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 Given by 
 
THE NARCOTIC DRUG 
 PROBLEM 
 
 BY 
 
 ERNEST S. BISHOP, M.D., F.A.C.P. 
 
 Clinical Professor of Medicine, New York Polyclinic Medical School; 
 
 Member Narcotic Committee, Conference of Judges and Justices 
 
 of New York State; Committee on Habit Forming: Drugs, 
 
 Section on Food and Drugs, American Public 
 
 Health Association. 
 
 Formerly Resident Physician, Alcoholic, Narcotic and Prison Service, 
 Bellevue Hospital ; Formerly Visiting Physician and President of 
 the Medical Board, Workhouse Hospital, New York Department 
 of Corrections; Fellow Academy of Medicine, Visiting 
 Physician St. Joseph Tuberculosis Hospital, Con- 
 sulting Physician to St. Mark's Hospital, 
 etc., etc. 
 
 THE MACMILLAN COMPANY 
 
 1920 
 
 All rights reserved 
 
COPTRIGHT, 1920 
 BT THE MACMILLAN COMPANY 
 
 
 Set up and electrotyped. Published January, 1920. 
 
TO 
 
 MY WIFE, 
 
 WHO HAS SHARED MY BURDENS AND HELPED I» 
 MY WORK, AND WHOSE INTEREST IN AND SYM- 
 PATHY WITH MY WORK HAS MADE MUCH OF IT 
 POSSIBLE, 
 THIS BOOK IS INSCRIBED. 
 
PREFACE 
 
 This book has been prepared in response to a growing 
 demand that the author group together under one cover 
 some of the material collected out of a varied experience 
 with many aspects and phases of narcotic drug addiction, 
 and with activities in the attempted solution of its prob- 
 lems. 
 
 Some of this experience has been previously presented in 
 many addresses before scientific and other societies and 
 in articles in the medical press. 
 
 The author is not associated with nor interested in any 
 hospital or institution active in the care of these cases for 
 financial return or pecuniary benefit. He is not the ex- 
 ponent or mouthpiece or proponent of any special or spe- 
 cific " remedy " or " treatment " or method of so-called 
 " cure." He has no axe to gxind. 
 
 He is not a " specialist " in the treatment of narcotic 
 drug addiction. He is a practitioner of diagnostic and 
 clinical medicine, in whose professional work the care of 
 the narcotic addict has constituted much the smaller part 
 of his activities and studies, and that part has been largely 
 carried on without recompense and often at his personal ex- 
 pense. 
 
 Some years ago, through hospital affiliations a*nd duties, 
 the writer was brought to face this problem of opiate ad- 
 diction and after a while saw in it very important and very 
 interesting clinical problems of physical disease and phys- 
 ical reactions upon which he made observations and studies. 
 
 Hospital connections and the publishing of various ar- 
 ticles have since that time brought him into association 
 with practically all phases and aspects of activity in the 
 
PKEFACE 
 
 consideration and handling of the narcotic drug problem. 
 He has listened to discussions of the subject by promoters ; 
 by reformers of various sorts; by those engaged in legis- 
 lative, judiciar}^, administrative, custodial, penological, 
 sociological, psychological or psychiatrical, medical and 
 other lines of work, and by narcotic addicts from all classes 
 and types of people and their friends and relatives, etc., 
 in groups, or as individuals. 
 
 Two vital elements seem to the author to have received 
 insufficient consideration in the efforts to solve the narcotic 
 drug problem. One of these elements is the sufferings and 
 struggles and problems of the narcotic addict, *and the other 
 is the nature of the physical disease with which he is af- 
 flicted. 
 
 This book is an effort to accomplish two things, first to 
 present the two elements above stated, and second to out- 
 line, discuss and correlate various elements and conflicting 
 activities so that each of us can appreciate the relation of 
 his own endeavor to the whole narcotic drug problem, can 
 realize the comparative importance of his own observations, 
 and can cooperate with the others for the benefit of hu- 
 manity, for the welfare of society and posterity and for 
 the increased health and happiness and economic useful- 
 ness of the individual. 
 
CONTENTS 
 
 CHAPTER PAOE 
 
 Preface . . •. r. .. . vii 
 
 I. Inteoduction . > 1 
 
 II. Fundamental Considerations 11 
 
 III. The Nature of Narcotic Drug Addiction- 
 
 Disease 23 
 
 IV. The Mechanism of Narcotic Drug Addiction- 
 
 Disease 35 
 
 Y. Remarks on Methods of Treating Narcotic 
 
 Drug Addiction 50 
 
 VI. The Eational Handling of Narcotic Drug 
 
 Addiction-Disease 61 
 
 VII. Eelation of Narcotic Drug Addiction to Sur- 
 gical Cases and Intercurrent Diseases . 85 
 
 VIII. Laws, and Their Eelations to Narcotic 
 
 Drugs 95 
 
 IX. Some Comments Upon the Legitimate Use of 
 
 Narcotics in Peace and War 114 
 
 X. General Survey of the Situation and the 
 
 Need of the Hour 122 
 
 Appendix : Human Documents, — State- 
 ments OF Sufferers from Narcotic Drug 
 Addiction-Disease 137 
 
THE NARCOTIC DRUG PROBLEM 
 
 CHAPTEE I 
 
 INTEODTJCTION 
 
 It is a fact becoming more and more obvious tbat too 
 little study and effort to interpret their physical condition 
 have been given to those unfortunates suffering from 
 narcotic drug addiction. 
 
 We have neglected their disease in its origin and sub- 
 sequent progress and formed our conception of its char- 
 acter from fully developed conditions and spectacular end- 
 results. We have seen some of them during or after our 
 fruitless efforts at treatment, their tortures and poor 
 physical condition overcoming their resolutions, until they 
 plead for and attempted to obtain more of their drug. 
 We have seen others exhausted, starved, with locked-up 
 elimination, toxic from self-made poisons of faulty metab- 
 olism, worn with the struggle of concealment and hope- 
 less resistance, and for the time being more or less irre- 
 sponsible beings, made so, not because of their addiction- 
 disease itself, but because they were hopeless and discour- 
 aged and did not know which way to turn for relief. 
 
 What literature has appeared on the subject has usually 
 pictured them as weak-minded, deteriorated wretches, 
 mental and moral derelicts, pandering to morbid sensual- 
 ity; taking a drug to soothe them into supposed dream 
 » states and give them languorous delight ; held by most of 
 us in dislike and disgust, and regarded as so depraved that 
 their rescue was impossible and they unworthy of its at- 
 tempt. 
 
 1 
 
2 THE NARCOTIC DRUG PROBLEM 
 
 We have overlooked, ignored or misinterpreted intense 
 physical agony and symptomatology, and regarded failure 
 to abstain from narcotics as evidence of weak will-power 
 or lack of desire to forego supposed morbid pleasure. We 
 have prayed over our addicts, cajoled them, exhorted them, 
 imprisoned them, treated them as insane and made them 
 social outcasts ; either refused them admission to our hos- 
 pitals or turned them out after ineffective treatment with 
 their addiction still fastened to them. To a great extent 
 the above has been their experience and history. 
 
 In great numbers they have realized our failure to ap- 
 preciate their condition and to remedy it, and have after 
 desperate trials of quacks, charlatans and exploited 
 " cures," finally accepted their slavery and by regulation 
 of their drug and life, their addiction unsuspected, main- 
 tained a socially and economically normal existence. 
 Some failing in this, perhaps broken and impoverished, 
 their addiction recognized, have become social and eco- 
 nomic derelicts and often public charges. 
 
 From these last, together with the addicted individuals 
 from the class of the fundamentally unfit, we have painted 
 our addiction picture. Confined and observed by the 
 custodial official and the doctor of the institution of cor- 
 rection and restraint, or concealed as family skeletons in 
 many homes^ descriptions of them have given to the 
 narcotic addicts as a whole their popular status — cases 
 of mental and moral disorder due to supposed drug action 
 or habit deterioration, and based upon inherent lack of 
 mental and moral stamina. 
 
 It was with the above conception of these addiction con- 
 ditions that I began my work in the Alcoholic, Narcotic 
 and Prison Service of Bellevue Hospital, attracted to 
 the service not by hope of helping nor by interest in 
 " jags " and " dope fiends '' as I then considered them, 
 but by the mass of clinical material available for surgical 
 and medical diagnosis and study which was daily admitted 
 
INTRODUCTION 3 
 
 to those wards. When I left the service after sixteen 
 months of day and night observation, with personal over- 
 sight and attempt to care for in the neighborhood of a 
 thousand admissions a month, my early and faulty concep- 
 tion of narcotic addicts was replaced by a settled convic- 
 tion that these cases were primarily medical problems. I 
 realized that these patients were people sick of a definite 
 disease condition, and that until we recognized, under- 
 stood and treated this condition, and removed the stigma 
 of mental and moral taint from those cases in which it 
 did not exist, we should make little headway towards solu- 
 tion of the problem of addiction. 
 
 It is a fact that the narcotic drugs may afford pleas- 
 urable sensations to some of those not yet fully addicted 
 to them, and that this effect has been sought by the ment- 
 ally and morally inferior purely for its enjoyment for the 
 same reasons and in the same spirit that individuals of 
 this type tend to yield themselves to morbid impulses, 
 curiosities, excesses and indulgences. Experience does 
 not teach them intelligence in the management of opiate 
 addiction and they tend to complicate it with cocaine and 
 other indulgence, increasing their irresponsibility and 
 conducing to their earlier self -elimination. 
 
 Wide and varied experience, however, hospital and 
 private, with careful analysis of history of development, 
 and consideration of the individual case, demonstrates the 
 fact that a majority of narcotic addicts do not belong tq 
 this last described type of individuals. It will be found 
 upon careful examination that they are average individuals 
 in their mental and moral fundamentals. Among them 
 are many men and women of high ideals and worthy ac- 
 complishments, whose knowledge of narcotic administra- 
 tion was first gained by " withdrawal " agonies following 
 cessation of medication, who have never experienced pleas- 
 ure from narcotic drug, are normal mentally and morally, 
 and unquestionably victims of a purely physical affliction. 
 
4 THE NARCOTIC DRUG PROBLEM 
 
 The neurologist, the alienist, the psychologist, the law- 
 maker, the moralist, the sociologist and the penologist have 
 worked in the field of narcotic addiction in the lines of 
 their special interests, and interpreted in the lights of their 
 special experiences. Each has reported conditions and re- 
 sults as he saw them, and advised remedies in accordance 
 with his understanding. With very few exceptions little 
 has been heard from the domain of clinical medicine and 
 from the internist. It is only here and there that the 
 practitioner of internal medicine has been sufficiently in- 
 spired by scientific interest to seriously consider narcotic 
 drug addiction and to make a clinical study of its actual 
 physical manifestations and phenomena. 
 
 The idea that narcotic drug addiction should be ac- 
 corded a basis of weakness of will — neurotic or otherwise, 
 inherent or acquired — and should be classed as a mor- 
 bid appetite, a vice, a depraved indulgence, a habit, has 
 been generally unquestioned and the prevailing dogma for 
 many years. It is very unfortunate that we have paid so 
 little attention to material facts and have made so little 
 effort to explain constant physical symptomatology on a 
 basis of physical cause, and that there has not been a 
 wider recognition and more general acceptation of scien- 
 tific work that has been done. 
 
 Despite the years of effort that have been devoted to 
 handling the narcotic addict on the basis of inferiority and 
 neurotic tendencies, and of weakness of will and perverted 
 appetite — in spite of exhortation, investigation, law-mak- 
 ing and criminal prosecution — in spite of the various 
 specific and special cures and treatments — narcotic ad- 
 diction has increased and spread in our country until it 
 has become a recognized menace calling forth stringent 
 legislation and desperate attempts at administrative and 
 police control. And though a large amount of money has 
 been spent in custodial care and sociological investigation 
 on the prevailing theories, and in various legislation, much 
 
INTRODUCTION 5 
 
 of it necessary and mucli of it wisely planned, we have 
 made but little progress in tlie real remedy of conditions. 
 
 It is becoming apparent that in spite of all the work 
 which has been done — in spite of all the efforts which 
 have been made — there has been practically no change in 
 the general situation, and there has been no solution of 
 the drug problem. 
 
 In analyzing results of efforts and arriving at causes 
 for failure, it seems to me that it is always wise to begin 
 at the beginning, and to ask ourselves whether we have 
 not started out with an entirely erroneous conception of 
 our basic problem. Is it not possible that instead of 
 punishing a supposedly vicious man, instead of restraining 
 and mentally training a supposedly inherent neuropath 
 and psychopath, we should have been treating an actually 
 sick man ? Is it not possible that the addict did not want 
 his drug because he enjoyed it but that he wanted it be- 
 cause his body required it ? This is not only possible — 
 it is fact — and the whole secret of our failure has been 
 the misconception of our problem based on our lack of 
 understanding of the average narcotic drug addict and his 
 physical conditions. 
 
 In my own experience as a medical practitioner I know 
 that non-appreciation of this fact was the cause of my 
 early failures; and I further know that from the begin- 
 ning of appreciation of this fact dates whatever progress 
 I have made and whatever success I have attained. In 
 my early efforts as Eesident Physician to the Alcoholic 
 and Prison Wards of Bellevue Hospital, devoid of previ- 
 ous experience in the treatment of narcotic addiction, 
 directed by my available literature and by the teachings 
 of those in my immediate reach, I followed the accepted 
 methods. I tried the methods of the alienist ; I tried the 
 exhortations of the moralist; I tried sudden deprivation 
 of the drug ; I tried rapid withdrawal of the drug ; I tried 
 slow reduction of the drug; I tried well-known special 
 
6 THE NARCOTIC DRUG PROBLEM 
 
 " treatment." In other words I exhausted the methods 
 of handling narcotic drug addiction of which I knew. My 
 results were, in these early efforts, one or two possible 
 " cures,'' but as a whole suffering and distress without 
 relief ; in a word failure. 
 
 The blame I placed not where it belonged — on the 
 shoulders of my medical inefficiency and lack of apprecia- 
 tion and knowledge of the disease I was treating — but 
 upon what I supposed was my patient's lack of co-opera- 
 tion and unwillingness to forego what I supposed to be 
 the joys of his indulgence. In discouragement and de- 
 spair I held the addict to be a degenerate, a deteriorated 
 wretch, unworthy of help, incurable and hopeless. 
 Strange as it seems to me now, possessing as I did good 
 training in clinical observation and being especially in- 
 terested in clinical medicine, in calm reliance upon the 
 correctness of the theories I followed, I ignored the pres- 
 ence of obvious disease. 
 
 As to the existing opinion that the addict does not want 
 to be cured, and that while under treatment he cannot be 
 trusted and will not co-operate, but will secretly secure 
 and use his drug — I can only quote from my personal 
 experience with these cases. During my early attempts 
 with the commonly known and too frequently routinely 
 followed procedures of sudden deprivation, gradual reduc- 
 tion and special or specific treatment, etc., my patients be- 
 ginning with the best intentions in the world, often tried 
 to beg, steal or get in any possible way the drug of their 
 addiction. Like others, I placed the blame on their sup- 
 posed weakness of will and lack of determination to get 
 rid of their malady. Later I realized the fact that the 
 blame rested almost entirely upon the shoulders of my 
 medical inefficiency and my lack of understanding and 
 ability to observe and interpret. The narcotic addict as 
 a rule will co-operate and will suffer if necessary to the 
 limit of his endurance. Demanding co-operation of a 
 
INTRODUCTION 7 
 
 completely developed case of opiate addiction during and 
 following incompetent withdrawal of the drug is asking 
 a man to co-operate for an indefinite period in his own 
 torture. There is a well-defined limit to every one's power 
 of endurance of suffering. 
 
 Abundant evidence of what I have written is easily 
 found among the many sufferers from the disease of 
 opiate addiction who have maintained for years a per- 
 sonal, social and economic efficiency — their affliction un- 
 known and unsuspected. These cases are not widely 
 known but there are a surprising number of them. When 
 one of them becomes known his success in handling his 
 condition and its problems is generally attributed to his 
 being on a rather higher moral and mental plane than his 
 fellow sufferers and possessed of will-power sufficient to 
 resist temptation to over-indulge his so-called appetite. 
 We have not as a rule considered any other explanation 
 nor sought more at length for the cause of his apparent 
 immunity to the hypothetical opiate stigmata. It would 
 have been wiser and more profitable for us to have re- 
 spectfully listened to his experiences and learned some- 
 thing about his disease. 
 
 The facts in such cases are that instead of being men of 
 unusual stamina and determination, they are simply men 
 who have used their reasoning ability. They have tried 
 various methods of cure without success. They have 
 realized the shortcomings and inadequacy of the usual 
 imder standing and treatment of their condition. Being 
 average practical men, and making the best of the in- 
 evitable, they have made careful and competent study of 
 their own cases and have achieved sufficient familiarity 
 with the actions of their opiate upon them and their re- 
 actions to the opiate to keep themselves in functional bal- 
 ance and competency and control. The success of these 
 people is not due to determined moderation in the in- 
 dulgence of a morbid appetite. It is due to their ability 
 
8 THE NARCOTIC DRUG PROBLEM 
 
 to discover facts; to their wisdom in tlie application of 
 common-sense to what they discover; and to rational pro- 
 cedure in the carrying out of conclusions reached through 
 their experiences. They have simply learned to manage 
 their disease so as to avoid complications. When I tried 
 to account for some of the things I saw by questioning 
 these men who had studied and learned upon themselves, 
 I soon obtained a clearer conception of what opiate addic- 
 tion was. 
 
 When we eliminate the distracting and misleading com- 
 plications, mental and physical, and study the residue of 
 physical symptomatology left, we make some very surpris- 
 ing and striking observations. 
 
 We find that we are dealing fundamentally with a defin- 
 ite condition whose disease manifestations are not in any 
 way dependent in their origin upon mental processes, but 
 are absolutely and entirely physical in their production, 
 and character. These symptoms and physical signs are 
 clearly defined, constant, capable of surprisingly accurate 
 estimation, yielding with a sureness almost mathematical 
 in their response to intelligent medication and the recogni- 
 tion and appreciation of causative factors; forming a 
 clean-cut symptom-complex peculiar to opiate addiction. 
 Any one — whether of lowered nervous, mental and moral 
 stamina, or a giant of mental and physical resistance — 
 will, if opiates are administered in continuing doses over 
 a sufficient length of time, develop some form of this 
 symptom-complex. It represents causative factors, and 
 definite conditions which are absolutely and entirely du0 
 to changed physical processes which fundamentally un- 
 derlie all cases of opiate addiction, and which proceed to 
 full development through well-marked stages. 
 
 During the past years I have had under my care a num- 
 ber of excellent and competent physicians of unusual 
 mental and nervous balance and control in whom there 
 could be no hint of lack of courage, nor of deficient will- 
 
INTRODUCTION 9 
 
 power, nor of lack of desire to be free from their afflic- 
 tion. Possessing, some of them, unusual medical training 
 and scientific ability, having added to this the actual ex- 
 periences of opiate addiction, they with others have co^ 
 operated and aided in experiment, study and analysis, 
 and the result has been in their minds as in mine, com-' 
 plete confirmation of the facts above stated. 
 
 Primarily, there are two phrases I should like to see 
 eliminated from the literature of opiate drug addiction. 
 I believe they have worked great injustice to the opiate 
 addict and have played no small part in the making of 
 present conditions. It seems to me that to speak and 
 write as we still often do of " drug habit '' and '' drug 
 fiends " is placing upon the opiate addict a burden of 
 responsibility which he does not deserve. If long ago we 
 had discarded the word " habit " and substituted the word 
 " disease '' I believe we would have saved many people 
 from the hell of narcotic drug addiction. I believe if it 
 had not been for the use of the word " habit " that the 
 medical profession would long ago have recognized and in- 
 vestigated this condition as a disease. A man, physician 
 or layman, believes that he can control a habit when he 
 would fear the development of a disease. Until now, 
 however, the description has been " drug habit.'^ And the 
 man who acquires one of the most terrible diseases to be 
 encountered in the practice of medicine is unconscious of 
 his being threatened with a physical disease process un- 
 til this process has become so developed and so rooted 
 that it is beyond average human power to resist its physical 
 demands. 
 
 In the near future, I earnestly hope the true story and 
 the real facts concerning the opiate drug addict will be- 
 come universally known. Without familiarity with them 
 and understanding of them, and comprehension and ap- 
 preciation of their disease, we shall never make real prog- 
 ress in the solution of the narcotic drug problem. Prom 
 
10 THE NARCOTIC DRUG PROBLEM 
 
 the present day trend of articles and stories in the news- 
 papers and lay and medical magazines it cannot be doubted 
 that the time is not far distant when in the lay press will 
 appear, in plain, sober, unvarnished truth, the true story 
 of the experiences and struggles of the opiate drug addict. 
 I have marked a rapidly growing appreciation of facts 
 and a steadily increasing activity in the investigation of 
 conditions. This is sooner or later bound to be followed 
 by intelligent public and scientific demand for competent 
 and common-sense explanation and solution. 
 
CHAPTEE II 
 
 FUlTDAMENTAIi CONSIDERATION'S 
 
 My earliest efforts in the handling of narcotic addicts 
 were institutional. They were along the lines of forcible 
 control, based upon the theory that I could expect no help 
 nor co-operation from my patients. 
 
 While this theory is undoubtedly true as applied to 
 many of those who have developed opiate addiction, it is 
 true of them as individuals whose personal characteristics 
 are such that they require forcible control for the accom- 
 plishment of desirable ends in general. It is not true of 
 them simply because of narcotic addiction. It is equally 
 true of these same people afflicted with other diseases. 
 Their successful handling for tuberculosis, venereal disease, 
 cardiac conditions, or anything else requires for its suc- 
 cessful issue constant overnight and what practically 
 amounts to custodial care. I shall refer to them later. 
 XV They are fundamentally custodial or correctional cases 
 and success in their handling will never be accomplished in 
 any other way, whether they are being treated for narcotic 
 addiction or for anything else, mental, moral or physical. 
 
 What appears in this chapter does not solve the prob- 
 lem of the handling of the narcotic addict of this type. 
 There are many factors and elements in their mental and 
 physical make-up other than drug addiction which should 
 be considered, and these factors and elements lie at the 
 bottom of their irresponsibility and the real difficulty of 
 their handling. 
 
 Experience and the analysis of unsuccessful effort and 
 
 results showed that, however necessary forcible control 
 
 might be in the handling of some narcotic addicts, it was 
 
 11 
 
 y 
 
12 THE NARCOTIC DRUG PROBLEM 
 
 not successful nor suflScient nor even the most important 
 factor in the treatment of most cases of addiction-disease. 
 
 I soon came to see that I had an erroneous conception 
 of my medical and clinical problems and an unjust atti- 
 tude towards many if not most of my addiction patients. 
 Studying them — not as drug addicts, but as individual 
 human beings — I found them in their personal, mental, 
 moral and other characteristics, as various as people suf- 
 fering from any other disease condition. There were 
 no narcotic laws at that time and opiates were easily and 
 cheaply obtainable. Very many, perhaps most of those 
 who came to my wards were not forced in either by fear 
 of the law or by scarcity of opiate supply. They did not 
 have to come for treatment, but voluntarily presented 
 themselves in the hope of cure. Something was wrong 
 with my theories. 
 
 In seeking for solution I began to realize that the nar- 
 cotic addict of average individual characteristics obtained 
 no enjoyment from the use of his opiate, and that he co- 
 operated as a rule to the extent of his ability and endur- 
 ance in efforts to relieve him of his condition, so long as 
 he had any hope of possible ultimate success. I learned, 
 trained and experienced physician though I was, that I 
 was far more ignorant of the clinical manifestations and 
 physical reactions of narcotic drug addiction than many 
 of the patients I was trying to treat. It was soon evi- 
 dent to me, moreover, that the man who recognized my 
 ignorance above all others was my patient. I came to see 
 that what I had interpreted as lack of co-operation was 
 largely due ; first to his memory of previous experience, 
 second to recognition of my ignorance, and third to his 
 anticipation of useless and harmful suffering which he 
 expected from my care and treatment of his case. 
 
 Looking back over that period, I am free to confess 
 that my efforts, though honestly made, amply realized 
 his expectations. 
 
FUNDAMENTAL CONSIDERATIONS 13 
 
 I began to see that I knew nothing of this disease or 
 how to treat it as a problem of clinical disease. I saw 
 that addict after addict sneezed and trembled, jerked and 
 sweated, vomited and purged, became pallid and collapsed, 
 that his heart and circulation were profoundly and alarm- 
 ingly disturbed, that he had the unquestionable facies or 
 expression of intense physical suffering, and the many 
 constant and obvious signs which attend physical need 
 for opiate drug. I could not escape the conclusion that 
 here were tangible, material, incontrovertible physical facts 
 for which I had no physical explanation. It seemed un- 
 reasonable to be satisfied with any explanation of them 
 that did not have a physical basis ; and it seemed a logical 
 conclusion that the establishment of a basis of physical 
 disease mechanism could offer the only hope of remedy. I 
 therefore ignored for the time being my past teachings and 
 ideas of the drug addict, and I looked to the patient him- 
 self, questioning him as to his experiences and studying 
 the symptomatology and physical phenomena he presented. 
 In short, I adopted the attitude which must be widely 
 adopted before the medical problem of the clinical hand- 
 ling of drug addiction will be solved — in my attitude 
 towards these cases I became the clinical student and 
 practitioner of internal medicine, treating my patient to 
 the best of my ability as I would a sufferer from any other 
 disease, and studying his case. 
 
 Struck by clinical facts which did not accord with past 
 teaching, I tried to seek out from my personal study and 
 observation of the individual case data upon which to 
 form theories which would accord with clinical facts and 
 with verified histories and, if possible, give a basis of help 
 to these unfortunates. 
 
 Gradually since then I have gotten together, from my 
 own work and that of others, and with some success at- 
 tempted to interpret and explain and apply, what seemed 
 to me facts about opiate addiction. To my mind and 
 
14 THE NARCOTIC DRUG PROBLEM 
 
 in my experience these facts offer a beacon-light of hope 
 and assure ultimate rescue to a very large proportion if 
 not most of those suffering from narcotic drug addiction- 
 disease. 
 
 It is well to state here that of late some of these facts 
 have secured recognition in medical and lay authoritative 
 announcement and literature. The Preliminary Report of 
 a special investigating committee of the 'New York State 
 Legislature is quoted from elsewhere in this book, and the 
 report in June, 1919, of a special committee appointed by 
 the Secretary of the Treasury speaks of, " the more or 
 less general acceptance of the old theory that drug addic- 
 tion is a vice or depraved taste, and not a disease, as held 
 by modern investigators," 
 
 It is on account of " the more or less general acceptance 
 of the old theory " that it is necessary in this place to 
 discuss some of the tenets of that theory for the benefit 
 of those whose interests or emergencies have not led them 
 to investigation of and familiarity with the scientific and 
 other writings on this subject of recent years. 
 
 It has been demonstrated to be a fact that description 
 of narcotic drug addiction as " habit," " vice," " morbid 
 appetite," etc., absolutely fails to give any competent con- 
 ception of its true characteristics, and clinical and physical 
 phenomena. A large majority of opiate users are gravely 
 wronged in a wide-spread opinion still prevalent. This 
 opinion, as previously outlined, is that chronic opiate ad- 
 diction is a morbid habit ; a perverted appetite ; a vice ; that 
 only he who is mentally or morally defective will allow 
 it to get a hold upon him; and that its main and char- 
 acterizing manifestations are those of mental, physical and 
 moral degeneration. Opiate addicts are supposed to have 
 irrevocably lost their self-respect, their moral natures and 
 their physical stamina. They are still painted by many, 
 as inevitable liars, full of deceit, and abscjutely untrust- 
 worthy — people who are supposed to use 'a dream and 
 
FUNDAMENTAL CONSIDERATIONS 15 
 
 deliglit producing drug for the sensuous enjoyment it gives 
 them, and who do not want to discontinue its use. They 
 are thought of as physical, mental and moral cowards who, 
 after realizing their deplorable condition, refuse to exert 
 " will-power " enough to stop the administration of opiates. 
 
 With these views I did my early work on this condition. 
 On these hypotheses, trying to follow current available 
 literature and teaching, I treated my patients for a con- 
 siderable time with results which superficially interpreted 
 seemed to corroborate both literature and teaching. Many 
 of them managed to get their drugs even while in the in- 
 stitution, and practically all of them left uncured with 
 but an exceedingly small number of possible exceptions. 
 
 From my patients themselves, and from watching and 
 studying them, I later learned the truth, which has since 
 been continually strengthened — that the so-called " dis- 
 comforts " we think of them as suffering upon withdrawal 
 of their drug, are actually unbearable suffering, accom- 
 panied by physical manifestations sufficient to prove this 
 to be so. I also learned that the supposed delightful sen- 
 sations which have formed the background of most pic- 
 tures painted of them, had in many, if not in most of the 
 cases with which I came in contact, never been experienced. 
 If they had ever existed they had long ago been lost and 
 all that remained in opiate effect was support and balance 
 to organic processes necessary to the continuance of life 
 and economic activity. As I have written, these sensa- 
 tions seem to be, " part of the minor toxic action of the 
 opiate against which the addict is nearly or completely 
 immune and to the securing of which very many and prob- 
 ably a majority of the innocent or accidental addicts have 
 never carried their dosage." In plain English the sufferer 
 from opiate addiction has, in many if not a majority of 
 cases, never experienced any enjoyment as a result of the 
 drug and has endured indescribable agony in its non- 
 supply. 
 
16 THE NARCOTIC DRUG PROBLEM 
 
 I do not want to be understood as claiming that opiates 
 will not produce pleasant sensations, nor that they are 
 never used to the end of experiencing these sensations. 
 There is a class of the inherently or otherwise defective 
 or degenerate, who first indulge in opium or its products 
 from a morbid desire for sensuous pleasures, just as they 
 would and do indulge in any form of perversion or gratify 
 any idle curiosity. They are mentally incapable of self- 
 restraint, indulging jaded appetite with new stimuli. 
 They yield themselves to any and all forms of self-indul- 
 gence and gratification of appetite. There comes a time 
 when for them opiates, from increasing tolerance and de- 
 pendence lose power to give pleasurable sensations and be- 
 come simply a part of their daily sustenance, exacting 
 physical agony as a result of their non-administration. 
 When this occurs they make no effort to control amount 
 or method or use ; and overdosage together with conditions 
 incidental to and attendant upon their mode of life soon 
 relieves society of the menace of their membership. As 
 a class they have been regarded as incurable and hopeless 
 — socially, economically and personally unworthy of sal- 
 vage. To whatever extent this may be true, however, it 
 is not true simply because they happen to have acquired 
 opiate addiction, but because they are fundamentally what 
 they are, diseased, degenerate and defective. 
 
 The opiate element is as incidental to their fundamental 
 condition as are the venereal and other diseases from which 
 many if not most of them suffer. Observations and con- 
 clusions upon addicts from this type of humanity have been 
 given great prominence in the public press and elsewhere 
 and have had an unwarranted influence in the status of 
 opiate addiction and the conception of and attitude towards 
 the addiction sufferer. Because addicts of this class began 
 to use opium or its derivatives and products to secure sensu- 
 ous gratification is no reason for stigmatizing the mass of 
 those afflicted with addiction-disease as people of perverted 
 
FUNDAMENTAL CONSIDERATIONS 17 
 
 appetites. No one should study addiction in them unless 
 lie is possessed of sufficient ability in clinical observation 
 to separate physical signs of opiate addiction from the 
 manifestations of defective mentality — and unless he has 
 enough insight and breadth of vision to see behind end- 
 results, primary causative factors; and unless he has 
 enough common-sense to refrain from applying to the 
 worthy many the observations he has made upon the un- 
 worthy few. 
 
 It is only fair to state in passing, however, that from my 
 experiences as Visiting Physician in the wards of the 
 Workhouse Hospital, New York Department of Correc- 
 tion, I am convinced that we all too often casually include 
 in the above generally considered derelict class of society, 
 many who under intelligent and humane handling could 
 be restored to or converted into useful citizens. 
 
 There are some above this class, of the type of spoiled 
 and idle youth, who indulge first in opiates in a spirit of 
 bravado or curiosity. The tremendous increase in addic- 
 tion since its spectacular incidental and morbid aspects 
 became so widely published is largely contributed to from 
 this class. 
 
 There are some who first used opiates to temporarily 
 boost them over an emergency, post-alcoholic excesses, 
 severe mental strain, etc. 
 
 The majority of narcotic addicts, however, and especially 
 those developing previous to the activities of the past few 
 years, present a very different history, Mentally and 
 morally they are of the same average equipment as other 
 people. They form a class which might be called " acci- 
 dental or innocent " addiction-disease sufferers. They had 
 no voice nor conscious part in the early administration of 
 opiate, realizing no desire or need for it by name, but 
 only wishing for the unknown medicine which relieved 
 their sufferings. Very many addiction patients have re- 
 ceived their first knowledge of opiate administration in 
 
18 THE NARCOTIC DRUG PROBLEM 
 
 the withdrawal symptoms which followed the attempted 
 discontinuance of its use. There is in these sufferers no 
 element of lack of will-power; no trace of desire to in- 
 dulge appetite or to pander to sensuous gratification. In 
 some, before their condition was recognized, their tolerance 
 for or dependence upon opiate had proceeded to a point 
 where their bodies' demand for morphine was imperative 
 and their withdrawal suffering unendurable. In others, 
 before body need was completely established — with their 
 stamina and nervous resistance below par from sickness 
 and suffering — they have been unable to forego opiate's 
 supportive and sedative and pain-relieving action, or to 
 endure the nervous and other symptoms attendant upon its 
 withdrawal after even a brief period of administration. 
 
 As to what the addict is ; — the tendency and effect 
 of legislative, administrative, police and penological ac- 
 tivities in general have been to place the sufferer from 
 addiction-disease in the position of the criminal and 
 vicious. The tendency of the psychologist and psychiatrist 
 is to analyze him from the viewpoint of mental weakness, 
 defect or degeneration, and to so classify and regard him. 
 The average practitioner of internal medicine, and even 
 the recognized leaders and authorities in this field of 
 medical science will tell you that narcotic drug addiction 
 is a condition to which they have given but little attention 
 and have no clean-cut ideas of its physical disease problems. 
 The addict himself, whose testimony has been all too little 
 consulted or sought, will tell you that he is sick with some 
 kind of a physical condition which causes suffering and 
 incapacity whenever a sufficient amount of narcotic is not 
 administered. 
 
 In the above attitudes and statements the administrative, 
 police and penological authorities are right in some 
 cases ; — the psychologists and psychiatrists have good 
 basis for their opinions in some cases ; — the addict has 
 
FUNDAMENTAL CONSIDERATIONS 19 
 
 physical grounds for his statement in all cases ■ — ■ he is 
 always sick, sick with addiction-disease. 
 
 In my experience with and study of narcotic drug addic- 
 tion and the narcotic drug addict, an experience touching 
 practically every phase of the narcotic situation and giving 
 me opportunity to observe the condition in practically 
 every type of individual, the one constant and more and 
 more strikingly emphasized observation has been constant 
 physical symptomatology and the manifestations of pain 
 and suffering and of fear. I have in my possession his- 
 tories of addicts taken from all walks of life and from 
 all classes and conditions of men. Some of my histories 
 are of patients who were primarily defective, degenerate, 
 weak or vicious. Some of my histories are of people of 
 high mentality; of high ethical and moral standards; of 
 high economic efficiency and social standing. These his- 
 tories, stripped of names and possibilities of personal recog- 
 nition, would form a very instructive collection of material 
 for the man, physician, psychologist, sociologist, legislator 
 or administrator who wishes to study the addict as he 
 really is and to get some conception of the diversity of the 
 problems which he presents. 
 
