be carefully separated. Colonization of the hopeless is advisable only because such men, before they have descended to that stage, have cost their friends and society all that it is advisable to spend on them. If the man who is worth while is to be saved, it must be without the application to him of the brand.

So much for the existing public methods of dealing with the alcoholic. The most usual private method is for a man’s family or friends, when he has lost control, to send him to some place where he can “get a grip on himself.” But he often does not receive in such a place, any more than in the hospital or prison, that specialized treatment which can make that regained grip effective. General treatment, accompanied by a gradual withdrawal of stimulant, will restore his bodily strength, with the result, in nine cases out of ten, that when he emerges from the seclusion he is able to drink more than he was before he was sequestered, and will be sure to come to grief more quickly. In most cases his craving and need for stimulant are in no degree decreased, and in consequence he will frequently relapse while going to the railway station on the homeward journey. An even graver danger is that, while still in full possession of the alcoholic habit, he will in addition contract the hypodermic habit, and any drug habit developed in the alcoholic is the most difficult of cases to deal with successfully. If he does relapse, his friends will almost surely hold him blameworthy and impatiently abandon him as hopeless, believing everything to have been done which can be done. In reality nothing at all useful has been done to help him. He is a sick man, and no attack whatever has been made on his disease.

COMPLETE MENTAL CHANGE MUST PRECEDE REFORM

This brings us to the kernel of the matter. No man who has become addicted to the use of alcohol can possibly abandon it unless he has first undergone a complete mental change, and in ninety-nine cases out of a hundred this alteration of the mental state will not come until he has experienced a physical revolution. The reason for this is simple. Excessive use of alcohol really deteriorates body and brain tissue, and tissue degeneration transforms for the worse the entire physical and mental make-up of a man. The confirmed alcoholic is in the state which, save in rare instances, nothing short of specialized medical treatment can correct. Mere general building up of bodily tone is as ineffective with alcoholics as is enforced deprivation or punishment.

I emphasize this point particularly because many men are afraid to take any treatment for alcoholism lest through it they lose their standing with themselves or with their neighbors. Self-respect must be protected at every stage of the struggle as the patient’s only hope. My purpose here is to show that the only chance of reforming most alcoholics lies in giving them opportunity through this physiological change to reëstablish confidence in themselves.

In setting about the business of treating an alcoholic, the first step is to realize that he is in an abnormal mental state. To moralize or to appeal in the name of sentiment to a warped and twisted mind is, I believe, sheer waste of time. To the man who has lost control, it must be first restored before he can be put to thinking. You cannot expect the distorted alcoholic brain to be honest with you or with itself.

I cannot emphasize too strongly the harm that may come out of simply depriving the chronic alcoholic of his stimulant. I know that there are many relatives and friends and even physicians who, out of pure desperation, feel that they have accomplished much when they are able to put a man where he is unable to get his drink, irrespective of the amount which he has been accustomed to take. I consider the chronic alcoholic one of the most important cases in medicine to deal with successfully. Strange as it may seem to the layman,—and it is just as strange to the physician,—to such a case there is absolutely no other form of artificial stimulants that will take the place of alcohol, and when a patient is deprived of his accustomed stimulant, within twenty-four hours he begins to drift into delirium tremens, which means that the patient is a very sick man, and unless he is properly treated, will, if he lives through the active period of delirium, drift into a “wet brain,” or, in other words, alcoholic insanity; and even if the patient survives the latter illness, a large percentage of such cases prove in the end to be hopelessly insane, and about eighty per cent. of the delirium tremens cases that do not get proper medical help die. It is a very serious matter dealing with the chronic alcoholic. Something definite must be done for such a case; deprivation is impossible; simple reduction is sometimes a failure; nothing short of definite medical, hospital work will unpoison this sick man and avoid the complications of delirium, “wet brain,” or possible hopeless insanity.

