CHAPTER IX

The social standing of the man who took it from the tepees of the North American Indians to England is mainly responsible for its taking root there, for the acquisition of the tobacco habit is a painful process. Nature’s revolt against it is much more instinctive than her revolt against alcohol. Furthermore, like any other form of poison, its effects are most immediate and evident upon the young and weak; for they are easier to poison than the mature and strong.

THE FULL EFFECT OF THE TOBACCO HABIT IS NOT YET APPARENT

To one who has made a careful study of the effects of tobacco the prospect for the future is not encouraging. The habit was already widespread before the extensive manufacture, or even knowledge, of cigarettes was introduced into the United States, and this later form of smoking, which is easily the most obnoxious and harmful of all, has not yet had time to disclose its full power for injury. For it is in the inhaling of tobacco that the smoker receives his greatest injury, and the habit of inhalation is peculiar to the cigarette-smoker. While there are smokers of cigars and pipes who inhale their smoke, it will almost always be found upon investigation that they acquired the habit of inhalation through smoking cigarettes. The average man with a cigarette history gets no pleasure out of smoke which he does not inhale.

Even if a cigarette is made of the best tobacco, undrugged, and wrapped in the purest of rice-paper, the mere fact that the smoke is almost invariably inhaled suffices to make cigarette-smoking the most harmful form of the tobacco habit. Inhalation is harmful because it not only exposes the absorbent tissues of the mouth and upper throat to the smoke, but thrusts the smoke throughout the throat, lungs, and nose, all of which are lined with a specially sensitive membrane of great absorptive capacity. Thus from the smoke of the cigarette the system takes up many times as much poison as it takes up from the uninhaled smoke of the pipe or cigar. Indeed, it may be added that the purer and higher the grade of the tobacco, the more harmful it is to the smoker, for the more will it tempt him into inhalation. Another danger of certain brands of cigarettes, principally the costly imported and specially flavored brands, is that to the extraordinary dangers of nicotine-poisoning found in all cigarettes are added in these higher grades the perils of their flavoring materials, from which even so dangerous a drug as opium is not always absent.

I believe that the evil effects of tobacco will be much more apparent in the next generation than they are in this; for forty years ago, when I was a boy, the lad who decided to begin to smoke knew nothing of cigarettes, and had only the pipe and the cheap cigar to choose between, forms so overpowering that they frequently discouraged him at the start. Thus many were undoubtedly saved from the tobacco habit; but now, with mild cigarettes upon the market, at very low prices, and in most States found on sale in every candy store, the situation has perils undreamed of at that earlier period. It is noteworthy that cigarettes are “doped” expressly to allay nausea, which is the normal effect of tobacco-smoking upon the uninured human system, and at the same time to quiet that motor unrest which is the first symptom to follow the introduction of nicotine into the human system. The narcotic effect of the adulterant drugs is therefore to ease the smoker’s first pang and to make him more quickly the victim of the tobacco habit.

The smoker of cigarettes gets his narcotic by precisely the same mechanical process through which the opium-smoker gets his. The opium-smoker would find it far too long and expensive a process to obtain the desired effect from opium by taking it into his stomach; but by burning a very much smaller quantity of the drug and bringing it into contact with the sensitive absorbent tissues of the throat and nose, he obtains the narcotic effect that his system craves.

THE USE OF TOBACCO DESTROYS MORAL DISCIPLINE

I am convinced that the use of cigarettes is responsible for the undoing of seventy-five per cent. of the boys who go wrong. Few boys wait until they are mature and their resistance is at its maximum before they begin the use of tobacco. It would be remarkable if they did wait, for their fathers and their older brothers are constantly blowing smoke into their faces. Even where restrictive laws exist, minors find no difficulty in obtaining cigarettes, so that children of the age that is most easily harmed by the use of tobacco now habitually indulge in its most harmful form.

There is another unfortunate effect of the use of tobacco by boys. When they begin to smoke, they do so against the wishes and usually against the orders of their parents. This means broken discipline and deception. The boy who endeavors to conceal the fact that he smokes is started along a path that is even more harmful than tobacco. He has to invent excuses for being absent from home, and to explain away the odor of tobacco that is sure to cling to him; and when a boy begins to lie about these things, he will lie about others. So far as truth goes, the bars are down. Furthermore, he has to spend more money. Unless he is one of those unfortunate youths who are not held to a moderate weekly allowance, too often he will resort to dishonest means to obtain the money to satisfy his newly acquired taste.

And that is not all. Boys who spend their time in smoking go where they will find other lads also engaged in the forbidden habit. They find congenial groups in pool-rooms, where they learn to gamble, and in the back rooms of saloons, where they learn to drink. The step from the pool-room or the saloon to other gambling-places and to drinking-places frequented by the unworthy of both sexes is an easy one. Thus the boy whose first wrong-doing was the smoking of cigarettes against the wishes of his parents soon becomes the target for all manner of immoral influences.

In these days of advanced sociological study, when the mind of the world is set upon efficiency, it is astonishing that so little attention has been given to the effect of tobacco upon the young. To mankind at the present time nothing in the world is so important as the conservation of the boy. Humanity might well make any sacrifice conceivable in order to keep its boys clean. Keeping boys clean means keeping girls clean, and whatever keeps boys and girls clean purifies humanity as a whole. In other words, the boy is the most important thing in the world, and his cleanliness the most vital issue. Setting aside entirely the deleterious effect of nicotine upon his physical system, early smoking, which usually means the cigarette, is the most harmful single influence that is at present working against his welfare. We can appreciate the terrific total harm which tobacco does to youth, however, only when we add the psychological harm and the physical harm together. Everything considered, the question is an appalling one.