 I^eglect of this study and absence of this conception is 
 the chief cause of past failure. We have tended to re- 
 gard and handle and treat and legislate concerning narcotic 
 addicts simply as narcotic addicts, instead of appreciating 
 that different individuals and different types and classes 
 of people who may suffer from addiction-disease present 
 entirely different problems, and require entirely different 
 handling. 
 
 If we are going to consider all narcotic addicts as in one 
 class we can with justice only consider those characteristics 
 which are common to all members of that class. There is 
 just one fact and characteristic that stands out as of strik- 
 ing and paramount importance in every one of my histories 
 
20 THE NARCOTIC DRUG PROBLEM 
 
 — it is the fact of physical suffering upon complete with- 
 drawal of opiate drug, or a supply of that drug which does 
 not meet the requirements of the physical body-need. 
 Whatever or whoever the narcotic addict was before his 
 use of opiate drugs — whatever had been the character 
 and circumstances of the initial administration of narcotic 
 drug — after a time, as I have repeatedly written else- 
 where, after addiction-disease has once developed, the his- 
 tory of every opiate addict is that of suffering and of 
 struggle. After addiction-disease is once developed the 
 addict loses whatever euphoric sensation he may possibly 
 have experienced, and all that narcotic administration 
 spells for him is relief from suffering. Without the drug 
 of his addiction he endures intense physical suffering and 
 misery. Without the drug of his addiction he cannot pur- 
 sue a social, economic, or physically endurable existence. 
 He may have been primarily defective, degenerate, de- 
 praved or vicious ; his primary administration of the drug 
 may have been deliberate indulgence, disreputable associa- 
 tions, idle curiosity, any combination of conditions which 
 may be stated ; — he may have been an upright, honest and 
 intelligent, hard-working, self-supporting, worthy and nor- 
 mal citizen in whom the primary administration of opiate 
 drug was a result of unwise, ignorant or unavoidable medi- 
 cation ; — he may have been an ignorant purchaser of 
 advertised patent medicines containing addiction-forming 
 drugs. Whatever his original status, mental, moral, physi- 
 cal or ethical, and whatever the circumstances of his 
 primary indulgence; once addiction-disease has developed 
 in his body the vital fact of his history is the same — sub- 
 sequent use of opiate drug means not pleasure, not vice, 
 not appetite, not habit — it means relief of physical suf- 
 fering and the control of physical symptoms. 
 
 My present definition of narcotic drug addiction is as 
 follows; a definite physical disease condition, presenting 
 constant and definite physical symptoms and signs, prog- 
 
FUNDAMENTAL CONSIDERATIONS 21 
 
 ressing througli clean-cut clinical stages of development, 
 explainable by a mechanism of body protection against 
 the action of narcotic toxins, accompanied if nnskillfully 
 managed by inhibition of function, autotoxicosis and auto- 
 toxemia, its victims displaying in some cases deteriora- 
 tion and psychoses which are not intrinsic to the disease, 
 but are the result of toxemia, and toxicosis, malnutrition, 
 anxiety, fear and suffering. 
 
 To express this somewhat differently — a narcotic drug 
 addict is an individual in whose body the continued ad- 
 ministration of opiate drugs has established a physical re- 
 action, or condition, or mechanism, or process which mani- 
 fests itself in the production of definite and constant symp- 
 toms and signs and peculiar and characteristic phenomena, 
 appearing inevitably upon the deprivation or material les- 
 sening in amount of the narcotic drug, and capable of 
 immediate and complete control only by further adminis- 
 tration of the drug of the patient's addiction. 
 
 In plain English, the sufferer from narcotic drug addic- 
 tion-disease is one who experiences the symptoms and 
 signs referred to above and which will be discussed later, 
 as a result of lack of supply or physically insufficient 
 supply of opiate drug. I know of no definition along any 
 other lines which will include all who suffer from narcotic 
 drug addiction. This symptomatology, and the mechan- 
 ism or process which produces it, are the only common and 
 characteristic attributes and possession of all opiate addicts. 
 
 How these are developed and how they may be controlled 
 and arrested is the demand which the sufferer from narcotic 
 drug addiction, and society as a whole, are making. Un- 
 til a competent and acceptable answer to this demand is in 
 the general possession of those handling narcotic addic- 
 tion, all other discussions will remain inconclusive, and 
 all other considerations incidental, for purposes of definite 
 and final solution. This is the medical problem of narcotio 
 drug addiction, and until those who handle narcotic ad- 
 
22 THE NARCOTIC DRUG PROBLEM 
 
 diets, and those who eontrol the handling of narcotic ad- 
 dicts, have recognized it, are familiar with it, and can to 
 some working measure explain and control its sufferings, 
 physical phenomena and symptoms and signs, they are un- 
 prepared to assist intelligently and competently in the 
 solution of a prohlem which now as never before menaces 
 the welfare of society. 
 
CHAPTEE, III 
 
 THE ITATUEE OF NAECOTIC DEUG ADDICTION-DISEASE 
 
 It is a pertinent question to ask, " What type or class 
 of individuals become narcotic addicts ? " The only cor- 
 rect answer unquestionably is, any type or class or in- 
 dividual to whom opiates are given for a suflSciently long 
 time. It has yet to be demonstrated that there is any 
 warm-blooded animal, which following sufficiently pro- 
 longed and constant administration of opiate drug, is im- 
 mune to the development of the symptomatology and con- 
 stant physical phenomena of addiction-disease. 
 
 Color, nationality, social or economic position, age, 
 mental and moral attributes of whatever sort are no bar 
 to the development of the condition. These may influence, 
 of course, the conduct and incidental manifestations of the 
 individual addicted, just as they do in any other condi- 
 tion. The addicted judge, or the addicted physician, or 
 the addicted clergyman, or the addicted man of business 
 or other affairs, or the addicted clerk or industrial worker 
 reacts differently to the sufferings and trials of narcotid 
 drug addiction than does the addict of the underworld, or 
 the heroin " sniffer " of idle and curious adolescence, or 
 the addicted defective, degenerate, or criminal. Also he 
 reacts differently to everything else. What is true of one 
 man who has opiate addiction may be absolutely false of 
 another. One narcotic addict is honest, competent, truth- 
 ful and intelligent. Another is dishonest, incompetent, 
 untruthful and incapable of appreciation or self-control. 
 Neither the one set of attributes, nor the other, is peculiar 
 
 to narcotic addicts. They are simply personal attributes 
 
 23 
 
24. THE NARCOTIC DRUG PROBLEM 
 
 possessed by different men and types of men who may or 
 may not be narcotic addicts. If the addict of a higher 
 type displays at times attributes not typical of his pre- 
 addicted days, and seems to show a lowering of his mental 
 and ethical tone, it is well to estimate in his case the in- 
 fluences of past worry, fear, suffering, strain and struggle, 
 the attitude of society, medical and lay, towards him, and 
 the manner in which he has been handled, before blaming 
 it all upon the mere presence and effects of narcotic drug 
 addiction, or of narcotic drug. If such changes were in- 
 herent in the action of continued narcotic drug medication, 
 they would be found in all addicts, whereas the fact is that 
 they most decidedly are not. 
 
 As to age in addicts there is no limit. I have seen an 
 infant newly-born of an addicted mother, displaying the 
 characteristic physical symptoms, signs and phenomena of 
 body-need for opiate a few hours after birth. This case 
 is discussed more in detail in the transcribed testimony of 
 the New York State Legislative Investigation hearings, 
 (Whitney Committee) pages 1524 to 1529, at which I re- 
 ported it. The infant undoubtedly developed addiction- 
 disease prenatally, reacting in its unborn body against the 
 presence of opiates, supplied through its mother's blood, 
 exactly, as is now demonstrated through experimental labo- 
 ratory animals and by clinical study upon adults, this 
 disease is always developed — through physical ' and con- 
 stant reaction of the body to the continued presence of 
 opiates, however supplied. There have been many such 
 cases, some of which are matters of medical record. This 
 condition of prenatal development of addiction-disease 
 exists beyond dispute and certainly cannot be explained 
 upon grounds of conscious appetite or deliberate self- 
 indulgence. I am told that there are or until very recently 
 have been old soldiers, veterans of the Civil War, whose 
 addiction dated from medication for wounds received dur- 
 ing that struggle. The late Doctor T. D. Crothers told 
 
NARCOTIC DRUG ADDICTION-DISEASE 25 
 
 me once that opiate addiction in this country received its 
 first wide dissemination in that way. This points to the 
 serious consideration of what may be an urgent and im- 
 portant medical prohlem of modem warfare. 
 
 This brings ns up to the origin of addiction. There is 
 only one actual origin of addiction, and that is the con- 
 tinued administration of an addiction-developing drug suf- 
 ficiently long to develop the physical manifestations symp- 
 tomatology, and phenomena and body need for that drug. 
 This statement is the only one which can be made as gen- 
 erally inclusive. I have many records and histories, much 
 correspondence, and other data, collected from addicts, 
 relatives, friends and associates of addicts, physicians, 
 official conferences and workers in the various fields of 
 narcotic endeavor. My material covers an active interest 
 of many years duration, and an experience which has dealt 
 with various types and classes of patients under various 
 conditions. I have held different beliefs at different times, 
 influenced by the demands of my immediate position, and 
 by my best interpretation of my own experience, by the 
 conditions under which I happened to be working and by 
 the class of people coming to my attention under the con- 
 ditions of my work. At one time I believed that all addicts 
 were defective, irresponsible, degenerated, unreliable and 
 liars, made addicts by curiosity, environment and morbid 
 appetite. At one time I believed that the narcotic addict 
 did not physically need narcotic drug under any circum- 
 stances, and that he could get along without it if he only 
 had the will and the desire to do so. I proceeded on that 
 theory for a while in the handling of my cases, and have 
 to thank the, illicit supply which is present in all institu- 
 tions that my mortality was no higher, for it is 
 agreed and on record by many competent authorities that 
 forcible deprivation of opiate drug may at times cause 
 death. 
 
 These are examples of a few of the various beliefs and 
 
26 THE NARCOTIC DRUG PROBLEM 
 
 ideas I have held at various times, and upon which I used 
 to generalize^ as is the habit and tendency of those who 
 as yet lack experience or breadth of experience. I have in 
 time found many of my beliefs wholly or partly erroneous, 
 or to apply only to selected groups of cases or to incidental 
 phases and aspects of the main problem. They all have 
 their bearings on the general situation, and may be of 
 primary importance in the immediate handling and control 
 of certain phases of it. I have come now to keep my 
 general statements to the solid rock of basic disease and 
 draw on my past experience for the measure and estimation 
 of associated problems and complications as they arise. 
 
 The actual origin of addiction is the administration of 
 opiate drugs continuously over a sufficient length of time. 
 The incidental details in their early administration to 
 those who become addicted vary widely. In the origin of 
 some proportion of addicts, we of the medical profession 
 must sooner or later come to recognize and assume our part, 
 unconscious and innocent, but none the less beyond ques- 
 tion. What this proportion is is variously estimated by 
 various authorities and statisticians and investigators. It 
 is now beyond dispute that many cases of addiction-disease 
 had their origin in medication during illness, the condi- 
 tion developing unsuspected by either physician or by 
 patient until its physical manifestations had passed the 
 bounds of control. 
 
 The old fallacy that an opiate might be administered 
 safely to a sufferer so long as the patient did not know 
 what was being given him is completely disproven by the 
 evidence of addicted infants, and by the excellent and ex- 
 haustive laboratory experiments upon addicted animals by 
 such men as Giofreddi, Hirschlaff and more recently 
 Valenti of Italy whose work, published in 1914, should 
 have widest recognition. This fallacy has been responsible 
 for many a case of addiction. Very many opiate addicts 
 have passed into the stage of fully established addiction- 
 
NARCOTIC DRUG ADDICTION-DISEASE 27 
 
 disease before they were aware that they had ever taken 
 an opiate. 
 
 Clinical familiarity with the symptoms and signs of 
 beginning and developing addiction should be the posses- 
 sion of every physician and snrgeon. It would save from 
 the physicial sufferings, and mental tortures and fears 
 of narcotic addiction many human beings. It has been my 
 experience when called in as a medical consultant upon 
 medical and surgical cases whose progress towards recov- 
 ery seems unaccountably tedious and unsatisfactory, to 
 detect as the basis for the lack of function and recuperative 
 power, unsuspected developing opiate addiction in time to 
 prevent its further progress. Unwisely prolonged opiate 
 medication makes more opiate addicts than we have real- 
 ized. 
 
 The addict in whom it is most profitable to study addic- 
 tion origin and development and handling, if we are to get 
 a clean-cut picture of addiction-disease, is the individual 
 who is primarily normal, mentally, morally and physically, 
 whose addiction condition is a result of ignorant, mis- 
 guided or unavoidable medication, either professionally or 
 self-^administered. Their number is far greater than is 
 yet generally appreciated. Many if not most of them are 
 unsuspected and unknown and they include eminent peo- 
 ple in all walks of life. They are social, and economic 
 assets whose interests and welfare we cannot ignore when 
 we are considering the disposition and handling of the 
 narcotic addict. 
 
 Many of them have gone from one institution to another, 
 and have attempted, in desperate effort to be cured, each 
 newly-discovered and announced specific or theory of treat- 
 ment. They have never derived any pleasure from nar- 
 cotic use. For them the narcotic drug has been only neces- 
 sary medication to relieve physical suffering and to main- 
 tain economic existence and the support of themselves and 
 their families. They should be classed as innocent or 
 
28 THE NARCOTIC DRUG PROBLEM 
 
 accidental addicts — normal and worthy sick people. 
 They earnestly desire treatment and help, and once their 
 addiction process is completely arrested do not tend to 
 return to narcotic drug use. Whatever associations they 
 may have had with the unworthy or unfit of the so-called 
 " underworld '' and with illicit and illegitimate traffic has 
 been the result of desperate necessity, in their best judg- 
 ment, in the obtaining of opiate supply when it has seemed 
 to them to be otherwise denied them, and which was neces- 
 sary to them for the relief and avoidance of suffer- 
 ing and for the maintaining of a condition making pos- 
 sible self-support and the avoidance of revelation and 
 disgrace. 
 
 The narcotic addict of this type presents primarily and 
 ^ fundamentally a purely medical problem. Competent and 
 complete arrest of the physical mechanism of narcotic 
 drug need permanently removes him from the ranks of the 
 narcotic drug user. The problem of his handling is one 
 falling within the province of medical practice. His care 
 is purely and simply a matter of the treatment of disease 
 with medical intelligence and judgment on the established 
 lines of medical practice in disease conditions generally. 
 His after-care is simply such management of convalescence 
 as is needed in ordinary medical cases. The length of 
 his convalescence will depend entirely, just as in other 
 diseases, upon the competency and intelligence of his medi- 
 cal handling and upon his physical condition, reaction, and 
 recuperative ability. 
 
 For such a man custodial care and institutional handling 
 under conditions of enforced restraint are undesirable and 
 harmful. His withdrawal from self-supporting citizen- 
 ship should be for the shortest time commensurate with 
 adequate therapeutic results. He should be restored to 
 normal personal, social, and economic environment and 
 activity at as early a time as possible following his clinical 
 
NARCOTIC DRUG ADDICTION-DISEASE 29 
 
 treatment and the arrest of his physical mechanism of 
 addiction-disease. Given intelligent clinical handling, 
 with rational therapeutic treatment, and a comprehensive 
 meeting of the indications of disease in his case, he is no 
 more a subject for unusual restraint and custodial care 
 than is a case of malaria or pneumonia or other medical 
 condition. He is in most cases a clinically curable medical 
 case. He presents the true picture of addiction-disease 
 uncomplicated by the distracting and confusing incidentals 
 often met with in the types of cases more commonly dis- 
 cussed. The development of addiction in a case of this 
 type is a purely physical matter, and is the addiction which 
 should be considered in the fundamental comprehension 
 of basic facts. 
 
 Stages of Addiction Development 
 
 Every case of well-developed addiction has followed in 
 its development a course through several stages, definitely 
 marked by clinical signs and reaction phenomena. I shall 
 not exhaustively discuss all of these stages and their phe- 
 nomena. The ones I shall mention will be recognized by 
 most of those who have gone through them or have watched 
 them develop. 
 
 1. 8tage of Normal Reaction to Therapeutic and Toxic 
 Doses. 
 
 The manifestations of this state in morphine adminis- 
 tration for example are more fully described in our text- 
 books of materia medica than I can take space for in this 
 book, and are familiar to all physicians. The narcotic 
 and analgesic effect with therapeutic doses ; the euphoric 
 and inhibitory action of doses in excess of the therapeutic ; 
 the toxic action manifested by the slowed pulse, slowed 
 respiration, and generally arrested metabolism and func- 
 tion are too familiar to need elaboration. 
 
30 THE NARCOTIC DRUG PROBLEM 
 
 2. Stage of Increased Tolerance, 
 
 following continuous and consecutive administration of 
 morphine (and the same is true of other opiates) comes 
 failure to secure the effect which followed the early ad- 
 ministration. Larger doses are needed for the relief of 
 pain or other symptoms, or the original doses give re- 
 lief for a shorter time. Toxic manifestations do not 
 follow what would formerly have been a toxic dose. The 
 patient requires what was formerly a toxic dose to secure 
 the former therapeutic effect. The phenomena of this 
 stage are familiar to every observing clinician who has used 
 or seen morphine used for continued therapeutic action. 
 The patient has acquired an increased tolerance of the 
 drug and a beginning immunity to its toxic action. He 
 does not, however, suffer appreciable hardship from drug 
 deprivation. Discontinuance of the drug causes little or 
 none of the symptoms to be described as " withdrawal 
 signs." 
 
 3. Stage of Beginning Addiction, 
 
 Following the stage of increased tolerance comes a stage 
 where discontinuance or lack of administration of the 
 narcotic drug gives definite signs and symptoms, beginning 
 " withdrawal signs," due to some beginning physical body 
 demand for the drug and completely relievable only by its 
 administration. These signs are identical with the first 
 appearing withdrawal signs in a case of established addic- 
 tion but as yet do not go beyond the beginning manifesta- 
 tions of " withdrawal " in a completely developed addic- 
 tion. They are limited to a peculiar nervousness, rest- 
 lessness, weakness, depression, etc. They persist for a few 
 days only if the drug is denied and are endurable. 
 
 As to length of time required for the passage through 
 each of these previous stages or through both of them — 
 dogmatic statement is impossible. The time is apparently 
 
NARCOTIC DRUG ADDICTION-DISEASE 31 
 
 influenced by a number of factors. Of course the varying 
 inherent resistance or susceptibility of different individuals 
 to any given disease condition must be considered in this 
 disease. It varies also with different forms of opiates 
 used and their modes of administration. The probable 
 physical factors I am not yet ready to discuss. The recent 
 Report of the Special Committee of the Treasury Depart- 
 ment says, " Any one repeatedly taking a narcotic drug 
 over a period of 30 days, in the case of a very susceptible 
 individual for 10 days, is in grave danger of becoming an 
 addict." Certainly a physician should look for the signs 
 and symptoms of tolerance and beginning addiction 
 throughout his opiate administration. It is also well to 
 exhaustively inquire into possible past history of unrecog- 
 nized addiction in any of its three general stages. Some 
 of those patients who have demonstrated an apparent un- 
 usual susceptibility and very rapid development will be 
 found on careful analysis to have experienced an un- 
 recognized or forgotten addiction in some stage of develop-^ 
 ment. I have interesting data on this point. 
 
 4. Stage of Established Addiction, 
 
 In this stage the " withdrawal " symptoms and signs be- 
 come more evident as results of opiate deprivation. They 
 proceed through the mild discorofort and nervousness of 
 the previous stage to the definite manifestations and con- 
 stant unmistakable withdrawal phenomena to be described. 
 The patient endures physical suffering and displays all 
 the clinical evidence of it. There can be no question of 
 will-power in this stage, nor of desire for narcotic drug 
 for any other purpose than to escape physical suffering. 
 Whether the patient was primarily an innocent and un- 
 conscious recipient of the drug, or of the class of the 
 vicious and weak, he is now fundamentally a sick man, 
 afflicted with a physical disease. Whether or not he ever 
 experienced any euphoria or sensuous enjoyment, he now 
 
S2 THE NARCOTIC DRUG PROBLEM 
 
 gets nothing of pleasure from narcotic administration. He 
 gets, sirrvply, relief from suffering. The opiate drug has 
 become his only immediate means of securing and main- 
 taining a physical efficiency, a semblance of normality. 
 ifsTo other drug will take its place. He can take tremendous 
 doses without toxic effect. In this stage, if the drug is 
 denied or withdrawn without competent handling, his 
 suffering and incompetency is not, as in the previous stage, 
 a matter of days but may persist for weeks or months 
 after no narcotic has been administered. 
 
 The general stages of addiction-disease development as 
 above rather superficially outlined are not of course sharply 
 marked in their transitions. They slowly merge one into 
 the next and taken together constitute a gradual develop- 
 ment from normal reaction to opiate to established addic- 
 tion-disease. 
 
 Most patients are in or nearing the stage of developed 
 addiction when they are recognized or come for treatment. 
 Developed addiction for narcotic drug means physical, 
 bodily need for that drug; functional incompetency and 
 suffering without that drug; comparative normality and 
 efficiency only to be immediately secured and maintained 
 by the continued use of that drug. 
 
 This is the situation of the sufferer from addiction- 
 disease until such time as the activity of his addiction- 
 disease mechanism is arrested. 
 
 Before I attempt exposition of the mechanism which 
 seems to me best to explain addiction-disease and offer a 
 basis for its rational handling, I shall offer several ob- 
 servations bearing upon physical or body reaction in the 
 state of addiction, 
 
 1. Experience of addicts and observations upon them 
 show that the length of time over which an addiction 
 sufferer is free from his ^^ withdrawal " manifestations 
 is in proportion to the amount he has recently taken. 
 
NARCOTIC DRUG ADDICTION-DISEASE 33 
 
 Under conditions eliminating various factors, outside of 
 the addiction meclianism, which may influence this gen- 
 eral rule, the ratio between the amount of recent dosage 
 and the interval of freedom is almost mathematical. Eor 
 example, if under given conditions one grain of morphine 
 will keep an addict free from withdrawal manifestations 
 for four hours, two grains will do this for nearly eight 
 hours and three will have the same effect for about eleven 
 hours. It would almost seem as if there were some sub- 
 stance produced in definite amount in each individual 
 case at a given time, and neutralized or opposed by or 
 in some way negatived in its action by a definite amount 
 of opiate drug. 
 
 2. Each addict shows a definite and approximately 
 measurable daily minimum need for the drug of his addic- 
 tion. If he is suffering from the deprivation of his drug, 
 he will require a certain dose, measurable by its effect 
 upon his symptomatology, before he is made physically 
 comfortable and physically efficient again. 
 
 3. The narcotic drug administered to an addict suffering 
 withdrawal phenomena and symptomatology will relieve 
 those manifestations exactly in proportion to the amounts 
 of drug administered. Each addict has a constant se- 
 quence of symptoms attending the so-called " dying-out '' 
 of the drug. These symptoms are relieved in constant 
 reverse sequence by the administration of the drug, and in 
 exact proportion to the amount of drug administered, 
 various incidental influences being eliminated. A small 
 amount of the opiate will relieve the symptoms last ap- 
 pearing; another insufficient amount will relieve another 
 proportion of the withdrawal signs, and so on, until the 
 opiate drug administered balances in amount the extent 
 of the addict's deprivation, or physical need. 
 
 This is almost mathematical in its working, and the 
 average intelligent addict, after a few trials, can tell within 
 a very close margin just how much opiate, in his accus- 
 
34 THE NARCOTIC DRUG PROBLEM 
 
 tomed form, lias been administered by the extent to wliich 
 it relieves his withdrawal signs. It almost seems as if the 
 narcotic drug acted as some sort of an antidote for some 
 poison present in definite amounts in the addict's body. 
 
CHAPTER lY 
 
 THE MECHAITISM OF NAECOTIO DRUG- ADDICTIOIir-DISEASE 
 
 I HAVE in previous chapters referred to what are known 
 as "withdrawal signs.'' By this term has come to be 
 known the manifestations displayed by a sufferer from 
 addiction-disease at such times as his opiate is taken away 
 or " withdrawn," either totally or in part to such an 
 extent that its amount does not meet the requirements of 
 his physical needs. 
 
 In observing opiate addicts over a length of time no 
 one can escape the recognition of a chain of constantly 
 present physical manifestations inevitably following the 
 non-administration of the drug of addiction. These may 
 vary in priority of onset, in sequence, and in relative 
 violence of manifestation in different cases, but they are 
 the inevitable result of non-administration of opiate to 
 an opiate addict. I described them as follows in a paper 
 on " iN'arcotic Addiction — A Systemic Disease Condi- 
 tion,'' which was published in the Journal of the American 
 Medical Association, February 8, 1913. " In a general 
 way they may be said to begin with a vague uneasiness 
 and restlessness and sense of depression ; followed by yawn- 
 ing, sneezing, excessive mucous secretion, sweating, nausea, 
 uncontrolled vomiting and purging, twitching and jerking, 
 intense cramps and pains, abdominal distress, marked cir- 
 culatory and cardiac insufficiency and irregularity, pulse 
 going from extremes of slowness to extremes of rapidity 
 with loss of tone, facies drawn and haggard, pallor deep- 
 ening to greyness, exhaustion, collapse, and in some cases 
 death." 
 
 35 
 
36 THE NARCOTIC DRUG PROBLEM 
 
 These manifestations have been noted in various ways 
 and to various extents and have been casually commented 
 upon by most writers of the past. The conception of 
 drug addiction as a " habit " has, however, in the past 
 so overwhelmingly dominated the attitude of writers both 
 medical and lay, that consideration of withdrawal signs as 
 physical phenomena, and the analysis of their origin and 
 mechanism on the basis of physical disease and constant 
 body reaction has received all too little attention. The 
 tendency has been to casually regard or belittle them as a 
 part of the essential picture of narcotic addiction, and to 
 place overwhelming emphasis upon mental desire as an 
 !} explanation of the drug addict's inability to discontinue 
 the administration of opiate drugs. That these physical 
 manifestations have had such incidental place and consid- 
 eration in the general handling of the narcotic addict and 
 in the consideration of the drug problem is to my mind the 
 basic cause for past failure. I^on-appreciation of them 
 unquestionably explains in part the almost uniform lack of 
 success which attended my own earliest efforts. 
 
 One of the obstacles to an appreciation of narcotic drug 
 addiction-disease has been the casual assumption on the 
 part of the average person, both lay and scientific, that 
 opiate drugs act upon the addict, and that he reacts to 
 them similarly to the actions and reactions in the non- 
 addicted individual. Morphine action, however, as com- 
 monly observed following therapeutic administration or in 
 experimentation upon un-addicted animals gives no con- 
 ception of its manifestations in the man or woman grown 
 tolerant to its use. Many of the actions and reactions 
 of opiate upon the un-addicted are practically lost in the 
 addicted, and absolutely new reactions, unfound in the un- 
 addicted individual, become the dominating factors in the 
 opiate medication of the addict. 
 
 To some extent the fallacies connected with the general 
 conception of narcotic addiction have arisen from the mis- 
 
NARCOTIC DRUG ADDICTION-DISEASE 37 
 
 taken application to addicts of opiate experience, experi- 
 mental or otherwise, of the non-addicted. In the matter 
 of sensations, for example, supposed to follow opiate ad- 
 ministration, and to the enjoyment of which is widely at- 
 tributed the addict's indulgence — in practically none of 
 the opiate addicts, once tolerance and organic dependence 
 are completely established, do these sensations occur. The 
 immediate effect of opiate to the addict, depending upon 
 the extent of tolerance, and the reaction of the patient, in 
 dosage not too much in excess of physical body need, is 
 apparently support to function, the restoration or main- 
 taining of normal circulation and nerve and glandular 
 balance, prevention or relief of the agonizing withdrawal 
 pains and manifestations and of impending collapse. 
 
 Opiate is used by the large majority of opiate addicts 
 simply and solely for its supportive action, and a certain 
 amount for each addict becomes as much of a definite need 
 and a necessary and integral part of his daily sustenance 
 as food or air. The dream states and other sensuous 
 results, occasionally observed, are when they occur as part 
 of the minor toxic action of the drug, against which the 
 developed addict is nearly or completely immune, and to 
 the experiencing of which very few of the honest, innocent 
 or accidental addicts have ever carried their dosage. They 
 are commonly found only in the opium pipe smokers, an 
 entirely different problem from that of the average nar- 
 cotic addict. 
 
 As has been stated, it is a fact that for each addict, a 
 definite amount, varying with his condition of health, 
 elimination, physical and mental activity, etc., meets a 
 definite body-need. On this amount he can be put and 
 kept in good physical and mental condition under normal 
 circumstances of environment, exertion, and general hy- 
 giene. Years of efiicient activity and upright responsible 
 lives, accomplished by well-known men and women, unsus- 
 pected addicts, bear witness to this fact. An addict neither 
 
38 THE NARCOTIC DRUG PROBLEM 
 
 ■Qiiderdosed nor overdosed practically defies detection. 
 Less than the definite amount required for nervous and 
 glandular and circulatory support and organic balance de- 
 prives the patient of reaction^ places his vitality and energy 
 far below par and for a long time hinders his betterment. 
 More than this amount displays the inhibitory effects of 
 opiates, locks up or slows secretions and body functions, 
 and causes malnutrition, autotoxemia, autotoxicosis, and 
 the consequent mental and physical deterioration com- 
 monly and erroneously attributed to the direct action of 
 opiate drug. 
 
 In 1912 I wrote that so far as I knew the sympto- 
 matology attending insufficient supply of morphine (or 
 other opiate) to an opiate addict had never received the 
 amount of detailed study and analysis that it deserved 
 and was not adequately interpreted. W. Marme had at- 
 tributed the symptoms of morphine addiction to the toxic 
 action of oxydimorphine. Rudolph Kobert, however, 
 stated that Ludwig Toth subjected Marme's claims to 
 subsequent testing and was unable to confirm them, and 
 that his own findings agreed with those of Toth. They 
 found that oxydimorphine was inert by subcutaneous in- 
 jection and that when thrown into the blood-stream it 
 formed an insoluble substance causing emboli, and so pro- 
 ducing the symptoms observed by Marme. Kobert seems 
 to be in accord with the early findings of Magendie, that 
 oxydimorphine is non-toxic. The experiments of Faust 
 on dogs concerning increased power of the body to destroy 
 morphine are well-known. It is still a matter of scientific 
 dispute as to what extent the body of the opiate addict has 
 developed the power to limit or destroy the poisonous prop- 
 erties of opiates by the conversion of these poisons through 
 oxidation or other chemical action. 
 
 The explanation of tolerance and withdrawal phenomena 
 on the basis of something akin to an antitoxin or antitoxic 
 substance circulating in the blood of the addict, has also, 
 
NARCOTIC DRUG ADDICTION-DISEASE 39 
 
 like the oxidation explanation, been a subject of contro- 
 versy. Hirschlaff claimed to have produced an antitoxic 
 serum against morphine. Morgenroth failed to confirm 
 Hirschlaff's findings, and argued against the existence of 
 an antitoxin. The animal experimental and laboratory 
 work and findings, however, of such men as Hirschlaff, 
 Giofreddi and Valenti have helped to influence the trend of 
 modern thought towards what may be regarded as the 
 present strong tendency in scientific conception of the 
 physical mechanism of narcotic drug addiction-disease — 
 an autogenous antidotal or antitoxic substance. 
 
 A recent paper by DuMez of the United States Public 
 Health Service gives a comprehensive review of the work 
 which has been done in connection with the study of in- 
 creased tolerance and withdrawal phenomena, and shows 
 conclusively the gradual inclination of modern opinion. 
 
 There is considerable literature discussing various 
 theories and experiments and observations, which has, 
 however, not had widespread recognition. 
 
 EEFEEENCES 
 
 Bishop, E. S., "Narcotic Addiction — A Systemic Disease 
 
 Condition/' Journal A. M. A,, Feb. 8, 1913. 
 Marme, W., " Untersuchungen zur acuten und chronischen 
 
 Morphinvergiftung/' Deutch. med. Wchnschr. 9: 197- 
 
 198. 
 Kobert, E., " Lehrbuch der Intoxikationen/' Stuttgart, 2; 995, 
 
 1906. 
 Toth, L., " Bemerkungen zur Erklarung der chronischen Mor- 
 
 phium Intoxikation,'' Schmidt's Jahrb. 329 : 135, 1891. 
 Faust, E. S., "tJber die Uraschen der Gewohnung an Mor- 
 
 phin '' Arch, f exper. Path. u. Pharmakol. 44 : 217-238, 
 
 1900. 
 Hirschlaff, L., " Ein Heilserum zur Bekampfung der Morphin- 
 
 sucht und Ahnlicher Intoxikationen,'' Berl. klin. 
 
 Wchnschr. 39 : 1149-1152 and 1174-1177, 1902. 
 
40 THE NARCOTIC DRUG PROBLEM 
 
 Gioffredi, C, " L'immunite artificielle par les alcaloides/' 28, 
 402-407, and 31, fasc. 3, 1897. 
 
 Valenti, A., " Experimentalle Untersuchungen liber den 
 chronischen Morphinismus ; Kreislanf stomngen hervorge- 
 rufen durch das Serum morphinistscher Tiere in der 
 Abstinenzperiode,'^ Arch. f. exper. Path ti. Pharmakol, 
 75: 437-462, 1914. 
 
 DuMez, A. G., " Increased Tolerance and Withdrawal Phe- 
 nomena in Chronic Morphinism, A Eeview of the Lit- 
 erature," Jour. A. M. A., 72 : 1069-1072, 1919. 
 
 My own present opinion and conception remains as ex- 
 pressed in a paper, ^' IsTarcotic Addiction — A Systemic 
 Disease Condition," written in 1912 and published in the 
 Journal of the American Medical Association, Eeb. 8, 
 1913, as follows, " It is my opinion that, however much 
 increased oxidation aids in the handling of morphine, it 
 is to the formation of an antitoxic substance that we must 
 look for explanation of our clinical manifestations and 
 for the classification of morphine-addiction as a definite 
 medical entity. This opinion is based on certain clinical 
 manifestations of morphine effect and the symptomatology 
 attending insufficient supply of morphine to those addicted, 
 on certain phenomena observed during and following treat- 
 ment, on the persistence of tolerance and on the suscepti- 
 bility of the cured patient to the re-formation of addic- 
 tion.'" 
 
 Before elaborating this conception of addiction-disease, 
 I think it desirable to repeat the enumeration of the prin- 
 cipal manifestations of ^^ withdrawal " or body-need for 
 opiate drug. In a general way, they may be said to begin 
 with a vague uneasiness and restlessness and sense of de- 
 pression and weakness; followed by yawning, sneezing, 
 sweating, excessive mucous secretion, nausea, uncontroll- 
 able vomiting and purging or diarrhea, twitching and 
 jerking, sometimes violent jactitation, intense muscular 
 cramps and pains (described as if the flesh were being 
 
NARCOTIC DRUG ADDICTION-DISEASE 41 
 
 torn from the bones )^ abdominal pain and distress, marked 
 cardiac and circulatory insufficiency, and irregularity 
 (often with marked dyspnea), pulse going from extremes 
 of slowness to extremes of rapidity, with lowered blood- 
 pressure and loss of tone, f acies drawn and haggard, pallor 
 deepening to greyness, exhaustion, collapse and in some 
 cases, death. 
 
