Drug Abuse

Before an examination of what has been written on the pathology of chronic opium intoxication—the somatic and psychic changes brought about in the individual by the chronic use of this drug--attention should be drawn to the opinions recorded from time to time on the general nature of this condition. It is natural that the more or less active consideration of the whole problem has led, especially within the last decade or two, to the expression of opinions on this phase of the subject by all classes of writers. These authors include those qualified by reason of their technical knowledge and experience in handling these cases to speak with authority, as well as those whose limited equipment but keen interest have prompted them to offer their views. Whatever their foundation in fact, it readily may be seen that the free expression of such opinions has played an influential part in shaping current medical and lay conceptions and not infrequently has determined, whether warrantably or otherwise, the treatment of individual cases and public efforts at control. A careful evaluation of the material on pathology presented in the next chapter may assist in a determination of the relative strength or weakness of these opinions.
Just when the chronic use of opium and its train of symptoms first were described we do not know. From the point of view of the development of this practice in Europe and later in America, however, it is sufficient to note that at least from the beginning of the seventeenth century on through what we may regard as the beginning of scientific medicine, opium was employed in the treatment of practically every human ailment and writers called attention to the condition which they variously designated as a vice, habit, appetite, disease, etc.
George B. Wood-1856.1
While not attempting to define the condition of chronic opium intoxication, Wood depicts it as follows:

"Occasionally the medical man is consulted in this country by the slaves of opium, and has the opportunity of witnessing the consequences of its excessive abuse. In his own therapeutic observation, he also witnesses frequent disturbances must exist in those who use it as a luxury within the same limits. The greatest sufferings, experienced. by the opium-eater, are those which attend the state of nervous depression, always existing when its direct influence is no longer felt. There are excessive restlessness, a universal and indescribable uneasiness, feelings of intolerable distress, especially in the epigastrium and lower extremities, an irksome sense, moreover, of incapacity both for intellectual exertion, and for mental or emotional enjoyment, constituting together a state of exquisite misery, from which the only relief is by renewed recourse to the stimulus, which, if taken in an increasing dose, renders him happy again, and again capable of exertion; and thus he goes on, in an alternation of lessening comfort and increasing misery, to the end. At the same time, there is a gradual depravation of the functions, which impairs the degree of health though it may not very materially shorten life, unless the indulgence be carried to great excess. The ordinary derangements of the organic functions are impaired appetite and digestion, habitual constipation, and defective action of the liver; those of the animal functions, tremors, wakefulness, weakened memory and intellect, and loss of interest in the usual concerns of life, and social relations. The lowest stage of degradation has been attained, when the indulgence ends in a total loss of self-respect, and indifference to the opinions of the community; and everything is sacrificed to the insatiable demands. of vice. Not infrequently, this habit of excess has been engendered by the supposed necessity of obtaining relief from painful affections, such as cancer, and certain incurable cases of neuralgia; but, though some palliation, this is no satisfactory excuse, for, by proper management considerable relief of pain can generally be obtained, without an excess sufficient to degrade the mind, or even materially the general health; and it is rather a weak yielding to the seductive pleasures of opium, than any necessity for its anodyne influence, that leads to the lowest depths of the evil."

Alonzo Calkins-1871.2

Calkins emphasizes the psychologic symptoms of chronic opium intoxication and the moral depravity as evidenced for the most part by oriental opium smokers, describing the condition as a morbid appetite or habit.

E. Levinstein-1878.3

According to Harrer's translation of "Die Morphiumsucht," Levin-stein takes issue with those who describe the conditions as a "mental alienation" and claims that

. . every person, whether of a strong or of a weak constitution, has a tendency towards a morbid craving for morphia if from any disease he has become accustomed to injections of morphia, providing these injections are under his control. Consequently, the morbid craving for morphia injections ranks amongst the category of other human passions, such as smoking, gambling, greediness for profit, sexual excesses, etc. The desire for morphia injections, felt by all debilitated and nervous persons, who lack the power of resistance against it as soon as they have come to appreciate its effects, results from their natural constitution, and not from a certain predisposition for its use."