The second step is to give the patient that definite medical treatment which will correct his physical condition. Once this change has been effected, you have a man whose system is no longer crying out for liquor, with every nerve a-quiver for it, every tissue thirsting for it. There have been reforms from alcoholism which were not preceded by this physiological change, but they have been rare.

The physiological metamorphosis may be accomplished from without, by means of treatment, without assistance from the patient other than mere acquiescence. The mental change can be assisted from without; it cannot be accomplished or maintained by any one except the patient. Despite himself a man may be successfully treated for other ailments, but not for alcoholism. By an intelligent subsequent attitude friends or physicians may help to restore self-confidence, but that is all they can do.

After the desire for it has once been eliminated, the patient cannot afford to take any alcohol whatever, and after a proper change of mental attitude he will not wish to. From alcohol he must abstain altogether, even in illness. Let no recovered alcoholic risk relapse because alcohol seems to his physician to be desirable as a medicine. Indeed, the most extreme care should be exercised to avoid medicines containing alcohol even in small percentages, and this will bar most of the proprietary remedies. When he is hungry, let the recovered alcoholic eat; when he is weary, let him be sure to rest; when he feels ill, let him be sure to consult without delay a competent physician. None of these conditions indicates a necessity for alcohol.

Thus the man who is not hopeless may be saved. Society owes every alcoholic a fair opportunity to reform; it may be questioned if it owes him repeated opportunities. Many alcoholics never have been and probably never could be useful citizens. Waste of money and emotion on them is lamentable to contemplate; the sums at present thus hopelessly thrown away would aggregate enough really to restore every alcoholic actually curable. Sentimentalists do not like to admit the limitations of useful help, but those limitations do exist, and we should reckon with them. If we do, the man really curable will have all the better chance.

A TEST OF THE WORTHY

It is possible to discriminate between the curable and the incurable by the simplest of expedients. Usually the question, What is this man willing to do in return for help? will, with its answer, also supply the answer to the inquiry as to his future. No man of sufficient mental fiber to make helping him of any actual value is willing to accept charity. Even if he finds himself at the moment unable to repay the debt involved, he will be anxious to make it a future obligation. My fifteen years of experience have proved to me that the sense of personal obligation is of great moment in this matter. Even when it becomes necessary for a relative, employer, or friend to assist a patient by the payment of his bills, it should be regarded a part of the treatment to consider this a loan, which must be repaid, and not a gift. It follows, sadly enough, that the most hopeless alcoholic is the rich young man to whom financial obligations incurred for treatment mean nothing whatsoever, and to whom responsible employment is unknown. Indeed, it seems well-nigh impossible to reform the vagrant rich. The man who thinks that giving up his alcohol is primarily a privation, although he may admit the definite necessity of this privation, is not likely to reform permanently; but there is hope for that one who declares without apology that drinking is a bad business and that he wishes to be helped to stop it. I cannot say with too great emphasis that self-respecting pride is the main hope of the alcoholic.

It must not be overlooked, however, that it is the pride of the curable alcoholic which makes him difficult to reach. To try to help such a man when it is too late is a pitiably usual experience, for not until it is too late does the pride of such a man allow him to apply for help. The man who says, “I will not drink to-day,” and finds himself compelled to; who promises himself, but cannot keep his promise, is the man who most deserves help, and is most likely to yield some sort of good return on an investment made in him. Indeed, it is the rare alcoholic, curable or incurable, who of his own initiative submits himself to treatment. Friends must assist; but while the importance of such friendly service cannot be overestimated, it must be of the right kind or it will be worse than useless. Friends of alcoholics too often either sentimentalize or bully when they go about the task of helping, or they allow too little time for the accomplishment of the reform. Successful business men are specially likely to act childishly when dealing with the mighty problem of assisting alcoholics to their feet. They are likely to affirm that there is no excuse for any man who yields to drink. If they have given help before, they are prone to call attention to the fact that their beneficiary has not recompensed their kindness by reforming, and declare, for instance, that they will pay his board another week, but that will be the end of their endeavor. This spirit—and it is the usual spirit—can accomplish nothing; and the money spent in this and other ill-considered and half-hearted efforts to save men has not decreased, but has increased, the dissipation it has sought to stop. Even relatives and intimate friends are likely to become weary of a case which shipment to some private institution, deportation to a ranch, or embarkation on a sailing-vessel for a long voyage has failed permanently to help.