 Essential Mechanism of Narcotic Drug AddictionrDisease 
 
 If such clean-cut, strikingly apparent, constant, and un- 
 deniably physical phenomena and symptomatology as I 
 have described are to be adequately explained, there must 
 be some physical mechanism, some definite body process 
 working upon fundamental principles of disease reaction. 
 They certainly are not psychiatric manifestations nor the 
 expressions of habit, appetite, vice, nor morbid indulgence. 
 Enjoyment of morphine for itself, even in such patients as 
 have ever experienced such enjoyment, is lost long before 
 the stage of rooted or completely developed addiction is 
 reached. Physical results must be explained by physical 
 cause. 
 
 Tolerance of and immunity to the toxic effects of nar- 
 cotic drugs are primary and striking characteristics in 
 the development of addiction. An antitoxin or antidotal 
 substance is the recognized mechanism of their production 
 in most diseases admittedly developing these characteris- 
 tics. I have adopted the hypothesis, therefore, that an 
 antidotal substance is manufactured by the body as a pro- 
 •tection against the poisonous effects of narcotic drugs con- 
 stantly administered. Such a substance, manufactured in 
 the body, being antidotal to morphine, might well possess 
 toxic properties of its own, exactly opposite in manifesta- 
 tion to those possessed by morphine and other opiates. 
 Toxic substances exactly opposite to opiate in their action 
 might readily account for the severe withdrawal signs, 
 parallel in their extent to the extent of opiate insufficiency. 
 
42 THE NARCOTIC DRUG PROBLEM 
 
 and resembling in their characteristics the manifestations 
 of acute poisoning. 
 
 A hypothetical antidotal toxic substance, manufactured 
 by the body as a protection against the toxic effects of con- 
 tinued administration of an opiate drug, will therefore ex- 
 plain the well-known development of tolerance and im- 
 munity in these cases, and will account for the violent 
 physical withdrawal signs. In a word, it will explain the 
 disease fundamentals on a definite physical basis. 
 
 Such an hypothesis will explain the stages of develop- 
 ment of addiction before outlined. In the stage of toler- 
 ance the antidotal toxic substance has begun to make its 
 appearance in the body and to protect it against slight 
 narcotic excess, but its manufacture is not sufficientlv 
 established to continue longer than necessary to neutralize 
 the narcotic administered. In the stage of beginning ad- 
 diction, or beginning narcotic-need, its manufacture has 
 become more developed and more constant and proceeds for 
 a longer time after the discontinuance of the narcotic drug. 
 In the stage of fully developed addiction, or absolute nar- 
 cotic need, the manufacture of the antidotal toxic substance 
 has become practically an established pseudo-physiological 
 body-process, and will continue long after the administra- 
 tion of the narcotic drug for reasons into which I have 
 gone elsewhere. In other words, in narcotic drug addic- 
 tion some antidotal toxic substance has become the con- 
 stantly present poison, and the narcotic drug itself has 
 become simply the antidote demanded for its control In 
 brief, fundamentally and basically, narcotic drug addiction 
 is a condition presenting definite physical phenomena, 
 symptoms, and signs, due to the presence within the body 
 of some autogenous poison requiring narcotic drug for 
 neutralization of it or of its effects. 
 
 This explains the phenomena of the mathematical ex- 
 actness with which the minimum daily need can be esti- 
 mated under experimental conditions, and with which doses 
 
NARCOTIC DRUG ADDICTION-DISEASE 43 
 
 less than the amount of actual body need relieve existing 
 withdrawal signs in definite proportion to the amount of 
 opiate administered. In exact proportion as the drug of 
 addiction is present in the body to neutralize or oppose 
 some antidotal poison, is the patient free from withdrawal 
 symptoms and from physical craving for the narcotic drug. 
 
 The development and existence of such mechanism in the 
 body of the opiate addict is suggested also by the apparent 
 continuance of tolerance to opiate existing after long pe- 
 riods without drug in individuals who had previously suf- 
 fered from addiction-disease, and in the susceptibility of 
 the former sufferer subsequent to the arrest of his physical 
 need for opiate, to the re-establishment of that need by the 
 subsequent administration of the drug. 
 
 Illustrative of this phenomenon is a case who, after 
 about two years of relief from addiction-disease, developed 
 pneumonia and to whom in delirium and threatened death, 
 opiates were administered as unavoidable medication. 
 After cessation of his delirium, he was dismayed to dis- 
 cover addiction-manifestations and body-need for opiate 
 drug had been re-established. This history is one of a 
 number in my possession, and has been verified. 
 
 The case demonstrating the longest persistence of sus- 
 ceptibility among my records, is that of a man in the early 
 fifties who underwent an emergency operation for infected 
 gall-bladder. A day or two following operation he de- 
 veloped excruciating pain in his right side just under the 
 ribs. It had been necessary to administer opiates since a 
 day or two before the operation. I was called in consulta- 
 tion for the purpose of determining the character and 
 origin of the pain, and diagnosed a pleurisy, the pain of 
 which subsided on the following day. Opiates were dis- 
 continued with a result of precipitating unmistakable 
 withdrawal phenomena. To his great anger and surprise, 
 I accused the patient of being an opiate addict. He in- 
 dignantly declared that he had never used opiates in his 
 
44 THE NARCOTIC DRUG PROBLEM 
 
 life. Subsequent investigation with tlie aid of older mem- 
 bers of bis family disclosed a distinct and typical history 
 of addiction manifestations following opiate administration 
 in the course of treatment of a complicated fracture of 
 bis thigh in early boyhood. The drug had been withdrawn 
 at that time and the addiction manifestations finally dis- 
 appeared, he never having been aware of the facts. His 
 reawakened addiction-manifestations were easily and 
 quickly checked. 
 
 It is evident from many histories that large dosage 
 robbed of or modified in its toxic effect, and even in the 
 opiate manifestations usual in subjects who have never 
 been made tolerant, and small dosage being sufficient to 
 re-awaken physical need for opiates are conditions which 
 do exist and persist for indefinite periods. The resem- 
 blance between this continued tolerance and the conditions 
 existing in diseases which confer immunity and having a 
 generally accepted antitoxin mechanism is too close to be 
 ignored. 
 
 Evidence of a toxic substance in the body of a narcotic- 
 addict is further presented by the similarity of the clinical 
 pictures presented by these cases of acute opiate need and 
 extremely severe cases of acute poisoning from materials 
 such as the ptomains and some other poisons. Acute 
 opiate need is clinically typical of intense suffering and 
 prostration from the action of some powerful poison. Its 
 symptoms cannot be due to opiate, for the reason that the 
 administration of opiate relieves them, and relieves them 
 exactly in ratio to the amount of opiate administered. 
 They can be held at any given stage by gradation of the 
 opiate dosage. Their manifestations, moreover, are ex- 
 actly opposite to opiate effect. They are to my mind best 
 explained as due to the action of some toxic substance, 
 antidotal to opiate, prepared by the body for its protection 
 in response to continued opiate presence in the body, as 
 antitoxins are prepared for the neutralization of or opposi- 
 
NARCOTIC DRUG ADDICTION-DISEASE 45 
 
 tion to the organic poisons of invading bacteria. The 
 chemical or physical character or nature of such substance 
 has not been yet determined. 
 
 The presence of such a substance would explain the 
 establishing of tolerance, the manifestations following 
 opiate administration and the apparent definiteness of the 
 amount of opiate needed. It would explain the results 
 of under-dosage and the results of over-dosage, and the 
 practical non-interference with function or general health 
 when a dosage is maintained exactly sufficient in amount 
 to neutralize the effect of some exactly antidotal body or 
 substance. 
 
 An antidotal substance would also explain the after 
 effects of and the so-called " relapses " which occur after 
 most of the cases treated by whatever method or proced- 
 ure, without due appreciation and proper estimation of the 
 clinical manifestations and indications of addiction symp- 
 toms and physical body need, and without due considera- 
 tion of the patient's reactive abilities and physical con- 
 dition. These patients are in a condition of restlessness, 
 discomfort, vague pains, mental and physical depression, 
 lowered physical vitality and weakness. They have a 
 sense of a physical lack of support. They cannt)t endure 
 nor react to over-exertion, worry, strain, etc. This con- 
 dition may persist for weeks and months after no opiate 
 has been administered. The above seem to be mild with- 
 drawal symptoms of an incompletely arrested addiction- 
 disease mechanism and might be explained by a continued 
 manufacture of small amounts of antidotal toxic substance, 
 causing a low grade chronic poisoning. They can be du- 
 plicated in active opiate addiction before withdrawal by 
 administering an amount of opiate slightly below the 
 amount of need and so leaving unneutralized a small 
 amount of the antidotal toxic substance. 
 
 If continued production of a toxic antidotal substance, 
 after discontinuance of the drug which called it into being 
 
46 THE NARCOTIC DRUG PROBLEM 
 
 is to explain the existence of the condition I have just 
 described, the causation of this continued production must 
 be accounted for. It is conceivable that in the develop- 
 ment of addiction-disease mechanism a tolerance of and 
 slowness to eliminate opiate or some product of opiate is 
 acquired by all the cells of the body, perhaps especially by 
 the liver, and that these tolerant and atonic cells are ex- 
 tremely slow of opiate elimination. Under this condition, 
 a residue of opiate or some product of opiate capable of 
 antidotal substance stimulation might remain unrespon- 
 sive, or very slow of response, to ordinary cellular and 
 other elimination. If this should prove to be the fact, 
 it would account for a continued production of antidotal 
 toxic substance, and might, moreover, in any given case, 
 either before or after cessation of opiate medication, be 
 one of the determining factors in the amount of antidotal 
 substance produced, or, in other words, in the measure of 
 the extent of body-need for opiate drug. 
 
 Inhibition of Function 
 
 What characteristic action exists in opiate or narcotic 
 drugs which gives them this power to establish the above 
 described mechanism ? It seems to me that it is, above all, 
 their power to inhibit body function. They tend mark- 
 edly to arrest metabolic processes. They inhibit glandu- 
 lar activity. They inhibit unstriped muscle activity and 
 hence peristalsis. They, therefore, cause a slowing up of 
 glandular function and intestinal activity, and of elimina- 
 tion. This results in an accumulation of opiate in the 
 body. It is this constant accumulation to which the body 
 must become tolerant by the development of some me- 
 chanism for its protection. 
 
 Autointoxication and Autotoxicosis 
 
 It is to the element of inhibition of function also that 
 we must look for explanation of what is by far the most 
 
NARCOTIC DRUG ADDICTION-DISEASE 47 
 
 important element in the immediate picture presented by 
 most individual cases. I refer to autotoxicosis and 
 to auto- and intestinal toxemia. The same power that 
 locks up within the body the opiate drug, locks up the 
 toxic products of tissue activity and tissue waste, of in- 
 testinal poisons and of insufficient metabolism. Auto- 
 toxemia itself is markedly inhibitory in its action, and 
 contributes no little to its own increase and to the further 
 development of narcotic disease. 
 
 It is not at all impossible that any inhibiting poison 
 constantly present in the body will some day be found to 
 establish a mechanism of protection, similar to that of 
 opiate addiction, and that some of the states now popularly 
 and loosely classified under the general head of " autoin- 
 toxications " will be recognized as really addiction-states, 
 in which the body has become progressively tolerant of its 
 own poisons. I believe that it can be demonstrated that 
 some of the phenomena and manifestations at times ob- 
 served in chronically inhibited and autotoxic individuals 
 in whom there can be no suspicion of any opiate or nar- 
 cotic element are analogous to the phenomena of narcotic 
 addiction mechanism. It is not inconceivable that any 
 inhibiting poison or toxin is capable of producing its own 
 addiction-mechanism, and it has seemed to me that my own 
 clinical familiarity with the action and reaction of nar- 
 cotic, inhibiting, or addiction-forming drugs and of ad- 
 diction-mechanism upon circulation, glandular and intes- 
 tinal and other function has been of no little assistance 
 in the interpretation, control and remedy of other chronic 
 intoxications. 
 
 Upon the extent of inhibition of function and autoin- 
 toxication, therefore, depend some of the immediately pre- 
 dominating manifestations in individual cases. They 
 must be reckoned with and eliminated in the measure of 
 addiction-disease in the individual sufferer. In many 
 cases they contribute the immediate and compelling in- 
 
48 THE NARCOTIC DRUG PROBLEM 
 
 dications for rational therapeutic endeavor. To a con- 
 siderable extent they determine circulatory efficiency and 
 metabolic and glandular activity and balance. They 
 largely control physical tone and physical reaction. In- 
 hibition and intestinal and autotoxemia cause most of 
 the physical and mental deterioration, and much of the 
 incidental symptomatology so widely ascribed directly to 
 narcotic drug effect. Upon the extent of their presence, 
 therefore, depends greatly the clinical picture in the in- 
 dividual case. This doubtless accounts for the acidosis, 
 noted by Jennings and others, inasmuch as it has been 
 definitely proved that acidosis is commonly present in all 
 conditions of functional depression and exhaustion. 
 
 With inhibition and auto and other toxemia eliminated 
 or reduced to a minimum, the patient can go through many 
 years, an apparent normal man, well-nourished, reactive, 
 in good physical tone, mentally sane and physically com- 
 petent. Under these conditions he shows practically noth- 
 ing abnormal as long as he gets properly administered, 
 his accustomed narcotic drug, in the amount of its min- 
 imum physical requirement or body-need. His condition 
 is often unsuspected by those nearest and dearest to him, 
 and the popularly held opinion that narcotic addiction 
 shortens life does not seem to be upheld by the facts in 
 his case. Such cases as his are far more numerous than 
 has as yet been realized. 
 
 In the types of narcotic addicts most widely recognized 
 inhibition of function and autointoxication is marked, and 
 the opiate drug is used in excess of body-need. The ad- 
 dict of this description becomes a deteriorated wreck, re- 
 quiring high doses of opiate for the satisfaction of abnor- 
 mal body-need, mentally and physically incompetent — 
 the generally accepted picture of the so-called " dope- 
 fiend," a deteriorated, degenerated, malnourished wretch, 
 degraded, avoided and condemned. 
 
 Inhibition of function and autointoxication should not 
 
NARCOTIC DRUG ADDICTION-DISEASE 49 
 
 be vague terms. They cause and are measurable by 
 definite clinical evidence. They display manifest phe- 
 nomena and symptoms, and become increasingly defined 
 material entities as the clinician looks for them as such. 
 Much of inhibition of function and autointoxication and 
 of their manifestations, has been recognized and taught 
 under their own heading and in connection with condi- 
 tions other than narcotic drug addiction-disease. That 
 the influence and importance of inhibition of function 
 and autointoxication in the development, and manifesta- 
 tions of the narcotic drug addict has escaped general and 
 widespread recognition, is evidence of the small amount 
 of unbiased clinical study, and of analytical clinical in- 
 terpretation of material physical phenomena, hitherto ac- 
 corded to narcotic drug cases. 
 
 I would not have it concluded that all symptoms and 
 manifestations arising in the handling of a drug addict 
 are due to the factors and elements I have discussed in 
 this chapter. It must be always in the mind of the in- 
 telligent and conscientious physician, that he has in his 
 care a human being with the same medical and psychical 
 possibilities that must be taken into careful and complete 
 account, as in the handling of any other sick person. 
 There is an unfortunate tendency to overlook concurrent, 
 or complicating or pre-existing conditions in the handling 
 of the narcotic drug addict. These cases are often ex- 
 tremely complex and difficult to analyze, and for adequate 
 comprehension and handling of them, the symptoms and 
 manifestations they show should be appreciated in their 
 true origin and character as they occur in each individual 
 case. 
 
CHAPTER V 
 
 EEMAEXS ON METHODS OF TBEATIl^G NAKCOTIC DETJG 
 
 ADDICTION 
 
 Most physicians have at some time or other in the 
 course of their practice encountered cases of narcotic ad- 
 diction. Most addicts have appealed to the physician for 
 advice and help. A very large proportion of them have 
 at different times made effort to obtain relief from their 
 affliction through the avenues of various forms of treat- 
 ment, advertised and otherwise. Most physicians have at 
 some time or other made effort to rescue some victim 
 from drug addiction, and as a rule have given over the 
 effort as hopeless, because even when they had succeeded 
 in taking his narcotic away from the patient, usually 
 after an experience trying and exhausting to both, the 
 patient has resumed narcotic administration — according 
 to the patient, because he had to — according to the aver- 
 age observer, because he wanted to. Frequently the pa- 
 tient has refused to persevere to the end of treatment and 
 has abandoned his attempts before the treatment has 
 reached the point of cessation of opiate medication — the 
 patient stating that he could not — the observer believing 
 that he would not, continue, and did not have the cour- 
 age or stamina or will to endure the necessary suffering. 
 The medical profession as a whole has adopted a cynical 
 attitude towards the possibility of permanent " cure," 
 and towards the efficacy of medical treatment, which has 
 tended to send the addict to quacks and charlatans and 
 various advertised remedies. 
 
 It is not my purpose to discuss in this book in detail 
 
 50 
 
TREATING NARCOTIC DRUG ADDICTION 51 
 
 the various methods, and treatments and cures advocated 
 and employed in the handling of the drug addict. This 
 alone would require a volume in itself. 
 
 Three broad lines of procedure have been employed; 
 so-called ^^ slow-reduction/' " sudden withdrawal," and 
 withdrawal accompanied by the administration of various 
 drugs, such as those in the belladonna group and its 
 alkaloids. 
 
 Slow reduction or " gradual reduction " as a " method " 
 is employed by slowly or gradually reducing the patient's 
 accustomed dosage to the point of discontinuance of opiate 
 medication. Interpreted by a great many to mean that 
 the fact of reduction is the principal indication in clin- 
 ical procedure, successful in the hands of a few who have 
 acquired unusual technical skill and clinical ability in 
 the interpretation of addiction manifestations, I believe 
 it to have failed as a method of cure in the hands of the 
 average. Practically every addict has attempted it one 
 or more times. As a method of procedure in some stages 
 and under some conditions of addiction treatment, slow 
 or gradual reduction of dosage has its value. In my opin- 
 ion, however, all other considerations aside, there are very 
 few who are possessed of sufficient understanding of nar- 
 cotic addiction and ability in the interpretation of clinical 
 indications, and have the technical skill required to carry 
 it through to a clinically successful culmination. As a 
 method of routine or forcible application it has many 
 serious objections as well as potentialities for damage to 
 the patient. In cases whose opiate intake is in excess of 
 actual physical-need, gradual reduction as often practiced 
 is perfectly easy and unnecessarily slow down to the 
 amount demanded as a minimum by the patient's addiction- 
 disease requirements Then must come withdrawal, nag- 
 ging, exhausting and protracted, if unskillful reduction 
 is persisted in, and the wrench of actual final withdrawal 
 is nearly as severe from a very small dosage as from a 
 
52 THE NARCOTIC DRUG PROBLEM 
 
 moderate one, other conditions in tlie case, physical and 
 mental, being equal. Prolonged " withdrawal " without 
 rare technical skill and without unusual and not com- 
 monly available environment and conditions of life, means 
 subjecting the patient to the continued strain of persistent 
 self-denial and self-control in the face of continued suf- 
 fering, discomfort, and physical need and constant desire 
 for their relief. It is my opinion that this experience 
 has in many cases tended to deeply impress upon the mind 
 of the patient so-called " craving " for the drug, and has 
 converted many a case of simple physical addiction-dis- 
 ease into a more or less mental state which may be de- 
 scribed as " morphinomania " or " narcomania." 
 
 This last observation does not apply to the method of 
 gradual reduction only, but is equally true of protracted 
 suffering under any other procedure in which the in- 
 dividual is cognizant of the existence of means of im- 
 mediate if only temporary relief. 
 
 In the comprehension of this a physician has only to 
 glance back over his professional experience and recall 
 cases of various conditions other than addiction which 
 have come to him, and whose histories present the effect 
 of long protracted suffering and discomfort in the con- 
 version of an average normal, self-supporting human being 
 into a dependent neurasthenic. 
 
 The histories given by most narcotic addicts of their 
 efforts to get relieved of addiction, show that following the 
 withdrawal of opiate drug in many if not most instances 
 has come weeks and months of weakness, and discomfort, 
 nervousness, sleeplessness, and pain which have persisted 
 for weeks and months, establishing the basis for the much 
 emphasized " after care," of some investigators. 
 
 While so-called " after care " is unquestionably as im- 
 portant as convalescence from any other disease, it is my 
 belief that as understanding of addiction as a clinical dis- 
 ease becomes more general, and more attention is paid 
 
TREATING NARCOTIC DRUG ADDICTION 53 
 
 to the study and scientific management of the disease it- 
 self, the stage of " after care " will come to assume less 
 importance. Addiction is not the only disease which 
 furnishes examples of cases in which incomplete and un- 
 satisfactory results have been merely a low-grade con- 
 tinuation of the fundamental disease and have been in- 
 terpreted as a protracted convalescence. 
 
 " After care," or convalescence, following satisfactory 
 results of clinical treatment and complete arrest of ad- 
 diction-mechanism activity has no terrors for either 
 physician or patient. It is very short and does not re- 
 quire any more restraint than any other convalescence, 
 unless conditions exist following active treatment which 
 should have been recognized and handled and eliminated 
 earlier from the picture. I shall discuss this again later. 
 
 " Sudden " or " forcible " withdrawal, or immediate 
 deprivation of opiate drug is still advocated by some in- 
 vestigators, fewer and fewer of them, however, among 
 medical men. There are cases of, and stages in addiction- 
 disease and its development where this means of pro- 
 cedure may be pursued without all of the serious objec- 
 tions with which it must be regarded as a routine method 
 of general enforcement. 
 
 That forcible deprivation of opiate drug may end in 
 death is a matter of too easily found and authoritative 
 medical record to be ignored. It has been discussed as 
 one of the possibilities by medical writers over many years. 
 Even the newspaper reports of deaths and suicides fol- 
 lowing sudden deprivation of opiate should be sufficient 
 to give pause to those who would still advocate this meas- 
 ure as a desirable procedure. 
 
 Reference to the previous enumerations of the physical 
 manifestations of body-need for opiate, or '^ withdrawal 
 signs," should be sufficient for the comprehension of its 
 tortures and easily explains the suicides which have at- 
 tended sudden deprivation. Any one who has watched a 
 
64 THE NARCOTIC DRUG PROBLEM 
 
 well-developed case of addiction-disease in the agonies of 
 opiate deprivation should hesitate to prolong them if pos- 
 sibly avoidable. While under some conditions, and in 
 some cases, it may be argued that ^' the ends will justify 
 any means/' as a routine procedure of wide application, 
 it must be stated that both in its immediate torment and 
 in its end results, mere forcible sudden withdrawal is not 
 a procedure of election. Some of its supporters still cling 
 to and quote the old fallacy that after seventy-two hours 
 without opiate a narcotic addict no longer physically re- 
 quires it. This fallacy is probably based upon the esti- 
 mated maximum time of opiate elimination in normal 
 human beings and experimental animals. It is most de- 
 cidedly false doctrine as applied to the well-developed 
 case of addiction-disease in whom the mechanism of dis- 
 ease, and not the mere administration or elimination of 
 opiate has become what should be the dominating con- 
 sideration. 
 
 As stated before, the mere withdrawal of opiate drug 
 does not arrest the activity of addiction-disease, nor pre- 
 vent the endurance of the exhausting and incapacitating 
 and protracted low-grade manifestations before referred to. 
 Its potentialities of permanent damage, moreover, are 
 attested by and displayed by many who show for years 
 shattered nerves, premature old age, etc. 
 
 It is perhaps wise to state again in this place that in 
 this book the consideration of narcotic or opiate addiction, 
 its mechanism symptomatology and handling, is not to 
 be applied to cocaine and alcohol use nor to the various 
 other drugs often loosely grouped with opiates as " habit- 
 forming." Until a distinct physical disease mechanism, 
 attended by analogous characteristic and constant physical 
 phenomena, can be demonstrated as resulting from the 
 action of one of these drugs or substances, its continued 
 use should not be classed with opiate addiction-disease. 
 
 The third general method of procedure is that in which 
 
TREATING NARCOTIC DRUG ADDICTION 55 
 
 effort is made to utilize other drugs tlian opiates, or other 
 measures than mere reduction or withdrawal or depriva- 
 tion to secure cessation of opiate medication. The efforts 
 have been, in a general plan, either to oppose or replace 
 the action of opiate by substance or substances seemingly 
 to have physiologically antagonistic or substitution proper- 
 ties — or to combat, offset or benumb the sufferings of 
 what is described as the " withdrawal period/' Such 
 agents have been employed in this disease for very many 
 years, and in their variety include most of the known 
 analgesic, sedative, antispasmodic, hypnotic or anesthetic 
 agents and measures. 
 
 Prominent among the drugs mentioned have been the 
 preparations and alkaloids of belladonna, of hyoscyamus, 
 pilocarpine, and some others. These drugs have by rea- 
 son of more or less supposed specific action, alone, or in 
 various combinations or in conjunction with purgatives, 
 etc., formed the basis for many if not most of the various 
 special treatments and " cures.'' For example, what is de- 
 scribed as the ^^ specific mixture " of one of the most 
 widely-known treatments contains as its active agents 
 belladonna and hyoscyamus. These drugs are not men- 
 tioned here in condemnation of their employment as ther- 
 apeutic measures in the hands of those skilled in the es- 
 timation of their values, indications and actions — and 
 dangers if unskillfuUy employed. They have unques- 
 tioned therapeutic value in their proper places, as and 
 when properly indicated, in individual cases. Routinely 
 used, as specific curative agents, they seem to me to be 
 demonstrating their failure. In the conception of addic- 
 tion-disease herein outlined it is difficult to attribute to 
 them specific properties. 
 
 In a paper, ^' The Rational Handling of the Narcotic 
 Addict " read before the Section on Pharmacology and 
 Therapeutics, Annual Session of the American Medical 
 Association, 1916, I stated, " It is not my purpose to en- 
 
66 THE NARCOTIC DRUG PROBLEM 
 
 ter into discussion of the various therapeutic methods and 
 therapeutic measures which have been advocated and em- 
 ployed in the treatment of narcotic addiction. Their 
 number is legion, and they include most of the therapies 
 known to lay as well as to medical literature. 
 
 " Their multitude is conclusive proof of lack of concep- 
 tion and of understanding of addiction-disease in the past. 
 They have been directed towards incidental and com- 
 plicating manifestations. They have no more place in 
 the treatment of the addict than they have in the treat- 
 ment of any other disease condition. I know of no med- 
 ication that can be called ^ specific ' in the arrest of the 
 mechanism of narcotic drug addiction-disease. There is 
 no more of a specific remedy for narcotic drug addiction 
 than there is for typhoid or pneumonia. The wide ad- 
 vertisement of treatments based on supposed ' specific ' 
 action of the products of the belladonna and hyoscyamus 
 and similar groups is unfortunate. They have in my 
 opinion, no action as curative agents in narcotic drug 
 addiction-disease which can entitle them to consideration 
 as specific or special curative remedies. The drugs of this 
 group are useful in many cases, intelligently applied to 
 meet therapeutic indications. They exhibit wide varia- 
 tion of action and reaction in narcotic drug addicts at 
 different clinical stages and under different clinical con- 
 ditions, and their dosage presents an extremely wide range 
 of individual measure. They are dangerous drugs in the 
 hands of the inexpert or careless, or used in a routine 
 manner or dosage. The status which they have acquired 
 as specific medication in narcotic addiction disease I hold 
 to be a medical fallacy which should be strongly opposed 
 and early remedied." 
 
 The search for panaceas, specifics and routine treat- 
 ments has constituted a stage in the therapeutic history 
 of most disease conditions. It marks the effort to make 
 wide and general application of a partial comprehension 
 
TREATING NARCOTIC DRUG ADDICTION 57 
 
 of facts and imperfect recognition of fundamentals and 
 is successful only as an individual case is occasionally 
 capable of responding, perhaps by clinical accident, to tbe 
 specific routine employed. 
 
 Undue insistence and publicity secured for or given to 
 a procedure of this description, is a real obstacle to the 
 development of clinical and scientific understanding of 
 the condition treated. It distracts attention from broad 
 clinical consideration of disease itself, from scientific in- 
 vestigation into pathology and disease mechanism, from 
 determination and observation of fundamental facts, 
 whose comprehension and analysis form the essential fac- 
 tor in the widespread successful handling of any condi- 
 tion, and from proper conception and appreciation of the 
 addiction patient and the addiction problem as a whole 
 with its many and varied aspects. 
 
 Various procedures in themselves, however, are not to 
 be utterly discredited and condemned. They have per- 
 formed a function in a transitional stage of education and 
 progress. They can all bring evidence in support of some 
 " cures." In their origin and inception they represent 
 honest effort, study and original thought. In analysis of 
 them can be seen, in the minds of those who first evolved 
 them, recognition and application of one or another of 
 the basic elements, reactions or facts of addiction-disease. 
 Each generation builds upon and adds to the work of the 
 previous one, discards or adopts according to its more 
 complete knowledge. We are building upon the various 
 procedures of the past just as our successors will build 
 upon our work of the present and will discard or adopt 
 our v-arious instruments and theories. 
 
 We are nearing the end of consideration of routinely 
 applied procedures, in all diseases. In addiction we are 
 entering upon a stage of attitude and handling in which 
 there shall be in each case comprehension of intrinsic 
 elements and appreciation of their relative importance. 
 
58 THE NARCOTIC DRUG PROBLEM 
 
 and in wliicli there shall be competent interpretation of 
 symptomatology and competent selection and application 
 of therapeutic measures, placing our efforts on a rational 
 basis and adapting handling and treatment to the needs 
 of the individual. 
 
 Our stumbling-block in the past has been that our minds 
 have been too much focused upon the mere use of narcotic 
 drug and upon the stopping of drug use and too little upon 
 the individual we were treating and the mechanism of his 
 disease. We have tended to apply our remedial efforts to 
 narcotic use instead of to narcotic drug addiction-disease. 
 
 This may explain the paucity of clinical and scientific 
 information as to addiction-disease coming from the in- 
 stitutions in which these cases are gathered. It seems 
 to be the fact that the narcotic wards of our great charity 
 hospitals and institutions of custody and correction still 
 in gTcat measure proceed with their handling of narcotic 
 addicts on the basis of mental or moral degeneracy or 
 deficiency or weakness of will, or morbid appetite, etc., 
 or apply one or another of the various remedies or com- 
 binations of remedies. Their internes and nurses do not 
 seem to graduate with a conception of addiction as a 
 definite physical disease, with clinically significant 
 symptomatology and constant physical reactions and phe- 
 nomena. That these institutions have after many years 
 given us so little information as to the definite physical 
 symptoms and phenomena which their patients constantly 
 manifest is in large measure the result of attention directed 
 to control of drug use instead of to alleviation of physical 
 addiction-disease. There has been much discussion over 
 various methods of treatment and over measures for the 
 control of patient and of narcotic drug, and there has been 
 insufficient study and analysis of the clinical details of 
 addiction-disease manifestations and their possible thera- 
 peutic significance. 
 
 There has been of late, however, signs of change in 
 
TREATING NARCOTIC DRUG ADDICTION 59 
 
 this situation, and in this change lies one of the greatest 
 hopes of solution of the narcotic drug prohlcm. The at- 
 titude towards addiction is heginning to follow th© trend 
 of modern medicine in getting away from special or 
 routine treatments, and the search for specifics and pan- 
 aceas, and in aiming at and devoting great effort to the 
 searching out, consideration of, and treatment of funda- 
 mental cause and underlying condition. When this 
 method of approach is applied widely to addiction-dis- 
 ease, and the facilities of our great hospitals and institu- 
 tions of research properly directed to its furtherance, 
 there will come a re-arrangement of conception of opiate 
 addiction. Restraint and custodial care, and psychologic 
 and psychiatric classification will be applied more spar^ 
 ingly. Many worthy sick people will — instead of being 
 refused treatment, or turned back upon their own re- 
 sources after inadequate treatment — thus adding to the 
 public and private burden of the care of the unfit — be 
 rationally treated as sick people and returned to health 
 and self-supporting competency. 
 
 The one great point to be kept in mind is that narcotic 
 addicts are sick; sick of a definite and now demonstrable 
 disease. This disease is variously complicated and widely 
 variable as it occurs in individual patients. Although 
 some individuals, afflicted with this disease, may require 
 custodial or correctional handling — the fundamental 
 physical disease cannot be properly arrested nor handled 
 successfully by mental, moral, sociological or penological 
 methods only. Any toxic, worried, fear-ridden or suf- 
 fering sick man may show psychological or even psychia- 
 trical manifestations or complications, but observing and 
 attempting to control complications only will not cure 
 basic disease. 
 
 Even if it should some day develop that a serum can 
 be produced against the underlying toxins of addiction- 
 disease ; and this is not beyond the bounds of possibility ; 
 
60 THE NARCOTIC DRUG PROBLEM 
 
 its usefulness and application must remain for the pres- 
 ent matter* of academic speculation. Other than this 
 possibilitj, there seems practically no hope of a properly 
 called " specific medication " in narcotic drug addiction^ 
 disease. Even with its discovery, it is highly improbable 
 that a routine treatment applicable to all cases could ever 
 be successfully adopted. In the very few disease condi- 
 tions in which we can properly be said to have " specific '' 
 medication, routine handling and treatment of all cases 
 is inadvisable and unsatisfactory. 
 
 There is not and probably never will be any specific 
 routine treatment successfully applicable to all cases of 
 any complex and variable disease condition. We shall 
 save much public money, and personal effort and time, 
 and shall save the narcotic addict much suffering and dis- 
 couragement, and shall add much to human health, com- 
 petency and happiness when we realize these facts as ap- 
 plied to addiction-disease, and proceed upon them in a 
 spirit of broad humanity and of rational clinical study and 
 remedy of obvious disease symptomatology. Narcotic 
 drug addiction-disease is a definite, and in most cases 
 arrestable disease. It should be widely so regarded and 
 studied and treated. 
 
CHAPTER VI 
 
 THE EATIONAL HAI^DLING OF NAECOTIC DEUG 
 ADDICTION-DISEASE 
 
 If anything has been demonstrated conclusively con- 
 cerning narcotics it is that the methods of the past, legal, 
 administrative, and medical, have not solved the narcotic 
 drug problem, nor controlled the narcotic drug situation, 
 nor been successful in the handling of the narcotic drug 
 addict. 
 
 Some factor or element of great and fundamental im- 
 portance has obviously been neglected. This lacking 
 element is general recognition of the presence of disease 
 processes which cause the symptomatology and phenomena 
 of body-need for opiate drug. One of the essentials for 
 the practical solution and management of the narcotic drug 
 problem is the realization by the medical profession, 
 legislators, administrators and laity that opiate drug ad- 
 diction is a definite disease entity, to be treated as such, 
 and calling for extensive clinical and laboratory investi- 
 gation and study such as have been accorded other dis- 
 eases over which we have gained the mastery. One of 
 the most needed achievements in the line of practical 
 remedy is the admission of narcotic drug addiction-dis- 
 ease to its legitimate place as an accepted part of the prac- 
 tice of internal medicine and the stimulating of education '\ 
 concerning it "among medical practitioners, medical stu- ^ 
 dents and nurses. 
 