THE TEMPTATION TO USE TOBACCO

It is impossible to blame most boys very severely for yielding to the smoke-temptation; therefore it becomes a difficult matter to blame them for the wrong-doing which tends to follow it. Their error is only the continuation of a similar error that their fathers have made before them and now tacitly encourage. It is difficult to make any lad believe that he need not be a fool because his father is one. Yet in most cases to save a boy from the demonstrable ills of tobacco-using entails just this course of reasoning. Orators and essayists from the beginning of time have found a stumbling-block in preaching to their followers virtues they admire and value, but do not themselves possess. The father who forbids his son to smoke because it is harmful and expensive, while his own person reeks with it, is not likely to impress the lad very vividly with either the force or the honesty of his argument. More than one parent has found himself abashed in such circumstances by a son with logic and intelligence. For such a parent there is only one really honest course—to admit to his son that he himself has been a fool, but that he does not wish his son to follow in his footsteps.

THE NECESSITY OF EDUCATION CONCERNING THE DANGER OF TOBACCO

There is no question in my mind that this matter of tobacco should be made the basis of a very thorough educational campaign among the youth of the United States. The shocking spread of the tobacco habit among the women of American cities indicates, moreover, need for extending this instruction to girls as well.

If cleanliness of body is next to godliness, then cleanliness of mind is godliness, and cleanliness of mind, real cleanliness, is impossible while ignorance exists. Nothing in education is more generally neglected than the enlightenment of the young—an enlightenment which can come only from the mouths of elders who are themselves clean—as to the deadly nature of alcohol, habit-forming drugs, and tobacco. I should very much dislike to send a young and impressionable son for instruction in any subject to any teacher, male or female, who used cigarettes. Thousands upon thousands of parents in this country feel as I do on this subject; but while they realize the danger which might result from the influence of a teacher who smokes, they utterly neglect the far more dangerous and powerful influence of a father who smokes. To my mind, however, it is essential that parents should seriously consider the personal character of the men to whom they intrust the education of their boys.

But the use of tobacco reaches far beyond the home circle and the schools and even pollutes the atmosphere of the church itself. There are few clergymen in the United States who do not use tobacco, and so a clean father who rears a clean son is under the tragic necessity of urging his attendance at a dirty church, and later on sending him to be a student in a dirty college, for the simple reason that there are no clean ones.

Society seems to have been viciously organized for the destruction of the boy, in whom lies its chief hope of preservation and improvement. The boy who keeps clean does so against tremendous odds, to which frequently his father, his school-teacher, and his clergyman are the chief contributors. A dozen times during every day of his life he is subjected to the third degree of temptation, and twice out of three times this ordeal is thrust upon him by the very persons who really should do most to safeguard and protect him. And now that society has set its sanction upon the use of tobacco by the women of the nation, he is confronted with the further peril of a mother who smokes. It seems to me that this tobacco question detracts enormously from that very vivid hope we might feel for the rising generation, which is also handicapped with alcohol and drugs.

TOBACCO ADDICTION MORE DANGEROUS THAN DRUG HABIT OR ALCOHOLISM

I have no desire to moralize upon the subject of tobacco. I am not a moralist, but a practical student of cause and effect, urging the elimination of bad causes so that bad effects may be eliminated in turn. A very wide experience in studying the result of the use of narcotics has convinced me that the total harm done by tobacco is greater than that done by alcohol or drugs. Nothing else at the present time is contributing so surely to the degeneration of mankind as tobacco, because, while its damage is less immediately acute than that done by alcohol or habit-forming drugs, it is, aside from its own evil effects, a tremendous contributory factor to the use of both. There is nothing to be said in its favor save that it gives pleasure, and this argument has no more force in the case of tobacco than in the case of opium. Any man who uses tobacco poisons himself, and the very openness and permissibility of the vice serve to make the process of self-poisoning dangerous to the public as well.

To sum up, the tobacco habit is useless and harmful to the man who yields to it; it is malodorous and filthy, and therefore an infringement upon the rights and comforts of others. Its relation to alcohol is direct and intimate. When an alcoholic comes to me for treatment, I do not regard my chances of success with him as good unless I can make him see that to abandon smoking is a necessary step in his treatment. My deductions concerning the intimate relationship between the use of tobacco and liquors are the result of years of observation and study. And if it is true that no man whose system is alcoholic is fit to be the father of a child, it is no less true that the habitual smoker is also unworthy to be a guardian of his kind. The alcoholic fiend almost invariably becomes the parent of children provided with defective nervous systems, of children as definitely deformed nervously as they would be physically if born with club-feet or hare-lips.

CHAPTER X

There is also a class of institutions in which the “cure” for the drug habit consists in the administration of the drug itself in a disguised form. In such surroundings a patient will contentedly stay indefinitely, for the chains of his habit bind him to the spot. The very fact that he wishes to stay may be accepted as a proof that he has not been benefited by it. For the man who has been freed from a drug habit desires a normal life in the world; indeed, only his reëntrance into its turmoil and bustle can set him surely on his feet.