Such treatment works no reforms, or almost none. Until the cause of drinking is removed, travel from one place to another in an effort to obtain reform by breaking up old associations will be of no avail, but will, instead, repeat the experience of the old woman in the fairy-tale who was bothered by a goblin. When she uprooted herself from her old home and sought another, the goblin, hidden in a churn, went with her. It was the old woman, not the cottage, he was haunting; it is the man, not his environment, in which the alcoholic habit finds its stronghold. When a patient by intelligent treatment has been put into a receptive state of mind, he should be told to look up his old associates and to them declare himself upon the liquor question. If they are friends, they will congratulate him; if they are not, he will have gained by making certain of it. And there is very little danger that, after he has seen them, he will wish again to make intimates of them; that after, in his sober senses, he has examined the surroundings which they frequent, he will be willing to return to them. Being himself normal, he will wish for normal men as friends; being far more fastidious than he was when he was alcoholic, the old haunts will fill him with disgust. This declaration of himself the man must himself make. Good friends may help him otherwise, and chiefly by refraining from the slightest thing which may by any chance tend to decrease his self-respect and his confidence in his own power to stay reclaimed. What a man needs is a new mind on the subject.

CHAPTER VII

CLASSIFICATION OF ALCOHOLICS

Alcoholics are more easily classified than drug-takers. With few exceptions, alcohol-users have their beginnings in social drinking. Not a few women and boys have had their first taste of alcohol, and may even have acquired a definite alcoholic habit, through the small quantities administered as stimulants by physicians; but in a general way it is as easy and just to absolve the physician from responsibility in the matter of alcoholism as it is easy and just to put a heavy responsibility upon him in the case of the use of drugs.

THE DEMAND FOR STIMULANTS

In these days all mankind searches for exhilaration. The instinctive demand for it is an inevitable result of the artificial social system which we have built up. We work beyond our strength, and naturally feel the need of stimulants; we play beyond our strength, and as naturally need whips for our vitiated energies. The greatest social disaster of all the ages occurred when first alcoholic stimulation, which is only one step in advance of alcoholic intoxication and narcotization, found its place as an adjunct of good-fellowship. All humanity turns in one way or another to artificial stimulants, and while alcohol and narcotics are the worst among these, we cannot slur the fact that many who would shun these agents as they would a pestilence, turn freely to milder, but not altogether harmless, stimulants, such as tea, coffee, and tobacco.

I do not purpose to go into a long dissertation upon the chemical peculiarities of alcohol; I do not purpose to discuss the value or peril of alcohol as food; there are plenty of published chapters telling exactly what alcohol is. I feel that it is my mission to do none of these things, but to endeavor to reveal to the student the most effective way of dealing with a patient who has drifted into a definite alcoholic addiction.

THE MAN WHO CANNOT BE SAVED

It seems impossible to arouse any enthusiasm or sympathy for the human derelict whose natural weakness is inevitably such that one taste of alcohol means a gallon, and final wreck and ruin. The human cipher, plus alcohol or minus alcohol, it matters not which, means nothing. It may be true that alcohol subtracted from nothing leaves nothing, but it is certain that alcohol added to nothing may mean a peril to society and a serious charge upon it.