 As was stated in the last chapter, too much emphasis 
 
 has been placed on drug use and drug withdrawal, as if 
 
 the drug itself were the most important element in the 
 
 clinical picture of addiction. In the handling and treat- 
 
 61 
 
62 THE NARCOTIC DRUG PROBLEM 
 
 ment of addiction-disease it should be constantly borne in 
 mind that the ultimate withdrawal of opiate from the 
 addict is simply one stage, and not by any means the 
 most important consideration in his rational handling. 
 Its management in most cases is a matter of scientific 
 clinical certainty and satisfactory accomplishment by the 
 physician who understands the disease he is treating and 
 who is clinically proficient in the control of its elements 
 by indicated therapeutic procedure. The ease of hand- 
 ling the stage of final withdrawal, the extent to which 
 suffering, nervous strain and exhaustion can be avoided 
 in it, and its final issue depend greatly upon the physical 
 and reactive condition of the man from whom drug is 
 withdrawn. Like the stage of crisis in pneumonia, its 
 course and conduct and results are largely influenced by 
 the condition in which the patient approaches the with- 
 drawal. It is of vastly more importance to measure and 
 control reactions and treat a patient so as to get him into 
 the fittest possible condition for final withdrawal and 
 rapid convalescence, than it is to focus attention on the 
 mere reduction or withdrawal of drug, or on the mere 
 amount of drug used. Linal withdrawal of drug, like an 
 operation of election, is to be done when the patient is in 
 the fittest condition and ready for it. With the addict 
 who is well nourished, non-inhibited, and physically and 
 glandularis^ reactive, it can be accomplished with little 
 or no discomfort, in a very short time, leaving practically 
 nothing to demand a protracted and difficult stage of con- 
 valescence or of so-called ^' after care.'* 
 
 It becomes evident, therefore, that the handling of an 
 opiate addict, preliminary to withdrawal of the drug to 
 which he is addicted is of greatest importance. The ease 
 of withdrawal and rapidity and completeness of subse- 
 quent recuperation, is largely commensurate with the ex- 
 tent of organic dependence upon the drug and the physical 
 condition of the patient. One man using the same amount 
 
NARCOTIC DRUG ADDICTION-DISEASE 63 
 
 as another is dependent upon its effects for the support 
 of his organic processes to a much greater extent. The 
 evident solution lies in a preliminary stage, removing in- 
 hibition, reducing in so far as possible organic and func- 
 tional dependence upon drug, and putting the patient into 
 the best possible reactive condition. I believe that in 
 many cases it is imperative for successful issue to train 
 the patient for the shock and strain of opiate withdrav^al 
 and in practically all other cases, though less imperative, 
 most desirable. 
 
 It has been objected that this v\;^ill prolong treatment. 
 My experience has been that it very much facilitates with- 
 drawal treatment, and not only renders it easier and more 
 uniformly successful and complete, but that it tends to 
 shorten and make less troublesome, and in some cases 
 practically eliminates, convalescence. 
 
 I have therefore instituted as an important part of my 
 procedure, a Preliminary Stage of study and handling 
 and treatment of my patient before attempting withdrawal 
 of the drug. During this time I study my patient, re- 
 garding him not simply as a narcotic addict but as a 
 sick man to be investigated as carefully as a cardiac or 
 any other patient, and all his organic and functional 
 conditions appreciated, and all of his functional and 
 glandular actions estimated in their competency and bal- 
 ance and their reactions both to the drug of addiction and 
 to the influences of addiction disease mechanism. Condi- 
 tions long masked by opiates, and forgotten, even by the 
 patient himself, may seriously affect treatment, con- 
 valescence and prognosis if undetected before withdrawal 
 is instituted. Their relations to and possible influence 
 upon addiction and its treatment, and fully as important 
 — the possible effect of treatment and withdrawal of drug 
 upon them, should be very carefully estimated. If ad- 
 visable or possible they should be remedied before with- 
 drawal of the drug of addiction. 
 
64 THE NARCOTIC DRUG PROBLEM 
 
 Also such mental or psychical disturbances as may exist 
 in a given case should be traced to their origin, esti- 
 mated and reckoned with. Very often they will be found 
 to be not inherent but a result of past suffering and 
 present worry and fear. The patient's confidence in his 
 physician's ability to treat the disease from which he 
 suffers should be strengthened, and his doubts and fears 
 allayed. Addiction patients are well informed concern- 
 ing opiates and are acquainted with the manifestations of 
 addiction-disease, and have had experience with or full 
 information concerning the various methods of cure. 
 They are, like any other chronic sick person, suspiciously 
 and keenly analytic of themselves and of the physician, 
 and unless handled with appreciation of their condition 
 are naturally the prey of constant worry and fear. Co- 
 operation and confidence between patient and physician 
 vastly influence the amount of nervous energy expended 
 by both, and in this, as in other diseases are big factors in 
 treatment and in convalescence. 
 
 Another advantage of a preliminary stage is one which 
 has been too little considered, but which will before long 
 come to demand the same intelligent attention and meas- 
 ure as is given to the contemplation of operations in and 
 treatment for chronic other conditions. It is this — in 
 what condition will withdrawal of opiate even though 
 skillfully conducted and successfully accomplished, leave 
 the individual in his value to himself, and to his family 
 and to the community, in view of co-existing physical 
 conditions? Withdrawal of opiate drug has been in not 
 a few cases the cause of transforming of a capable and 
 useful citizen into an invalid incompetent, for whose ulti- 
 mate salvation and competent physical and mental func- 
 tion and organic and glandular control resumption of 
 opiate medication was determined to be a therapeutic 
 necessity. 
 
 Such considerations as this should be all taken, analyzed 
 
NARCOTIC DRUG ADDICTION-DISEASE 65 
 
 and estimated in a preliminary stage and if treatment 
 is only going to injure a patient lie slionld be instructed 
 how to handle his addiction, and advised to continue his 
 opiate medication^ and not be subjected to useless expense 
 and trials. 
 
 Basic Principles of Addictiorirdisease Handling 
 
 Intelligent addicts well know that, other factors being 
 equal, the less number of times in a day they take their 
 drug, the less inhibited, the less constipated and more nor- 
 mal they are, and the smaller amount of narcotic drug they 
 require to maintain them physically and mentally com- 
 petent. It is unfortunate that this therapeutic principle 
 so widely recognized among intelligent addicts has not re- 
 ceived full recognition and therapeutic employment by all 
 of those who handle and treat addiction-disease. Its prob- 
 able explanation is very simple — apparently a period of 
 inhibition follows the administration of narcotic or opiate 
 drugs ; and the length of this period is not in ratio to the 
 size of the dose administered. Consequently, the fewer 
 number of times in a day a dose of narcotic drug is ad- 
 ministered, the greater amount of competent metabolism 
 is present — the more adequate is the patient's elimination 
 and nutrition — the smaller amount of opiate or its 
 product lies stored in inhibited and atonic cells, and the 
 smaller amount of antidotal substance is manufactured 
 for the protection of the body, and to some extent, the 
 smaller amount of opiate is required. 
 
 In caring for the narcotic addict, therefore, one of the 
 most important therapeutic measures is the regulation of 
 the interval of his narcotic drug administration. I have 
 repeatedly experimented upon addicts who were not con- 
 fined or under restraint in any way. I explained to them 
 the inhibitory effects of too frequent dosage and instructed 
 them to use the amount of drug they found necessary for 
 twenty-four hours in larger doses at longer intervals. 
 
66 THE NARCOTIC DRUG PROBLEM 
 
 This procedure alone, in many cases transforms the pallid, 
 starved, constipated and deteriorated addict within a sur- 
 prisingly short time into a well-nourished, well-reactive 
 and practically normally functionating individual. With 
 the return of health, vitality, and normal nutrition and 
 elimination, his hody requires still less drug and he vol- 
 untarily and without mental struggle and nervous strain 
 reduces the amount of drug used. I wish to emphasize 
 that in these experimental cases there were no other 
 therapeutic measures employed in the way of medication. 
 
 The practical therapeutic application of wide-interval 
 administration of opiate drug is made possible by the 
 fact that the narcotic addict can tolerate without harm 
 large doses of the drug of addiction. It is made con- 
 trollable by the fact, that, within certain limits, the length 
 of time over which a dose of narcotic drug will maintain 
 a patient in narcotic drug balance — or free from the 
 symptomatology of drug need — is in mathematical ratio 
 to the size of the dose administered. Each addict requires, 
 under the conditions of his daily life at a given time, to 
 satisfy the demands of his physical addiction-disease 
 mechanism, and to maintain him in narcotic drug balance, 
 an amount of drug which can be estimated in terms of 
 twenty-four hours and which I have called the amount 
 of minimum daily need. The most important considera- 
 ation in the administration of narcotic drug to a narcotic 
 addict is to supply the amount of minimum daily need 
 and maintain narcotic drug balance with the least in- 
 hibition of function. 
 
 Failure to maintain narcotic drug balance and a de- 
 gree below the amount of minimum daily need renders 
 the addict functionally and physically incompetent. He 
 is in a condition of physical and nerve incapacity and ex- 
 haustion. He has no physical tone ; he has markedly im- 
 paired circulation ; he cannot react, he has no recuperative 
 powers; he has constantly in his body, according to mod- 
 
NARCOTIC DRUG ADDICTION-DISEASE 67 
 
 ern theory, unneutralized autogenous poison wliicli robs 
 him of vitality, reaction and functional efficiency even 
 though it may not be present in sufficient amounts to give 
 rise to the violent spectacular and agonizing manifesta- 
 tions of complete narcotic deprivation. In other words, 
 as I have written elsewhere, " the reduction of the drug 
 of addiction below the amount of body-need robs the 
 addict of his most valuable asset in securing and main- 
 taining recuperative powers." In no other disease would 
 an intelligent physician persist in the application of meas- 
 ures which robbed his patient of recuperative powers and 
 expect satisfactory issue of the case he was trying to 
 treat. Until the physician and patient are ready and pre- 
 pared for the institution of the stage of final withdrawal 
 of drug, the patient should never be allowed to drop be- 
 low the amount of minimum daily need in his opiate 
 intake. 
 
 It is evident therefore, that upon the intelligent and 
 competent estimation, measure and control of physical 
 narcotic drug balance and inhibition of function depend 
 the reaction, well being and therapeutic progress of the 
 man who has narcotic drug addiction-disease. These fac- 
 tors also markedly influence the action of all medication, 
 including the drug of addiction, upon the body of the 
 opiate addict. They influence the reaction of the addict's 
 body to all medication. Medication cannot be intelli- 
 gently administered to the opiate addict unless those who 
 administer it have understanding and clinical appreciation 
 of the widely varying reaction of the addict under differ- 
 ent conditions of drug balance and inhibition of function. 
 Failure to recognize and appreciate this fact explains a 
 considerable portion of the past failures and the past 
 mortality attending specific and special methods and 
 treatments, and so-called ^^ cures." The dosage of medica- 
 tion administered and the time of its administration 
 should therefore be determined upon with watchful eye to 
 
68 THE NARCOTIC DRUG PROBLEM 
 
 the reaction of the patient, and with intelligent compre- 
 hension of the possibilities in reactionary change. 
 
 The actions and the dosage of therapeutic agents have 
 been largely determined by experimentation on individ- 
 uals and animals of average normal reaction. The toxic, 
 the inhibited and the narcotic addicted do not display 
 the normal reaction to therapeutic agents. Under some 
 conditions they over-react both physically and nervously, 
 and under other conditions they under-react. Detailed 
 consideration of this matter is not possible in this book. 
 It offers for investigation a field well worthy of exploration 
 both clinical and laboratory. It will only state that as 
 the manifestations and influences of toxemia, functional 
 exhaustion, inhibition, and, in the addicted, of varying 
 physical diTig balance, have become increasingly definite 
 and tangible and capable of clinical measure and determin- 
 ation, my medication of the toxic and the exhausted and 
 the inhibited individual, as well as of the narcotic ad- 
 dicted, has become progressively more effective. These ob- 
 servations apply to conditions other than opiate drug ad- 
 diction, and are worthy of consideration in all toxic, and 
 exhaustion and depression states. 
 
 I have already spoken of the imperative physical need 
 for the drug of addiction. I have also referred to the 
 amount of minimum daily need for the drug of addiction. 
 The recognition of factors which influence these is of great 
 importance. Many of these factors are so commonplace 
 and so obvious in their relation to the extent of body need 
 that they are appreciated by most intelligent addicts. 
 Anything which increases the expenditure of physical and 
 nervous energy increases the addict's need for opiate drug. 
 iVmong the most potent influences are worry, fear and 
 physical suffering. They consume physical fuel; and an 
 important part of the addict's physical fuel is the drug of 
 his addiction. In addition to this, worry and fear and 
 suffering are also markedly inhibitory of glandular and 
 
NARCOTIC DRUG ADDICTION-DISEASE 69 
 
 peristaltic function. The expenditure of energy in mental 
 and muscular work also calls for increased supply of tlie 
 drug of addiction. I need not enlarge upon this impor- 
 tant fact. Its application to the handling and treatment 
 of the addict is evident. Narcotic drug should be supplied 
 to meet the physical needs of the individual case, and only 
 be decreased as intelligent handling of the factors which 
 determine that need have lessened it. 
 
 The method of gradual reduction of dose to the point ^ 
 of ultimate discontinuance is practical and feasible imder 
 conditions and at an expense of time and money which are 
 possible to but very few addicts. The forcible reduction 
 of dose without regard to the environmental, mental, eco- 
 nomic, physical or other conditions of the average and in- 
 dividual addict, and absolutely ignoring the considerations 
 of the mechanism and symptomatology of his addiction- 
 disease is barbarous, harmful and futile. Enforced re- 
 duction of dose below the point of body need is not worth 
 what it costs in nerve-strain, suffering, and physical in- 
 adequacy. The extent of addiction-disease and the de- 
 gree of progress in its remedy cannot be measured in 
 terms of amount of drug administered. It must be meas- ) 
 ured in terms of clinical symptomatology, just as progress 
 is measured in any other disease. Reduction of dose be- 
 low the amount of body need, prior to the stage of final 
 withdrawal, constitutes a serious therapeutic handicap 
 and is most decidedly contra-indicated. Withdrawal of 
 opiate from an addict whose physical reaction and strength 
 and nerve force have been reduced and depleted by con- 
 tinued reduction of amount of drug without commensur- 
 ate reduction in the extent of body need is harder than 
 withdrawal from a reactive individual with reserve nerve 
 and physical force who may be taking a much larger dose. 
 
 The average addict must support himself and his family. 
 His physical well-being and economic efficiency should be 
 considerations in the welfare of the community in which 
 
70 THE NARCOTIC DRUG PROBLEM 
 
 he lives. Legislative and other investigation has shown 
 that we are entirely unequipped both institutionally and 
 professionally for the successful immediate withdrawal of 
 opiate from even a small proportion of our present census 
 of the opiate addicted. In view therefore, of the practical 
 impossibility of immediate successful withdrawal treat- 
 ment, and in view of what is known and can be demon- 
 strated and taught in the accomplishment of final with- 
 drawal, I do not hesitate to state that, until we are pre- 
 pared and in a position to skillfully and competently 
 handle the stage of final withdrawal to assured successful 
 issne, it is much wiser to supply to the addict who is not 
 a public menace the drug of his addiction to the extent of 
 his physical needs, and to teach him how to use the drug 
 of addiction in such a way as will maintain his physical 
 and economic efficiency, than it is by enforced reduction 
 of dose to deprive him for a long time of working ability 
 and his family of his support. Furthermore, the addict 
 who is insufficiently supplied with the opiate of his addic- 
 tion, turns in desperation to the use of things far more 
 harmful to him than the drug of his addiction. This he 
 does in the vain hope of obtaining mental and nervous 
 and physical stimulus and support and some surcease of 
 his misery. The many wrecks of addicts to be seen try- 
 ing through insufficient supply of narcotic drug, self- 
 poisoned with other drugs which they have purchased, 
 alcohol, bromides, coal tar products, cocaine, and of late 
 hyoscine — their addiction disease unrelieved and un- 
 diminished — are sufficient argument against mere re- 
 duction of dose, below physical body need. 
 
 The personal attitude of the physician towards opiate 
 addicted patients is of great importance. The medical 
 man who is to treat a case suffering from addiction-dis- 
 ease successfully to the end of relieving this condition, or 
 who is treating addiction-disease as an intercurrent con- 
 dition complicating another disease, must first of all make 
 
NARCOTIC DRUG ADDICTION-DISEASE 71 
 
 his patient realize tliat the physician himself knows some- 
 thing about addiction as a disease. He must never give 
 his patient any hint or reason to suspect that he regards 
 opiate addiction as a habit, a vice, a degrading indulgence 
 which can be to any curative or even therapeutic extent, 
 combatted by the exercise of will-power. 
 
 In their desperation and ignorance, the vast majority 
 of addicts have repeatedly exercised will-power in self- 
 denial of their drug to the limits of their physical en- 
 durance, and they know the futility and suffering of at- 
 tempts based simply and solely upon the exercise of will- 
 power. Experience has taught them actual facts concern- 
 ing the physical action of narcotic drugs and concerning 
 the results of insufficient supply of narcotic drug in a man 
 who is addicted. The addict knows that he does not take 
 a drug because he enjoys it. He knows that he exper- 
 iences no sensuous gratification or other pleasure from its 
 administration. He knows that he uses a narcotic drug 
 simply and solely because he has to use it to escape physical 
 incompetence and physical agony. As I said before, al- 
 most without exception the narcotic addict has proceeded 
 of his own accord, or under the direction and advice of 
 others, on the theory of exercising will power, and resist- 
 ing temptation. With the few exceptions of those made 
 in a very early stage and before addiction mechanism had 
 become strongly developed and rooted in his physical 
 processes, such efforts on the basis of this theory have 
 been useless. 
 
 It is practically impossible to argue successfully on the 
 basis of theory with the man who has experienced facts. 
 Narcotic addiction furnishes a class of patients who know 
 more about their own disease than any other class of 
 people. They can accurately estimate the extent of un- 
 derstanding and knowledge possessed by the man who is 
 treating them, and they are desperately critical. Almost 
 without exception, except for some of the true '' under- 
 
72 THE NARCOTIC DRUG PROBLEM 
 
 world/^ they desire above all else to escape from their 
 v^ condition. I know tbat this is not tbe popular conception 
 and for the present may be by some regarded as heresy. 
 Therefore, it is of essential importance that between the 
 doctor who treats an addict of average intelligence and 
 that addict must exist co-operation and understanding. 
 As soon as this patient realizes two things — that the 
 doctor does not believe his expressed wish to be cured, and 
 that he interprets the patient's desire for relief from 
 suffering as simply a desire for more opiate and the ex- 
 pression of habit, vice or degraded appetite which should 
 be controlled by the exercise of '' will-power," — there is 
 an end to that patient's confidence in that doctor, and to 
 the help that that doctor can give to that patient. As I 
 have written elsewhere, the opiate addict of average in- 
 telligence will co-operate with his medical adviser to the 
 extent of his physical endurance, so long as he has any 
 belief in that adviser's understanding of his condition, 
 and ability to help him. 
 
 In my own work, and as a result of my own experience 
 I have found that as a rule the extent to which an in- 
 telligent addiction patient cooperates with me has been a 
 measure of the understanding and technical ability with 
 which I handled him, rather than a measure of his de- 
 sire to be helped. It is held by many that a majority of 
 addiction-patients are not possessed of average intelligence 
 and are not honest in their statements. I will simply say 
 that even in the Alcoholic and Prison Wards of Bellevue 
 and in the narcotic wards of the ISTew York Workhouse 
 Hospital I came more and more to seek in faults of medical 
 and nursing handling the explanation of apparent lack of 
 cooperation. In the Annual Report of the ^Tew York De- 
 partment of Correction for 1915, in commenting upon the 
 work of the narcotic wards, is stated, " In ratio as there 
 has been at any given time among our interne and nursing 
 staff comprehension and understanding of the manifesta- 
 
NARCOTIC DRUG ADDICTION-DISEASE 73 
 
 tions and underlying principles of narcotic drug addiction- 
 disease and of its rational handling in the individual 
 case, our results have been good or bad." 
 
 Several years ago I wrote as follows : ^^ As to the ex- 
 isting opinion that the morphinist does not want to be 
 cured and that while under treatment he cannot be trusted 
 and will not cooperate but will secretly secure and use his 
 drug, I can only quote from personal experience with these 
 cases. During my early attempts, my patients, beginning 
 with the best intentions in the world, often tried to beg, 
 steal or get in any possible way, the drug of their addic- 
 tion. Like others I placed the blame upon their sup- 
 posed weakness of will and lack of determination to get 
 rid of their malady. Later I realized the fact that the 
 blame rested entirely upon the shoulders of my medical 
 inefficiency and my lack of understanding and ability to 
 observe and interpret my patient's condition. The mor- 
 phinist as a rule will cooperate and will suffer to the limit 
 of his endurance. Demanding cooperation of a case of 
 morphinism during and following incompetent with- 
 drawal of the drug is much like asking a man to cooper- 
 ate for an indefinite period in his own torture. There is 
 a limit to every one's power of endurance of suffering." 
 
 Of primary importance, then, if a physician, institu- 
 tional or practitioner, is to have any success in handling 
 a case of opiate addiction-disease, is his attitude towards 
 his patient — divesting himself of all conception of habit, 
 appetite or vice as explanation of characteristic physical 
 manifestations and symptomatology, and approaching the 
 patient as a man with a definite disease requiring and de- 
 serving intelligent clinical handling. The patient will be 
 the very first to mark a physician's shortcomings. If he 
 has not confidence in the doctor's ability and understand- 
 ing of his illness the doctor can help him but little. This 
 statement applies not to addiction-disease alone but to 
 every medical condition. 
 
74 THE NARCOTIC DRUG PROBLEM 
 
 There are three clinical demonstrable elements to be 
 determined, measured and controlled in the actual 
 therapeutic handling of cases of narcotic addiction-disease. 
 The first of these is the actual amount of drug which the 
 patient's body demands to maintain functional and or- 
 ganic efficiency and to escape physical distress. The sec- 
 ond of these is the extent of auto- and intestinal-intoxica- 
 tion, autotoxicosis and malnutrition. The third of these, 
 which is both a result of and a causative element in the 
 other two, is the extent of inhibition of function. 
 
 In the successful handling of a case of addiction-dis- 
 ease, therefore, the first effort should be to determine ap- 
 proximately the amount of the patient's minimum daily 
 physical need for the drug of his addiction. This need 
 is clinically recognizable and definitely measurable. It 
 should be met to whatever extent it is present so long as it 
 exists, and dosage diminished only as competent treatment 
 diminishes the extent of need. This physical need can 
 be demonstrated and accurately measured by clean-cut 
 symptomatology. It can be expressed in mathematical 
 terms of amounts of drug required in twenty-four hours. 
 Work, worry, strain — anything which consumes physical 
 or nervous energy increases this need. If this physical 
 need is not met the patient is robbed of physical tone and 
 physical reaction. He is robbed of metabolic balance and 
 functional competency. He is, in short, robbed of the 
 basic ability which his body has to regain health. 
 
 In the estimation of this amount of physical need the 
 procedure is very simple. Have administered to the 
 patient who is manifesting the symptomatology of drug- 
 need, sufficient drug to remove the symptoms and restore 
 him to complete physical, functional and nerve balance. 
 Have the length of time observed which elapses before 
 the symptoms of drug need reappear. Have this repeated 
 several times and information is secured as to what quant- 
 ity of opiate under the existing conditions will hold that 
 
NARCOTIC DRUG ADDICTION-DISEASE 75 
 
 patient in drug-balance for a known length, of time. In 
 this way can be matbematicallj estimated the extent of 
 physical drug-need. The average need for twenty-four 
 hours can be easily computed from the data obtained. 
 It is merely a matter of arithmetic. 
 
 The regulation of dosage can also be estimated with 
 approximate accuracy. As has been stated before, the 
 interval of freedom from withdrawal manifestations is 
 found to be, in a general way and within certain limits, 
 in ratio to the size of the dosage. Tor example, if in a 
 given case, under given conditions of fear, worry, physical 
 or nervous strain, pain, etc., as discussed elsewhere — one 
 grain of morphine will last a given patient at a given 
 time for four hours ; under the same conditions two grains 
 will last for approximately eight hours. There are limits 
 to the application of this rule. It is stated as the general 
 operating of an addiction-disease phenomenon which, is 
 useful as a therapeutic guide. 
 
 The amount of actual physical body need as capable 
 of approximate estimation in the above manner should be 
 administered to the patient, any reduction being guided 
 by the fact that his clinical symptomatology and physical 
 manifestations demonstrate that the amount required by 
 his addiction-disease has been reduced. It is much wiser 
 for the progress of the average addiction case to have the 
 drug administered in the amount of estimated physical 
 need than it is to attempt to reduce the amount of drug 
 before his reactions show reduction in physical drug-need. 
 The success of outcome and the measure of progress in 
 such a case is not to be estimated by the amount of drug 
 the patient is receiving, but is to be measured by the pa- 
 tient's condition and clinical manifestations. The mere 
 fact that a physician has reduced a narcotic addict's 
 opiate intake from a large dosage to a very small dosage, 
 or indeed has denied him any opiate at all for a consid- 
 erable length of time, is no evidence that he is curing or 
 
76 THE NARCOTIC DRUG PROBLEM 
 
 has cured his patient of addiction-disease. Unless the 
 physical mechanism of body-need for an opiate has been 
 completely and actually quieted, the patient may have in 
 his body for perhaps weeks and months after the last ad- 
 ministration of the drug, a physical demand for it. The 
 taking of opiate does not constitute opiate addiction-dis- 
 ease. Also the mere fact that an addict is no longer tak- 
 ing opiate does not constitute proof that he is ^' cured " 
 of opiate addiction. The non-recognition of this fact 
 lies at the root of much past failure. The general axio- 
 matic statement might be that an addict should be supplied 
 with the drug of his addiction to the complete extent of his 
 physical need at any given time until conditions are right 
 for the undertaking of assuredly competent opiate with- 
 drawal and complete arrest of his addiction-disease 
 mechanism. 
 
 The mere amount of drug used by a patient in twenty- 
 four hours is a matter of minor importance compared with 
 the general health, physical tone, nervous glandular and 
 functional balance, reaction and resistance of that patient. 
 Also the amount of drug taken by a patient in twenty- 
 four hours is absolutely no adequate measure of the 
 strength or stage of development of his addiction-disease. 
 If he does not get enough opiate he cannot competently 
 functionate; he cannot be adequately nourished; he can- 
 not sufficiently eliminate. He is subjected to the in- 
 fluences of constant discomfort and nerve strain in the 
 endurance of low-grade withdrawal manifestations. He 
 is worried and becoming exhausted. It becomes apparent 
 that by continued maintainance of narcotic administration 
 below the amount of physical body-drug-need the very fac- 
 tors are created which have been described as increasing 
 body-drug-need. It is difficult to see any therapeutic ad- 
 vantage in such a situation. Moreover, as has been stated 
 before, it is far easier to eradicate completely and sue- 
 
NARCOTIC DRUG ADDICTION-DISEASE 77 
 
 cessfully narcotic drug need in a short time and without 
 marked discomfort, from a functionally competent and 
 organically healthy man who is taking a physically suffi- 
 cient amount, than it is from a nerve-racked, worried and 
 physically, nervously, and functionally exhausted wreck 
 who is under-dosed. 
 
 It is therefore much wiser to direct immediate efforts to 
 the securing and maintaining of health, reaction and tone 
 — irrespective of the amount of drug required — until 
 there is time and opportunity for the undertaking of com- 
 petent withdrawal — a stage of handling and treatment 
 concerning whose physical and clinical phenomena and 
 manifestations and dangers too few are educated to and 
 familiar with. 
 
 In regulating the administration of drug as to size and 
 intervals of dosage — amounts should be sufficient to allow 
 the patient long intervals between doses. In the deter- 
 mination of this, it is necessary to study and experiment 
 with the reactions in the individual case. The effort, how- 
 ever, should be to have the drug administered the smallest 
 possible number of times in the twenty-four hours com- 
 patible with the patient's well-being. Eor example — if 
 a given patient's daily need is three grains a day, it is 
 much wiser to administer this amount of drug in doses of 
 one grain three times a day or a grain and a half twice 
 a day as soon as practicable, than it is to have it admin- 
 istered in larger numbers of smaller doses at more fre- 
 quent intervals. The reason is, that, apparently after a 
 dose of narcotic drug is administered function is inhibited 
 for a length of time which is not in proportion to the 
 size of the dose administered. On the other hand, as 
 has been stated, within limits, the length of time over 
 which a dose of narcotic drug will hold a patient in drug 
 balance and free from the physical manifestations of drug 
 need is in proportion to the size of the dose. Therefore 
 
78 THE NARCOTIC DRUG PROBLEM 
 
 large doses at wide intervals permit greatest freedom from 
 functional inhibition and as well, if not better, supply 
 the demands of physical drug need. 
 
 I have briefly referred to the elements of intestinal and 
 autointoxication and autotoxicosis. Intestinal and autoin- 
 toxication, combined with worry, fear, and anxiety, con- 
 stitute very important causative and controlling factors in 
 whatever mental and physical deterioration has taken place 
 in a case of narcotic-drug-addiction-disease. Physical, 
 mental and moral deterioration are to a very small extent 
 direct results of narcotic drug action per se. As long as 
 a narcotic drug addict is maintained non-toxic, uninhibited 
 and unworried, he is practically at his individual normal, 
 plus an added physical need. It should not be necessary 
 to recall to memory many cases of upright, honorable 
 and competent and apparently healthy men and women 
 who have been narcotic addicts over very many years, 
 unknown to but very few or none of their relatives or 
 friends or even physicians. As has been stated before, 
 their apparent immunity to the supposed stigmata of nar- 
 cotic drug action was not due to the fact that they were 
 on a higher mental or moral plane than their less for- 
 tunate fellows, or that they were possessed of sufficient 
 will-power to resist temptation in the over-indulgence of 
 their so-called appetite. The facts are that by experience 
 they found out that if they used narcotic drug in amounts 
 indicated by the manifestations of their disease, and did 
 not take it too often and kept their bowels open and did 
 not worry, they were as normal as anybody else except for 
 the fact that they had to take a dose of a certain medicine 
 two or three times a day. In other words they simply 
 learned to manage their disease in a way to avoid compli- 
 cations. They met their issue squarely; they discounted 
 theory and recognized facts, and they used common sense 
 in the interpretation and application of what they learned. 
 
 The control of auto and intestinal intoxication in nar- 
 
NARCOTIC DRUG ADDICTION-DIEASE 79 
 
 cotic addiction is as a rule of easy accompli shment if the 
 patient is -uninhibited and in functional balance and is 
 not over-supplied or under-supplied with the drug of his 
 addiction. The narcotic addict who is non-toxic and in 
 drug balance and is not harassed by worry or fear needs 
 practically no more drastic methods of elimination than 
 his non-addicted brother. If he is over-dosed his elimina- 
 tion is inhibited ; if he is under-dosed his eliminative pow- 
 ers are not capable of response. The element in the secur- 
 ing of evacuation of the bowel in a drug case, as well as in a 
 toxic case of whatever description, is sluggish peristalsis ; 
 in other words, it is inhibition of nervous impulse. It is 
 therefore not necessary to load a bowel up with large 
 amounts of drastic and irritating cathartics. Indeed this 
 procedure is very harmful and abortive of ultimate results. 
 An over-irritated intestinal tract is not a good eliminative 
 organ. To my mind the so-called " typical stool," of the 
 so-called ^' Towns Treatment " with its content of jelly 
 mucus has no clinical significance other than its evidence 
 of a production of an exhaustive and irritative mucous 
 colitis and means that however much purging may be ac- 
 complished competent elimination from the colon is at an 
 end. Its appearance in a case under my oare I should 
 regard as evidence of injudicious treatment. Eor the 
 bowel elimination of a case of narcotic-addiction there 
 is needed practically nothing beyond the ordinary mild 
 and non-irritating catharsis. All that is needed is to re- 
 member that if inhibition of peristalsis has not as yet been 
 overcome, you may be wise to administer, about the time 
 you should get an evacuation, strychnine or other peristal- 
 tic stimulators in sufficient amounts to overcome existing 
 inhibition and stimulate peristalsis. 
 
 Inhibition of function, as I have already shown, is a ^\ 
 basic factor in the development and maintaining of the | 
 narcotic addiction-disease state. It is of great importance 
 to recognize, estimate and control its presence and influ- 
 
80 THE NARCOTIC DRUG PROBLEM 
 
 ence. Inhibition of function is due to nervous exhaustion 
 from overwork, fear, anxiety and suffering; it follows for 
 a few hours the administration of opiate drugs; it is a 
 constant result of chronic constipation and of intestinal 
 and auto-toxemia. The rationale of its control is evident 
 from the enumeration of its causes. Until its causative 
 factors have been removed or controlled, its manifestations 
 must be treated symptomaticallj — remembering always 
 that for therapeutic action in an inhibited individual dos- 
 age of medicinal agents varies, and must be estimated 
 from clinical observation and experiment and not from 
 memory of the text-books. To the man experienced in 
 their use some of the internal secretory glandular products 
 are at times helpful. As has been stated above, strychnine 
 or other peristaltic stimulator is useful. 
 
 Tinally I repeat again my disbelief in and opposition to 
 the use of any drug or combination of drugs under the 
 impression that they have or may have specific curative 
 action against addiction-disease. Although I at times em- 
 ploy various of the drugs commonly mentioned in connec- 
 tion with the treatment of addiction, I do so with no belief 
 that they have " specific " properties in this disease. I 
 use them in the treatment of addiction as I do in other 
 disease conditions, simply and solely as they meet individ- 
 ual clinical and therapeutic indications. Petty took this 
 stand years ago. I do not regard these dnigs as curative 
 of addiction-disease, and I do not constantly use any of 
 them. 
 
 I do not use or endorse, a " belladonna " treatment, a 
 " hyoscine " treatment, nor any other description of specific 
 or routine treatment in addiction-disease. I regard the 
 drugs of the belladonna and hyoscyamus groups, pilocar- 
 pine, etc., as extremely dangerous drugs to be routinely or 
 carelessly used in the treatment of addiction-disease. 
 They are rendered safe only after personal experience and 
 study into their action and appreciation of the factors and 
 
NARCOTIC DRUG ADDICTION-DISEASE 81 
 
 influences which control their action in the functional, 
 toxic, and narcotic drug conditions. The routine and un- 
 intelligent use of the products of these groups of drugs in 
 the treatment of narcotic addiction — under the mistaken 
 impression that they somehow or other have direct curative 
 action upon the disease condition — has been the cause of a 
 considerable mortality and an easily understood opposition 
 among intelligent addicts. Hyoscine or scopolamine and 
 the other members of this group, ezerine, pilocarpine, 
 the coal tar products, etc., are at times useful drugs to 
 meet indications in the treatment of a case of addiction. 
 Increasing intelligence in the handling of the addiction 
 mechanism itself, however, renders the necessity of their 
 use less and less frequent and the dosage of them required 
 for therapeutic action smaller and smaller. They should 
 simply be classed as of use among other things, peristaltic 
 and circulatory stimulation and support, indicated elimi- 
 nants, kindness and consideration, understanding and in- 
 telligence or any of the other therapeutic weapons in our 
 possession. 
 
 Elimination and the securing of it in the narcotic ad- 
 dicted has been referred to in this chapter. The chapter 
 should not be closed however, without a word of warning 
 against the excessive purgation with drastic and over irri- 
 tating agents employed by some in this condition. Drastic 
 purgation is not at all synonymous with competent elimina- 
 tion. Competent elimination is not to be measured in 
 terms of bowel-movements ; but in terms of clinical symp- 
 tomatology of toxemia, circulation and measure of func- 
 tional efficiency. Excessive purgation means over-irrita- 
 tion and over-stimulation of eliminative mechanism, re- 
 sults in the interference with and exhaustion of function 
 and defeats true elimination. 
 