The average sanatorium, accustomed to the time-honored and thoroughly established system of making its patients comfortable,—in other words, pampering and coddling them,—finds it difficult, if not impossible, to conform in every detail to the necessities of a system like mine.

Even if the institution is equipped with every possible facility, it is highly probable that the physicians in charge may be mentally unfitted to the work. Inured by every detail of their training to methods that make a successful treatment of drugs impossible, they find themselves incapable of changing when confronted by specific cases that demand a radically different treatment. The institutions themselves are equally inadaptable. The sanatorium, it must be remembered, is really a boarding-house or hotel, and the business of boarding-house or hotel, whether it presents an epicurean or “sanitary” bill of fare, or whether its staff is supplemented by trained nurses and physicians or not, remains a boarding-house or hotel. Its main province is to keep its paying guests and to make them comfortable.

The whole sanatorium situation so far as it relates to the “cure” of those addicted to the use of drugs and alcohol may be summed up in a few words. The average sanatorium is merely a small colony of drug-users. No one can deny that. Now, no man who has been freed from his desire for drugs and no one who is being made uncomfortable by deprivation will remain in such surroundings for any length of time. The natural conclusion is that such institutions are not accomplishing what they have promised to be able to accomplish. The inmates are still drug-users. This is not true of American institutions alone. Within a few months I have had as an eleven-day inmate of my own institution a very wealthy man who has made three European journeys to find relief from the drug habit, on each journey going the rounds of six or eight celebrated institutions, and taking the treatment of each without result. Successful treatment is brief treatment, and no establishment operating upon a system of a weekly charge to patients will make an earnest effort to release these patients as soon as possible. In their desire to make their patients comfortable, and so prolong their stay, their usual quantity of drugs is supplied to them, though of course in some disguised form. There is no other way of accomplishing this.

Moreover, so long as a patient is thus kept comfortable, he is unable to describe his symptoms, for he does not feel them. The drug, therefore, hides exactly those details of a man’s condition that it is essential for the attending physician to know. In a normal man the presence of pain is always a guide for a physician, but in a drugged case this is always absent. The constant drugging that conceals the symptoms of organic ailment may permit one of comparative insignificance at the time a patient entered a sanatorium to become incurable before he leaves. Thus the result of his stay may mean in the end a serious or even fatal deterioration.

And the prolonged stay becomes a means, intentional or unintentional, of mulcting the patient or his friends of money. The sum annually spent in the United States upon useless sanatorium treatment must certainly amount to millions. I have had patients come to me from such institutions to which they had paid sums as large as $10,000. Wealthy people are specially likely to become victims of this form of rapacity, and a mere glance at some of the receipted bills that I have seen in their possession is enough to stagger a modest financial imagination. The ingenuity with which a sanatorium manager devises “extras” is worthy of the name of genius. And the physically incurable patient is often retained in the sanatorium till his money or the money of his friends is exhausted in a needless sacrifice to greed.

THE PHYSICIAN’S ATTITUDE TOWARD THE DRUG-USER

It is also necessary to direct attention to some of the errors of the general medical practitioner who deals with cases of this sort. It is not unnatural for a doctor to hesitate at the thought of surrendering his patient into strange hands. There may be unselfish as well as purely mercenary reasons for this hesitation. The doctor may hope that he himself can aid the sufferer, and may therefore endeavor to administer this treatment either in the patient’s home or possibly in his own residence or private hospital. The patient is likely to be as much inclined to this course as the doctor, for the doctor is his friend and confidant, and he dislikes intensely the idea of revealing what he regards as the shameful secret of his enslaved soul to strangers’ ears. Treatment in the doctor’s or the patient’s own environment must of necessity be an expensive matter, but if the patient can afford it, he is likely to desire it. This is most natural, especially if the patient is one of the tens of thousands who have tried the treatment offered by a sanatorium and found it not only valueless, but horrifying. There are, too, many patients who from sheer lack of funds naturally desire a home administration of the treatment as a means of saving expense. Of course many of the most worthy cases are to be found among people of moderate or small means. The drug habit is itself impoverishing.

Even so I find myself irresistibly impelled to advise against any attempt to treat such cases in their own environment, or in any environment improvised by a local doctor. This I do only because I have known so many cases of utter failure, so many cases where the sufferer’s final hope has been destroyed by such experiments.

PRIVATE ADMINISTRATION OF TREATMENT NOT SUCCESSFUL

The friendship existing between a physician and his patient must often disarm the former and incapacitate him for the strict dealing that is required in a treatment like mine. The mere fact that in caring for a friend or one of his regular patients the doctor feels unwilling to exact a definite charge in advance is a certain handicap here, as is also the fact that each patient needs continual watching, and no doctor can afford to devote his entire time and constant medical attention to one patient. The average doctor in private practice, moreover, finds it impossible to secure upon demand nurses of sufficient moral responsibility and medical assistants of sufficient technical training to coöperate with him in the work. Above all, I find that only when the patient is on premises other than his own, in unfamiliar surroundings where he is subject to a strict and inviolable discipline, can the best results be obtained. The doctor who administers this treatment, if he is to win, must have every advantage. Hospital surroundings, unfamiliar nurses, and strange assistant doctors are of great value; but payment in advance may be regarded as the most effective means for inducing the patient to complete the necessary course. An amazing number of people have come to me who have confessed that while they have from time to time tried other treatments, they have never completed one of them. Others come in a skeptical frame of mind. I can mention one such who had been three times to Europe, each time on the advice of the very doctor who, as the patient was aware, had been responsible for his forming the habit.