He further states:

"To describe the morbid craving for morphia as a mental disease it would be necessary, first of all, to show that the persons suffering therefrom are really impaired in their intellect and feelings. But this is by no means the case. I know a number of sick persons who are suffering from morbid craving for morphia in a high degree, and who, at the same time, are not only in the full possession of their intellectual faculties, but who have risen to, and still hold their place in the foremost rank of science and art. Authorities in military matters, artists, physicians, surgeons, bearing names of the highest reputation, are subject to this craving, without the least detriment to their capacities.
"Surely we cannot deem a person insane whose mind or intellect never, or at least only for a few minutes or some hours, suffers from a slight aberration but who is, on the contrary, mostly absorbed by his art or profession; who fulfills his duties to his government, his family, and his fellow citizens, in an irreproachable manner; and who takes a warm interest in all that gladdens the human heart."

C. W. Earle-1880.4

This author expresses the opinion that the opium habit like alcoholic excesses is a vice. He continues:

"When I say this I am aware that I am expressing an opinion at variance with that believed by the majority of the profession, and one which will be called by many most unscientific, If the eminent gentlemen known as neurologists throughout the land, and those occupying the positions of medical superintendents of inebriate asylums were called upon to cast a pebble in favor of or against this theory, I know full well how the vote would stand. It is becoming altogether too customary in these days to speak of a vice as a disease, and to excuse men and women for the performance and indulgence of certain acts which not only ruin themselves and families, but brings burden on the community, simply because they are not responsible for the act, excuse them because they have a disease.

"That the use of opium for a long time will produce diseased condition, I cannot deny. This is true of alcohol. It is true of gluttony. It is true in the case of the old lady who takes an immense amount of tea. It is true of the licentious man or woman. They are all habits frequently followed with dreadful results, and in many cases lingering and incurable diseases.
"That the responsibility of taking the opium or the whiskey, or the gluttonous use of food, in the one, or the use of a stimulating drink like tea in the other, or the undue and unbridled gratification of the sexual passions, is to be excused and called a disease, I am not willing for one moment to admit, and I propose to fight this pernicious doctrine as long as it is necessary."

Daniel Jouet,-1883.6

"Morphinism is not morphinomania. It is a group of morbid, somatic phenomena due to the continued abuse, for a longer or shorter time, of morphin and constituting a true clinical syndrome."

Constantin Schmidt-1889.°

"The condition is known as morphin sickness—la maladie de la morphine; other terms as morphinism, morphinomania, etc., designate only certain details of this condition. In considering the subject from a truly humane point of view and without prejudice, according to the principles of psychology, the origin, development and fatal termination of this malady sui generis, we must entirely reject the generally prevalent opinion to the effect that this condition is a vice or a luxurious indulgence of certain depraved beings and recognize that it is, on the contrary, a very grave psycho-physical state, and that these patients whose condition is deplorable are worthy of our sincere sympathy."

G. Pichon-1889.7

Pichon says that, however initiated, it is well established physiologically and chemically that any organism that has received morphin for a certain length of time requires increasing doses; this is a somatic need. No one, however intellectual, is an exception to this rule.

Paul Sollier-1894.8

Sollier states that the demorphinization of a morphinist consists in setting up in him a true experimental disease which shows a close analogy to what takes place in an infection.
Recent correspondence with Sollier has elicited the following supplementary statements:

"It is incomprehensible how morphinism can be considered as a simple psychic habit when morphin is a toxic substance which causes in the body symptoms and alterations which bring on degeneration and lead even to death. It is therefore like any other poisoning."

"Anyone exposed to the prolonged administration of opium or its derivatives may become a tnorphinist or an opiumist. A neuropathic or psychopathic constitution particularly predisposes to it."

"In France it is admitted that any person with neuropathic trouble can become a nuophinomane if he is subjected for any reason at all to the administration of morphin for a period long enough to cause tolerance, but we recognize also that many people have a peculiar tendency to become toxicomanes from the fact of their neuropathic or psychopathic condition and to attain it rapidly, which fact does not prevent physicians from administering morphin without first taking into account this tendency."