 Presence of good circulatory tone and absence of con- 
 gestion in the eliminative organs is to me one of the most 
 important factors in true elimination. The addict who 
 
82 THE NARCOTIC DRUG PROBLEM 
 
 is in good functional tone, has competent circulation, is in 
 narcotic drug balance, and is noninhibited, needs no more 
 drastic eliminative measures than belong to ordinary ra- 
 tional therapeutics in the nonaddicted. 
 
 As to final withdrawal of the drug, and ultimate arrest 
 of the disease, I shall say but little in this book. 
 
 I follow no " routine " and have no set procedure. I 
 am guided, as in my handling of the other stages of addic- 
 tion-disease, by the condition of my patient and his clinical 
 requirements. There is no one procedure applicable to 
 all cases of any condition in medicine and surgery. In 
 narcotic addiction-disease, as in all other conditions of 
 medicine and surgery, the man who will have the best 
 results is the man who is possessed of the widest and most 
 varied experience combined with intelligent observation, 
 technical skill and clinical judgment in the selection of 
 procedure best adapted to the needs of the individual case. 
 Familiarity and experience with different methods and 
 procedures reveals in each and nearly all of them some 
 advantages and some defects. The wise man and the man 
 whose results will most approach uniform success is he 
 who can make intelligent selection and use of whatever is 
 most applicable to the needs of the case he treats, either out 
 of his own experience and discoveries, or out of his famil- 
 iarity with the work of others. 
 
 An element in successful withdrawal of narcotic must 
 also remain, as in everything else, the inherent personal 
 gifts and qualifications of the individual operator. A 
 man works best with the tools most adapted to his hand, 
 and operators of different temperaments and of different 
 experience and training will always disagree on points of 
 procedure and technique. My own procedure in final 
 withdrawal is determined largely by my study and measure 
 of my patient and my patient's reactions, addiction and 
 otherwise, during my preliminary or preparatory work, 
 
NARCOTIC DRUG ADDICTION-DISEASE 83 
 
 selecting the time for final withdrawal of drug by con- 
 sideration of similar factors as would be taken into account 
 in an operation of election. 
 
 After a preliminary stage, or stage of preparation, in 
 w^hich I have gotten rid of all possible abnormalities, 
 physical and psychical, with my patient robust and re- 
 active, confident and expectantly happy, with autointoxica- 
 tion, and inhibition removed and the possible residues of 
 opiate or opiate product no longer stored in atonic body 
 cells — the addiction-mechanism, therefore, only kept in 
 activity by the current intake of opiate, which if properly 
 handled and the patient not subjected to exhausting strain 
 and struggle and suffering, can be eliminated in a very 
 short time. With these conditions consummated, I hasten 
 elimination, keeping well away from exhausting purgation, 
 maintaining my patient's circulatory and other functions, 
 and conducting as rapid a withdrawal as is compatible 
 with my patient's reactive condition and the reactions of 
 his disease. 
 
 In other words, I endeavor by my conduct of the case 
 to reverse the process of development of the physical addic- 
 tion-disease with its concomitants and complications, as I 
 find it in the individual case, arresting the addiction- 
 disease mechanism only after I have cleared the clinical 
 picture in so far as possible of all other considerations. 
 
 In a majority of cases by experienced choice of clinical 
 procedure, combined with judgment and technical skill, 
 the arrest of addiction-mechanism and the restoration of 
 the narcotic addict to health and freedom from both opiate 
 need and thought of opiate drug is a matter of assured 
 accomplishment attended by little if any nervous strain 
 and physical suffering. 
 
 Ability to accomplish this is not beyond the power of 
 any competent practitioner, whether he reside in a hospital 
 or is in private practice. All that is required is instruc- 
 
84j the narcotic DRUG PROBLEM 
 
 tion or information as to the mechanism of addiction- 
 disease, clinical demonstration of its manifestations and 
 reactions and the same amount of experience in their 
 handling as is expected of a man who treats any other 
 disease. 
 
 I have purposely refrained in this book from discussion 
 of technical details of therapeutic procedures, and of vari- 
 ous medications, and of their various indications, contra- 
 indications, applications, dosage, etc. Such discussion, to 
 be adequate and competent, would require much space and 
 would distract from the general presentation of the prob- 
 lem, which is the purpose of this volume. 
 
 I have learned from experience in teaching and in 
 treatment of cases that before there has been established 
 appreciation of the whole personal and clinical problem 
 and picture, and conception of its disease mechanism, and 
 ability clinically to recognize and interpret symptomatol- 
 ogy, discussion of technical details is premature and mis- 
 leading. 
 
CHAPTEE VII 
 
 EELATIOIi OP iq'AECOTIC DRUG ADDICTION TO' SURGICAL, CASES 
 ANjy INTEECUREENT DISEASES 
 
 It is a conunon idea in tlie minds of botli surgeons and 
 physicians tliat an addict to narcotic drug is a difficult 
 case for surgical handling and is a poor surgical risk. 
 ISTumerous instances of surgeons refusing to operate upon 
 a narcotic addict until the addict should have " stopped '' 
 the use of the drug^ voice the almost prevailing attitude. 
 
 Very many, if not most, internists and practitioners 
 view with gravest concern the presence of addiction in a 
 serious illness coming under their care. 
 
 That the addict has borne this undeserved reputation as 
 a poor surgical and medical risk, and that this reputation 
 has been seemingly merited by previous medical and surg- 
 ical experience, is not to be laid at the door of the exist- 
 ence of addiction in the patient. It is to be laid at the 
 door of insufficient medical comprehension of addiction- 
 disease and its mechanism in its material manifestations, 
 and in its functional and organic influences, and at the 
 door of inadequate clinical study into the analysis, estima- 
 tion and control of these. Like much else that has been 
 for generations generally accepted as true about narcotic 
 drug addiction, the belief is erroneous that the addict is 
 a poor surgical and medical risk because he is an addict. 
 
 As a surgeon once stated " These addicts have no resist- v 
 ance, and they go right out." Swayed by the old concep- ' 
 tion of addiction, this more than ordinarily humane and 
 generous-hearted man had not the slightest suspicion as 
 to why the addicts that he had operated upon had displayed 
 
 i 85 
 
86 THE NARCOTIC DRUG PROBLEM 
 
 no resistance and had tended to " go right out/' He had 
 in his mind simply the then prevailing and practically 
 unquestioned conception of the narcotic addict, and he had 
 not the slightest suspicion that a definite physical disease, 
 whose mechanism should have received intelligent clinical 
 handling and control was complicating the surgical cases 
 of the addicts who went right out. He had based, as all 
 of us once did, his opiate medication on his materia medica 
 conception of therapeutic dosage instead of on the demands 
 of an addiction-disease mechanism. It is rumored that 
 more than one illustrious life, full of past accomplishment 
 and potential future benefit to humanity and society, has 
 ended in this way. 
 
 The above statements do not apply to surgery alone. 
 They are equally true of medical conditions. Dominated 
 by their teachings as to opiate dosage in ordinary therapeu- 
 tics, and by the older ^' habit " conception of addiction, 
 with little or no instruction as to the dosage indications 
 of addiction-disease, most practitioners, institutional and 
 private, do not adequately conceive and have no basis for 
 determination of opiate dosage in this disease. They do 
 not believe that the addict physically needs nor do many 
 of them realize that the addict can physically tolerate what 
 seems to them such dangerous and lethal amounts, and 
 they tend to ascribe his statements of usual dosage to 
 mental " cravings " to which they refuse to pander. Many 
 appreciate that such patients have often to be very care- 
 fully watched to prevent their suicide and that many of 
 them die, but fail to comprehend that these events may 
 be ascribed to inability to longer endure the suffering and 
 physical incompetency of body-need for opiate medication. 
 
 The recent epidemic of influenza and pneumonia fur- 
 nishes examples of the importance of recognizing addic- 
 tion-disease mechanism in intercurrent diseases. A num- 
 ber of instances have come to my attention. One of them 
 is of particular interest because of the graphic picture 
 
SURGICAL CASES 87 
 
 presented by a series of sphygmograpliic tracings showing 
 the physical organic dependence upon opiate in the cir- 
 culation of an addict. It may be said in passing that 
 these tracings and others made upon addicts in partial 
 or complete opiate withdrawal parallel similar tracings 
 by other clinical observers^ and also those made by ex- 
 perimental laboratory workers upon addicted dogs. 
 
 The subject of these tracings was a man well-known 
 and prominent in his community, 63 years of age, suf- 
 fering from pneumonia with marked and persisting 
 cardiac and circulatory deficiency which did not respond 
 to the administration of the usual circulatory stimulants 
 even in very large doses. I was called in consultation. 
 Found the patient very weak and exhausted, with facial 
 expression of protracted suffering and anxiety and de- 
 spondency. Morphine in usual therapeutic doses had 
 been daily administered for relief of pain, restlessness 
 and sleeplessness, being insufficient however to control 
 those manifestations. Pulse was, as shown in tracing 
 number 1, very weak and intermittent. It was impos- 
 sible to account for the whole clinical picture and history 
 on the grounds of a typical pneumonia, present or re- 
 solving. Opiate addiction was suspected and the patient 
 questioned. He had been suffering from opiate addic- 
 tion-disease for many years, his addiction developing un- 
 suspected by him as a result of medication for a painful 
 and protracted condition many years previous. He 
 begged to be allowed to die without his wife and son being 
 told of his affliction. The following tracings made upon 
 him are very instructive and significant, and cannot be 
 interpreted upon any grounds of psychical explanation of 
 addiction phenomena. 
 
 The last dose of morphine prior to these tracings was 
 one-eighth of a grain given at 3 :30 p. m. 
 
 First tracing (number 1) was made about 6:00 p. m. 
 
 Tracings 2, 3 and 4 were made at about fifteen minute 
 
88 THE NARCOTIC DRUG PROBLEM 
 
 (Chart of Sphygmographic Tracings) 
 
SURGICAL CASES 89 
 
 intervals. They were made following experimental hypo- 
 dermic injections of morphine sulphate to determine the 
 extent of opiate need and organic dependence upon opiate 
 medication, and the amount of opiate required to restore 
 organic function and tone. 
 
 Tracing numher 4, taking into consideration the 
 asthenic and exhaustion condition of the patient, shows 
 full support to circulation with some overaction. 
 
 Tracing number 5 was taken an hour or two after trac- 
 ing numher 4 to determine the holding power of the 
 dosage administered, after the circulation had reacted 
 from the immediate stimulation of the opiate medication. 
 This tracing, interpreted and considered together with 
 the clinical manifestations at the time, was decided to 
 be about normal for that patient at that time. 
 
 . This patient would have died, not from pneumonia with 
 cardiac complications, but from insufficient control of the 
 mechanism of opiate addiction-disease. 
 
 On balanced and indicated daily morphine dosage, 
 patient made very rapid recovery and has continued well 
 and active. 
 
 Such cases as this, where addiction-disease co-exists or 
 is intercurrent with other medical or with surgical con- 
 ditions, are not as uncommon as may be supposed. That 
 they are frequently unrecognized the histories of many 
 narcotic addicts demonstrates, and is discussed later. 
 Board of Health and Insurance mortality statistics are 
 undoubtedly very incomplete upon this situation. Ad- 
 diction, regarded as a habit or indulgence, may easily be 
 overlooked or disregarded as a cause of death, direct or 
 contributing. It may easily be omitted from returns 
 made out, however actually important a part in the final 
 issue may have been played by the influences, upon body 
 function and upon physical resistance and recuperation, 
 of an unappreciated and inadequately controlled addic- 
 tion-disease. 
 
90 THE NARCOTIC DRUG PROBLEM 
 
 It is earlier stated that tlie common idea of the addict 
 to narcotic drugs as a poor risk is an undeserved reputa- 
 tion, and is not to be laid at the door of addiction exist- 
 ence itself. In very many cases of opiate addiction, the 
 opposite of the popular belief is true. The opiate addict, 
 if his addiction mechanism is competently appreciated, its 
 reactions accurately estimated, and its influences wisely 
 controlled, is quite other than a bad risk. Indeed the me- 
 chanism of addiction and the opiate v^hich caused it can 
 often be handled in such a v^ay in the control of glandular, 
 circulatory, nervous and other function and reaction as to 
 aid in the carrying over of emergencies, medical and 
 surgical. A case in point is an emergency operation on 
 the pancreas, performed upon a man in extremis, v^hose 
 unexpected recovery and convalescence astonished all ob- 
 servers by being remarkedly rapid and uncomplicated, 
 due unquestionably in large part to the early recognition 
 and clinical handling of his addiction-disease, and the 
 possibilities it created for unusual opiate medication. 
 
 It has been my experience at times, when called in 
 medical consultation upon post-operative cases whose 
 lack of repair and slowness of recovery could not be ac- 
 counted for, to discover an unsuspected addiction, and to 
 find that the lack of repair and slowness of recovery was 
 due simply and slowly to the want of comprehension of, 
 or to inadequate control of addiction mechanism existing 
 in the patient. 
 
 Many opiate addicts when about to undergo operation, 
 have provided for possible contingencies by the conceal- 
 ment of, or by outside provision for, a supply of opiate 
 sufficient in amount to meet their physical needs. There 
 are very many addicts who have, out of their past ex- 
 perience and study upon themselves, competently con- 
 trolled their own narcotic-drug-disease during treatment 
 for other conditions, operative or medical. The number 
 of narcotic addicts is not few who have been cared for 
 
SURGICAL CASES ' 91 
 
 medically with nursing attention, or have undergone op- 
 erations for the remedy of various surgical conditions, 
 have recovered, convalesced and been discharged with- 
 out the physician or surgeon becoming aware that his 
 patient was addicted. This is not a comment in criticism 
 upon my professional brethren. In my own experience 
 such a case is a matter of quite recent occurrence. A 
 patient treated by me in a hospital, for conditions other 
 than addiction, one day unexpectedly revealed to me the 
 fact of long standing addiction. The patient had been 
 afraid to tell me about this condition until thoroughly 
 convinced of my attitude towards it, and had secured 
 opiate medication elsewhere. 
 
 It seems strange that a condition of as powerful in- 
 fluence over body function and metabolism as is exerted 
 by the addiction mechanism of narcotic drug-disease 
 should not long ago have received exhaustive and com- 
 plete clinical and laboratory study along the lines of its 
 manifestations and influences_, as well as along the line 
 of reduction and deprivation of the drug of addiction. 
 In view of the above it would seem to be of vastly more 
 importance at the present time that the mass of practi- 
 tioners of surgery as well as of medicine should under- 
 stand and be able to control action and reaction in a nar- 
 cotic addict as a result of his addiction-disease mechanism, 
 than it is that they should attempt the mere reduction or 
 denial of the drug of addiction. 
 
 Appreciation of the above would make available to nar- 
 cotic addicts, suffering from other conditions, hospital and 
 professional treatment and remedy of those conditions. 
 Under present prevailing conceptions of addiction, many 
 honest and worthy people addicted to opiates dare not 
 avail themselves of needed treatment for medical condi- 
 tions or operation for surgical conditions because of their 
 uncertainty regarding the attitude towards and handling 
 of addiction-disease existing in and carried out by the in- 
 
92 THE NARCOTIC DRUG PROBLEM 
 
 stitution or practitioner to whoin they would ordinarily 
 appeal for help. The addict lives in constant fear of 
 some injury or illness which may necessitate his coming 
 into the hands of those whose conception of addiction is 
 not in accord with the addict's experience of addiction- 
 disease facts. 
 
 As I have emphasized in previous chapters, the actual 
 withdrawing of opiate from an addict is simply one stage, 
 and by no means the most important stage in the rational 
 consideration and handling of a case of narcotic drug 
 addiction. The fact that a patient is using an opiate 
 drug, and that he uses, within reasonable limits, a larger 
 or smaller amount of that drug, is a matter of very minor 
 importance as compared with his general functional, 
 nutritional, and metabolic efficiency. This is true as a 
 general proposition in the handling of any case of nar- 
 cotic drug addiction, and is vastly more true in the hand- 
 ling of cases of other conditions or diseases, operative or 
 otherwise, that are complicated by narcotic drug addiction- 
 disease. The physician or surgeon should realize that 
 the use of a narcotic drug by a patient under his care 
 is of very little immediate importance compared with the 
 satisfactory recovery of his patient from the condition for 
 which he is treating him. The physician or the surgeon 
 who has in his care a narcotic drug addict whom he is 
 treating for another disease condition should remember 
 that the patient's recovery from the condition for which 
 the doctor was consulted, depends to a great extent upon 
 the amount of functional balance and organic and meta- 
 bolic adequacy which exists in that patient, and he should 
 realize that functional balance and organic and metabolic 
 adequacy in a narcotic addict are largely under the con- 
 trol of, and vary with the extent to which that patient is 
 kept in, adequate narcotic drug balance. 
 
 The establishing and maintaining of adequate drug bal- 
 ance, therefore, is one of the most important elements to 
 
SURGICAL CASES 93 
 
 be considered in the conduct of a case of narcotic addiction 
 undergoing operation or treatment for a condition other 
 than the cure of his addiction. In handling such a 
 patient, the physician or surgeon should completely put 
 out of his mind any idea of at the same time trying to 
 " cure " the addiction with which his patient is afflicted. 
 I have repeatedly heard of many, and have personally 
 come into contact with cases where the physician or sur- 
 geon was trying to withdraw opiate drug from a patient 
 with addiction-disease, as an incidental in the course of 
 treatment of other disease conditions. There are cases 
 of addiction-disease in which this may he successfully 
 accomplished. In the majority of cases, however, this 
 procedure is too harmful to be anything but condemned. 
 'Not only will the surgeon or physician ordinarily fail in 
 his attempt to remedy the addiction condition, but he may 
 very severely handicap his other work on that patient and 
 very seriously jeopardize the success of his efforts in the 
 remedy of the condition which he was originally called 
 upon to treat. 
 
 It must be remembered that addiction-disease is a 
 chronic condition, and that it is practically never indicated 
 as a matter of clinical emergency, in a case of established 
 addiction, that the opiate be immediately withdrawn. As 
 has been previously stated, drug withdrawal is very much 
 like an operation of election to be done when the patient 
 is ready for it and by whatever procedure is indicated 
 when the proper time arrives. The getting of the patient 
 ready for it often determines, just as is the case in the 
 operation of election, to a great measure, the success of 
 the work and the freedom from complications and 
 sequelae. 
 
 Since the final withdrawal of drug is to be regarded 
 as comparable to an operation of election, and the best 
 time for its execution is a matter of arrangement and of 
 preceding preparation, it is obvious that it should not be 
 
94 THE NARCOTIC DRUG PROBLEM 
 
 undertaken witL expectation of satisfactory issne in the 
 course of treatment for an ailment or condition which 
 demands and expends much physical resistance and re- 
 cuperative powers. Recuperative forces should he main- 
 tained and directed towards whatever is the indication of 
 paramount importance at any given time. In the conduct 
 of a surgical case or a serious medical case, the indication 
 of paramount importance is recovery from the condition 
 for which the patient applies to the surgeon or physician. 
 All other conditions present should he handled in such 
 a way as to interfere as little as possible with the suc- 
 cessful accomplishment of the main issue. The proper 
 control of narcotic addiction-disease mechanism and of 
 its influences upon the patient addicted is the important 
 problem presented by narcotic addiction as met in the 
 field complicating surgical and general medical conditions. 
 
CHAPTEK VIII 
 
 LAWS, ANJy THEIK EECLATIONS TO ITAHCOTIC DEUGS 
 
 The first general appreciation of the widespread exist- 
 ence of narcotic drug use was brought about by the pas- 
 sage of anti-narcotic laws. The United States Federal 
 legislation wbicb went into effect in 1914, was what is 
 known as the Harrison Law, still in effect and in its pur- 
 pose and drafting a wise piece of legislation. It sought 
 to limit and control the use of opiate drugs and cocaine 
 by making their possession and distribution illegal by 
 other than those of professional and other status designated 
 in the law, as qualified for their intelligent application 
 and responsible distribution. Its administration was 
 placed in the Department of Internal Eevenue under a 
 provision which licensed responsible distributors and re- 
 quired a yearly tax. 
 
 Taken as a whole, in its original form, administered 
 with understanding of addiction-disease facts, and with 
 honest and intelligent scientific, educational and remedial 
 activities coincidently pursued, it should be sufficient to 
 control a rapidly growing menace. In its attitude to- 
 wards the medical profession it wisely limited its restric- 
 tions to the broad statement that these drugs named must 
 not be distributed other than in the " course of legitimate 
 professional practice,'' wisely making no attempt to de- 
 fine such '^ legitimate practice," but apparently anticipat- 
 ing investigative activities of the scientific professions in 
 the determination and dissemination of medical facts for 
 the guidance of honest practitioners, and of those who 
 should interpret and enforce the law. 
 
 95 
 
96 THE NARCOTIC DRUG PROBLEM 
 
 Unfortunately addiction as a disease was, at tKat time, 
 not a matter of wide recognition, the public in general 
 and tlie medical profession itself still almost universally 
 holding to the old conceptions of it on the basis of sup- 
 posed morbid indulgence and '^ habit." It seems to the 
 author that the failure of the Harrison Law to check or 
 limit the illegitimate use of the drugs it describes, is not 
 due to a defect in the law itself, but is due to the failure 
 of the scientific professions to clarify the situation with 
 a clean cut understanding of the condition legislated 
 against. jThe reaction within the medical profession as 
 "a resithof this law was unfortunate. Instead of stimulat- 
 ing scientific interest and investigation into the character 
 of this disease, the result was that medical men in gen- 
 eral having little or no conception of its disease basis, re- 
 garded the narcotic addict as a mental or correctional 
 problem and left his consideration and handling to the lay 
 ofiicials and the special institutions whose activities had 
 been along other lines than scientific research into physical 
 disease. 
 
 In the minds of most lay and of many medical work- 
 ers the only consideration was the stopping of drug use 
 per se, an attitude which to a less extent still persists. 
 Uninformed as to the now established facts of addiction- 
 disease, the administrators of the law, and to a large ex- 
 tent the medical profession, tended to regard supply of 
 opiate to an addict as the prolongation of a habit, and 
 not as medication indicated by the mechanism and sympto- 
 matology of a disease — and therefore as not being legiti- 
 mate medical practice. This attitude had the effect of 
 making the practitioner of medicine unwilling to receive 
 the narcotic addict as a patient. 
 
 The immediate result was the sudden deprivation of 
 opiate to such addiction-disease sufferers as had not had 
 financial means or foresight to purchase large reserves 
 before the laws went into effect. The history of the 
 
LAWS AND THEIR RELATIONS 97 
 
 drastic early enforcement of the various laws, reduplicated 
 with more or less completeness by periodical legislative 
 and administrative activities, without adequate arrange- 
 ment for the relief of the narcotic-deprived addiction- 
 disease sufferer, shows suicides and deaths, and a rapid 
 development of exploitation of the needs of the addict 
 at the hands of illicit commerce. Eor this illicit com- 
 merce the laws themselves, however, are not so much to 
 be blamed as the influence of long-prevailing and widely- 
 taught attitudes and conceptions which caused scientific 
 and other forces to fail to recognize and meet the need 
 for clinical handling of the situation, and for study and 
 investigation of the condition. Legislators and adminis- 
 trators simply reflect prevailing theories. 
 
 Early theories took scant if any account of the possibili- 
 ties presented by the now rapidly-growing disease con- 
 ception of addiction. The popular conception of an 
 addict and even the description met in standard medical 
 text-books was that of a " dope-fiend,'' an irresponsible 
 panderer to a morbid ^' habit," bereft of will-power, honor 
 and decency, a menace to himself and to society, and this 
 conception has had unfortunate influence in the making, 
 interpretation, and administration of laws. That it can 
 be truthfully applied to some people who have developed 
 addiction-disease is unquestioned, but that it fails to take 
 into consideration a much larger number who are not 
 irresponsible panderers to morbid habit, nor bereft of will- 
 power, honor and decency, nor a menace to themselves or 
 to society, but are honest and upright members of society 
 and economic assets in the community, accounts in large 
 part for the failure of laws and their administration to 
 remedy the narcotic drug situation. Measures which 
 might be very useful in the forcible control of those who 
 can be justly characterized as " dope fiends " work great 
 harm to those who are simply sick people. 
 
 That these sick people have been commonly regarded 
 
98 THE NARCOTIC DRUG PROBLEM 
 
 and classed as " dope-fiends " was due to the fact that the 
 points of view and special experiences of the psychologist 
 or psychiatrist, sociologist or penologist and the exponents 
 of special methods of treatment dominated the literature 
 and teaching in which appeared practically nothing of 
 essential pathology, symptomatology and broad principles 
 of addiction-disease therapeutics and handling. The oc- 
 casional voice of the clinical student or experimental 
 laboratory worker was almost unheard, and the opposition 
 accorded unorthodox views and announcements made him 
 a brave man who would state them, and tended to cause 
 him to be regarded as an academic theorist, or possessed 
 of ulterior motives. 
 
 In such a situation the dominant theme has been the 
 stamping out of so-called ^^ drug use." The physician 
 who under his best and honest therapeutic judgment 
 strove to meet the immediate indications of the worthy 
 and innocent addiction-disease sufferer by the administra- 
 tion of opiate drug, incurred a danger of severe criticism 
 and at times of jeopardy to his liberties under the inter- 
 pretation of his acts as perpetuating a " habit." 
 
 It cannot be denied that in some cases unscrupulous 
 holders of medical degrees have availed themselves of 
 existing conditions in such a way that their supplying of 
 opiates to narcotic addicts constitutes simply traffic in 
 narcotic drugs and not the intelligent practice of medicine. 
 It should be a matter of serious consideration for our law- 
 makers, administrators and judiciary, however, as to what 
 extent the performance of the occasional medical vampire 
 should be made a basis for the legal or administrative con- 
 trol of the honest practitioner, and to what extent he 
 should be enveloped by legal and administrative restric- 
 tions, the innocent and unconscious violation of whose 
 technicalities may at any time be made a basis for criminal 
 procedure. It should be remembered that zealous admin- 
 istrators may not have proper conception of the scientific 
 
LAWS AND THEIR RELATIONS 99 
 
 facts of disease nor of tlie practical problems of legitimate 
 medical practice in addiction-disease. The quality of the 
 act in the determination of legitimate medical practice 
 is often if not as a rule more important than the mere act 
 itseK. There has been as yet, so far as I know, no satis- 
 factory legal definition of legitimate medical practice. 
 The author sees no reason why the same rules and criteria 
 as have developed or are formulated for legitimate med- 
 ical practice in other diseases might not be applied to the 
 treatment of addiction-disease. In a general way the 
 legitimate practice of medicine in the care of, handling 
 of or treatment of a disease consists of such medical at- 
 tention, advice, instruction and guidance, and clinical 
 or therapeutic ministrations as may be indicated by the 
 needs of the individual case. In addiction-disease if a 
 physician proceeds upon the physical, clinical and other 
 indications exhibited in the individual case, being held 
 responsible for reasonable familiarity with such indica- 
 tions, and fulfilling to the best of his available equipment 
 and professional ability the general and therapeutic re- 
 quirements of each case, it is difficult for the author to see 
 how he can be held to be engaged in illegitimate practice. 
 He can of course be held responsible for reasonable 
 familiarity with available teaching and information on 
 the subject treated by him, and for average intelligence 
 and honest application of medical principles and practice. 
 It seems to the author that legitimate practice as deter- 
 mined in other diseases would go a long way towards the 
 elimination of the charlatan and shyster physician and 
 would not carry with it the menace and jeopardy which 
 technical violation of often medically impractical admin- 
 istrative demands may involve. If the honest physician 
 is left no leeway for the exercise of medical judgment in 
 the handling of widely differing cases of addiction-dis- 
 ease, or if his exercise of honest clinical judgment is to 
 be constantly influenced by a necessity of worrying about 
 
100 THE NARCOTIC DRUG PROBLEM 
 
 its possible interpretation, in the light of unduly stringent 
 laws and regulations, a condition is created in which the 
 intelligent practice of medicine upon the sufferer from 
 addiction-disease becomes impossible. 
 
 A matter about which there has been a great deal of 
 dispute is that of the prescribing or dispensing by the 
 practitioner of medicine of opiate drugs to the narcotic 
 addict in the handling of narcotic addiction, itself. The 
 adherents of the older theory of addiction being merely 
 habit or vicious indulgence, oppose as illegitimate practice 
 the continued supply of the opiate to an addiction patient, 
 unless in some oases the patient also suffers from some 
 painful and incurable disease. 
 
 They take the attitude that, if the addict did not want 
 to keep on using opiate he would go somewhere and be 
 cured, and that as long as he can get opiate drug he will 
 not get " cured." The possibilities of immediate so- 
 called " cure " are discussed elsewhere in this volume. 
 Sufficient for present statement is the fact that, as demon- 
 strated by the testimony of the Whitney Committee Legis- 
 lative Investigation hearings, one of the most complete and 
 valuable pieces of public investigation work into addiction 
 ever done, there exists at present practically no adequate 
 or competent machinery for the successful so-called 
 " cure " of the great numbers of narcotic addicts. This is 
 discussed elsewhere. Those who talk casually of the en- 
 forced immediate cure of the narcotic addict would do well 
 to investigate and realize the lack of possibilities of itg 
 immediate attainment on any large scale. This is a basic 
 fact which has been too little taken into account by those 
 who still hold to the appetite and habit theories. 
 
 In the narcotic drug situation we are confronted by 
 fact and not by theory. Intelligent comprehension and 
 unbiased investigation are needed far more than we need 
 premature conclusions drawn from insufficient experience 
 or too narrow observation along special lines. The funda- 
 
LAWS AND THEIR RELATIONS 101 
 
 mental fact is this, as has been repeatedly stated, that 
 the narcotic addict, until his disease mechanism can be 
 competently and snccessfuUy arrested physically, needs 
 the daily administration of sufficient quantities of the 
 drug of his addiction to meet the indications of his dis- 
 ease. If the drug is not administered to him in sufficient 
 amounts to meet these disease indications, he cannot be 
 blamed if, in the agony of his suffering and the desperate- 
 ness of his plight, he is forced into the underworld and 
 the illicit channels of supply for the continuance of a 
 physically endurable and economically possible existence. 
 Until the medical profession and the medical institutions 
 — hospital and otherwise — have in competent execution 
 methods of handling and treatment of the narcotic addict 
 which are more humane and more effective than those 
 shown by ample testimony to be in common use, the sup- 
 ply of narcotic drug to the responsible narcotic addict to 
 the extent of physical need, without unjustifiable exploita- 
 tion, financial or otherwise, is the duty of the medical 
 man. Any law which to this extent limits the supply of 
 opiate drug to the addict should receive the support of 
 the medical profession. Any law which renders it diffi- 
 cult or impossible for a physician to conscientiously and 
 rationally meet, to this extent, the indications of narcotic 
 drug disease, should meet from the medical profession 
 with a united and honest attempt at its modification. 
 
 Above all there should be fostered and promoted by the 
 medical profession an intelligent, unbiased investigation 
 into the actual facts surrounding the problem of narcotic 
 drug addiction as a definite disease. Such information 
 concerning the physical and clinical facts of this disease, 
 as we should be in a position to give, would be eagerly 
 welcomed by the law-makers and the administrators and 
 the judiciary; and we should be in a position to co-op- 
 erate with them in the making and interpreting of nar- 
 cotic drug laws. Lack of such information h'as played 
 
102 THE NARCOTIC DRUG PROBLEM 
 
 an important part in whatever mistakes our police, legis- 
 lative and administrative bodies have made, and forced 
 them to proceed as best they could to meet the demand 
 of a public menace that could no longer be denied. 
 
 What has the law done for the addict ? Like the 
 physicians, the legislators have done the best they could 
 in the light of their knowledge, experience and teaching. 
 Some of them seem, however, to have had their attention 
 directed unduly to a special class of those addicted, the 
 addicts found among the type of person which begins or 
 tends to end among the criminal or vicious of the so- 
 called " underworld." Legislators and administrators 
 have realized that the taking of narcotic drugs was rapidly 
 spreading, and that it constituted a public menace in the 
 class to which their attention was directed; and they ap- 
 plied the means at their disposal in the remedy of what 
 they saw. But again, like the physician, they tended to 
 center their attention upon the mere taking of narcotic 
 drug, and they attempted to control by legislation the 
 possession and use of narcotic drugs with too little ap- 
 preciation of fundamental disease facts and of general 
 basic considerations of widespread application. They did 
 not seem to have appreciated the extent to which their 
 legislation or administration would affect the great num- 
 bers of upright, and innocent and worthy addiction-suf- 
 ferers of whom they did not know, and who did not 
 possess the fundamental characteristics of the class and 
 type of person addicted against which they legislated. 
 They rightly directed their attention towards the control 
 of the sources of drug supply and they rightly limited the 
 ultimate legal supplying of drug to duly licensed and 
 responsible persons and institutions, specifically described. 
 The slogan of most of the special legislation has been to 
 place responsibility for the supply and use of narcotic 
 drugs squarely upon the shoulders of the medical profes- 
 sion. Such effort is wise, and this is where the respon- 
 
LAWS AND THEIR RELATIONS 103 
 
 sibility belongs. And this is wliere the medical profes- 
 sion would have it placed in so far as the medical pro- 
 fession supplies narcotic drugs. 
 
 The honest physician has no desire to dodge respon- 
 sibility for his handling of narcotic addicts to the best 
 of his ability, nor should he have any objection to a rea- 
 sonable responsibility and accounting for narcotic drugs 
 used in that handling; especially since the taking of nar- 
 cotic drugs has in certain of its phases, developed as a 
 serious situation entirely outside of the medical profes- 
 sion, in v^hich situation these drugs are non-professionally 
 supplied and used to such an extent as to constitute a 
 public menace. The non-medical supplying and admin- 
 istering of such drugs should not, however, be controlled in 
 such a way as to unduly hamper their honest and legiti- 
 mate use by medical men, and to deprive the honest, worthy 
 and innocent sufferer from addiction-disease of their 
 legitimate therapeutic administration. 
 
 One of the chief and most serious phases of the nar- 
 cotic drug problem, which for obvious reasons has espe- 
 cially called for legislation, is the illicit and illegitimate 
 commerce in narcotic drugs. The class of addicts which 
 constitutes a public menace is largely so supplied. This 
 fact is recognized in the recent report of the Special Com- 
 mittee of Investigation Appointed by the Secretary of 
 the Treasury, in which is stated, " This illegitimate traffic 
 has developed to enormous proportions in recent years, 
 and is a serious menace at the present time. It is through 
 these channels that the addict of the underworld now 
 secures the bulk of his supplies." 
 
 This Report further states that " there is the so-called 
 ' underground ' traffic which is estimated to be equal in 
 magnitude to that carried on through legitimate channels. 
 This trade is in the hands of the so-called ^ Dope ped- 
 dlers,' who appear to have a national organization for 
 procuring and disposing of their supplies. For the most 
 
104 THE NARCOTIC DRUG PROBLEM 
 
 part it is thought that they obtain their supplies by 
 smuggling them from Mexico or Canada, although smaller 
 quantities of these drugs are obtained from unscrupulous 
 dealers in this country or by theft," etc. There should 
 be some way to dissociate entirely, conclusively and finally 
 in the minds of the public the illegitimate and underworld 
 traffic in narcotic drugs from the efforts of the honest 
 physician to practice rational and scientific medicine in 
 the help of the worthy and deserving addict. The regu- 
 lation of the narcotic drug traffic of the underworld or 
 " underground " is not the business of the medical pro- 
 fession, and the burden of responsibility for it should not 
 be placed upon the shoulders of the medical profession or 
 the consequences of it made to react upon the head of 
 the honest physician and innocent addiction sufferer. 
 There is a tremendous number of excellent and worthy 
 and even illustrious people in whom addiction is in no 
 way associated with vice, or other morbidity of mental or 
 environmental origin, who are merely, solely and simply 
 sick people suffering from addiction-disease, whose prob- 
 lem is the control of that disease until it can be arrested 
 by competent therapeutic procedure, for which they con- 
 stantly seek. Misconception of them and neglect of 
 sufficient consideration of them is the tragic aspect of 
 the narcotic drug situation, and causes tremendous in- 
 dividual and economic wastage. They do not in any way 
 associate with underground traffic unless or until driven 
 to it by failure of legitimate sources of opiate medication, 
 or by the surrounding of legitimate sources with such 
 restrictions as make the man of standing and reputation, 
 afflicted with addiction-disease, fear possible publicity and 
 economic detriment. 
 