No physician in private practice should ever attempt to relieve a patient from a drug habit in a manner incidental to the conduct of his practice, though it is nevertheless true that the temptation for doctors to attempt this are extraordinary. A patient who becomes aware that his physician knows of a treatment which will bring relief is likely to bring to bear upon the physician every possible pressure in the effort to induce him to administer it. The doctor must be liberal indeed who, having made such an attempt and failed to achieve good results with it, will acknowledge that he was mistaken at the start.

THE NECESSITY OF A FIXED CHARGE FOR TREATMENT

The advantage of a definite charge, paid in advance, was a discovery that I made early in my work. With a large proportion of my patients it would otherwise have been impossible for me to obtain the definite medical result which has characterized my work.

It is quite impossible to make an intelligently satisfactory mental or physical diagnosis of any patient brought to me until he has been entirely freed from the drug which he has been taking. As soon as this has been fully accomplished, it is possible to consider the case carefully. It is also necessary to make an invariable rule that no person entering my institution for treatment shall be permitted to come into contact with any other person who is there for treatment, for there can be nothing psychologically worse than the discussion of symptoms and the exchange of experiences among people under treatment. It is also a rule that in the institution physicians employed in the establishment shall not become intimate with the patients or spend with them any time not necessarily devoted to professional investigation and attendance.

Nurses also must be as businesslike as possible in all their relationships with patients, and must do as little hand-holding and sympathizing as possible even in the cases of ultra-nervous women patients. It is a principle of the average sanatorium to encourage the “sympathetic” nurse. Wittingly or unwittingly, the old-time sanatorium made a practice of manufacturing habitual sanatorium inmates. The most hopeless cases I have ever seen have been those who have become inured to wearing sanatorium stripes. Such will never change their tailor till their pocket-book becomes empty.

Another detail of my treatment not easily compassed in the average sanatorium is to consider every case as an individual case, to be dealt with individually. In private practice this is often overlooked, and to this I also attribute many failures in treatment. The individuality of every case must be borne in mind not only throughout the treatment itself, but afterward, during the period of recuperation. The case itself is sure to indicate in some measure the further treatment which should be followed in the period immediately succeeding the patient’s discharge from my institution, and very frequently indicates, in fact, the necessity for consultation with other specialists and for a surgical operation. After the patient has been relieved of drugs comes the time to begin the necessary physical upbuilding by means of exercise. Although I may have seemed to condemn the sanatorium, I must add now that some institutions are specially qualified to assist in this building-up process. Some health-building institutions that devote their entire attention to strengthening their patients by means of physical exercise are doing wonderfully good work.

The fact that my methods in treating these cases have prevented me, and will prevent me, from becoming directly or indirectly interested in any institution other than my own, in New York City, gives me a freedom in offering advice to patients concerning what they should do after they have left my care that I should not feel if my institution were operated upon the old-time keep-them-as-long-as-you-can plan. I find it possible to suggest physical exercise and even professional training to those who especially need it with entire disinterestedness, just as I find it possible to suggest to some an investigation of some religious influence.

It must be laid down as an axiom that the patient must have a mental as well as a physical change before the treatment can accomplish all the good of which it is capable. Such a mental change is highly improbable in the comfortable surroundings of the average sanatorium. No man or woman ever achieved it by sitting on a pleasant veranda in an easy-chair exchanging tales of symptoms with other invalids.

THE REASON FOR THE FIXED CHARGE

The principal consideration which has influenced me in shaping my policy of a definite charge and limiting the length of stay of my patients has been the fact that I find it impossible when the effect of the drug has been perfectly eliminated to hold most of the patients under restraint. The man who has won freedom from his habit feels sure of himself; he desires to get away, and he is not afraid to go out into the world, where it may be possible for him to get the drug again. He will not yield to the temptation to get it, partly because he will not want it, and partly because he knows the horror of the habit and does not wish to become involved in it again. As a matter of fact, one of the hardest tasks I have is that of inducing people to stay as long with us as we think necessary, although their prolonged stay means no additional payment to us and no additional expense to them.

That is one of the principal arguments against colonization; and it is as much an argument against the average municipal or state institution as it is against the average sanatorium. The theory of colonization in this matter is all wrong.

The question of a definite charge has as much influence on my own attitude as on that of the patient. From the fact that I know when a patient enters my house that I can get no further money from him or her beyond the advance payment I gain a distinct advantage. I do not feel it necessary to cater to my patient’s whims, nor do I feel it necessary to sacrifice any portion of the necessary routine of the treatment because the patient may be rich or influential and may make extraordinary demands upon me. All that I have to do is to go ahead along those lines which I know are effective and which will gain results.

The effect of this system is equally admirable upon the members of my medical staff, for our efforts are devoted not to keeping the patient as long as possible for the purpose of increasing revenue but to getting rid of him as quickly as possible, so that the profit will be relatively large. That it is to his advantage as well as to mine to see that the treatment is complete and effective before the patient leaves is obvious.

These methods take into consideration my own and my patient’s psychology. A man who deals with this type of patient needs every advantage which he can get, for invariably he is dealing with abnormalities.