A man who has achieved nothing up to the point where he has become addicted to excessive alcoholism will rarely repay the trouble involved in an effort to preserve him from his folly, although of course his preservation from it might be of general social service as a means of saving the public money that otherwise might be expended in the reparation of the work of his destructive tendencies, besides the public expense involved in police, court, and prison economy that prevents him from the opportunity of indulgence. But thousands of decent men annually yield to alcohol, and are wrecked by it. The decent and potentially valuable citizen who through overwork, worry, sickness, sorrow, or even through a mistaken conception of social amenities or duties, drifts into excessive alcoholism is a victim of our imperfect social system, and repays remedial effort. Furthermore, such a man is invariably savable if he himself applies for salvation, assists with his own will in its application to his case, and pays his own money for the cure.

The proportion of the cases that can be saved among the general run of alcoholics who are sufficiently prosperous or have sufficiently prosperous friends to make them likely to come under my direct observation amounts to about one quarter of the whole. It will be observed that this claim for alcoholics is far below the claim which I have made for drug-users.

Where it is found that a case of excessive alcoholism has grown out of a lack of a normal sense of responsibility, where excessive alcoholism has reached the point at which deterioration of the moral nature has set in, or where social and financial entanglements already have resulted, a problem is presented which is complicated and even very doubtful. In such a case far more than definite medical treatment must be resorted to before a complete restoration of the unfortunate to social usefulness can be hoped for. The naturally irresponsible person or the person already led into irresponsibility by alcoholism may be regarded as an almost hopeless proposition. This is peculiarly the case where no financial obligation can be imposed upon the patient as a part of the treatment. The very poor for whose treatment some one else must pay, and the very rich to whom the sum paid for treatment is a matter of no moment, are almost equally hopeless. My long experience has taught me that the man who does not feel a financial responsibility for that which is done for him is usually the least promising of all the cases brought to me. I have found it necessary to regard as a definite part of my treatment the imposition of a monetary obligation.

If, for example, the employee of a person or a corporation is sent to me for relief from alcoholic tendencies by his employer or employers, I invariably refuse to accept the case unless it is agreed that the sum paid for the patient’s treatment shall be held against him as an obligation to be repaid as soon as possible to those who have advanced it. Even the man who is curable will fail in a psychological realization of the misfortune into which he has actually fallen through alcoholic indulgence unless he himself must pay the fiddler. In the case of a working-man who is brought to me for treatment by his employers, I make a minimum charge as a rule, but only on the condition that with all due speed it is deducted from his pay-envelop. In the case of men of a higher order, as professional employees, heads of departments, etc., I insist in a general way upon following the same line of procedure. I cannot too strongly emphasize my absolute conviction that it is invariably a waste of money and time for an employer or an employing company to attempt to help alcoholics by means of free medical treatments. No good will come from this in the long run, as it never will prove to be worth while. Thus we may classify very rich, utterly poor, and irresponsible inebriates as among the hopeless. From every moral, social, and economic point of view the hopeless inebriate is a liability to the world at large. Throw him in the sieve of respectability, and soon or late he will always prove small enough to slip through the meshes.

COLONIZATION OF ALCOHOLICS

Among such cases will be found fit subjects for colonization, and these are the only ones who should be treated in this way. No greater social mistake is possible than the colonization and segregation, either in sanatoriums or inebriate farms, of other than utterly hopeless alcoholic cases. The next greatest mistake undoubtedly is society’s failure to segregate those who are utterly beyond the pale of hope. These men and women will be less of a burden to their friends and the community after segregation; their segregated existence will not constitute a threat against society of the present and future generations. It is my opinion that these people, men and women, rich and poor, should be sterilized and put at work. It is possible that this plan, if properly carried out, might develop some institutional effort worth while. That at present practised means a waste of time and money.

It should be borne in mind that deprivation never yet removed the underlying cause of the desire for alcohol, no matter over how long a period this deprivation may have extended, nor has it ever removed the desire itself. These things can be brought about only by the elimination of the poison from the victim’s system.

All alcoholics, no matter whether they are preferred risks or hopeless cases, whether they are to be returned to society or isolated and sterilized, should be unpoisoned.