American Textbook of Applied Therapeutics-1896.°

"Morphinism is a disease both of the body and the mind, caused by chronic poisoning by morphin. When the disease is developed there exists an irresistible craving for the drug, and it is this artificial appetite that is the chief difficulty to be overcome in the treatment."

B. T. Deering and A. Lutaud-1899.1°

These authors state that they do not subscribe to the theory that morphinism is a psychosis but agree with Levinstein that any individual, no matter how constituted, is subject to the development of the condition when accustomed through some pathologic cause to injections of morphin which they also control. It cannot be placed, they say, in the category of other vicious habits such as the use of tobacco, gambling, etc.

William Gilman Thompson-1902."

"Morphinism is an uncontrollable craving for morphine, to satisfy which the patient takes the drug in constantly increasing doses, and sometimes at irregular intervals in large doses, as in alcoholism. . . . Those who have a strong neurotic inheritance are especially the victims of morphinism, and often give evidence of feeble will-power by addiction to other habits; thus the morphine-taker may indulge excessively in cocaine, chloral, opium-smoking, absinthe-drinking, or the use of alcohol in general."

James M. French-1903.12

French speaks of the condition as a habit and the patient as an nabitue.

Sir William Whitta-1908."

"Morphinism usually originates in the use of morphia or opium which has been prescribed for the relief of physical pain caused by some functional or organic disease. The relief of the physical suffering, if the latter is continuous or frequent, calls for increasing doses, till in a comparatively short time enormous quantities are necessary for the obliteration of the pain. It is not to the condition which culminates in the capacity for swallowing or injecting the colossal doses that the terms `Morphinism' and the 'Morphia-habit' are applicable. It is to the craving which the use of the drug engenders that these synonyms should be applied. Long after the disease which first called for the exhibition of. the narcotic has passed away, the individual, having experienced the pleasant stimulating effects of the drug, soon finds that he cannot exist without them. As the pleasurable sensations pass off there succeed feelings of lassitude, listlessness, and depression of spirits which call loudly and irresistibly for further stimulation. The morphinomaniac or the victim of the morphin-habit then finds that he is incapable of exercising his brain or performing the ordinary duties of his calling without resorting to his narcotic; this he uses in doses which for the time bring him up to the level of his normal mental and physical vigour."

John V. Shoemaker-1908.'4

"The treatment of chronic morphine poisoning, or opium-eating, is often more moral than medical. In such cases, the will of the unfortunate victim is so weakened by self-indulgence that the acquired taste for the drug cannot ordinarily be resisted, and he will acquire means for its gratification at any cost, or, if it is not obtainable, he may destroy himself."

G. F. Butler-1908.15

"Chronic opium-poisoning, resulting from the habitual use of opium, its most active constituent morphine, or its salts, is undoubtedly one of the most pernicious habits to which the human body can be subjected, its mental, moral and physical phenomena being among the saddest and most terrible known to therapeutics."

C. W. Carter-1908.1°

Carter states that morphinism is not a habit, as habit makes no change in the organism. The use of the drugs stamps an impression upon the organism impossible to be imprinted by the elements responsible for the formation of a true habit. It is not a moral perversion, although it is true that weak, vicious, and degenerate characters more readily lapse into drug abuse. But it is also true that persons of the highest moral type not infrequently become equally subject to narcotic addiction. They are often in no sense perverted. Their ideals may remain as high and their lives in private and before the public as faultless as before addiction began or after it had been abandoned. The moral nature of itself probably plays only a minor role in the formation of the condition and, until this is more generally recognized to be a fact, a large part of well meant temperance and reform work will continue to be misdirected and must prove ineffective and a great deal of injustice must be perpetrated upon unfortunate persons. Morphinism is not a disease or an immorality, but a physical or psycho-physical disorder or a condition of disease. Morphinism is not an organic disease, but a derangement of function, a change in the mode of action of the organism, not a change in its structure. It is a condition of auto-intoxication for the relief of whose discomforts morphin is taken, a condition of double poisoning, first and least by the drug, and second and mostly by the toxins of the body itself.