PHYSICAL DEFECTS REVEALED BY TREATMENT

The treatment itself is certain to uncover these abnormalities, revealing whether or not they are due to physical causes. It becomes very quickly evident if there is any real physical reason why a patient is not eligible for treatment, as in the case of an incurable and painful physical ailment. No matter how careful and frank a patient’s statements may be or how elaborate the diagnosis that his physician has transmitted to me, no matter how elaborately careful are the preliminary examinations made by my own physician, it is not until the drug has been entirely eliminated that we find it possible to make a really intelligent diagnosis. The symptoms of disease, however, are sure to appear before the first part of the treatment is completed. It is a standard policy of my hospital at once to inform a patient who has proved to be physically ineligible, and to return to him his fee.

This method of procedure has made us careful before accepting patients to study their histories, for, naturally, we do not wish to do even preliminary work and then return the fee in full. We accept no patient for treatment until we are provided with a careful and detailed history of his case, and it is upon a large collection of such histories that I have based many of the theories embodied in the subject matter of this book. It is especially these detailed histories which have enabled me to fix with some accuracy of judgment the circumstances leading up to the formation of most drug habits. In our invariable practice of returning the fee and discharging the patient whom we find ineligible for treatment we have surely taken a step in advance. There is scarcely an institution of this sort in the United States to which a patient might write, “I am taking drugs,” without receiving in reply the invitation, “Come to us, and we will treat you,” implying that they will give the treatment whether or not an examination of the patient shows that he is one who can benefit from it.

THE DUTY OF THE MEDICAL PROFESSION

The victim of drugs, whether he is rich or poor, old or young, good or bad, deserves the public sympathy in a measure scarcely equaled by any other class. These folk are sick folk in every way I can possibly think of. I am attempting to see to it that they are protected by every safeguard from being victimized. It is my hope that through continual and untiring education I may force the state medical institutions throughout the country to assume their rightful responsibility in providing proper care for drug victims who have slight means or none. I purpose to work toward the awakening of the medical profession to its responsibility not only in regard to the growth of new crops of drug-users, but to the care and relief or sequestration from medical practice of those among its own members whose condition warrants action.

Perhaps this last step should be the first one to be taken. I have given it much thought, and can see only one way out of the veritably infernal tangle in which the medical profession has enmeshed itself. That would involve a conference between delegates from the medical societies of the various States to form a plan whereby the medical profession as a whole or in groups might establish and support an institution or a number of institutions. These should be backed by the most eminent and conscientious men in the profession. They should be managed by men fully competent, and should be open not only to physicians who need treatment and are unable to pay for it at a private institution, but to all patients, in the certainty that there they will receive the proper treatment, properly administered, and at a reasonable charge. I purpose furthermore that every institution under private management in the United States shall by law be held responsible for its methods of treatment.

LEGISLATION TO REGULATE SANATORIUMS

There should be the most drastic legislation compelling all physicians and institutions accepting this class of patients for treatment to report periodically to the board of health which has jurisdiction in their district whenever, after a three weeks’ medical supervision, they still require the administration of habit-forming drugs. It is only reasonable that any institution accepting a patient for this treatment, and failing to secure favorable results within a period of twenty-one days, should report the case to the authorities, giving detailed reasons for the failure of the patient to respond to treatment.

The general adoption of this rule of procedure would mean that a class of unfortunates who have never had any protection from any source would be immediately provided with definite medical help. An accompanying provision would insist that patients who for physical reasons are found to be ineligible for treatment—unable, that is, to exist in comfort without regular doses of their drug—will be relieved of all sense of disgrace arising from this necessity, and will be preserved from victimization, and will find it possible to get the drug without difficulty and at reasonable prices, if necessary, from the boards of health themselves. If this plan accomplished nothing more than to prevent the operation of medical fraud against sufferers for a period longer than three weeks, it would even then have accomplished an extraordinary good.

I have in my present hospital only fifty beds, and as a rule I receive and discharge about four patients a day. Were my institution operated along the colonization lines which are common in the United States, the volume of business which I handle in a year, running well above a thousand patients, would require not fifty, but at least five hundred beds, and rooms in proportion. This statement of the exact situation in my own institution may possibly explain existing conditions in some others.

It must not be understood that I attribute all the efforts at colonizing drug-users to unworthy motives. Much of it has been due to the complete ignorance of the medical profession in regard to this form of affliction. Finding itself unable intelligently to cope with conditions, it seeks the line of least resistance and adopts the colonizing sanatorium, with all its evils, as the best plan that can be found. When I first took up this work I went for information and assistance not to the humble members of the medical profession, but to the most eminent men whom I could find. Even these men invariably admitted their ignorance of the nature of the drug habit and the means for its relief. I was told by some of the best-known neurologists in the world that out of thousands of patients whom they and their confrères had sent to the best-known and most conscientiously operated institutions in the country not one had really been helped. They assured me that if I had found something which would give actual and material aid in any degree to even five per cent. of the drug victims who were sent to me for treatment, I would be doing more than any man had ever done before.

CHAPTER XI

THE NEED FOR PRACTICAL INSTRUCTION

At the present time there is in existence no clinic or other practical place of demonstration where a doctor can get competent instruction in this important branch of medical work. I hope the time will come when it may be possible for me to offer to the medical profession a clinic where the professional student may prepare for this line of effort as effectively as he may now prepare himself for any special work, like nose and throat diseases. This can come about only through some arrangement in which I have no financial interest.