SUCCESS OF THE SPECIFIC TREATMENT

The first exhaustive test of this treatment for alcoholism was made at Bellevue Hospital, and its results were announced in a pamphlet published by Dr. Alexander Lambert. The hospital in which the work was carried on was without ideal facilities; overcrowded wards and an insufficiency of nurses were among the many handicaps. That the results were more hopeful than anything theretofore accomplished is indicated by the following extracts from articles by Dr. Lambert:

RESULTS

I am often asked as to the success of this treatment and the percentage of patients who remain free from their addiction. This varies enormously with the individual patients and one can only judge from one’s experience. My personal experience is that 11 per cent. of the morphinists and 12 per cent. of the alcoholists return for treatment. Doubling this percentage it still gives us 75 per cent. as remaining free from addiction. Of these a very high percentage are known to have stayed free.

SCOPE OF THE TREATMENT

This treatment is not offered as a cure of morphinism or as a cure of delirium tremens or chronic alcoholism, as I said in the first article. It will, however, obliterate the terrible craving that these patients suffer when, unaided, they endeavor to get off their drugs or are made to go through the slow withdrawal without some medication to ease them. Compared with the old methods of either slow withdrawal or rapid withdrawal, it is infinitely superior. Deprivation of a drug is in no way equivalent to elimination of that drug from the body. Deprivation causes suffering; elimination relieves it. But neither this combination of drugs nor any other combination known to man can prevent persons, after they are free from their addiction—be it alcohol or morphin—from going out and repoisoning themselves by taking again the drug which has poisoned them and led them on to their habitual intoxication.

There are many more morphinists who have unconsciously fallen under the spell of the habit through no fault of their own, than can be said of alcoholists.

To any one who has ever tried to break off a patient by the old withdrawal methods when they were taking goodly amounts of the drug, and has struggled to keep them free from it after they have ceased taking it, the difference in the picture when undergoing the treatment by this new method is most striking.

With this treatment most patients do not suffer more than a bearable amount of discomfort of hot flashes, slight pains, and the discomfort of their cathartics. When properly administered, this is the full extent of suffering with the majority of patients. Some do not go as far as this, a few suffer more. But when improperly administered, they can suffer as much by this method as by any other.

No test more exacting than the one made at Bellevue Hospital could be devised. Most of the cases appearing for treatment in the wards of that institution are of the most advanced type, for the nature of the New York hospital system may be said in a general way to select for Bellevue the least hopeful patients coming from the least hopeful classes of society. If, therefore, anything approaching permanent relief was secured for as many as twenty out of every one hundred cases, an extraordinary efficiency was indicated.

Of course the intelligent reader will understand that no man with reason can claim for any treatment the power permanently to divorce from alcohol a man who does not wish to be divorced from it. To take a man whose system has reached that degree of craving for alcohol that he would sign away his right to salvation in exchange for a drink after a brief period of deprivation, if he could not otherwise obtain the alcohol, and to unpoison him so that he feels no necessity or even the slightest desire for a drink or for any stimulant, is to accomplish a great deal of good. It means that his nervous system has been restored to something nearly normal, and that he has been given a chance. The man who has not had this help from outside can do nothing for himself; but having been cleared of alcoholic poison, he is brought into a mental state wherein he finds it possible to estimate reasonably the harm which alcohol has done him. The patient is then in a mental state that enables his relatives and friends to deal with him without being forced to estimate and allow for alcoholic abnormalities in his processes of thought. He is in a physical state that, although it apparently may be worse than that in which the alcohol had placed him, is nevertheless one that will enable his physician to work with him intelligently.

Such an achievement seems a perfect piece of medical work of its kind. Properly carried out, my treatment will accomplish exactly this in every instance. It will accomplish it within five days and very likely within three days. I have never known it to require a period of more than seven.

When this treatment is properly provided for throughout the country, it will be found that neither large nor costly institutions will be necessary. The stay of every patient is so brief that in the average community a small institution containing only a few beds will be found sufficiently large to meet all local needs.