Oscar Jennings-1909.17

Jennings states that the "morphia habit" is a "psychosomatic affection" in which the mental and physical troubles are interdependent, conditioned the one by the other.

"Morphia craving which constitutes the difficulty of treatment, is not a pathological entity like malaria or syphilis and curable by agents like quinine, atoxyl or mercury acting on a materies morbi, but a general pathological disturbance caused by the withdrawal of an accustomed stimulant which affects all the functions of the body."

Furer-1909.18

This author describes morphinism as a symptom of an underlying condition rather than a disease entity, as follows:

"An exhaustive presentation is not possible in a short time. On the basis of 12 years of experience in the observation and treatment of patients in question, the lecturer has formulated a view—different from the usual one—of the essential nature of the so-called abstinence symptoms and of the conditions antecedent to the development of morphinism. According to his experience, a state of nervous exhaustion, even though of slight degree, is, quite apart from the occasional cause, an antecedent condition for the development of chronic intoxication. Morphin now asserts its power by reinforcing these symptoms of nervous exhaustion. When an attempt is made to stop the use of morphin, the symptoms make their appearance in such tormenting form that the resistance of the individual is overcome and the continued use of morphin is forced upon him. Morphinism is, therefore, to be regarded in practice not as a disease but only as a symptom of disease. The withdrawal is only a preparation for the treatment of nervous exhaustion; the latter should be strictly individual and specifically psychic and should take advantage of every means of help which might be applicable. Its final aim should be the orientation of the individual as to the difficulties which have their origin in his own personal disposition and to make terms, so to say, with his personal, i.e. relative, state of health, that he may thus be rendered capable of resisting the complaints which must come in due course. Furthermore, he should as far as possible be enabled, by the arrangement of his mode of life, to avoid too severe nervous exhaustion. Without considering the question as to whether certain symptoms which occur in connection with abrupt withdrawal are to be regarded as abstinence symptoms, the lecturer upholds the view that the disturbances which appear in connection with the only correct—slow and suited to the individual—mode of withdrawal are to be regarded merely as manifestations of the nervous exhaustion. Rejecting the usual definition: 'Abstinence symptoms are the nervous disturbances which occur in the course of a withdrawal, without other etiology, and which disappear at once when morphin is administered,' he sets up the statement—since practically nothing is known as to the nature of the chronic operation of morphin and hence, a scientific explanation of the abstinence symptoms cannot be given: 'Those symptoms which appear in the course of a morphin withdrawal cannot be regarded as abstinence symptoms when we observe them also as functional disturbances in connection with other purely nervous symptoms. The disappearance of these symptoms through the administration of morphin cannot be a criterion of their nature, since the simple functional nervous disturbances can also be made to disappear by means of morphin.'"

C. L. Case-1910.'9

Case states that morphinism is a disease as really as is typhoid fever or pneumonia. He further states that there is no structural pathology in morphinism, but that the pathologic changes are entirely of a functional nature, the nervous system is under the benumbing influence of the drug and all vital functions are sluggishly and imperfectly performed. What is commonly spoken of as "the craving" is not a craving at all, but a physical condition.

George E. Pettey-1910.2°

Pettey points out the teaching that every manifestation of disease has underlying it a "structural pathology" and that writers on drug addiction accepting this as true, strove to demonstrate a structural lesion in drug addiction, but failed, though many still claim it exists. Others took refuge in the general term "neurosis" and, as the nervous symptoms were prominent and mystifying, practical men who attempted to treat the condition symptomatically came to the conclusion that it was incurable and gave up in disgust. Others unable to demonstrate structural lesions took the position that there was no pathology. Confronted with the manifestations attending the use of narcotics, they took refuge in the word "vice," and classed narcotic addiction as a vice, a perversion of the will, a degenerate state into which the victim entered by choice, being prompted or led into it by inherited or acquired degeneracy. They stated that all who used narcotics were primarily neurotics or weaklings, who by using the drugs were made doubly unreliable. They made free use of such terms as pervert, fiend, inveterate liar, etc. Speaking of those who held this view of the condition, Pettey says:

". . . . by the very fact of holding such views, totally unfitted to make suggestions for treatment along rational lines. With them, as there was no demonstrable structural pathology, there was no disease to treat, therefore there was nothing left to do but to deal with the patient as one who was dominated by a mere vice, one who was wilfully abandoned to a loathsome habit which he could give up by the mere exercise of his will if he chose to do so. Since he did not abandon it, the conclusion was reached at once that he did not desire to do so, that the will was absent, and they forthwith undertook to supply this supposed deficiency by coercion. They advised •taking the drug away abruptly and confining the patient where he would be forced to forego its use, that, inasmuch as he did not abandon the use of the drug voluntarily, he should be forced to do so. This course was and is still advised by many, notwithstanding the fact that others who have tried it have wound up with a maniac or a corpse to testify to the success of their efforts."

The author asks how one holding these views would account for the intensity of such symptoms upon withdrawal of the drug, as vomiting, colic, diarrhoea, sweating, labored and deficient heart action, rigors, cold and finally collapse and even death.

Later Pettey says:21

"The essential pathology of narcotic drug addiction (disease) is a toxemia, a toxemia of drug, auto and intestinal origin."

F. McK. Bell-1911.22

"We may describe morphinism as the habit of taking morphine in small doses for the relief of pain and without any appreciable increase in dosage except as necessity demands. . . . Morphinomania, on the other hand, is a condition in which morphine is taken for pleasure or as a stimulant and in ever increasing doses. . . . Morphine not only robs its victim of his physical vitality but leads finally to his mental and moral degradation."
The author emphasizes the mental side, directing attention especially to the visions and hallucinations of the patient, his insomnia, ill-humor, despondency, transitory brilliancy, etc., inability for consecutive mental work, and moral inertia.

Daniel Morat-191128

Morat states that, regardless of the cause of the condition, morphinism is a true organic disease which must be treated like any other chronic intoxication, moral treatment being of use only to prevent relapse.

Foster Kennedy-1914.24

Kennedy states that the sufferer from this disease has too long been the object of contempt of "well-meaning but muddled moralists," and further:

"morphinism is a disease, in the majority of cases, initiated, sustained and left uncured by members of the medical profession. A small number of cases only take origin in love of a new sensation, a novel adventure, and in these morphinism is but a by-product in an individual innately perverted, whose heredity is most frequently of the poorest, and the salvage of whom, apart from his acquired disease, is an affair of doubtful benefit to society."
Speaking of the withdrawal symptoms Kennedy says:
"Against such collapse and pain the unaided will is as powerless as it is to control the amount of air entering the lungs. The analogy is perhaps completely sound, for the deprivation of oxygen results also in the rapid accumulation of poisonous waste against the onslaught of which we have only an acutely limited voluntary control. We have been accustomed to view the morphine addict as a hopeless liar, a moral wreck, a creature sunk in vice, and lost to all sense of decency and honor. He will lie as to the dose necessary to sustain moderately comfortable existence, he will stoop to subterfuge and theft to achieve delivery from his bodily agonies, but there is nothing inherent in the drug to cause his moral degradation in those activities of life in which his addiction has no part. There can be no telling how many sad victims of this disease there may be among people who are of the highest qualities, morally and intellectually, and of the greatest value to their communities, who, if driven by sudden deprivation of their drug and by morphine hunger, might be led to felony or violence to rid themselves of a distress, of the intensity of which there can be no adequate description.
"Such deterioration as sometimes occurs in the morphine addict malgri is partly the result of his chronic autointoxication, of which I have just spoken, and largely the reaction to the attitude of his fellows which confounds disease with viciousness and makes of the confessed morphinist a social pariah. Furthermore, this type of patient—who, as has been said, constitutes the vast majority of his species—does not nestle with his vice in secret as has too often been imagined. He seeks aid and cure, and only in despair gives up the struggle, afflicted and misunderstood by his fellows, who, appropriating the functions of a priesthood, look on him, not as a physically diseased entity, but as a moral problem—a brand to be snatched from the flame. Thus morphinism is not an unmoral or a demented, but a physical condition, a diseased state, of the inception of which the sufferer is usually innocent; its symptomatology is exact, and of a constancy not always found in much more clearly understood ailments. Though treatment is beyond the scope of this paper, the majority of cases can be cured, though to the furtherance of this end our attitude must be, not that of parsons, but of physicians."