SKEPTICISM OF THE MEDICAL PROFESSION

I am fully aware that I must first overcome a strong undercurrent of skepticism among the members of the medical profession. The efficacy of the treatment must be proved. Even among the best-informed physicians it is a popular belief that the treatment which I announce as simple is really an impossibility. No matter what the doctor has hoped that he might do, he has been told by text-books and articles in medical periodicals that it cannot be done. This fallacious teaching must be counteracted before much can be accomplished, and in the progress of the work many traditions of the profession must be violated. Before he can hope to accomplish anything of importance in the administration of my method of treatment, the physician must understand that the length of time a drug-user has been taking the drug, the quantity that he has taken, and the manner of its administration are matters of no consequence. Short histories and small amounts, long histories and large amounts, are all one when it comes to the administration of this treatment. I went to Dr. Richard C. Cabot of Boston with a letter of introduction from Dr. Alexander Lambert of New York, whom he knew well and admired. He listened to my statement of the facts which I have just set forth.

“I have heard what you say, but I shall not believe it until it has been demonstrated to me,” he declared.

I demonstrated it, and convinced him. A similar skepticism remains general throughout the medical profession.

The experience that the medical profession has already had in New York State as the result of prohibitive legislation indicates the many problems that arise immediately after the drug is put beyond the reach of those who have acquired the habit. It is only natural that the unscrupulous should seek to take advantage of the opportunities created by this situation. Without proper treatment, an habitual drug-user cannot endure the agony of deprivation until a definite physiological change has occurred; so that unless the medical profession is informed of this fact, and the community at large is provided with facilities for the administration of the required treatment, it is almost inevitable that restrictive measures will be followed immediately by the victimization of the unfortunate by the unscrupulous. One detail of the peril to society which may accrue from a general cessation of the drug traffic without the provision of proper facilities for the care of those who have been its victims is that those who are accustomed to drugs, on being suddenly deprived of them, almost invariably turn to alcohol for stimulation and, without being the least relieved of the drug habit, with abnormal speed become alcoholics. Modern society presents few spectacles of suffering more acute than that endured by the drunken drug-fiend. Few persons, moreover, are so dangerous to its welfare.

MEDICAL ETHICS

Constantly I must lay emphasis upon the responsibility of the physician in regard to drug habits. This phase of the subject must be an ever-recurring one, because the whole unpleasant situation has grown out of medical ignorance. While treatment for drug-users is at last making headway, for a long time experimentation had no chance save with a small number of broad-minded and bright-minded doctors who were able to shake off the shackles that held the less intelligent members of their profession.

When I made public the formulas of my treatment, I did not understand this phase of medical ethics. I assumed that certain dangers might arise from the probable activities of the omnipresent medical faker, who without any genuine effort to administer my treatment properly would advertise it widely, and thus victimize the innocent. I also assumed that the medical profession would eagerly grasp the idea, put the treatment into operation, to their own benefit and that of the world at large, and by the very beneficence of their work far more than offset the harm the charlatans would do.

Both of these assumptions proved incorrect. The fakers avoided even counterfeiting my treatment, because the articles which had announced it in the medical and lay press had made its brevity clear to the public; they did not care to promote any treatment in which their victims would be justified in demanding immediate relief. From that real peril the community was thus saved. But the general indifference of the medical profession was equally surprising and at first somewhat discouraging. I have since decided, however, that this was perhaps fortunate; for as the work develops, it becomes more and more apparent that it is a strictly hospital treatment, and cannot often be successfully administered in the environment of the home or in the regular course of a general practitioner’s daily work.

In another part of this book I shall have more to say about the medical buzzards who, working outside of medical ethics and in defiance of the usually admirable spirit of the profession as a whole, without regard to financial or ethical honesty, indulge in whatever practices seem to promise them the greatest profit. How dangerous these men are not only to the patient, but to the profession has many times been illustrated. Various medical discoveries imported from abroad or achieved and announced by eminent American medical men have brought flocks of unscrupulous practitioners to New York, not with the progressive desire to study and honestly apply these new theories for the benefit of their patients, but with the idea of learning barely enough about them to enable them to offer credulous sufferers cheap and worthless counterfeits at exorbitant rates. Where secret methods have been heralded, they have bid against one another frantically to secure locality privileges, working to this end with all the fierce competitive enthusiasm shown by eager commercialists seeking county rights to a practical and popular patent flat-iron. It is my earnest hope that the wave of reform which has begun in New York State, and which undoubtedly will carry new and effective drug legislation into every State of the Union before it loses its forward impulse, may not revitalize these unworthy schemers. It was partly the hope of preventing this evil that led to the writing of this book.

The progress of intelligent legislation will fill the land with much suffering from the tortures of drug deprivation. Therefore events have placed a solemn obligation upon the medical profession to satisfy itself of the efficacy of my treatment, even though a new organization for that purpose should be necessary. After the profession is assured of the value of the treatment, many should achieve competence in its administration. Then it will become a matter of duty to see that every community is provided with facilities and a staff of experts sufficient to meet the special needs that may arise there. If such an organization should be formed, I should be glad to devote my services to it.

THE AUTHOR’S EXPERIENCE WITH THE DRUG HABIT

My opportunities for observation in this field have extended over fourteen years of constant study. They have included investigations in the Orient and Europe as well as in the United States, and have dealt with patients of every class. Early in my work I found it difficult to secure subjects, and presently saw that I could do so only by personally searching the under-world for them.