THE HABITUAL DRUNKARD IS NOT A CRIMINAL

Legislation restrictive of the sale and use of habit-forming drugs is in reality a dangerous experiment until other legislation that provides for the medical help of those who would thus be deprived has first been written upon our statute-books. I am inclined to think that many of the failures which strew the paths of experimentalists in anti-alcohol movements have been due to a lack of similar foresight. The man who is penalized for drunkenness will usually get drunk again the moment he finds himself at liberty to do so; and this will not be due to any natural depravity upon his part, but, rather, to an almost inevitable result of the bodily craving that thrills his every fiber and for the relief of which nothing whatever has been provided. We shall never make any serious progress in dealing with the most serious evils of alcoholism until we waken to the folly of treating the hard and habitual drinker as a criminal, exacting from him penalties and inflicting upon him disgrace.

In every instance the passage of restrictive legislation should be accompanied by the passage of remedial legislation; for provision for the relief of suffering caused by prohibitory laws must be provided. The courts should carefully consider the facilities at the disposition of the communities in which they labor, and in imposing sentences they should be careful not to overtax them. It would be better for a community to keep a victim upon a steady diet of alcohol for weeks while he was waiting for a bed in a curative institution than to risk causing the man’s death or insanity by depriving him of his alcohol until the means for relieving his system’s acute demand for it were at hand. By following a similar plan, it will be found that the evil of habit-forming drugs can be exterminated in the United States. Whether alcoholism, which is a social vice, ever can be similarly exterminated by like methods I do not know; but I am convinced that an intelligent pursuit of such a policy would do more to accomplish the desired results than ever has been done by other means.

HOW SOCIETY TREATS THE VICTIM OF ALCOHOL

The care of the inebriate who already comes under the law, and who by his habits forces his way into the state and municipal hospitals, forms one of the great burdens upon society of the present day. It should be regarded as one of the most important problems of modern medicine.

No other class of the sick includes so great a number of individual cases. We find, for example, the almost incredible fact staring us in the face that more than one third of all the patients admitted to Bellevue Hospital in New York City are sent there by alcohol, while less than two per cent. are sent there by habit-forming drugs.

I am casting no reflection upon this or any other institution when I say that there and elsewhere little understanding is shown in dealing with these cases. As a matter of fact, no intelligence is anywhere shown in this matter. The policeman who finds a drunken man or woman on his beat arrests the unfortunate with as much wrath and probably as much brutality as he would show a burglar or a murderer; the committing magistrate before whom the victim is taken treats him or her precisely as he would treat a criminal; in the various penal institutions to which this man or woman is committed the idea upon which their whole treatment is based is that of punishment.

It seems to me that the imperfections of this system might most easily be corrected by the committing magistrates. It is the largest problem which confronts these officials; therefore they might very well afford the time necessary to study it carefully. Concerted action by this group of the judiciary might accomplish worthy results almost immediately. As matters are at present organized, the committing magistrate may do any one of four things with an inebriate who has been brought before him: he can release him without penalty, he can put him on probation, he can fine him, he can imprison him. I have yet to discover any one capable of telling me why measures of this sort can possibly be expected to have a beneficial effect upon a person who through over-indulgence has set up in his system a demand for alcohol.

I have no wish to appear publicly as the critic of our petit judiciary, but no class of men is less informed upon this subject—the one subject upon which they should be best informed—than the committing magistrates not only of the United States, but of every other country in the world. A year or two ago I made a somewhat comprehensive European tour, and studied carefully the methods of dealing with inebriety. Nowhere did I find the faintest indication of a tendency for real intelligence in regard to the matter. We insist upon special education for the professors of our colleges; yet the influence of a committing magistrate upon the human life that is brought under his direct sphere of influence may be greater even than that of a college professor or a college student, and of our committing magistrate we make no educational demand whatsoever, and have never established even a minimum standard of intelligent information for our petit bench. It is my belief that expert sociological knowledge should be required of every man considered for the important post of committing magistrate.