 It is the duty of the medical organizations to see to it 
 that these deserving purely medical problems and worthy 
 sick people and their honest medical advisers shall no 
 longer than avoidable be permitted to remain confused 
 
LAWS AND THEIR RELATIONS 105 
 
 in the minds of the laitj and of the medical profession 
 itself with the problems of regulation of " underground '' 
 traffic and the control of the " underworld '' addict. It is 
 the duty of the medical organizations also to see to it that 
 in the public press and elsewhere, and especially in their 
 own scientific journals, the acts of the occasional in- 
 dividual with medical degree who prostitutes his medical 
 standing and the aims and ideals of his profession in the 
 commercial exploitation of the drug addict are not pre- 
 sented in such a way as to cause by inference or otherwise, 
 their confusion with the honest efforts of honest medical 
 men who are engaged to the best of their ability in the 
 humane and ethical help of the deserving sufferer from 
 addiction-disease. 
 
 It is, furthermore, the duty of the medical organiza- 
 tions to see to it that whatever laws and regulations are 
 promulgated in the control of criminal and unworthy 
 shall not be framed or administered in such a way as to 
 unnecessarily jeopardize the reputation and liberties of the 
 honest practitioner and to interfere with his conscientious 
 efforts to care for his honest and innocent addiction-dis- 
 ease patients to such an extent as makes that care impos- 
 sible. 
 
 Legislation or administrative regulation which limits 
 to responsible and authorized persons possession and dis- 
 tribution of narcotic drugs and which compels from such 
 persons reasonable accounting for such possession and dis- 
 tribution, is under conditions which have long existed but 
 only recently been sufficiently recognized necessary and 
 desirable. The Harrison Law was a definite response to 
 an obvious need, in its obvious intent and draughting a 
 wise and unobjectionable legislation. It provided for re- 
 sponsible possession and distribution and it enforced an 
 accounting for the same, but did not unwisely restrict, in 
 its text, nor hamper the legitimate possession and honest 
 therapeutic employment of narcotic drugs. From the 
 
106 THE NARCOTIC DRUG PROBLEM 
 
 medical organizations and educational and scientific in- 
 stitutions should be available scientific study and under- 
 standing of narcotic drug addiction-disease available for 
 tbe information of conscientious executives and adminis- 
 trators, who must exercise their best judgment in the 
 light of available and prevailing teaching. It is the duty 
 of the medical organizations to see to it that available and 
 prevailing addiction-disease information and teaching is 
 honest, unbiased and competent. 
 
 Those who are responsible for our laws should remem- 
 ber that the possible interpretation and administration of 
 the laws they draught are very important considerations, 
 and determine the real effect of the laws often more than 
 does the intent of the makers. Legislation which is un- 
 duly stringent or is capable of unduly stringent adminis- 
 tration may have unfortunate reaction and influence upon 
 honest effort in the care of the deserving sick. Kestricting 
 beyond reasonable limits the care of the honest narcotic 
 drug addict simply tends to make it impracticable and 
 dangerous for the average medical man to have anything 
 to do with narcotic addicts, and to drive the honest and 
 deserving patient into (the underworld, into the insane 
 asylum or to suicide. Until we have provided scientific 
 and clinical study, and have thoroughly investigated pres- 
 ent and possible medical treatment and handling of nar- 
 cotic-drug addiction-disease, and have established humane 
 and effective therapeutic measures and procedures in the 
 control and remedy of this disease, we should not deprive 
 the majority of honest addicts of the only medication and 
 means by which they can at present remain self-supporting 
 citizens. The handling of the problem of the underworld 
 and of underground supply is not going to be solved by 
 too restrictive regulation of the honest physician. Legis- 
 lation or regulation which makes it practically impossible 
 for the honest physician to care for the honest case of 
 
LAWS AND THEIR RELATIONS 107 
 
 addiction-disease is a boon to charlatans, and medical 
 shysters, and the illicit underworld traflBc. 
 
 It is the opinion of some that the handling and treat- 
 ment of narcotic addiction should be taken out of the 
 hands of the practitioner of medicine. The statement is 
 made that the practitioner of medicine is not competent 
 to handle a case of this disease. It has been advised that 
 the treatment of narcotic addicts should be restricted to a 
 small number of specially designated and licensed men and 
 institutions. How and by whom are those special men 
 and institutions to be selected? In the present state of 
 chaotic and widely diversified medical and lay opinion 
 as to narcotic addiction and the narcotic addict it would 
 be a very difficult matter to select the men or the institu- 
 tions for such absolute control. The comprehension, 
 study and investigation of narcotic drug addiction has en- 
 tered a stage of evolution and development in which new 
 facts and new truths — both as to the addict and as to 
 the condition from which he suffers — are being recognized 
 and must be threshed out, correlated and coordinated with 
 hitherto existing opinion before too restrictive measures 
 will be anything but narrow-visioned, premature and 
 harmful. 
 
 There are undoubtedly institutions, many of them not 
 widely known, in which is available skilKul, humane, in- 
 telligent and successful handling of this disease. From 
 personal observation and experience in institutional work, 
 and from analysis and investigation of many histories, 
 it is my opinion that the results of institutional treatment 
 depend more upon the quality of its medical and nursing 
 staff than upon any other consideration. That the mere 
 fact that addiction-disease is handled in an institution 
 is a very minor consideration in comparison with the in- 
 telligence of that handling, is amply attested to in the 
 testimony of the Whitney Hearings and by the experience 
 of many addicts. Unquestionably, unknown and large 
 
108 THE NARCOTIC DRUG PROBLEM 
 
 numbers of narcotic addicts have been relieved of their 
 addiction in reputable sanitaria conducted by skillful and 
 competent medical men. Also unquestionably, large 
 numbers of addicts have been relieved of their addiction 
 through the honest efforts of practitioners of medicine, 
 in private practice. Unfortunately these efforts and their 
 results have received entirely too little recognition. 
 
 The average physician may be inexpert and not as com- 
 pletely educated in the appreciation, understanding and 
 clinical handling of narcotic drug addiction-disease as he 
 is in other diseases. The common-sense remedy for this 
 situation, however, is not to drive the addict out of his 
 hands, but to make him as competent in that addict's 
 handling as he is in any other clinical condition. It is 
 only a matter of time and education before the competent 
 practitioner of internal medicine can be brought to a com- 
 prehension of and ability to intelligently handle addiction- 
 disease. It is largely a matter of securing general ap- 
 preciation of and ability to clinically recognize, and in- 
 terpret physical symptomatology, and to meet the indica- 
 tions of individual disease manifestations. 
 
 The ultimate solution of the problem of handling the 
 narcotic addict lies largely in the education of medical 
 men, both in institutions and in private practice, and 
 through them securing lay appreciation of disease facts. 
 Any legal or administrative restrictions which drive the 
 care of the honest addict out of the hands of the honest 
 medical man simply postpone the day when this ideal 
 may be consummated. 
 
 Some addicts, as individuals and tiv'pes, will of course 
 always require institutional and custodial handling. The 
 handling of the addict who is criminal or vicious belongs 
 within the province of the penological authorities, just as 
 does the handling of any other man who is criminal or 
 vicious. The handling of the addict who is fundamentally 
 degenerate, defective or mentally weak may require the 
 
LAWS AND THEIR RELATIONS 109 
 
 attention of the alienist and institutional restraint, just 
 as may the handling of any other man who is degenerate 
 or defective. ^N^arcotic drug addiction-disease in the man 
 who is vicious or criminal or defective or degenerate 
 should be treated as narcotic drug addiction-disease, as any 
 other disease is treated in the same individual. 
 
 To our legislators and administrators and forces of 
 penology, custody and correction rightfully belongs the 
 problem of looking after the criminal and vicious addict 
 as well as providing for the eradication of illicit, irre- 
 sponsible, and ^^ underground " traffic in narcotic drugs. 
 If the illicit trafficker happens to be a physician he should 
 have no more consideration at the hands of the law than 
 any other criminal and in its action the law should have 
 complete co-operation of the medical profession, which 
 should see to it also that conscientious endeavor of its 
 honest members is not confused in its consideration with 
 illicit traffic and that the acts of the doctor shall be de- 
 termined and estimated upon broad principles of medical 
 practice and not upon violation of incidental technicalities. 
 Great care should be taken that the sins of a guilty few 
 are not visited upon the heads of a deserving many. 
 
 Until there is available competent and adequate med- 
 ical care for the honest narcotic addict sufficient in extent 
 to meet the needs of the thousands of sufferers, and en- 
 couragement and protection as well as restriction is 
 afforded to the honest physician, the illicit traffic will con- 
 tinue and grow, including in its toils many who would 
 not otherwise seek it. Before we have further medical 
 restrictions, we should have both medical and lay and 
 official education. Over-emphasis on any aspect result- 
 ing in premature, narrow, ill-considered and ill-advised ac- 
 tion only increases the complexity of the situation and 
 defers final remedy. Por as great and complicated a 
 problem as narcotic drug addiction there will be found 
 no special or specific panacea. 
 
110 THE NARCOTIC DRUG PROBLEM 
 
 In conclusion I feel that a great deal more thought and 
 attention should be paid to the testimony of the public 
 hearings of the ^ew York Legislative Investigating Com- 
 mittee, under the leadership of Senator George H. Whit- 
 ney, Chairman of the Committee. A vast amount of 
 valuable data was produced. It showed for the first time 
 to my knowledge an official effort to secure the true story 
 of the narcotic addict in all of its applications and cir- 
 cumstances. It is significant that the Preliminary Re- 
 port of the Whjtney Committee gave official recognition 
 of the fact thaf narcotic drug addiction is a physical dis- 
 ease. So important and enlightening was the above men- 
 tioned report, that it is deemed desirable to quote from 
 it in part as follows : 
 
 " Lack of understanding and appreciation of the dis- 
 ease of narcotic drug addiction and its treatment by a 
 large majority of the medical profession has fostered con- 
 ditions which make it impossible to determine a rational 
 procedure for treating and curing the addicted by the 
 State at this time. 
 
 ^^ Such absence of uniformity of opinion has worked 
 great hardship upon the public and has laid the narcotic 
 drug addict open to misconception, misunderstanding and 
 medical treatment which, in many instances, has resulted 
 in harm rather than good. 
 
 " Evidence offered by physicians shows that many 
 addicts have died under the methods of treatment existing 
 to-day and that a large percentage of those discharged 
 from institutions as ' cured ' are driven back to use of 
 narcotics through unbearable physical torture induced by 
 improper withdrawal of their drug. 
 
 " Evidence from physicians was adduced which denied 
 that any cure for narcotic drug addiction existed in any 
 of the private or public institutions of this State. Evi- 
 dence from other eminent physicians was adduced which 
 
LAWS AND THEIR RELATIONS 111 
 
 bore testimony to the fact that the disease of narcotic 
 drug addiction was curable. *.'-- ^m^ /*^V^,, . 
 
 " The difference of medical opinion existing in medical 
 circles regarding this vitally important question should 
 be made the subject of a thorough and searching investi- 
 gation as a matter of the greatest importance to the wel- 
 fare of a large number of people in the State of E'ew 
 York. 
 
 " Your Committee has found that narcotic drug addic- 
 tion bears no relation in point of character and serious- 
 ness to any other known habit induced by the use of stim- 
 ulants. ISTarcotic drug addicts, according to evidence 
 adduced, should not be classed with the alcoholic or the 
 tobacco addict or the cocaine habitue. 
 
 " The constant use of narcotics produces a condition-^ 
 in the human body that many physicians of medical au- 
 thority now recognize as a definite disease, which diseased 
 condition absolutely requires a continued administration 
 of narcotics to keep the body in normal function unless 
 proper treatment and cure is provided. 
 
 " Withdrawal of the drug of addiction induces such 
 fundamental physical disorganization and unbearable pain 
 that addicts are driven to any extreme to obtain narcotic 
 drugs and allay their suffering by seK-administration. 
 
 ^^ Testimony of physicians coming in contact with the 
 addicts and statements of addicts themselves show that 
 those afflicted with this disease express every desire to 
 secure humane and competent treatment and cure and 
 that most narcotic drug users are willing to undergo 
 physical torture and often do voluntarily undergo such 
 torture, in an effort to be rid of their so-called habit. 
 
 ^^ In the present chaotic condition of medical opinion^, 
 on this subject, it is impossible for the addict to-day to | 
 either secure authentic information on the subject of his 
 disease and its treatment, or to procure at the hands of 
 
112 THE NARCOTIC DRUG PROBLEM 
 
 the average physician competent treatment for his malady. 
 ^ " It has further been stated by competent authorities 
 before your Committee that drug addiction is not con- 
 fined to the criminal or defective class of humanity. 
 
 ^^ This disease, however contracted, is prevalent among 
 members of every social class. Some physicians estimate 
 that addicts of the so-called underworld are far out-num- 
 bered by unfortunate drug users drafted from social 
 circles of refinement and intelligence in the State of 'New 
 York, who have become addicted to the constant use of 
 narcotic drugs, but who are able to hide their affliction 
 from the public. 
 
 " The attitude of the public toward the narcotic drug 
 , addict, fostered by the increasing prevalence of the dis- 
 ease in the criminal classes and by the apparent lack of 
 medical help, has forced such drug users to keep their 
 affliction a secret. 
 
 '^ This necessity in turn, your Committee finds, has ap- 
 parently contributed to the existence of many unsound 
 nostrums for the cure of narcotic drug addiction and many 
 private institutions where this disease is purported to be 
 cured which exist solely for the purpose of preying upon 
 the addict. 
 
 ^' State investigation and regulation of such cures and 
 institutions is recommended by your Committee. 
 
 " Your Committee is inclined to criticize the medical 
 profession for its lack of study of the increasingly im- 
 portant subject of narcotic drug addiction. The only 
 excuse which can be offered for this unfortunate condi- 
 tion lies in the fact that there has not been medical ap- 
 preciation of conditions and that legislation, both State 
 and Federal, has forced upon the physician a situation 
 for which he was wholly unprepared. 
 
 " The testimony taken by your Committee shows that 
 those charged with the sale and distribution of narcotic 
 drugs are in the main observing the law, and that the 
 
LAWS AND THEIR RELATIONS 113 
 
 legal distribution of these drugs is less than before the 
 enactment of existing narcotic laws. Federal and State. 
 
 " On the other hand it is apparent from this testimony 
 that public consumption of narcotic drugs has increased 
 to an alarming extent. The inevitable conclusion is that 
 the unfortunate addict has been forced to and does obtain 
 his supply illegally. 
 
 " This condition arises very largely from the fact that 
 many physicians and pharmacists, either through misun- 
 derstanding of the law or the true nature of the addict's 
 disease, have refused to prescribe or dispense narcotic 
 drugs to the sufferer. 
 
 " Your Committee contends that any member of the 
 medical or pharmaceutical professions who refuses either 
 to prescribe or to dispense narcotic drugs to the honest 
 addict to alleviate the suffering and pain occasioned by 
 lack of narcotics is not living up to the high standards of 
 humanity and intelligence established by these great pro- 
 fessions." 
 
CHAPTER IX 
 
 SOME. COMMETsTTS UPON THE LBGITIMATE USE' OF 
 NAUCOTIOS IN PEACE AND WAE 
 
 Before commentiiig upon the legitimate use of nar- 
 cotics, it is desirable to emphasize again that the term 
 ^' narcotics " as used in this volume refers particularly to 
 the preparations and derivatives of opium, because as 
 the term ^^ narcotics " has come to be used it is synony- 
 mous in the minds of many with " habit-forming drugs,'' a 
 phrase often loosely used and grouping under its title a 
 number of drugs of widely dissimilar action and proper- 
 ties. 
 
 Although many of these drugs have narcotic properties, 
 their action upon the human body is in many respects 
 totally unlike the action of the opiates themselves. Also 
 the condition resulting from their prolonged and con- 
 tinuous administration is an entirely different condition 
 clinically and physiologically from that manifested in the 
 case of opiate addiction-disease. The problems associated 
 with the use of alcohol, cocaine, chloral, cannabis, the 
 various coal tars, etc., differ from each other and all of 
 them are, in their basic medical principles, of an entirely 
 different character from the problems associated with the 
 use of opiates. As has been previously stated, it has not 
 yet been demonstrated that any of them form the basis 
 for an addiction-disease mechanism such as clinical study 
 and laboratory experiment seem to demonstrate in opiate 
 addiction-disease. 
 
 In considering legitimate as well as illegitimate use 
 
 of opiates, therefore, it is important not to confuse them 
 
 114 
 
LEGITIMATE USE OF NARCOTICS 115 
 
 witH tlie drugs above mentioned and to be sure that in 
 the mind of the reader there shall not exist any lingering 
 impression that attributes popularly supposed to be as- 
 sociated with so-called " habit-forming drugs " are of 
 necessity displayed in the opiate group. 
 
 The habitual use of cocaine for example, may be re- 
 garded as an indulgence of appetite and the obtaining of 
 sensation and artificial stimulation and not as based upon 
 the demands of a specific physical addiction-disease 
 mechanism. The therapeutics of its discontinuance are 
 entirely different. Habitual indulgence in cocaine tends 
 to result in mental and moral deterioration. In the addict 
 of the so-called " underworld " it is the coincident use of 
 cocaine with its manifestations of mental, moral and 
 physical deterioration that has led to the wide and 
 erroneous attributing of characteristics of this class of 
 cocaine habituates to the average opiate addict. The 
 habitual use of cocaine is an entirely different matter 
 from the continued administration of opiate in the case of 
 an opiate addict, and its manifestations should be com- 
 pletely dissociated from the clinical picture and problem 
 of opiate addiction-disease. 
 
 Some writers, especially those associated with municipal 
 or state institutions of penology and correction, lay em- 
 phasis upon the case of the so-called " mixed addict." 
 The crimes of violence with which addiction has become 
 associated in the popular mind are practically never con- 
 nected with the action of opiate drug. They are, however, 
 characteristic of the cocaine crazed individual. When 
 they are performed by a so-called ^^ mixed addict " they 
 are the result of cocaine habituation rather than of opiate 
 addiction. Such crimes of violence as are committed by 
 the opium or morphine addict are well explained in the 
 Report of the Treasury Investigation Committee in the 
 following words, " There are many instances of cases 
 where victims of this disease were among people of the 
 
116 THE NARCOTIC DRUG PROBLEM 
 
 highest qualities morally and intellectually, and of the 
 greatest value to their communities, who, when driven hy 
 sudden deprivation of their drug, have been led to com- 
 mit felony or violence to relieve their misery." 
 
 This erroneous grouping of so-called " habit forming 
 drugs " is to some extent responsible for a misconception 
 of opiates and of opiate use and opiate result to such an 
 extent that there is unfortunately manifested at times a 
 lack of appreciation of the very important legitimate uses 
 of these drugs. 
 
 The paramount issue of legitimate narcotic medication 
 is that of the opiates. Opiates form and must continue 
 to form the most indispensable medication, emergency and 
 otherwise, for shock, wounds and allied conditions. It 
 ^ may be safely stated that of all emergency medication, 
 the opiates would be the last to be surrendered by the in- 
 telligent physician or surgeon. This is true of every day 
 civil practice and its importance is increased tremendously 
 under conditions of active warfare. 
 
 The opiates possess combined actions and powers not 
 found in any other group of drugs. In therapeutic doses 
 they support the heart and circulation, they relieve pain, 
 they hold in check excessive activity of the glands of 
 internal secretion with all their associated phenomena of 
 exhaustion and collapse ; they control spasm and they give 
 sleep. In no other drugs or group of drugs are these 
 properties combined as they are in the opiate group. In 
 emergency medication, opium and its alkaloids, especially 
 morphine, are the medications often most responsible for 
 the saving of life and reason. It is not necessary to argue 
 this point with any intelligent physician or surgeon. Eor 
 the benefit of the laity, however, and for the benefit of 
 the occasional fanatic and hysterical reformer it is well 
 to state that without the use of morphine and other opiates 
 the mortality among the sick and wounded would be vastly 
 greater, and many of those who might survive in spite 
 
LEGITIMATE USE OF NARCOTICS 117 
 
 of its non-administration to tliem would bear for the rest 
 of their lives physical and mental and nerve consequences 
 of gravest character. The lives and minds that have been 
 saved by the timely administration of an opiate drug are 
 incalculable. One has only to talk with those who have 
 worked under the stern necessities and emergency condi- 
 tions of warfare to appreciate this fact. There is no 
 known drug which will replace clinically and therapeut- 
 ically the opiate group. At present it is as indispensable 
 in meeting emergency indications as is the scalpel of the 
 surgeon. 
 
 It would be entirely unnecessary to discuss or to ap- 
 parently defend the use of narcotics in peace as well as in 
 war-time medication if it were not for the fact of recent 
 recognition of the wide existence of opiate addiction in 
 the civilized world. Combined with this is the belief, 
 often met, that as a result of prolonged opiate adminis- 
 tration, a certain proportion of soldiers have developed 
 this condition. If the facts of addiction-disease were 
 widely known and applied to its proper handling and 
 remedy, there should be no hysteria concerning and no 
 criticism against legitimate opiate medication ; even if un- 
 avoidably continued to the point of creating this condi- 
 tion. That opiate-addiction is one of the medical prob- 
 lems of war is recognized and must be openly met. In 
 many cases^ just as in private civil practice, the physician 
 is confronted by a choice of evils. To save life or rea- 
 son he must continue opiate medication even into and 
 past the danger zone of beginning opiate addiction. Lack 
 of popular recognition, appreciation and comprehension of 
 this fact, in the present status of narcotic addiction, con- 
 tains grave dangers of hysteria and of undeserved and 
 irresponsible criticism. That this criticism is based on 
 ignorance makes it none the less unpleasant and hamper- 
 ing to efficient service. 
 
 It should be at once and widely taught that the cases 
 
118 THE NARCOTIC DRUG PROBLEM 
 
 of opiate addiction tliat follow war time administration 
 of opiate do not constitute a new medical problem, but 
 simply constitute additional cases of a disease wbich has 
 existed insufficiently appreciated in this country for over 
 half a century. When the conditions under which 
 wounded and sick must be handled in the emergencies of 
 war, and the higher percentage of urgent and severe cases 
 are taken into account, it will be found that the propor- 
 tion of wounded and sick soldiers with this addiction-dis- 
 ease is no greater and is very probably not so great as the 
 proportion of people in civil life and practice who have 
 in the past contracted this disease, and are even at pres- 
 ent contracting it as a result of opiate medication, un- 
 avoidably or otherwise continued to the point of addiction. 
 
 As the facts of addiction-disease development as a re- 
 sult of unavoidable military therapeutics become known 
 it will be well to remember that the conditions are no dif- 
 ferent in character and exist in no greater relative propor- 
 tion than the same conditions in civil life and practice. 
 The principal difference .lies in the greater opportunity 
 for early recognition. 
 
 As to the illegitimate or non-therapeutic contraction of 
 addiction within the army, its dangers are no greater and 
 possibly not as great as in civil life. Some non-medical 
 cases of addiction may have developed within the ranks 
 of the army. It may be said of them, however, that army 
 life and activity and training probably saved many more 
 or less idle and ignorant youths imbued with a spirit of 
 curiosity, and with lack of normal outlet for physical and 
 nervous surplus energies, from the associations and en- 
 vironments which have been taken advantage of by those 
 associated with illicit commerce in the creation of the 
 addict of non-medical origin, which has so increased in 
 the past four or five years. 
 
 It is my belief that the gathering together of young 
 men presents an opportunity for the education of the 
 
LEGITIMATE USE OF NARCOTICS 119 
 
 youtli as to the physical and disease facts of opiate ad- 
 diction which should be of incalculable benefit in the solu- 
 tion of the narcotic problem and in the suppression and 
 prevention of " underground " and underworld narcotic 
 traffic. 
 
 The foregoing opens to discussion another legitimate 
 use of narcotics. This use is the intelligent administra- 
 tion of opiate in the control and therapeutic handling of 
 whatever cases of addiction are found to exist. The sit- 
 uation within the army as regards addiction is in the gen- 
 eral indications for its handling, identical with the situa- 
 tion existing in civil life. The man who has fully de- 
 veloped opiate addiction-disease will have to have his 
 opiate supplied to him intelligently and with proper ap- 
 preciation of the symptomatology and reactions of addic- 
 tion-disease until there is equipment and educated per- 
 sonnel provided for his intelligent and competent hand- 
 ling. Under any other immediate arrangements, the 
 addicted soldier, just as the addicted civilian, will in his 
 desperation and physical torments of bodily need for 
 opiate drug, endeavor to smuggle, steal or otherwise ob- 
 tain in any way possible this medication. 
 
 In brief then, and to recapitulate, the legitimate use 
 of narcotics will be roughly divided under two broad 
 heads. The first is the necessary administration of opiate 
 to those who are not addicted for the control of emergency 
 or other indication v^ith which every competent physician 
 or surgeon is familiar. To use opiate as indicated in 
 such cases is not only legitimate, but failure to use it 
 would be inhuman and barbarous and result in the loss 
 of many lives and in the making of wrecks of many others. 
 The second is the administration of opiates to those un- 
 fortunates, who either through their own ignorance or j^ 
 carelessness, or through unavoidably or otherwise pro- 
 longed legitimate or necessary medication have developed 
 in their body the condition of opiate addiction-disease, 
 
120 THE NARCOTIC DRUG PROBLEM 
 
 until sucli time as their disease can be arrested by com- 
 petent medical care of their addiction-disease mechanism. 
 
 As to addiction created in war time, there is consider- 
 able amount of information. This is not the time nor the 
 place for detailed discussion of that information. Calm 
 consideration of it should, however, suffice to still the voice 
 of any objections and irrefutably answer arguments 
 criticizing existence of war-time addiction. The greatly 
 lacking and needed element in its consideration and hand- 
 ling is appreciation of it as physical, controllable and 
 arrestable disease. The laity and the mothers and other 
 relatives and the friends of those in the Army and Navy 
 will not exhibit panic and fear once the intangible horror 
 and vague and morbid and erroneous picture of the ^' dope 
 fiend " is in its application to opiate addiction erased from 
 popular conception and replaced by comprehension of a 
 definite physical disease clinically controllable and in 
 most cases therapeutically remediable. 
 
 To what extent narcotic drug addiction-disease will prove 
 to be a medical sequela of war and of necessary war- 
 time medication may never be made a matter of accurate 
 statistics. The popular and prevailing attitudes towards 
 and conception of the condition and of its possessor tend 
 to influence towards desperate concealment rather than to 
 encourage self-revelation. As has been stated before ad- 
 diction-disease followed the Civil War, occasional cases 
 recently existing and possibly still existing among the 
 few remaining veterans of that struggle, addiction dating 
 back to Civil War medication. The Spanish War and 
 necessary medication added to the list of war-time con- 
 tracted addiction-disease. Of addiction among those 
 participating in the last war, it is at present wise to 
 simply recognize the condition, and to hope that as the 
 addiction-disease sufferer, developed through necessary 
 war-time medication becomes known, he will not have to 
 
LEGITIMATE USE OF NARCOTICS 121 
 
 carry tlie addiction stigma of past attitudes and concep- 
 tions, and that we shall be in a position to accord him 
 intelligent and humane consideration and handling as a 
 deserving sick man, whose disease was contracted in our 
 defense. 
 
 ktca<. i^^ 
 
CHAPTER X 
 
 GEITEEAL SURVEY OF THE SITUATION AND THE NEED 
 
 OF THE HOUK 
 
 Fbom the foregoing it is easy to see that the sooner the 
 established facts of the fundamental physical basis and 
 reactions of the addiction-states become matters of med- 
 ical, sociological, administrative, and lay knowledge, the 
 earlier there will be a rational and practical consideration 
 of the use as well as of the abuse of narcotic drugs, and 
 a beginning of solution of the narcotic drug problem. 
 
 Lack of knowledge of the fundamental and constant 
 physical reactions and phenomena, and of the characteris- 
 tic clinical manifestations of this disease, and of the 
 physical suffering of drug deprivation is in a very large 
 measure responsible for failure in its therapeutic hand- 
 ling in the past, and indirectly responsible for whatever 
 is unjust and misdirected in the framing of the various 
 laws, and also for a great part of whatever incompetency 
 and lack of wisdom has appeared in their administration. 
 
 Lack of knowledge of the disease facts of narcotic ad- 
 diction is also responsible for the practical absence of 
 widespread provision for humane and intelligent handling, 
 for much of the jeopardy and fear on the part of the 
 medical practitioner towards these cases, and for the ex- 
 istence of conditions resulting in the rapid growth and in- 
 crease of the worst evils of the present situation. 
 
 The worst evils of the narcotic drug situation are not, 
 
 as is widely taught, rooted in the inherent depravity and 
 
 moral weakness of those addicted. They find their origin 
 
 in opportunity, created bv ignorance, neglect and fear, 
 
 ' 122 
 
GENERAL SURVEY 123 
 
 for commercial and other exploitation of tlie physical suf- 
 fering resulting from denial of narcotic drug to one ad^ 
 dieted. The many widely advertised drug cures derive 
 their prosperity from the desperate desire of the narcotic 
 addict to be cured of the condition which may at any 
 time cause him intense physical suffering. The worst 
 evil of the narcotic situation in the past few years, and 
 especially since the enforcement of restrictive legislation, 
 without provision for complete investigation of the whole 
 situation, for education, and adequate treatment of dis- 
 ease aspects, is the rapid growth and spread of criminal 
 and underworld and illicit traffic in narcotic drugs. This 
 exists to its present extent because conditions have been 
 created which make smuggling and street peddling and 
 criminal and illicit traffic tremendously profitable, and it 
 would not exist to its present extent otherwise. It is 
 simply and plainly the exploitation of human suffering 
 by the supplying to desperate and diseased individuals, at 
 any price which may be demanded, one of the necessities 
 of their immediate existence. 
 
 Such exploitation would become unprofitable on any 
 large scale if the disease created by continued adminis- , 
 tration of opiates were recognized as it exists and its / 
 physical demands comprehended and provided for in more 
 legitimate and less objectionable ways. 
 
 One of the most important and immediately available of 
 these ways is the honest practitioner of medicine. If the 
 average practitioner of medicine were made familiar with 
 the physical facts of addiction-disease, and its phenomena 
 and reactions, and were encouraged by both legal and 
 medical authoritative support to admit addiction-disease 
 patients to his practice, to be cared for just as other 
 patients to the best of his honest therapeutic ability and 
 judgment — if he were taught to regard them as sick 
 people whom he could help — if he were relieved of uncer- 
 tainty as to the meaning and possible interpretation of 
 
lU THE NARCOTIC DRUG PROBLEM 
 
 laws and reflations, and as to tlie possible action or lack 
 of action and attitude of his medical brethren and medical 
 A- organizations towards him — the best available, honest, 
 humane and intelligent machinery would be set in motion 
 for the immediate care of the average honest sufferer from 
 addiction-disease, and for the discouragement of under- 
 world or underground exploitation. This has been demon- 
 strated. It would react furthermore as a stimulus to the 
 education of the physician, to familiarize himself with 
 the scientific and medical facts of this disease. 
 
 Another immediate provision is the establishing under 
 proper supei'vision and management, especially as to com- 
 petent medical management, and without possibilities of 
 humiliation and interference with self-support, of stations 
 or clinics at which those who for financial or other reasons 
 are unable to secure reputable and honest medical help, 
 may obtain their necessary opiate at minimum expense and 
 in physically necessary amounts to enable them to work 
 and support themselves and families, without resorting 
 to underworld associations and illicit commerce. Such 
 clinics might be established in connection with the various 
 hospitals on the same basis as their other medical and 
 surgical clinics or dispensaries, and in connection with 
 various health departments. In them the narcotic addict 
 could not only be supplied with opiate medication, but 
 taught the nature of his disease and the elements and 
 principles of its control and be given such medication 
 other than opiate for the relief of such associated or inter- 
 current conditions as might exist. Such clinics would 
 have great educational value, as well as fulfilling a 
 therapeutic need. 
 
 Pending further study and investigation and education 
 into narcotic drug addiction-disease and the conditions 
 surrounding it, and pending the widespread acceptance 
 and recognition of practical and desirable procedures in 
 the handling of the disease, and pending the provision of 
 
GENERAL SURVEY 1^5 
 
 sufficient and scientifically adequate accommodations for 
 the army of those who seek relief — legitimate supply of 
 the drug of addiction under medically competent and 
 intelligent direction fulfills a great economic and sociologic 
 and medical need. 
 
 The financial possibilities of commercial exploitation 
 of the sufferings of addiction-disease, combined with gen- 
 eral ignorance of the true nature of the addiction condi- 
 tion, are responsible for the tremendous increase of late 
 of narcotic addiction, of non-medical or non-therapeutic 
 origin, among the youth. In ignorance of actual physical 
 results, not knowing nor ever having been told that they 
 are contracting a disease of torturing manifestations, act- 
 uated by curiosity and search for adventure, in some 
 cases stimulated by unfortunate spectacular publicity, the 
 youths fell easy prey to the agents, male and female, of 
 the drug trafiicker. The trafficker's intended consumma- 
 tion is reached when these youths finally become, to their 
 surprise and consternation, through the development of 
 addiction-disease and physical dependence upon narcotic 
 drug, enforced and continued customers and in some 
 cases, virtual slaves. 
 
 Those who are interested in prostitution and in so- 
 called " white-slavery '' would do well to turn their at- 
 tention to the chains forged by the suffering, and the fear 
 of suffering, experienced by those who have developed nar- 
 cotic drug addiction-disease. 
 
 It is this class of youthful addicts that has so alarm- 
 ingly increased since the enforcement of the various nar- 
 cotic laws. I have previously called attention to this 
 situation, and also to the fact that for this increase the 
 laws themselves are not so much to be blamed as is the 
 totally inadequate meeting of the clinical and therapeutic 
 and educational needs of the narcotic drug situation. 
 There has been practically no organized scientific, medical 
 or public health activity, so far as I know, directed to- 
 
1^6 THE NARCOTIC DRUG PROBLEM 
 
 wards tlie clinical and laboratory investigation of this 
 disease — towards a dispassionate review, analysis and 
 testing out of tlie truths and errors of its literature — to- 
 wards an investigation of the scientific and other qualifica- 
 tions and experience of those whose utterances or writings 
 influence medical and lay opinion and action, towards the 
 establishing of pathological and physical facts and reac- 
 tions and of clinical symptomatology and phenomena as 
 fundamental bases for its rational handling and therapeu- 
 tics, and for practical education of the public as to its 
 sufferings and dangers. 
 