It was a complicated task, full of unexpected problems. As I could not engage salaried people for the carrying out of the details of the treatment, it became necessary for me to do everything except the medical work, and to assume all except the medical responsibility. But what I at first deemed a hardship proved in the end to be an advantage, for if I had had plenty of money with which to carry on my work, I should never have mastered its details.

It may be that the need for making the work strictly self-supporting from the start led to one of my first important psychological discoveries: that any person worth saving is either able to pay a reasonable amount for treatment or can make the price of it a deferred obligation of such a character that it will certainly be met. The experience from which this and other statements in this book have been deduced is not an experience gained from casual or even regular daily calls of a few minutes or a few hours upon the patients under treatment, but is due to years in which I have frequently spent twenty-two hours out of every twenty-four in the same building with them, and subject to their constant call.

After having proved the efficacy of treatment at home it seemed advisable to make a journey to the Orient, where drug habits were notoriously more common than elsewhere. It was the desire to study them at first hand and literally by wholesale which led me to China, where I opened three hospitals, and in the course of eleven months supervised the treatment for the opium habit of over four thousand Chinese. During this period I treated all who presented themselves, the ages of those to whom relief was given ranging from eighteen to seventy-six. Among the four thousand patients not one fatality occurred, although many of them were extreme cases, and I was able to obtain the assistance of only one foreign physician who could be considered responsible. The rest of the work was done by untrained Chinese boys, who administered the capsules at stated hours, and not one of whom was capable of intelligently counting a patient’s pulse.

I have said that not one fatality occurred. It is pleasant for me to add that during the whole fourteen years of my practice, although I have had thousands under treatment, many of them in exceedingly bad physical condition at the time the treatment was begun, with their drug symptoms complicated by various and serious physical ailments and often accented by alcoholism, only four cases have died.

SUCCESSFUL ACHIEVEMENTS IN THE CURE OF DRUG-USERS

A new precedent has been established with cases of this character in the course of my hospital experience. For the first time the treatment has been reduced to a definite hospital system, during which the resident physician is never divorced from his patient, and in the course of which complete and elaborate bedside histories and charts are kept. I have in my possession at the present moment the complete bedside notes of every patient to whom my treatment has ever been administered. I call attention to this fact because it shows that the work has not been hit or miss, but has been as carefully systematized and made as highly scientific as it has been possible to make it.

A second precedent has been set, as is proved by the fact that within a brief time any case of drug or alcoholic habit that is not complicated by physical disabilities due to other causes can be successfully treated in a few days without heroic methods and without risk.

This has at once proved the fallacy of old methods. It has demonstrated how false, for instance, is the principle of colonization. As I have said, drug cases should never be colonized, and among alcoholics only the absolutely hopeless inebriate should be subjected to this method of treatment. With the latter, of course, there is no chance of real relief, so that here colonization offers a means of relieving society of all of the burden upon the police which the inebriate’s freedom necessarily implies, and from a large part of the economic burden which his existence entails upon the community.

MAKING SANATORIUM CONVICTS

For drug-users colonization is the worst possible treatment that can be followed. From what I know of the conduct of the average sanatorium at this time in the United States, I feel absolutely certain that no person could possibly be helped if sent there, and I am convinced that definite and virtually incalculable harm would be the almost inevitable result of following such a course. Drug-users, as well as alcoholics, who are sent officially or otherwise to institutions of this character become what are called “sanatorium convicts.” These cases are virtually hopeless, and are little less pitiable than that of the “lifer” in a prison. There are in the United States many people of the better class who through no fault of their own have became afflicted with the drug-habit, and who have drifted from bad to worse until a sanatorium has been the only recourse left.

Treatment for drug and alcoholic habits and treatment tending toward the recuperation of the patient cannot be carried out together with one patient or even simultaneously with several patients in the same institution. An understanding of this fact has placed me in an advantageous position for giving advice about whatever remains to be done when a patient is ready to leave my hospital. I have always worked in the closest and most perfect harmony with physicians who have sent cases to me and have never permitted any of the doctors employed in my institution to visit a patient who has left my care. On the other hand, no physician who has brought a patient to my hospital has ever been divorced from him as a result of his stay with us.

ACCURATE DIAGNOSIS POSSIBLE AFTER TREATMENT

Physical revelations which follow the unpoisoning of patients frequently startle the patients themselves as well as the physicians who have their well-being in charge for long periods. Nor are the mental revelations less astonishing. There have been many cases, after the unpoisoning was complete, in which a man or woman has been found to be as seriously ailing mentally as others have been found ailing physically. Drugs and alcohol, especially drugs, have frequently been responsible for extraordinary mental and moral twists. But it must be maintained that the use of drug or liquor is usually the result rather than the cause of such conditions. There are many cases in which no type of medical help will bring about satisfactory permanent results, though other victims, after the elimination of alcohol or narcotics, quickly take their places as useful and admirable members of society.

The problem confronting the physiologist after a patient has been relieved of a drug or drink habit is comparatively simple. If this relief makes diagnosis possible and reveals the existence of an unsuspected, but curable, ailment, the course to follow is obvious. With the psychologist the problem is frequently far more complicated. The useless citizen who becomes a drug- or drink-user will remain a useless citizen after the drug or drink habit has been eliminated.