Alexander Lambert-1915-1921 25 26

"Morphinism is still looked upon as a vice, deliberately acquired, not as a misfortune sometimes accidentally inflicted on the patient by the physician."

"The sight of the suffering of the drug habitue, his haunting terror lest the drug be taken away from him, his pitiful suffering when it was withdrawn, and the traditional belief in the profession that it was absolutely hopeless to deal with them in any way, combined to awake a keen desire in my mind to search and to see if something could not be found to relieve this misery. Especially did it seem incumbent to do this when I realized how many patients come into the hospital suffering from morphine addiction who had acquired this addiction through legitimate medication, and they were at that time hopelessly condemned to an unhappy and useless existence."

In 1920, he says: 26

"The morbid process is a functional poisoning resulting in perversion of the functions."

In Nelson's Loose-Leaf Medicine, Lambert, who writes the section on chronic opium intoxication, says:

"It has often been stated, both in lay and medical writings, that the purely physical craving for narcotics is directly inherited. This, today, is a discarded theory, as the facts do not bear it out. The craving is always an emotional impulse often overpowering the so-called will even against the judgment and reasoning endeavors of the personality to resist. Feeble-mindedness is inherited. The weak-willed self-indulgent personality, prone to excess in all things, is inherited. The self-conscious, introspective personality, unable to stand the hard knocks of life, is a personality often transmitted from parent to offspring. In these psycho-neurotic individuals, alcohol and drug addiction is but the expression of the desire for relief from a strain which cannot be borne."

"The intoxication and narcotic impulses, as Trotter expresses it, have been almost universally regarded as either, on the one band, a sin or a vice, or on the other hand, as a disease; there can be little doubt that in fact it is essentially a response to a psychological necessity. In the tragic conflict between what he has been taught to desire and what he is allowed to get, man has found in alcohol, as he has found in certain other drugs, a sinister but effective peace-maker."

"The presence in the body of these narcotics produces perversion of the function of many of the viscera, such as chronic constipation and intestinal fermentation, which in turn react upon the disposition and even the temperament of the individual."

*    *    *

"Some patients have been able to take morphine only when recurrent pain has been present, and, seeking safety by never administering the drug themselves, have managed to go for years without really acquiring a habit, which they could not break. If the use of the drug is too long continued, these persons will, in the end, show morphine poisoning, but they never become morphinomaniacs, in the sense of the term as defined by the French, who always show the difference between the morphinist and the morphinomaniac. The real differentiation seems, however, to arise from the different causes which bring about the continued use of morphine, the morphinist being driven by physical pain, the morphinomaniac by psychologic conflict for which forgetfulness is sought."

"Morphin given daily for three weeks or longer, in small doses, almost invariably produces that peculiar narcotic necessity which we designate as the narcotic habit. Some patients may resist longer than others; but the average power of resistance is slight. The habit of morphin-taking is always acquired from small doses frequently repeated. The idea that because the dose is small no habit will follow is an erroneous one which has frequently led to the necessity of habitual use."

"While the psychoneurotic and the inadequate personality break down more completely under the mental conflicts and strains of life and resort more quickly to narcotism than normal persons, all morphine users are not of this type. Many are normal personalities of more than average intelligence and realize fully their position and their progressive degeneration. Such individuals are really filled with remorse and resent the stigma which is placed upon them for a habit for which they are often not responsible."

Solomon H. Rubin-1916.27

"Those who come in professional contact with the narcomaniac are convinced that drug addiction is a definite disease having a well defined symptomatology and an indefinite pathology. Indeed, the symptoms of abstinence in almost all cases appear with regularity, in classical order, and so constant as to constitute a definite disease condition which may be easily recognized by the train of symptoms it represents."