RESPONSIBILITY OF THE MAGISTRATE

The fact that in New York State a colony for inebriates has been established by law makes this special knowledge more necessary there than it was before. Wherever such institutions have been founded, and the courts may contribute to their population by commitment, an unintelligent magistrate finds it within his power not rarely, but every day, to do more harm during one session of his court than he is likely to find it within the scope of his intelligence to do good during the course of a year’s sitting. I find it impossible to be otherwise than bitterly pessimistic in regard to the work our courts are doing with alcoholics.

Under the New York law, a man taken for the first time before a magistrate and charged with alcoholism must either be fined or told that if he again appears charged with that offense, he will be subject to commitment to the inebriate farm for a period of not less than three months. By this procedure not one thing has been accomplished toward the salvation of the man. If he is not committed, but is only threatened and ordered to report weekly or oftener to the probation officer or the court itself, the greatest of all damage has been done, since the man’s pride has been depreciated. After definite medical treatment has been administered to an inebriate, the only other thing that can be done is to make an intelligent appeal to his pride. In this appeal is included at least one half the possibilities of his salvation. Nowhere save in a few instances in New York City is the alcoholic case treated with medical intelligence, and nowhere in the world is the balance of the necessary treatment—the right appeal to pride—carried out with any degree of common sense.

I find one system of special horror in this treatment of inebriates—committing a man for three months, then for six months, and then for twelve. No more certain means could be devised to increase the harm done by alcohol to the community. Not only does this course fail to help the man in any measure whatsoever, but it increases the unspeakable harm which his misfortune must inflict upon his family. In most instances such a commitment not only means the man’s separation from his means of livelihood for the period of its duration, but his discharge from it as the result of this utterly inefficient and legally inflicted disgrace.

The whole effort of society in dealing with the alcoholic should be to prevent those things which at present are the very ones which it accomplishes—mental depression, loss of pride, disgrace, and loss of social position. I am inclined to think that as the world grows older it will be more and more convinced of the inefficiency of punishment, and more and more aware of the necessity of reform through helpfulness.

It seems obvious that penalization, probationary influences, or colonization must be utterly useless in removing from a man’s physical system the craving for alcohol. Therefore it is equally obvious that their only successful mission must be to remove the victim of drink from contact with society for the length of time during which his sentence is operative. The man who is in all probability incurable is not put permanently out of harm’s way by these means, or placed where he can do no harm; the man who has good stuff in him but who has through chance used drugs to excess upon one or more occasion is offered by these methods nothing in the nature of a fair show toward regaining his usefulness.

I see the possibility of many serious results in New York’s board of inebriety plan. These, I think, have their beginning principally in the fact that nothing along the line of classification has been devised or, as far as I know, has been even suggested. If its work were made efficient by means of the adoption of a plan of classification, this board really might become a great boon to society. Suppose that instead of penalizing the man who has been taken before it for inebriety, the board, after intelligent and detailed investigation has shown that the man is probably curable, should provide for him the necessary definite medical treatment to relieve his system from the ill effects of alcohol, and then should bring him into contact with psychological and analytical minds capable of enforcing upon him a realization of the terrible meaning of alcoholism. Without having affected the man’s pride it would send him back to his family and his task with a cool brain and a new point of view. Would not this be a vastly better way of dealing with him than those which are at present followed?

There is no reason why some small charge should not be enforced against such beneficiaries of an enlightened public intelligence who might be found able to meet it. This would accomplish two things: it would reduce the public expense of the system and it would add very greatly to the mental impression left upon the mind of the person for whose benefits the State was working. Furthermore, if a magistrate had once formed the habit of feeling personal interest in individual cases probably his first act after a man had appeared before him would be to send for the accused’s employer and make the truth of the situation clear to him. The mere fact that a man has once been intoxicated should not justify his discharge from employment in which at normal times he is useful and efficient. Both for his sake and for his employer’s, efforts should be made toward reform; for it is not infrequently the case that the man who has lost control through drink is in normal conditions the best man in the office, factory, or workshop. That is one of the chief tragedies of the problem of alcohol.

