The Project Gutenberg EBook of Habits that Handicap, by Charles B. Towns This eBook is for the use of anyone anywhere at no cost and with almost no restrictions whatsoever. You may copy it, give it away or re-use it under the terms of the Project Gutenberg License included with this eBook or online at www.gutenberg.org Title: Habits that Handicap The Menace of Opium, Alcohol, and Tobacco, and the Remedy Author: Charles B. Towns Release Date: February 14, 2011 [EBook #35270] Language: English Character set encoding: ISO-8859-1 *** START OF THIS PROJECT GUTENBERG EBOOK HABITS THAT HANDICAP *** Produced by The Online Distributed Proofreading Team at https://www.pgdp.net (This file was produced from images generously made available by The Internet Archive.) 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 [Pg v] 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 [Pg vi] [Pg vii] [Pg viii] [Pg ix] [Pg x] [Pg xi] 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 CHAPTER PAGE I THE PERIL OF THE DRUG HABIT 3 II THE NEED OF ADEQUATE SPECIFIC TREATMENT FOR THE DRUG-TAKER 27 III THE DRUG-TAKER AND THE PHYSICIAN 46 IV PSYCHOLOGY AND DRUGS 61 V ALCOHOLICS 76 VI HELP FOR THE HARD DRINKER 87 VII CLASSIFICATION OF ALCOHOLICS 113 VIII THE INJURIOUSNESS OF TOBACCO 140 IX TOBACCO AND THE FUTURE OF THE RACE 162 X THE SANATORIUM 174 XI PREVENTIVE MEASURES FOR THE DRUG EVIL 194 XII CLASSIFICATION OF HABIT-FORMING DRUGS 215 XIII PSYCHOLOGY OF ADDICTION 227 APPENDIX 265 [Pg xii] [Pg xiii] [Pg xiv] [Pg xv] I HABITS THAT HANDICAP HABITS THAT HANDICAP CHAPTER I THE PERIL OF THE DRUG HABIT T 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 [Pg 1] [Pg 2] [Pg 3] [Pg 4] [Pg 5] [Pg 6] [Pg 7] 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 [Pg 8] [Pg 9] [Pg 10] [Pg 11] [Pg 12] 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 [Pg 13] [Pg 14] [Pg 15] [Pg 16] [Pg 17] 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 [Pg 18] [Pg 19] [Pg 20] [Pg 21] [Pg 22] 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 [Pg 23] [Pg 24] [Pg 25] [Pg 26] [Pg 27] T HE 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 [Pg 28] [Pg 29] [Pg 30] [Pg 31] [Pg 32] 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...