To this class belong most of those who readily relapse into their old habits after their systems have been thoroughly cleared of the physiological demand for the substance of their habit. Thus perhaps the most important query the psychologist interested in this work must ask after the treatment of a patient is, What is left of value, and what can be done with it? It is a curious fact that usually more is left in the case of a poor than in the case of a rich patient. No one is so hopeless as the vagrant rich. No man will ever make a reputation in work of this character who deals wholly or even principally with people to whom money has no value.

UNPOISONING THE USER IS ONLY THE FIRST STEP

My work has brought me to the conclusion that few physicians seem able accurately to classify their own patients. Even the specialist in psychology, who should be able to weigh all the details of men’s mental and moral as well as physical being, seems likely to go astray when he considers a psychology that has been affected either by drink or drugs. Many physicians seem to be imbued with the idea that after a patient has once been through the process of treatment for a drug or drink habit he will be entirely made over; but the fact is that the elimination of drugs or drink from a degenerate will not eliminate degeneracy. Nothing, in fact, will eliminate it except stopping the breeding of degenerates.

In my work I have found it necessary sometimes to seek advice from as many as half a dozen physical and psychological specialists in connection with one case. While instances have been very numerous in which several specialists have been really required for the welfare of the patient, the need had been so thoroughly concealed by the patient’s drug habit that it was not apparent until the effect of the drugs was thoroughly eliminated.

NECESSITY FOR CAREFUL PSYCHOLOGICAL STUDY

In most instances expert treatment for the mental condition after drug or drink elimination is as essential as expert attention from the doctor of medicine, and if success is to be achieved, must be regarded as an entirely separate task. Habitual users of drugs or drink are literally human derelicts. The symptoms of their true condition are submerged, and to clear them of their concealed weaknesses it is necessary to lift them like a barnacle-ridden hulk into the dry-dock for investigation and repair.

I regard as a preferred risk among the victims of the drug habits those who have acquired it through the administration of a narcotic by physicians in time of pain or illness. Such a case, if treated before too great a deterioration has taken place, may be considered almost certain of relief, provided no other ailment discloses itself.

On the other hand, where the drug habit is the direct or indirect result of alcoholic dissipation or sexual excesses, or is a social vice, the case is extra-hazardous. Here the lack of moral standards and the loss of pride are serious handicaps. These matters are of extreme importance to the physician who is considering the care or treatment of cases of a drug habit. That he should classify his subjects of investigation, recognizing the hopeful ones and admitting the hopeless to be hopeless, is essential to successful work. He must know the material with which he has to work; familiarity with his material is as necessary to him as it is to the carpenter. Many cases have been brought to us that we have declined to accept because we could hope to accomplish nothing with them. Not long after I began my work I tried to help a man against my better judgment; I felt reasonably sure that he lacked the worthy qualities that would make him cling to and appreciate whatever advantages the treatment might afford. My estimate of his character proved to be correct; the man relapsed, and became a traveling liability on me, a reproach against my institution and my treatment.

THE HOPELESS CASE

I have already said that the idle rich to whom money has no value cannot usually be classed among hopeful subjects for treatment. The same may be said of those for whom others take financial responsibility, paying the cost of their treatment. If such cases do not already belong in the human scrap-heap, this mistaken kindness is very likely to place them there.

However, I believe that those among this class who have become public charges and refuse to work should be forced to do so by state or municipal authority. Society or their own families should not bear the burden of their useless existence. They should be segregated in some place where they will be physically comfortable, where they may be made industrious and useful, and where a separation of the sexes will prevent the increase of their worthless kind. My judgment is that the man or woman who through the vagaries of his or her own disposition has once been forced to wear the stripes of disgrace is likely to employ the same tailor during the rest of his or her life. Such persons will become permanent boarders at one or another of the places provided for the seclusion of the worthless. It is well that where they are first sequestrated there they should be permanently kept. Through this course alone society will be spared the periodical havoc they will be sure to work during their intervals of freedom.

IMPERSONAL RELATIONS BETWEEN PHYSICIAN AND PATIENT NECESSARY

Certain dangers inevitably arise where an intimacy exists between doctor and patient, since few physicians are morally so constituted that they will order a prosperous patient to do this or that or find another physician. In other words, instances have not been uncommon where the toleration of physicians for unfortunate practices among their patients has had its basis, and perhaps one not entirely inexcusable in these days of high pressure from professional competition, in self-interest. Social relations also have often led physicians to tolerate practices that they knew to be harmful to their patients and to the community. A patient who is a member of an influential club or a fashionable church is likely to be an asset of exceptional value to the physician whom he patronizes, for he is likely to recommend him to his friends. Good business management on the physician’s part leads him to keep such a patient good natured and comfortable, and to keep him comfortable means, among other things, to keep him free from pain. Where the patient suffers from an incurable malady, the use of drugs is not only excusable, but commendable; but instances are all too frequent where the malady is not incurable, but only puzzling and beyond the average practitioner’s power of diagnosis, so that he covers up his ignorance by the administration of pain-deadening substances. Patients who invariably and promptly pay their bills are sometimes in a position where they can tell a doctor what to do; whereas it should be the doctor’s unalterable resolution to retain the upper hand. Instances of this kind are far less grave in connection with the use of alcohol than in connection with the use of drugs; the physician may be said almost never to play any part in the establishment of an alcoholic habit among his patients, while he has surely played a most important part in the spread of drug habits.