There is no subject upon which society more sadly needs enlightenment. In this educational process it is probable that the magistrate will be the largest factor. He must realize that he is not society’s instrument of vengeance, but society’s instrument of helpfulness. It should be his aim not to punish, but to protect and preserve. He must realize that scientific knowledge of the problems which confront him is as necessary to his real efficiency as scientific knowledge is to the analytical chemist.

The heart of a conscientious magistrate should thrill with a special sympathy, should be aware of a great responsibility, whenever there appears for judgment in his court a man who for the first time has lost control of himself through drink. To mar this man forever is an easy task; to make him may be difficult, but it is certainly not beyond the bounds of possibility.

The hard drinker who for the first time is haled into court as the consequence of intoxication never is willing to concede either to himself or to others that he needs help. His soul revolts before the mere thought that he has more than temporarily, even momentarily, lost control. He is likely to deny that he has developed a craving for alcohol, and emphatically and indignantly to assert that his drunkenness has been merely incidental to the social spirit, an accident, and in general a thing of no primary importance. The thought that without help there is even a possibility that he may drift from bad to worse is abhorrent to him, and is indignantly repudiated. He will cheerfully admit that many other men of his acquaintance have fallen victims to the effects of alcohol, but he will vehemently deny the possibility of a similar fall on his own part. The magistrate who thoroughly understands all the details of the alcoholic’s psychology, and who is sufficiently adroit of mind and speech to take advantage of this understanding, giving the culprit who has been brought before him every benefit of a carefully and intelligently organized knowledge of alcoholism, could not fail to be one of the most useful of society’s servants and safeguards.

The man or woman taken before a magistrate as the result of alcoholic over-indulgence offers a peculiarly perplexing problem. Society has placed itself in a highly inconsistent position as regards its relation to alcohol. It permits a man to pay it for the privilege to sell alcohol to any one who asks for it, the only restriction being that he may not sell it to a person who already has “had too much.” This leaves the decision as to a customer’s needs and capacity, as well as perils, to be rendered by the man behind the bar. Thus to an extent we intrust daily the destinies of an appreciable proportion of our public to a class of men who certainly have done little to earn general confidence. In nearly every State, if not in all, laws exist imposing penalties upon the dealer in alcohol who sells drink to a person who is already in a state of intoxication; but a careful study of the records of our courts would fail to reveal any large number of liquor dealers who have been charged with this offense, while it is obvious that most persons found upon the public streets or elsewhere in a state of intoxication must have had alcohol served to them at a time when they had already “had enough.” As a matter of fact, the intelligent mind cannot fail to realize that the man who has “had enough” invariably has had too much.

This is only one of many reflections which must occur to the inquiring mind occupying itself with this problem. We have made innumerable laws dealing with, and fondly supposed to control, the sale of alcoholic beverages, but as a matter of fact only one sort of law has ever been devised which possibly could control it, and that law provides for absolute prohibition.

THE NEED OF AN ORGANIZED EFFORT TO HELP THE ALCOHOLIC

If the world wishes to be relieved in any measure from the human waste attributable to alcohol, the time must speedily arrive when municipalities will recognize it as their duty to provide definite medical help for every man who wishes to be freed from the craving for alcohol, and who cannot afford to pay for treatment. It must be recognized that it is society’s duty to hold out this helping hand to every man who has a job and is in danger of losing it through the trap which society itself has set for his feet by authorizing, and thereby encouraging, the sale of alcoholic intoxicants.

Notwithstanding the presence in our social fabric of innumerable charitable bodies, churches, religious societies, and other groups of people who mean well and work hard to aid the unfortunates, it is a fact that nowhere in the United States or, as far as I know, anywhere else is there a single organization which is effectually working along definite and intelligent lines for the preservation of the endangered man who is still curable.