 The neglect of this education is largely indirectly re- 
 sponsible for illicit traffic in narcotic drugs. Illicit and 
 underground traffic exists because it is profitable. This 
 is the direct and immediate reason for its existence. 
 Every new addict made of an adventurous youth means 
 a new customer for the smugglers and vendors. If that 
 adventurous youth had been taught the facts of the physi- 
 cal hell of the " withdrawal signs " of opiate addiction- 
 disease — if he knew the sufferings attendant upon body- 
 need for opiate drug — if he knew that any red-blooded 
 animal will develop this physical body need if opiate drug 
 is administered for a sufficiently prolonged period — that 
 no living being is immune to the development of this 
 disease — if he thought of addiction as he thinks of tuber- 
 culosis, and as he is now being taught to regard venereal- 
 disease, instead of it as being something vague and sur- 
 rounded by a halo of adventure and experience, he would 
 not fall an easy victim to the agents of the trafficker. In 
 other words, the most potent activity in the arrest of de- 
 velopment of even the vicious and criminal aspects of 
 the narcotic addiction situation lies in education. Laws 
 and their enforcement in the control of the incorrigible 
 and vicious will always be a necessity, but laws and their 
 administration alone are not sufficient for the control of 
 the many-sided addiction situation. Even in the control 
 
GENERAL SURVEY 127 
 
 of smuggling and illicit traffic we need the application 
 of every available influence capable of exertion, not only 
 upon its end results but upon the machinery of its origin 
 and development. As so much of it originates and de- 
 velops through ignorance, the method of its remedy lies 
 in education, education as to the facts of narcotic drug 
 addiction-disease. 
 
 It is ignorance also that has stamped the honest and 
 innocent, v^orthy and intelligent, and often illustrious 
 suiferer from narcotic addiction-disease with the attributes 
 and characteristics of the inherently irresponsible or other- 
 wise incapable of self-guidance and self-restraint. The 
 ignorance of the facts of addiction-disease has taken from 
 these people even their ordinary legal and public rights 
 in any issue which involved the possible revelation of 
 their addiction. It has placed them in a position where 
 any procedure which might reveal their narcotic medica- 
 tion would expose them to public gaze as members of a 
 popularly despised and unworthy class of individuals. 
 Until very recently the testimony of a known narcotic 
 addict has been almost as a rule of no value in a court 
 of law. Irrespective of a life-time of honesty and accom- 
 plishment, the revelation of a minute might destroy the 
 reputation and standing of many years. Whatever the 
 injustices or grievances suffered by an addict, he could 
 not hope to evoke the protection or rights accorded an 
 ordinary individual under statute law without the prac- 
 tical certainty, if his addiction became revealed, of per- 
 sonal, social and economic detriment far in excess of the 
 legal rights to which he was entitled. The continuation 
 of whatever is spurious or unworthy in methods of hand- 
 ling, advertised or otherwise, lies partly in the fact that 
 the former patient cannot afford, however great his physi- 
 cal or other damage, to make public the existence of 
 addiction-disease by the instituting of a suit for malprac- 
 tice or other civil or criminal procedure. This alone has 
 
128 THE NARCOTIC DRUG PROBLEM 
 
 been one of the factors in lack of progress and in the 
 persistence of narrow vision or false conception. He is 
 in effect, however high his personal, moral and other 
 status, deprived of some of his constitutional rights, simply 
 because he has developed addiction-disease. 
 
 The great numbers of innocent and worthy unsuspected 
 sufferers from this disease, who could not by any stretch 
 of wildest imagination, be regarded as mentally or mor- 
 ally abnormal or subnormal have therefore been placed 
 in a position where they could not afford to demand 
 their rights or state their case. Their problems are only 
 recently beginning to receive general consideration. Their 
 cases have compelled us to revise our conception of the 
 narcotic addict, and to question ourselves as to the neces- 
 sity for their continued addiction over the years of their 
 addiction. Tor their own good and that of society, what 
 shall we do with them, and what can we do for them? 
 In the present state of public opinion and public attitude 
 towards narcotic addicts in general would it benefit either 
 them or society to class them merely as " drug addicts " 
 along with the drug-users of other types of individuals 
 and other personal characteristics for administrative 
 handling by detailed administrative supervision and con- 
 trol ? Can the same administrative and other methods 
 which admittedly must be employed to protect society 
 from the manifestly unfit accomplish anything of good 
 in the cases of these responsible and valuable citizens? 
 
 Until there is a truer understanding of addiction-disease, 
 and a wider appreciation of the facts that the personal 
 attributes of its victims differ as widely as those of cardiac 
 or any other disease condition, and that merely because 
 a man has contracted this disease is no reason for regarding 
 him as in any way unworthy or unfit — will stringent 
 and drastic forcible regulative measures directed against 
 mere use of narcotics work out to the advancement or 
 hindrance of ultimate solution and to the ultimate benefit 
 
GENERAL SURVEY 129 
 
 or liann of society? These are the questions to be ap- 
 plied to all restrictive administrative activities. The 
 problem of the care of the worthy and innocent addict 
 in such a way as not to unnecessarily harm him nor deprive 
 his family and society of his competent activity is just 
 as important as the handling of the addict of the type of 
 individual from whom society must be protected. The 
 large numbers of worthy and valued citizens who are in- 
 dividually and personally social and economic assets and , 
 who are sufferers from addiction-disease constitute a very<^ 
 important consideration in the narcotic problem. n 
 
 They certainly are not fit subjects for enforced custodial 
 and correctional handling, and if such were forced upon 
 them they would be seriously harmed, personally, socially, . 
 economically and physically. Very many of them our 
 equals or betters, we have no right to subject them to 
 associations and experiences which we ourselves would 
 rebel against and be humiliated by simply because they 
 have developed a disease condition from which no one of 
 us is immune. 
 
 Where is the blame for their continued addiction ? Cer- 
 tainly not because of lack of effort on their part. Ad- 
 dicted for years, they have tried one after another of 
 the various and diverse treatments and so-called cures with- 
 out success or benefit. Is the blame theirs for lack of 
 success and cure, or has there been something wrong in 
 our treatment and handling of them? Did we know 
 enough about . addiction-disease to treat them intelligently 
 and to exercise upon their cases the same professional 
 skill and technical ability that we have been educated 
 and trained to apply to other diseases ? In the light of 
 present available clinical information and study, and in 
 the light of recent and competent laboratory research, we 
 are forced to admit that we have not treated our addiction 
 sufferers with sympathetic understanding and clinical com- 
 petency, and that the blame for past failure to control the 
 
130 THE NARCOTIC DRUG PROBLEM 
 
 narcotic drug problem rests largely upoii the educational 
 inadequacy of the past. 
 
 We are in a stage of transition in our concepts of, atti- 
 tude towards, and handling of the narcotic addict. Serious 
 consideration of drug addiction as a problem of clinical 
 and internal medicine, and of experimental laboratory re- 
 search is a comparatively new thing to a majority of the 
 medical profession, and of course also to legislators and 
 administrators. We should all remember that no matter 
 how strong we are in our beliefs and theories, there are 
 many others whose experiences and results have caused 
 them to hold just as strongly to opposite theories and be- 
 liefs, and that we are all on trial for the validity and extent 
 of practical application of our beliefs and theories. 
 
 Each new theory or belief that is brought forward should 
 be taken simply for record and investigation. Much that 
 we believe to-day we know to-morrow to be based upon 
 misinterpretation and lack of complete information. 
 Much that we believed in the past to apply to and solve 
 conditions, we found later to have been merely based 
 upon observations of distracting incidentals or non-basic 
 aspects and phases. What we need is competent, disin- 
 terested, and honest effort to get together and evaluate all 
 available material of whatever sort and from whatever 
 source. If it were possible of accomplishment, it would 
 be of advantage to get together in open and frequent 
 discussion the various workers in the field. We are all 
 partly wrong and partly right. There is no one of us 
 who cannot learn from any one of the others. The real 
 end of effort should be^ not to prove one or another of us 
 right, but to take each from the other whatever is of value 
 and all to contribute in true scientific spirit of broad 
 tolerance towards the ideas of others and of willingness 
 to correct or modify ideas and theories of our own, search- 
 ing for no panaceas or specifics, medical, legislative or 
 administrative, simply hunting for truth wherever we may 
 
GENERAL SURVEY 131 
 
 find it and applying it intelligently to meet the needs of 
 the individual. 
 
 There is too mnch work to be done^ and the situation 
 is too urgent for remedy, to permit of longer delay in 
 scientific approach. Under present conditions, no man's 
 announcement of theory or of remedy is to be taken as 
 ultimate authority, but simply as his opinion based on his 
 personal deductions, and his personal experience, to be 
 evaluated in accordance with the extent and variety of 
 his personal experience in the light of his individual ability 
 and training. 
 
 Education and training are the best hopes we have as a 
 foundation for the alleviation of present conditions and 
 the prevention of their further spread. Lack of appre- 
 ciation of and of ability to recognize and meet varied and 
 various clinical and other indications for treatment and 
 handling under widely different circumstances and in 
 widely differing individuals means failure in a majority 
 of cases, and throws a burden upon society and a com- 
 plexity of problems upon municipal, state and federal au- 
 thorities which they are unable to meet. Each class of 
 workers should be working in its own field in co-operation 
 with those working in other fields, none trying to dominate 
 the rest, but each giving to the others credit for honest 
 effort and appreciation of difficulties to be made easier if 
 possible. 
 
 All possible forces should be encouraged to the work 
 of study and investigation and education. A campaign of 
 medical and lay investigation and education will require 
 a much shorter time than a continuous trying out of various 
 panaceas, medical, legislative or administrative. Also, it 
 will bring far more satisfactory and earlier results. The 
 narcotic wards of our great charity hospitals should be 
 made use of for honest unbiased and trained clinical and 
 laboratory study. The narcotic addict himself should be 
 given a much wider hearing than he has in the past re- 
 
132 THE NARCOTIC DRUG PROBLEM 
 
 ceived. The mass of honest and intelligent narcotic ad- 
 dicts should be encouraged to tell their stories and their 
 experiences, and should receive a fair and unbiased hear- 
 ing as to the reactions upon them of various measures 
 proposed. We, doctors, legislators, administrators are in 
 truth as much on trial with the narcotic addict and with 
 society for our understanding and handling of the narcotic 
 addict and his problems as the addict is for his condition. 
 The remedy is plain, and the necessity for immediate 
 activity is obvious. Education — scientific medical and 
 lay, administrative and public health education is the lack- 
 ing element or factor in the solution of the many sided 
 narcotic drug problem. Appreciation of addiction-disease 
 and what it may mean in the individual should be as 
 widespread and as comprehensive as possible and at the 
 earliest possible moment. 
 
 Without a basis of generally recognized and widely ap- 
 preciated fundamental facts, there can be no competent 
 treatment, legislation, administration or judicial decision. 
 There can be no competent evaluation of the merits and 
 defects of various measures promulgated, medical, legis- 
 lative or administrative. There can be no competent selec- 
 tion of those in whose hands shall lie the handling of a 
 tremendous problem, a problem of disease, of sociology, 
 of economics, of public health and welfare. There can 
 be no competent evaluation of the remedies advanced, 
 nor of the qualifications and true authority of those who 
 recommend them. Under such conditions various meas- 
 ures or procedures in their adoption or discarding or 
 application must depend more upon the publicity and other 
 influence of their proponents than upon their intrinsic 
 values. 
 
 There are always some things about any condition which 
 either are or are not, some things which are physically 
 determinable. The basic facts of addiction-disease are 
 
GENERAL SURVEY 133 
 
 now physically determinable. There are many material 
 and obvious and easily demonstrable physical facts of 
 greatest value to the medical profession and to the laity, 
 facts which are still but little appreciated, and not widely 
 known. 
 
 These facts in addiction-disease could be easily investi- 
 gated. The various conflicting statements of different 
 schools of thought or of observers working from different 
 angles should be investigated, evaluated and correlated — 
 taking from each whatever is useful, determining its true 
 sphere of application and making it available to all. 
 Every possible interest or worker should be encouraged, 
 and every source of information sought out, not least among 
 them the honest and intelligent sufferer from addiction- 
 disease of many years duration whose knowledge of the 
 facts of his condition, and efforts to control it, and search 
 for and trial of remedy and remedies for it, and the ex- 
 periences and problems, social, economic and personal, 
 which its possession has forced upon him would constitute 
 a touchstone of greatest value for the determination of 
 validity of promulgated measures and procedures. 
 
 The wards of the great charity hospitals, the institu- 
 tions of science and medical experiment and research, 
 the Departments of Health, and the Public Health Serv- 
 ices are in existence and are equipped for the early deter- 
 mination of clinical, and laboratory facts, and for their 
 dissemination. These are the things towards which their 
 activities are directed in other diseases and conditions 
 affecting public welfare and public health. It would take 
 a very short time to determine the physical facts of ad- 
 diction-disease — to establish finally and conclusively its 
 clinical symptomatology and constant reactions and phe- 
 nomena for authoritative and educational dissemination. 
 Every one of us who has written in description or ex- 
 position of his study and observations, together with what 
 we have written and taught, should be made the subject 
 
134< THE NARCOTIC DRUG PROBLEM 
 
 of critical and unbiased investigation, and whatever of 
 truth, we have stated should be made the possession of 
 all. The experimental development of addiction-disease 
 in dogs and other experimental laboratory animals^ the 
 symptoms and phenomena observed in them recorded by 
 instruments such as the sphygmomanometer and the 
 sphygmogTaph and paralleling similar records and obser- 
 vations upon the addicted human, the reactions of the 
 serum of these animals injected into the non-addicted of 
 their species are not to be lightly ignored, and should be 
 matters of common scientific knowledge. The manifesta- 
 tions of addiction-disease in the new-born developed in 
 the infant's body prenatally long before vice or habit or 
 appetite can be possibly considered as causative factors, 
 demand more than casual consideration and have a signi- 
 ficance much deeper than as occasional curiosities. 
 
 An educational campaign as to the facts of addiction 
 would save many an innocent person from the contraction 
 of the disease, and many a present sufferer from unin- 
 telligent handling. Authoritative bodies with sufficient 
 power and independence might easily institute unbiased 
 review of what is written, and trial and proving out of 
 what is stated by various writers, and give out their find- 
 ings for the guidance of future work and action. Hospi- 
 tals and public institutions for the handling of narcotic 
 addicts may be erected Without comprehension of addic- 
 tion-disease and full and complete familiarity with its 
 manifestations, the possession of those who work in them, 
 will they accomplish anything of good ? 
 
 The deduction from the testimony of the Whitney In- 
 vestigation and from other sources leads to the conclusion 
 that one of the reasons why the narcotic addict does not 
 go to many of our present institutions is that he is more 
 afraid of them, and anticipates more suffering in them 
 than he cares to face in view of the fact that neither from 
 previous personal experience or from repute he has little 
 
GENERAL SURVEY 135 
 
 hope of being discharged from them in a condition of 
 physical competency with his addiction mechanism ar- 
 rested. He sees no use in going through them only to 
 come out in a condition where he will have to revert to 
 his opiate to enable him to endure and work. This is 
 not an all-inclusive statement. It expresses, however, the 
 frequent response of the addict seeking advice when asked 
 why he does not go to the municipal institutions for treat- 
 ment. Again then the work of those in the institutions 
 will be the determinating factor in their success or failure, 
 and their education is the dominant element required for 
 success. Some interesting observations upon this point 
 will be found in the Yearly Report for the Department of 
 Correction of N'ew York City, 1915. 
 
 Of public clinics the same thing may be said. Whether 
 they react to the benefit of the addict and of the com- 
 munity, or to the harm of the addict and community will 
 depend upon their intelligent understanding and competent 
 management. 
 
 Hospitals and clinics might be made into sorely needed 
 educational centers for the training of doctors and nurses 
 to go out and take up the work of the care of the addict 
 — either private or institutional. 
 
 Education is the great need of the hour. Until it is 
 accomplished all else will fail. Until we all know what 
 we are dealing with, how can we hope to successfully 
 handle it ? It is to be hoped that the time is not far dis- 
 tant when in every medical school and hospital will be 
 taught in principle and practice, in class-room and clinic 
 all that is known or will be known of the pathology, 
 symptomatology, physical phenomena and rational thera- 
 peutics of narcotic addiction-disease. It is to be hoped 
 that in school and college, in pulpit and press, the facts of 
 addiction will be presented in their practical existence, 
 stripped of spectacularity ; a calm, cold presentation of 
 basic facts. There is no subject upon which philanthropy 
 
136 THE NARCOTIC DRUG PROBLEM 
 
 can better expend its forces than to this end of education 
 as to addiction-disease and humane help to its sufferer. 
 
 In the past the problem of control of addiction has 
 been " What shall be done with or what shall be done to 
 the narcotic addict to make him stop using drugs ? " It 
 is now gradually coming to be realized that the true prob- 
 lem is " What can be done for the narcotic addict to 
 relieve him of the physical necessity of using drugs ? " and 
 ^' What can be done to so educate the public as to the facts 
 of addiction, so that this disease will claim as few victims 
 as possible ? " 
 
 In this change of attitude lies the hope for the future. 
 Some of the narcotic addicts will have to be done with 
 or done to. They are the inherently irresponsible, vicious 
 or defective. They demand care and restraint irrespec- 
 tive of their addiction. The mass of addicts, however, 
 need something done for them. They are clinical prob- 
 lems of internal medicine, victims of a definite disease, 
 characteristic in its symptomatology, reactions and phe- 
 nomena, a disease which will before long come to be known 
 as clinically and therapeutically controllable and arrest- 
 able. 
 
APPE]^DIX 
 HUMAN" DOCUMENTS — PEESONAL STATEMENTTS 
 
 The great importance of the real story of the sufferer from 
 narcotic drug addiction-disease has been referred to several 
 times in this book. It had been my first intention to include 
 in the course of the various discussions, stories and state- 
 ments of narcotic drug addicts illustrative of the various 
 matters discussed, and to take them from my own collection 
 of addiction histories. 
 
 That I might avoid any personal controversy, however, as 
 to their personality or reliability, and also to make such state- 
 ments free from any possible hint of influence or bias, I have 
 taken them from medical literature and am using them as an 
 appendix. 
 
 In December, 1917, American Medicine published a spe- 
 cial addiction number, containing statements written for it 
 by addicts of evident and vouched for intelligence and stand- 
 ing, stating their personal experiences and personal views. 
 
 Through the courtesy of American Medicine and its editors, 
 I am reproducing these, believing that they are of great 
 value and that they illustrate many of the discussions which 
 appear in this book. 
 
 HUMAISr DOCUMENTS ^ 
 THE PEESONAL SIDE OF DRUG ADDICTION 
 
 Some Views ok Drug Addiction — Personal and Legal 
 By a Pbominent Member of the New Yoek Bab 
 A half dozen years ago I had a long, severe attack of gall- 
 
 1 For obvious reasons the names of the authors of these con- 
 tributions are not given. The editor, however, has every one of 
 them, and has taken especial care to establish the authenticity and 
 good faith of each article. Each contribution appears as received. 
 
 137 
 
138 THE NARCOTIC DRUG PROBLEM 
 
 stones and inflammation of the gall-bladder. I suffered so 
 much pain that the physicians gave me morphine for nearly 
 a year. When I got better I tried my very best to get along 
 without the drug, but could not. I came to a physician in 
 N'ew York for treatment who had made a special study of 
 drug addiction and is a recognized authority on that subject. 
 However, he could not help me at that time on account of a 
 recurrence of my gall-bladder inflammation with severe jaun- 
 dice and fever. 
 
 Since that time I have tried repeatedly to stop and reduce 
 the quantity of the drug, but have found it impossible because 
 of the physical pain and exhaustion due to the lack of the 
 drug. This is unbearable. I have since then kept my daily 
 amount of morphine medication at a minimum which permit- 
 ted me to work and to maintain good health and bodily func- 
 tion. The idea which I have heard so often expressed, that 
 addicts tend to increase their daily intake of narcotic, is 
 certainly untrue in my case, and there seems to me no reason 
 nor temptation to do so. I have simply found the smallest 
 amount which would keep me from physical suffering, and 
 have experienced no difficulty in maintaining that dosage, 
 except in occasional emergencies of gall-bladder attacks or 
 other crises, after which I found it a simple matter to dis- 
 continue the excess dosage. As I have never experienced the 
 slightest pleasurable or sensually enjoyable sensations from 
 the administration of morphine, there seems to me no founda- 
 tion for this prevalent idea of tendency to increase. It may be 
 true of the degenerate who has become addicted, but it cer- 
 tainly is untrue in my case, and must be untrue of the thou- 
 sands like me whose misfortune it has been to become afflicted 
 with this condition. 
 
 Recently I have again consulted specialists, and it seems 
 that with my condition I must continue the administration of 
 morphine for the present, and perhaps for the rest of my life. 
 Physical conditions render present attempts to discontinue its 
 use impractical, undesirable and dangerous. 
 
 Now what am I to do under the present " Drug Habit " 
 laws of this State? I am a lawyer long past middle age — 
 have held important state and judicial positions, and many 
 
APPENDIX 139 
 
 positions of responsibility and trust. It would be ruinous 
 to me if my addiction condition became public. 
 
 This law was enacted to control the drug traffic and to stop 
 the evils which are connected with it. In many respects it is 
 an excellent law, but the provisions which require the record 
 of the name, age and residence of the addict to be filed in the 
 Board of Health Office is outrageous. It does not affect the 
 underworld, for they don't care and avoid registration by not 
 going to those who have to register them. But see the posi- 
 tion of a man who has a good reputation and standing in the 
 community — forever recorded in the records of the State 
 Board of Health as a " dope fiend/' even though his condition 
 is not the result of his own acts or desires and absolutely 
 beyond his control. 
 
 This part of the law which requires the recording of the 
 name, age and residence of the addict should be repealed. 
 The only effect of these provisions is to record the addict as 
 what everybody considers a " dope fiend " or force him to go 
 to the smugglers for his drug. He must either place his 
 good name and social and economic position in constant 
 jeopardy or in some way or other evade the law with its at- 
 tendant penalty, and constant fear of detection. I should not 
 be surprised if it finally develops to be the fact that a major- 
 ity of decent sufferers from this condition have chosen the 
 latter course as the lesser of evils. 
 
 I am informed that the Health Department has recently 
 issued monthly registration blanks to physicians, demanding, 
 in addition to the name, age and residence of the addict, the 
 date and amounts of each prescription together with other in- 
 formation as to the individual cases treated. This makes 
 conditions still more obnoxious and unbearable. Further- 
 more, this action of the authorities of the Board of Health is 
 imwarranted and illegal. There is nothing in the powers of 
 the Board of Health which permits them such action, and such 
 action is without any justification in the letter of the law or 
 in any possible interpretation of the spirit and intent of the 
 law. 
 
 The data demanded were submitted to the Legislature as 
 provisions in the law when the bill was being considered, and 
 
140 THE NARCOTIC DRUG PROBLEM 
 
 were rejected. The Health Department is usurping the pow- 
 ers of the Legislature, which it has no authority to do. The 
 law plainly states what the physician shall report and the 
 Board of Health has no power to require additional matters. 
 Such action constitutes illegal interference with the rights of 
 physician and patient as to matters of treatment and as to 
 violation of professional confidence. It is my opinion that a 
 narcotic addict might have grounds for legal procedure against 
 a physician who furnished such information as the Health De- 
 partment demands. 
 
 Conditions in New York today, affecting the honest addict, 
 constitute in effect persecution of the sick. It is bad enough 
 to be afflicted with this disease. Agonizing as gall-stone at- 
 tacks have been, the physical suffering from lack of morphine 
 in an addict is worse. Added to this is the knowledge that 
 your name is on file at Albany, and perhaps elsewhere, as an 
 addict. You know that disclosure of your condition will ruin 
 you and disgrace your family. You are potentially subject 
 to leakage from those records and the attendant possibilities 
 of blackmail and other persecution. Such conditions tend to 
 force and undoubtedly have forced many innocent and honest 
 addicts of good social and economic standing to become crimi- 
 nals by obtaining their necessary opiate medicine through 
 illegal channels. 
 
 Something certainly should be done to remedy existing con- 
 ditions and existing laws. The great State of New York 
 should not place its unfortunate sick in their present position. 
 
 The Personal History of a Medical Addict 
 By a Well-known American Physicl&.n 
 
 When the suggestion was first made by a medical friend that 
 I should write a short account of my personal experience 
 as a drug addict, particularly in reference to my status as 
 a practitioner of medicine, the idea, for obvious reasons, was 
 repellent, notwithstanding the fact that my identity should 
 not be disclosed. But after mature deliberation, I realized 
 that it is largely due to this natural reticence on the part of 
 those in position to speak, that the unfortunate addict is re- 
 
APPENDIX il41 
 
 garded as a social pariah by the general public, and that 
 tmtil the medical profession shall acquire more accurate and 
 less distorted knowledge of this serious question, we cannot 
 hope for any improvement along these lines. IJntil this is 
 done, cruel and unjust laws will be enforced, wretched victims 
 will be imprisoned as felons, and what is more distressing, 
 these unfortunates will, in many instances, be subjected to 
 torture to which death is preferable — and not infrequently 
 results. All this is based upon the accepted theory that drug 
 addiction is a vicious habit requiring only a little fortitude and 
 strength of will on the part of the wretched victim to rid 
 himself of it, while the saddest feature of it all is that this 
 canker, eating at the very heart of the nation itself, blighting 
 and destroying the lives of many useful men and women, is 
 not being reached. 
 
 That the average medical men can remain so hopelessly, I 
 might say criminally, negligent of the true conditions of drug 
 addiction is a cause for wonder as well as condemnation. If 
 the perusal of my paper induces even one conscientious 
 physician to seek more definite information upon this tre- 
 mendously vital subject, my efforts shall not have been in vain. 
 And now for my story. 
 
 At the age of 24 I had finished my medical and hospital 
 courses and was ready to begin my career. My plans had 
 long been formed with reference to entering the army as a 
 surgeon; the decision having been made for two reasons, first 
 as a matter of predilection; secondly, for lack of means to 
 sustain me during the time usually required to establish a 
 private practice. 
 
 Then a tragedy occurred that blasted my hopes for the army 
 and altered my entire future. 
 
 The examinations were scheduled for the late spring; in 
 January I had come down from my home in New England 
 to New York to complete some clinical work. Generally, I 
 was in bad shape, and about that time I began having attacks 
 very suspicious of angina pectoris. Finally I consulted a great 
 specialist, who after thorough and repeated examinations, 
 frankly told me that from overwork and long hours of study 
 my heart had become enlarged and badly disordered function- 
 
142 THE NARCOTIC DRUG PROBLEM 
 
 ally — that I need never hope to pass the physical examination 
 required for entrance to the army. He prescribed rest and 
 freedom from care — two remedies entirely beyond my reach. 
 
 It was then that I went to a far distant city in the West to 
 begin my career on a small amount of borrowed capital. It 
 would be useless to dwell upon my struggles, hampered as I 
 was by lack of funds and ill health, but in due time I became 
 established. During the first few years my heart attacks were 
 infrequent, but as work increased they returned, especially 
 after an attack of typhoid fever which left my heart in a most 
 disturbed state. Naturally, all remedies were tried with an 
 occasional rest, but to no avail. One night after a very 
 trying day I was called to an obstetrical case ; while hurriedly 
 dressing I felt the premonitory sjrmptoms of a heart attack; 
 it was then in a state of desperation T took my first hypoder- 
 mic. The attack was aborted, but the next day I was des- 
 perately sick. I may here add that at no time did I ever 
 experience any of the ecstatic sensations described by some 
 from a dose of morphine — it steadied my heart, but for some 
 time after it was followed by a general malaise. 
 
 My obstetrical work increased rapidly and I frequently 
 found it necessary to resort to the one remedy that proved 
 efficacious. As was natural the time came when I found that 
 the daily necessity had become fijxed. 
 
 Having been taught that it was only a habit that required 
 self will and force of character to abandon — both of which I 
 knew I possessed — I was not particularly worried, as I had 
 planned a long vacation when summer came, which I would 
 devote to the accomplishment of my purpose. But for certain 
 unavoidable reasons the vacation became impossible, and the 
 next winter found me with added responsibilities. 
 
 During all this time I had constantly struggled against 
 the increase of the drug. If under great pressure I was 
 obliged to take an additional amount, as soon as it was over I 
 began to reduce. There were occasions when I succeeded in 
 taking only a fraction of my accustomed dose, but if a call 
 came, I was either obliged to refuse it, or resort to the needle. 
 
 While naturally I had taken no one into my confidence, 
 the habit had been so insidious and gradual that I had failed 
 
APPENDIX 143 
 
 to realize how necessary it was that it shoiild not be suspected. 
 I did not consider myself an addict and only awaited a pro- 
 pitious occasion to relieve myself of it, but that winter I awoke 
 to the realization that some radical step must be taken or my 
 professional reputation would be damaged. 
 
 In the midst of this perplexity I developed an attack of la 
 grippe and judging from past experience I felt that I would 
 be confined to the house for some time, so resolved to take 
 advantage of the enforced rest and abandon the use of the 
 drug. 
 
 It was a hazardous and probably unwise decision, but I 
 reasoned it was for the best. At the end of three weeks, after 
 days and nights of physical and mental torture, I was able 
 to leave my bed, freed from the specter that had haunted me, 
 but for the time a wretched t3rpe of humanity. Four weeks 
 of rest in the country enabled me to return to my practice, 
 and although the heart attacks mercifully remained in abey- 
 ance, it was only by sheer force of will that I could accomplish 
 my routine work, resting every spare moment that was af- 
 forded me, often refusing calls. 
 
 At the end of six months my work had so increased that 
 the heart symptoms began to trouble me. The situation was 
 desperate. Besides a wife and two children depending upon 
 me I had other obligations, and was still in debt from my 
 illness. I was unfitted for any other form of business. 
 
 I shall not enter into a discussion of the ethics of my act, 
 but after sleepless nights of deliberation I reached the d^ecision 
 to return to the remedy that alone would enable me to at- 
 tend to my duties, knowing all that it involved, but hoping 
 that by constant vigilance to lessen the baneful effects of the 
 drug until some day when I should be free to leave off work 
 and again be cured. 
 
 During the years that followed, this object was ever before 
 me, always fighting against an increase, devoting my vaca- 
 tions always to the same cause. In a measure I succeeded. I 
 never progressed to extremely large doses, and I watched for 
 and combatted any possible symptoms of peculiarity or degen- 
 eration that are supposed to obtain with the addict. I felt 
 no sense of moral inferiority or degradation, nor did I deplete 
 
144f THE NARCOTIC DRUG PROBLEM 
 
 my strength with useless anticipation of dreaded possibilities. 
 I would do all that lay in my power to preserve myself and 
 the future lay in the hands of fate. 
 
 During these years success came to me. My clientele grew 
 both in size and character. Positions of trust were conferred 
 upon me, such as the examinership for some of the most im- 
 portant insurance companies, presidency of the County Med- 
 ical Society, etc. I was elected visiting physician to two of 
 our largest hospitals, and for some years did special work for 
 the federal government, the nature of which for obvious 
 reasons I do not care to mention. 
 
 In mentioning these facts, I do so with no vainglorious idea 
 of boasting, but simply to record the history of my career. 
 At the same time I used sometimes to ponder over the 
 anomaly of my position — realizing with what horrified 
 promptness the public would strip me of my honors, and 
 transform its patronage and good will to contempt and pity, 
 if it suspected the truth, although from its continued patron- 
 age my work was evidently entirely satisfactory. Even my in- 
 timate friends would shrink from me if the truth were known. 
 Yet my philosophy and natural optimism sustained me. 
 
 It was at the end of about fifteen years that my circum- 
 stances were such that I felt in position to leave off work 
 and take the long anticipated ^^cure.^' The institution se- 
 lected was one whose methods seemed most reasonable. I 
 stated to the specialist that I was anxious to be cured as 
 rapidly as possible, and was willing to undergo whatever was 
 necessary, to the limit of my endurance. 
 
 The three weeks that followed I remember as a horrid night- 
 mare of mental and physical agony. The method was not 
 intended to be harsh, and the physician was well-intentioned, 
 though far from scientific. 
 
 In my desire for rapid recovery I overestimated my powers 
 of endurance and my nervous system sustained a shock from 
 which it has never recovered, but I persisted, with the as- 
 sistance of my wife who remained with me and without whose 
 assistance T should have lost my reason. 
 
 When T left the sanitarium T was no longer an " addict," but 
 a wretched neurasthenic. Naturally the possibility of return- 
 
APPENDIX 145 
 
 ing to my practice in this condition was not to be thought of 
 so I began making plans to spend the winter in southern Cali- 
 fornia. Here again the fates interposed. It was the autumn 
 when the sudden financial panic swept the country, wrecking 
 the fortunes of so many and tying up the resources of so 
 many others. I was among the latter. There was nothing 
 for me to do but to return to practice which I did after a 
 further rest of six weeks — I need not add that in a short 
 time I was again depending upon the drug to sustain me in 
 the work that I was obliged to resume. 
 
 During the next five years I directed every energy towards 
 shaping my affairs with the one end in view — that of retiring 
 from practice and getting permanently well. By this time 
 my two sons had finished their education and were established. 
 My income was sufficient to provide us with the comforts, if 
 not the luxuries of life. So with a heavy heart, but with a 
 feeling of gratification, I abandoned the practice that I had 
 acquired and sustained through so many years of bitter and 
 sometimes heart-rending struggles. 
 
 My hopes for speedy restoration were doomed to disappoint- 
 ment. I should have realized that when release suddenly 
 came from the long years of daily combat with so powerful 
 an antagonist, a decided reaction must be the natural sequence. 
 It came in the form of an almost complete prostration, that 
 only by force of will prevented from permanently overcoming 
 me; but more than two years elapsed before I felt equal to 
 the effort of again submitting myself to treatment. 
 
 This time I selected a well-known specialist in the Middle 
 West. I bared my entire life to his scrutiny, placing myself 
 absolutely in his hands. Forty-eight hours as an inmate of 
 the institution convinced me that I had made an unfortunate 
 selection ; but from a sense of false pride at being a " quitter ^^ 
 and a belief in my own powers I remained. The methods 
 were absolutely crude and unscientific, the food poor and un- 
 suitable, and the entire environment unfitted to the well being 
 of such patients as I was. 
 
 At the end of seven weeks I was visited by the one most 
 interested in me, who took me from my bed, from which I 
 could not have arisen without assistance, and brought me 
 
( 
 
 146 THE NARCOTIC DRUG PROBLEM 
 
 East. It is true that the amount of the drug that I had been 
 taking had been reduced to a very small amount^, but at the 
 expense of a badly shattered nervous system which required 
 many months to regain even its partial normal status. 
 
 This fall I am in New York and have placed myself under 
 the care of a physician who, while not claiming to be a 
 specialist has, in my opinion and the opinion of many others, 
 the clearest conception of the meaning of drug addiction and 
 its pathology. His opportunities for the study of these cases 
 have been most imusual. His methods are both humane and 
 scientific. Through him I have the hope that should time be 
 allowed me I shall when I am summoned to the great un- 
 known, be freed from the chains that so long oppressed but 
 failed in the end to overwhelm me and compass my ruin. 
 
 Drug Addiction from the Vievtpoint of an Afflicted 
 
 Physician 
 
 By a Peominent Medical Man, Formeely a Health Officla.l of 
 
 An American City 
 
 Maximum efficiency of every individual member of this 
 nation is necessary today as never before in its history. 
 Hence any condition responsible for lessened efficiency on 
 the part of thousands of citizens is a thing to be seriously 
 considered, especially when among these are to be found a 
 large proportion of men and women who would otherwise be 
 useful workers in every important field of activity. 
 
 Addiction to narcotic drugs is today depriving the country, 
 either wholly or partially, of the services of thousands of in- 
 dividuals who but for this handicap would be entirely fit 
 (many of them preeminently so) for work of the utmost im- 
 portance. This is a problem of the first magnitude and one 
 which will have to be solved largely by the medical profession. 
 
 But the medical profession as a whole is utterly lacking 
 at the present time in such knowledge of addiction as is needed 
 ' to enable them to attack the pro1)lem. For these reasons I 
 feel it to be my duty to do my "bit" as a medical man, to 
 put on record some of the lessons which, from years of per- 
 sonal experience, I have learned as to addiction itself, and the 
 
APPENDIX 147 
 
 methods of treatment with which I have had experience in my 
 efforts to be cured. 
 
 The subject is too important to excuse anything but the 
 utmost frankness in speaking of the serious misconception 
 which medical men only too generally share with the masses 
 in regard to the subject of addiction. Unless the profession 
 realizes its own ignorance, all point will be taken from the 
 appeal which I wish to make to the physicians of this country 
 to lose no time in equipping themselves to deal adequately 
 with this great problem. 
 
 It may well be imagined that the task which I have thus 
 set myself is no easy one, viewed from any one of half a dozen 
 angles. Yet, if I am correct, in believing that I can thereby 
 make a small contribution to the cause which now means so 
 much to all of us, I must do so regardless of every difficulty. 
 
 Addiction with me goes back a number of years, covering 
 in fact, almost my entire career as a physician. During this 
 entire time, as will be more fully referred to, I have tried 
 cure after cure, besides having, time and again, sought by 
 own efforts to rid myself of this burden. I have naturally 
 during these years studied and thought much about the prob- 
 lem which has meant so much to me. All this by way of 
 showing wh}^ I believe that my experiences and opinions 
 should have some value. 
 
 First of all, let it be clearly understood that the addiction 
 which I shall discuss is limited strictly to opium and its 
 derivatives ; first, because my own experience is limited to this 
 group and, second, because much that I shall have to say 
 does not apply to all so-called habit-forming drugs to an equal 
 extent, and to some of them not at all. Addiction as thus 
 limited is as true a disease as any with which the human body 
 is afflicted. 
 
 To look on the opium addict as a man with a vicious habit 
 which he could quit if only he truly cared to do so displays 
 a profound misunderstanding of plain facts. As well claim 
 that a man with typical malarial infection has simply be- 
 come so accustomed to having chills and fever at a given 
 hour on certain days that when this hour arrives he quakes 
 through mere habit as to claim that the equally characteristic 
 
148 THE NARCOTIC DRUG PROBLEM 
 
 and even more pronounced and distressing symptoms which 
 manifest themselves when the addict is deprived of his drug 
 are due to habit, that is, to " a condition which by repetition 
 has become spontaneous/^ 
 
 We would, as a matter of fact, be less absurd in the former 
 instance than in the latter; for we could argue the case out 
 with our malarial friend, telling him he could conquer his 
 '^ habit " by the exercise of will power, and — provided we 
 argued long enough — we might convince ourselves that we 
 were right because he would cease to shake, his fever would 
 subside and until the next crop of parasites was turned loose 
 in his blood stream, he would to all intents and purposes feel 
 a well man, while in the latter case the more we talked of 
 habit — that is, the longer the addict was deprived of his 
 dose — the plainer would become the picture of a disease- 
 racked body and a tormented mind. 
 
 I do not, of course, mean to offer the above comparison as 
 either perfect in itself, or as sufficient to establish the claim 
 that addiction is a true disease. The fact that it is a disease 
 has impressed itself on all competent observers of a sufficient 
 number of cases, and must be accepted. Yet it is astonishing 
 to find that many educated physicians do not know this, 
 while an even larger number, though readily admitting that 
 addiction is a disease, nevertheless show, both by their manner 
 of discussing the subject and by their attitude towards addicts 
 seeking their advice, that this is little more than a verbal 
 concession on their part. 
 
 If, however, it be argued that the contention as to addiction 
 being a disease is vitiated by the fact that an occasional addict 
 stops taking his drug by " will power," that is, without taking 
 treatment, we can point to an even larger proportion of mild 
 cases of malarial fever in which spontaneous cure has come 
 about. But this does not prove that thc^ one, any more than 
 the other, is not a disease. 
 
 Indeed, there could be no stronger argument in favor of 
 the fact that addiction is an actual disease than the very 
 phenomena presented by the occasional addict who stops tak- 
 ing the drug by " will power." Neither medical writers nor 
 literary geniuses, whether themselves addicts or mere ob- 
 
APPENDIX 149 
 
 servers, have yet succeeded in presenting a true picture of the 
 tortures which this involves. There could be no greater error 
 than to regard cure as dating from the time the last dose 
 was taken. When, in these cases, cure comes at all, it is 
 only after weeks, or months, of horrible existence, during 
 which kind nature brings about a more or less complete 
 restoration of body and mind not alone from the disease of 
 addiction, but also from the profound shock of unskilled or 
 unwise withdrawal. Will power has enabled the addict 
 to abstain from taking the drug, while nature cured the dis- 
 ease. 
 
 There has been no time during all the years of my addiction 
 that I have not earnestly longed to be free from its clutches. 
 This is sufficiently proved by the many efforts which I have 
 made to find a cure, each time at great personal sacrifice and 
 expense, each time only to have my hopes shattered, after un- 
 told suffering and fresh disillusionment. 
 
 But a real cure I have thus far been unable to find. I have 
 tried everything that seemed to offer a chance: gradual re- 
 duction, self-conducted and at institutions, the Keeley cure 
 several times, and since then all of the vaunted cures, as each 
 appeared in turn, advocated by men of high standing in the 
 medical profession. Concerning this last class, I have each 
 time hoped that such men could not be totally in error as to 
 the practical results of their methods, notwithstanding what 
 has seemed to me the most bizarre pathology on which they 
 have claimed these methods to be based. 
 
 I might, perhaps, have been warned by certain palpable 
 danger signs, but I have been too anxious to find the cure. 
 I cared not at all how mistaken their pathology ; for I could 
 not believe that men of such standing could be equally mis- 
 taken as to the success or failure of what went on under their 
 very eyes. 
 
 And right here let me set down what has impressed me as 
 inexcusable neglect of these cases by most of these self same 
 "big'^ men of the medical profession. One after another I 
 have found physicians who receive and undertake to treat 
 cases of addiction brought to them by the lure of high pro- 
 fessional reputation and medical articles in which is painted 
 
150 THE NARCOTIC DRUG PROBLEM 
 
 a glowing picture of some new and wonderful cure. And, 
 one after another, I have found these men of high professional 
 standing giving to their cases not even enough time and atten- 
 tion to enable them to form an intelligent opinion as to their 
 condition and progress, much less what would be needed for 
 the proper stud}^ and treatment of one of the most difficult 
 and distressing ailments which afflict mankind. 
 
 Moreover, comparing notes with medical men who have 
 been fellow patients under similar circumstances (many of 
 them, I may remark, of the highest type, as men and as 
 physicians), there has been among us a universal sense of 
 shame and indignation that men with such reputation and 
 standing should lay the medical profession open to the justly 
 founded criticism of extortion and neglect of duty, frequently 
 of seemingly rank commercialism, even including the splitting 
 of fees with quacks and charlatans of the worst sort. 
 
 In saying that I have found no cure, I do not mean that 
 I have never succeeded in getting to the point where I could 
 get along for shorter or longer periods without the drug. 
 Many times I have succeeded by myself in gradually reducing 
 the dose to a minimum and then making the final plunge 
 and taking none at all for some time. What this has meant 
 I will not undertake to describe. Several times I have man- 
 aged to keep from using the drug for a while after taking 
 treatment of one kind or another. But have I been cured ? 
 
 Let no one thoughtlessly reply that the very fact of my 
 having on each of these occasions reached a point where, ac- 
 cording to my own statement, I was able to live without the 
 drug, constitutes proof that I was cured, or that when I started 
 to use it again I was merely yielding weakly. 
 
 What has actually happened has been this. Each time 
 that I have succeeded, in one way or another, in reaching a 
 point where I was no longer taking the drug, I have, even 
 while the suffering was still acute, been filled with a sense of 
 happiness and hope that enabled me to stand it thankfully. 
 I have argued with myself that, being then able even to exist 
 without the drug and, for a while finding this existence day 
 by day a little less of torture, I might reasonably hope for 
 continued improvement. I have not expected miracles, but I 
 
APPENDIX 151 
 
 have felt that each week should be easier, until, after a period 
 of some few months, I should again be normal. 
 
 But this has not come about. Always I have reached a 
 point where progress seemed to stop, and beyond this point 
 my system refused to react. Occasionally this standstill has 
 been quickly reached, that is, I could not react beyond a point 
 where I was unable to sleep, where my legs ached atrociously, 
 and where I was so completely unstrung that life was unen- 
 durable. At best, progress has continued for a few weeks, 
 after which, though resting well, having a prodigious appetite 
 and not undergoing marked physical suffering, I have actually 
 been far from normal. This was shown, on these special 
 occasions, chiefly by my inability to do satisfactory work, by 
 my tiring altogether too easily and by a general feeling of 
 unrest and disquietude. 
 
 I realize the difficulty of so describing my condition during 
 these most favorable occasions as to show at all convincingly 
 that I was not actually cured and that, in consequence, my 
 resuming the taking of the drug was anything but a relapse. 
 This, however, I must not attempt to do, since the main con- 
 tention which I wish to make is here directly led up to. 
 
 And, hard as is the whole task I have set myself in writing 
 this account, this special part of it is peculiarly difficult, in- 
 volving the risk of appearing to set a false value on certain 
 personal considerations. 
 
 My life has been an active and useful one. I have done 
 work which I know to be good and which has brought recogni- 
 tion. Successful work, even in a given line of endeavor, is 
 not always due to the same qualities in different men. My 
 own work has been characterized by the exercise of careful 
 judgment and the power of accurate analysis, qualities which 
 I have always been credited with possessing. Now, after 
 the most favorable of the so-called treatments which I have 
 taken, and after allowing considerable time for complete re- 
 covery, I have in no instance regained these most essential 
 requisites for my work, and thus I have been placed in a 
 position where I would either have had to discontinue my 
 work, or else do the only thing v^hich made the resuming 
 of that work possible. And always there has been the absolute 
 
152 THE NARCOTIC DRUG PROBLEM 
 
 conviction that this state of affairs was due to my not having 
 been actually cured. On this point there has not been one 
 iota of doubt. 
 
 Perhaps if I had been able at such times to take a complete 
 rest of six months or even a year, I might have been fully 
 restored, but this has not been possible. I have not been 
 able to remain away from work for over five or six weeks 
 after the " cure ^^ proper, and even this has, as may well be 
 understood, been a severe drain, when I have taken some cure 
 or other at as short intervals as I could manage to get to- 
 gether sufficient funds and the opportunity to leave my prac- 
 tice. 
 
 Of course it may be argued that, rather than return to 
 the use of the drug and thus again be able to live a life as 
 nearly approaching normal as is possible for an addict, it 
 would be better to refrain from using the drug, even though 
 this involved never again being able to do those things which, 
 to the ambitious man, are essential to make life worth the 
 living. I submit that it is a high motive and not a low one 
 which makes a man willing to pay the price rather than live 
 a vegetative existence when he knows himself capable of 
 better things. To understand this point of view it must be 
 remembered that the addict gets no rosy dreams, no wonderful 
 journeys into a beautiful and unreal world, no artificially 
 enhanced powers beyond those of the non-addict, but at best 
 only such equanimity and energ}^ as are the latter's happy 
 possessions. 
 
 My point, therefore, is that my resorting to the drug after 
 having stopped its use a number of times does not mean that 
 I have many times been cured, and many times relapsed, but 
 that I have not been truly cured. \\Tien the latest " cure " 
 which I have taken has left me, even after weeks, still suffer- 
 ing acutely and continuously, and not improving in the slight- 
 est so far as I could see, I have taken the drug again for 
 relief from torture no longer bearable. After " cures " which 
 have left me in decidedly better plight but in the intolerable 
 condition last described above, and with progress at a stand- 
 still, I have taken the drug onl}^ after calmly surveying the 
 situation, and as the lesser of two evils. 
 
APPENDIX 153 
 
 I must reiterate my strong desire to find a cure, a real 
 cure, one deserving the name ; that is, a cure which will leave 
 me normal, without need of the drug, and able to do the work 
 which I must do in the world unless I am willing to be a 
 slacker. But until I can find such a cure (and, in spite of my 
 unhappy experiences, I will keep up the quest) I would have 
 only contempt for myself as a physician and as a rational 
 being if I failed meanwhile to make the best compromise 
 possible, namely, to take each day, just as I would take thy- 
 roid substance were I suffering from hypothyroidism, a suf- 
 ficient amount of morphine to enable me to attend to life's 
 duties and to occupy in the world that useful place which 
 my qualifications enable me to occupy. 
 
 One of the great hardships under which every addict suffers 
 is the constant dread lest his affliction become known and he 
 be branded a " morphine fiend,'' a term which should be pro- 
 hibited, or at least never used by an intelligent physician. 
 What this exposure would mean to a man of standing in his 
 community I need not explain. This risk he must always 
 run, but it would be robbed of some of its terror if the nature 
 of addiction were better understood. 
 
 Therefore the law now existing in some states requiring 
 the registration of addicts is little short of barbarous. So 
 little possible good can be accomplished by this law that one 
 is tempted to believe that its passage was not instigated pri- 
 marily by honest, though misguided zealots but by quite an- 
 other class. The addict, in his efforts to find a cure, has 
 learned something of a class of men, who, posing as public 
 benefactors, are in reality a shrewd set of rascals, capitalizing 
 the misfortunes of the addict most successfully. If such men 
 were not the originators of the idea of registration, certainly 
 they, and not the body politic, are its chief beneficiaries, since 
 it affords them an authentic list of prospective victims. 
 
 As for the effect of this law on the addict, it merely adds 
 further to his dread of exposure. Think of the position of a 
 man of prominence and respected in his community, having 
 his own feelings as have other men, holding equally dear the 
 sensibilities of those he loves, living under the constant dread 
 that his necessities may any day force him to seek aid in a 
 
154. THE NARCOTIC DRUG PROBLEM 
 
 ; state in which his name will, as it were, be added to a rogues' 
 gallery ! 
 
 My plea is for realization of the great need for finding 
 some means whereby the individual addict may get real relief 
 and whereby addicts collectively may be restored to such con- 
 dition as will render them capable of performing those services 
 of which our country is now in need. 
 
 I am confident that I am understating the case when I 
 say that nine addicts out of ten earnestly desire to be cured. 
 Why should they not? They get no pleasure out of taking 
 the drug, but only relief from intolerable suffering which they 
 must otherwise endure. Hence to be free both from this 
 suffering and from the necessity of getting this relief by 
 artificial, and at present exceedingly costly, means is bound 
 to appeal to them. Most addicts, I am confident, are willing 
 to go through whatever acute suffering may be involved in any 
 really rational treatment which will, after a reasonable time, 
 restore them to normal condition. 
 
 Experiences such as I have described above are, I know, 
 the rule and not the exception with those who have tried the 
 various so-called cures. They can hardly be called satisfac- 
 tory. Even admitting that they may prove successful in a 
 small proportion of cases, relatively few addicts are able to 
 find the means of taking them, such as I have been able to 
 make for myself in the midst of a very active life. 
 
 Surely a disease having so definite a symptomatology and, 
 I believe, so plain a pathology, must be susceptible of rational 
 cure. That such a cure has not yet been found by those who 
 so loudly proclaim to have found one I honestly believe. 
 Whether others have devised more promising lines of treat- 
 ment I frankly do not know. 
 
 But a cure must be found which does more than any I have 
 succeeded in finding. In what other disease would a patient 
 who, after reaching a certain point, beyond which he could 
 not progress towards recovery, be told that from then on 
 everything rested with him, although he himself knew that his 
 need for help was really as great as it ever was? In what 
 other disease would any physician worthy of the name calmly 
 tell a patient that, having taken a " cure,^' he was, ipse facto, 
 
APPENDIX 155 
 
 cured, and become highly incensed when the patient pleaded 
 that his condition was in many respects more desperate than 
 before treatment ? 
 
 The medical profession must seriously study addiction. Of 
 material there is, unfortunately, an abundance. Some high 
 authority should see that every facility is afforded the proper 
 persons for employing it. It is not unlikely that many of the 
 " cures " which have been advocated have in them some ele- 
 ments of good, properly selected and properly applied in each 
 individual case. Possibly competent investigation, furnished 
 with every facility, might result in the discovery of a truly 
 specific cure. I have long thought that there was such a 
 possibility in more than one direction, but investigation of 
 these would involve very careful and laborious work, as well 
 as considerable cost. Here indeed^ would seem to be a won- 
 derful opportunity for philanthropy. 
 
 But while such a specific cure would be an untold blessing, 
 we need not find one in order to meet the situation — at 
 least, much more successfully than it is being met at present. 
 Coordination of the entire problem of addiction, in the hands 
 of the few men whose work in this field is most promising 
 (and the men I have in mind are not those with whose 
 vaunted cures I have had such unhappy experiences) would 
 almost certainly lead to valuable results. 
 
 While every effort should be exerted to determine the best 
 lines of treatment, meanwhile there is a great deal which 
 should be done in other directions. Let the medical profes- 
 sion help in bringing about better understanding of addiction 
 — first, of course, learning this themselves. Until the addict 
 can be offered rational treatment, the profession should do 
 what it can in making the lives of addicts less unbearable by 
 removing from the public mind some of the gross miscon- 
 ceptions concerning addiction, seeing to it, especially, that 
 these unfortunates are not stigmatized as " morphine fiends ^' 
 and that they are given the means of obtaining, without risk 
 and hardship and almost prohibitive cost, the supply of their 
 drug which, until they are cured, is to them as necessary as 
 the air they breathe. 
 
 But IJie finding of a real cure or treatment — not neces- 
 
156 THE NARCOTIC DRUG PROBLEM 
 
 sarily specific, not a thing to be applied indiscriminately in 
 every case, but a rational method of handling addiction as 
 other well known diseases are handled — is the great aim, 
 or, if it be that sufficient is already known by some men in 
 the profession as to the rational handling of addicts, let 
 these men be found and their services subsidized by the gov- 
 ernment and used to the fullest extent, in teaching others, and 
 these still others, until there is built up a system extending 
 over the entire country, capable and equipped for giving to 
 every addict the opportunity for cure. This is a crying need 
 ia our country today. Surely there must be somewhere recog- 
 nition of this fact and resources enough to make it possible 
 for this need to be supplied. 
 
 A Plea for the Broader Consideration" of ISTarcotic 
 Drug Addiction by the Medical Profession 
 
 By a Peacticing Physician Who Has Met the Problem in 
 His Own Family 
 
 In view of a recent experience of mine in seeking intel- 
 ligent medical help for a near relative whom I learned was 
 a narcotic drug addict, I take pleasure in recounting experi- 
 ences of the past few months in the handling of such a case, 
 and in calling attention to the conditions which my investiga- 
 tions have shown me to exist in our profession. 
 
 My line of professional activity had not brought me know- 
 ingly into touch with narcotic drug addiction, and I enter- 
 tained the prevailing medical opinions in regard to it. 
 
 About five months ago I received a letter couched in apolo- 
 getic language from a practitioner in another state informing 
 me that a younger brother of mine had been under his care 
 for a number of days suffering from withdrawal S5rmptoms 
 occasioned by inability to purchase morphine, and advising 
 me to place him in some institution where he could be re- 
 strained. 
 
 I immediately began asking my colleagues where I could 
 send such a case, and was amazed at the general lack of 
 knowledge in regard to and sympathy for these unfortunates. 
 In truth no one could point out a single institution where 
 
APPENDIX 167 
 
 such a patient could be sent with any hope that he might 
 be handled in a humane and intelligent manner. 
 
 My investigations of the institutions they suggested showed 
 this to be the fact. 
 
 Most every one seems to regard those suffering from this 
 condition as being of a lower order of humanity, unwilling 
 or too weak-minded to help themselves and fit subjects only 
 for association with what is commonly known as the " under- 
 world.^^ I wish to say that I myself have undergone a very 
 complete revision of mind regarding these cases since the 
 case of my brother has compelled me to investigate them. 
 I have known my brother too well and for too many years 
 to believe that he can possibly be placed in any such category. 
 
 I have made careful inquiries into the circumstances and 
 origin of his addiction, and the results are absolutely con- 
 vincing that the first administrations of the narcotic were 
 to meet therapeutic indications and were continued without 
 his knowledge or appreciation of its actions or ultimate re- 
 sults. I know that he has never experienced any pleasure 
 from the narcotic, and I know that when the condition of 
 addiction manifested itself he did not know what was the 
 matter with him. He only knew that narcotic relieved in- 
 tense suffering. I had never seen a case of addiction to my 
 knowledge before I went to see him in response to the letter 
 I received. The clinical symptomatology of withdrawal of an 
 opiate was truly a revelation to me. That the condition 
 from which these patients suffer is a distinct disease cannot 
 be questioned by any intelligent observer. 
 
 I have found that the majority of patients who begin the 
 use of opiates do so in search of relief from pain, and are 
 not aware of the fact for a long time that the suffering they 
 endure when the drug is discontinued is due to a disease 
 they have contracted. Apparently the medical profession is 
 also ignorant of this fact. 
 
 A more pathetic sight I have never seen than one of these 
 patients who has been suddenly deprived of his medicine. 
 They will tell you that they will become insane or be driven 
 to suicide if they cannot obtain relief from their suffering. 
 Hence their willingness to obtain the drug at any cost. I 
 
158 THE NARCOTIC DRUG PROBLEM 
 
 have come to believe that any man is justifiable in lying or 
 stealing to escape the agonies I have witnessed. 
 
 It seems a crime that we of the profession have gone so 
 long without any attempt to study or understand the disease 
 which we in our daily rounds are constantly creating. Cer- 
 tainly our standard medical literature contains little if any- 
 thing of value in regard to this condition, and investigation 
 of the claims and procedure of the widely advertised so-called 
 " treatments " and " cures " readily convinces one of their 
 unworthiness. 
 
 I know that much can be done for the cure of these patients 
 by an intelligent effort on the part of the medical profession, 
 and a willingness to open their minds to the clinical facts 
 of this condition and to handle it like other diseases. 
 
 In search of information I have gotten into touch with 
 cases of addiction other than my brother's, and I find that 
 the majority of them are desperately anxious to be cured. 
 They tell me, however, that institutions such as jails, work- 
 houses, lunatic asylums, alcoholic wards of the charity hos- 
 pitals, and those that they have tried of the advertised cures 
 are places of insufferable torture from which they emerge in 
 worse condition than that in which they entered. 
 
 There are estimated to be as many as 500,000 or more ad- 
 diction cases in the State of 'Rew York alone. I ask in all 
 earnestness, is it not worth while to try to do something more 
 than we are doing for these sufferers ? 
 
 PRINTED IN THE UNITED STATES OT AMBEIOA 
 
INDEX 
 
INDEX 
 
 Abnormalities, getting rid of, in 
 
 preliminary stage, 83 
 Acidosis in opiate addiction, 48 
 Addict, criminal or vicious, han- 
 dling of, 108 
 drug, as a surgical and medi- 
 cal risk, 85 
 cooperation of, 72 
 often unknown and unsus- 
 pected, 7 
 honest, and need of competent 
 medical care, 109 
 and custodial care, 28 
 medical, personal history of, 
 
 140 
 mixed, 115 
 
 narcotic, failure to imder- 
 stand, 5 
 will cooperate and suffer, 6 
 Addicts, drug, accidental or in- 
 nocent, 28 
 age of, 24 
 
 and influenza and pneumo- 
 nia, 86 
 majority of, 17 
 often understand own cases, 
 
 7 
 what type or class become, 
 23 
 innocent and worthy, what 
 shall we do with them? 
 129 
 narcotic, average individuals, 
 3 
 often men and women of 
 high ideals, 3 
 worthy and innocent, problem 
 
 of, 128 
 youthful, 125 
 Addiction, author's definition of, 
 20 
 beginning stage of, 30 
 development of, 29 
 
 161 
 
 Addiction {contiwied) 
 
 disease, author's conclusions, 
 40 
 a chronic condition, 93 
 in newly born infant, 24 
 may afflict all classes, 19 
 mechanism of, 36, 41 
 rational handling of, 61 
 treatment of, and legitimate 
 medical practice, 99 
 drug, a medical problem, 28 
 among soldiers, 117 
 and defectives, 16 
 a plea for broader considera- 
 tion of, 156 
 and the average person, 17 
 as a sequelae of war, 120 
 contraction of, in the army, 
 
 118 
 in surgical cases, 85 
 medical problem of, 21 
 methods of treating, 50 
 origin of, 25 
 so-called specific, treatment 
 
 of, 55 
 unsuspected, 26 
 viewpoint of physician af- 
 flicted with, 146 
 wrongly described, 14 
 established, stage of, 31 
 narcotic, a demonstrable dis- 
 ease, 59 
 a recognized menace, 4 
 classed as a vice or morbid 
 appetite, 4 
 opiate, as a war problem, 117 
 complicated with cocaine, 3 
 picture wrongly painted, 2 
 Adequacy, metabolic and organic, 
 relation to other disease 
 conditions, 92 
 Administration, narcotic drug, 
 regulation of, 65 
 
16a 
 
 INDEX 
 
 "After Care" or convalescence, 
 53 
 
 Age of addicts, 24 
 
 American Medicine, human doc- 
 uments from, 137 
 
 Antidotal substance, 42 
 
 Any one liable to drug addiction, 
 8 
 
 Attempts at administrative and 
 police control, 4 
 
 Attitude of drug addict, 71 
 of lawmakers to drug addic- 
 tion, 102 
 of medical profession, 50 
 personal, of physician to drug 
 
 addict, 70 
 to drug addicts, author's un- 
 just, 12 
 
 Auto-intoxication and autotoxi- 
 cosis, 46 
 
 Balance, drug adequate, impor- 
 tance of establishing and 
 maintaining, 92 
 narcotic drug, and minimum 
 daily need, 66 
 and operative procedure, 92 
 necessity of maintaining, 67 
 Basis of success, 132 
 Beacon-light of hope for drug 
 
 addicts, 14 
 Belladonna, use of, 55 
 Bellevue Hospital, early work in 
 alcoholic and narcotic 
 wards, 2 
 
 Care, custodial, and the honest 
 addict, 28 
 
 Cases demonstrating presence of 
 antidotal substance, 43 
 
 Catharsis, non-irritating, 79 
 
 Cause of withdrawal symptoms, 
 38 
 
 Causes of failure in solving drug 
 problem, 5 
 
 Clinics, drug, need for, under 
 competent medical direc- 
 tion, 124 
 public, 135 
 
 Cocaine, habitual use of, 115 
 
 Committee appointed by Secre- 
 tary of Treasury, report, 
 14 
 
 Complications, avoided by intelli- 
 gent patients, 78 
 
 Conclusions of author, 40 
 
 Condition, another disease, rela- 
 tion of functional balance 
 to, 92 
 drug patient's, as index of suc- 
 cessful treatment, 75 
 
 Considerations, fundamental, 1 1 
 
 Convalescence, and " after care," 
 53 
 
 Cooperation of drug addict, fac- 
 tors which determine, 72 
 
 Cure of drug addiction. What 
 constitutes? 76 
 
 " Cures," basis of, 55 
 
 Custodial care and the honest 
 addict, 28 
 
 Danger of restrictive legislation, 
 123 
 
 Dangers of belladonna, hyoscine, 
 pilocarpine, etc., 80 
 
 Data, institutional, lack of, 58 
 
 Defectives and drug addiction, 16 
 
 Definition of term " narcotics," 
 114 
 
 Deprivation, forcible, danger of, 
 53 
 
 Development of addiction stage, 
 29 
 
 Discontinuance of narcotic drug, 
 difficulties of, 69 
 
 Disease, addiction, rational han- 
 dling of, 61 
 drug addiction, nature of, 23 
 
 Documents, human, 137 
 
 Dosage, narcotic drug, in rela- 
 tion to withdrawal symp- 
 toms, 75 
 
 Doses, therapeutic, and toxic 
 stage of normal reaction 
 to, 29 
 
 Drug, narcotic, balance, 67 
 definite body need for, 37 
 
INDEX 
 
 163 
 
 Drugs, narcotic, and the physical 
 condition established, 21 
 may afford pleasure, 3 
 legitimate use of, in peace 
 
 and war, 114 
 prescribing and dispensing 
 
 of, 100 
 relations of laws to, 95 
 Du Mez's recent paper, 38 
 
 Education and training, 131 
 lay, medical and ofl&cial, need- 
 ed, 109 
 neglect of, and illicit traffic, 
 126 
 Efficiency, functional, nutri- 
 tional and metabolic im- 
 portance of, 92 
 Efforts, author's early, 11 
 Elimination, competent, not 
 measured in bowel move- 
 ments, 81 
 of opiate, and cell tolerance, 
 46 
 Evils, chief, of present drug sit- 
 uation, 122 
 Exploitation, commercial, and its 
 financial possibilities, 125 
 of physical suffering, 123 
 
 Facts concerning drug addiction, 
 necessity for unbiased 
 medical investigation of, 
 101 
 significant, 13 
 
 Fear, constant, addict lives in, 
 92 
 
 Function, inhibition of, 46 
 
 Gioffredi, investigation of, 26, 38 
 
 Handling, institutional and cus- 
 todial, and certain types 
 of addicts, 108 
 of criminal or vicious addict, 
 
 108 
 preliminary to withdrawal, 62 
 rational, of addiction disease, 61 
 
 Harrison Law, effect on medical 
 profession, 96 
 reasons for failure of, 96 
 wise in purpose, 95 
 Hirschlaff's experiments, 26, 38 
 History of medical addict, 
 
 140 
 Hyoscyamus, use of, 55 
 
 Ignorance, the harmful effects of, 
 127 
 
 Immunity to narcotic drugs, 4 
 
 Inefficiency, medical, 6 
 
 Infant, newly-born, and addic- 
 tion disease, 24 
 
 Influenza and pneumonia in drug 
 addicts, 86 
 
 Information, clinical, paucity of, 
 58 
 
 Intervals, long, between doses, 
 desirable, 77 
 
 Introduction, 1 
 
 Jennings' studies of acidosis, 48 
 
 Kobert's and Toth's studies, 38 
 
 Law, Harrison, failure of, 96 
 makers, attitude to drug ad- 
 diction, 102 
 What has it done for the ad- 
 dict? 102 
 Laws and old conceptions of 
 drug addiction, 96 
 and their relations to narcotic 
 
 drugs, 95 
 drug, enforcement and in- 
 creased suffering of ad- 
 dicts, 96 
 
 Magendie's findings, 38 
 Mar me and oxydimorphine, 38 
 Mechanism, essential, of addic- 
 tion disease, 41 
 of narcotic drug addiction 
 
 disease, 36 
 of protection, 47 
 
164) 
 
 INDEX 
 
 Medication, ignorant or unavoid- 
 able, and drug addiction, 
 27 
 opiate, indispensable and le- 
 gitimate, 116 
 " specific," fallacy of, 56 
 Misunderstanding of addict, 
 cause of early failures in 
 treatment, 5 
 
 " Narcotics," definition of term, 
 
 114 
 Need, drug, minimum daily, 66 
 of the hour in study of drug 
 
 addiction, 130 
 narcotic drug, and mental and 
 muscular work, 69 
 
 Observation in Bellevue, sixteen 
 months, day and night, 3 
 
 Observations on physical or 
 body reaction, 32 
 
 Opiate, withdrawing, simply one 
 stage, 92 
 
 Opiates, and their unique prop- 
 erties, 116 
 
 Organizations, medical duty of, 
 104 
 
 Origin of addiction, 25 
 
 Oxydimorphine and Marme the- 
 ory, 38 
 
 Panaceas, search for, 56 
 
 Patients, intelligent, and the 
 avoidance of complica- 
 tions, 78 
 
 People, eminent, and drug addic- 
 tion, 27 
 
 Philanthropy and its opportu- 
 nity, 135 
 
 Physician, average, is inexpert 
 in handling addiction dis- 
 ease, 108 
 suffering from drug addiction, 
 viewpoint of, 146 
 
 Physicians, honest, and their re- 
 sponsibility, 103 
 
 Pilocarpine, use of, 50 
 
 Practice, legitimate medical, 95 
 
 Practitioner, honest, and con- 
 trol of illicit drug traf- 
 fic, 123 
 
 Principles, basic, of addiction- 
 disease handling, 65 
 
 Problem, drug, still unsolved, 5 
 of drug addiction, ultimate 
 
 solution of, 108 
 of the care of the innocent and 
 worthy addict, 129 
 
 Profession, medical, attitude of, 
 50 
 
 Prostitution and *' white-slav- 
 ery," 125 
 
 Protection, bodily, against opi- 
 ate, 42 
 mechanism of, 47 
 
 Pulpit and press, duty of, 135 
 
 Purgation, excessive, warning 
 against, 81 
 
 Purpose, chief, of most lay and 
 medical workers, 96 
 
 Questions that confront the 
 American people, 136 
 
 Reaction, normal, stage of, 29 
 to therapeutic and toxic 
 doses, 29 
 of drug addicts to therapeutic 
 agents, 68 
 Reduction, enforced, below bodily 
 need, dangers of, 69 
 slow, 51 
 References to recent literature, 
 
 39 
 Regulation, legislative and ad- 
 ministrative, 105 
 of intervals of narcotic drug 
 administraction, 66 
 " Relapses " and production of 
 
 antidotal substance, 45 
 Report, 1915, of New York Dept. 
 of Correction, 72 
 Preliminary, of Whitney Com- 
 mittee, 110 
 Responsibility for drug addiction 
 laid on medical profession, 
 102 
 
INDEX 
 
 165 
 
 Restoration of drug addict to 
 health, 83 
 
 Side, personal, of drug addiction, 
 137 
 
 Solution of drug problem, ulti- 
 mate, 108 
 
 Stage of study, preliminary to 
 withdrawal, 63 
 preliminary, abnormalities in, 
 83 
 
 Stages of addiction development, 
 29 
 
 Stool, " typical," of Towns treat- 
 ment, 79 
 
 Study, clinical and laboratory, 
 lack of, 91 
 of patient, essential as pre- 
 liminary to withdrawal, 
 63 
 
 Substance, antidotal, to opiate, 
 and bodily protection, 42 
 
 Suffering, physical, and drug ad- 
 diction, 20 
 
 Survey of the situation, 122 
 
 Terms that should be eliminated, 
 9 
 
 Testimony of Whitney Commit- 
 tee, deductions from, 134 
 
 Theories, author's wrong, 12 
 
 Tolerance, explanation of, 38 
 increased, stage of, 30 
 
 Traffic in narcotic drugs, illicit, 
 
 103 
 Treatment, importance of regu- 
 lating intervals of nar- 
 cotic drug administration 
 in, 65 
 
 rational, of addiction disease, 
 61 
 
 so-called specific, 55 
 
 specific, author's disbelief in, 
 80 
 
 " Underworld " and desperate 
 necessity of addict, 28 
 
 Use, legitimate, of narcotics in 
 peace and war, 114 
 
 Valenti's studies, 26, 38 
 Veterans, Civil War and drug 
 
 addiction, 24 
 Views, personal and legal, of 
 
 drug addiction, 137 
 
 Whitney Committee. Hearings, 
 
 testimony of, 107 
 Withdrawal accompanied by use 
 of various drugs, 51 
 forcible, and suicide, 53 
 stage of, 62 
 sudden, 53 
 symptoms, 35 
 Withdrawing of opiate simply 
 one stage, 92 
 
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