T. D. Crothers-1916.28

"The central fact should never be forgotten that drug addictions are distinct neuroses and psychoses, amenable to treatment and curable to an unknown extent."
Again, "the condition of the morphine addict is an assemblage of toxemias and autointoxication, obsessions, delusions and various forms of functional and transient paralysis."

Charles E. Sceleth-1916.29

"Too often it is not realized that small continued doses are dangerous; any amount of morphine sufficient to alleviate pain or to ease the patient is enough to create a habit. The contention that normal persons never become addicts in our experience is not true. Even in a strong-willed individual the regular use of narcotic for three weeks can establish the habit; while, after three months of such addiction, it is almost impossible for the patient unaided to discontinue its use."

W. W. Vinnedge-1916.8°

"As a profession we need a much better acquaintance with the subject than we now enjoy. There is such a close relation existing between drink, drugs and poison, and the connection between insanity and inebriety, which is defined as 'a disease of the will.' Alcohol and drug addiction are to be regarded as examples of the surrender of self-control in favor of self-indulgence; that of the voluntary preference for the lower in the presence of the higher alternative of volition, exercised in obedience to appetite rather than the 'higher command' of conscience."

H. A. Hare-1916.81

"Morphine or opium when taken constantly generate a habit. . . . This ability to take large doses depends upon an increased ability on the part of the body to oxidize the poison."

J. Rogues de Fursac and A. J. Rosanoff-1916.82

"Chronic intoxication by morphine brings about a condition known as morphinism. Morphinism constitutes morphinomania when the drug has become a necessity to the organism, so that its suppression causes a train of physical and psychical disturbances known as the symptoms of abstinence."

A. Gordon-1917.83

Gordon speaks of the condition as a "Pernicious habit." In the next paragraph he states:

"Morphinism usually occurs in individuals with a special make-up of their nervous system. Such persons present deficiency of the intellectual and moral faculties. In them the inhibitory power becomes an easy prey for all abnormal tendencies, particularly for alcoholism, morphinism or cocainism. The latter are results of a neuropathic constitution, the fruit of hereditary tendencies. In handling such individuals, one should remember Ball's dictum to wit. 'Morphinomania is entered by the door of pain, of sexual passion, of sorrow, but also by the door of contagion, viz. imitation.' "

New York Joint Legislative Committee-1917.

The "Preliminary Report on the Joint Legislative Committee appointed to Investigate and Examine the Laws in relation to the Distribution and Sale of so-called Habit-forming Narcotic Drugs, of New York State, 1917," states that lack of understanding and appreciation of the disease of narcotic drug addiction and its treatment by a large majority of the medical profession has fostered conditions which make it impossible to determine a rational procedure for treating and curing the addicted by the state at this time and that 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.
The report continues:

"Evidence offered by physicians shows that many addicts have died under the methods of treatment existing today 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."

"Your Committee has found that narcotic drug addiction bears no relation in point of character and seriousness to any other known habit induced by the use of stimulants. Narcotic drug addicts according to evidence adduced, should not be classed with the alcoholic or the tobacco addict or the cocaine habitué.
"The constant use of narcotics produces a condition in the human body that many physicians of medical authority 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 self-administration."

The Committee states that it held hearings in New York, Brooklyn, Buffalo, Syracuse, and Albany, that it gathered a large amount of testimony from those charged with the distribution of narcotic drugs and those responsible for the enforcement of the laws in respect to the sale and use of such drugs, that it received assistance from members of the Judges and Justices Association of the State of New York, from members of the medical profession associated in drug addiction work, in the penal, charitable and correctional, institutions of the state, and from laymen and members of the pharmaceutical profession. Among individuals mentioned especially as having assisted the Committee were Drs. Alexander Lambert, E. S. Bishop, Charles Rosenwasser, James F. Rooney, F. C. Graham, and George E. Pettey. The report was signed by George H. Whitney, Chairman, George R. Brennan, R. M. Prangen, John J. Boylan, and Maurice Bloch.

Walter A. Bloedorn-1917.34

"The public is still inclined to regard these cases as a group of mental, moral and physical defectives, who, through some inherent weakness, have been predestined to fall by the wayside and who, if not actual criminals, are potential criminals. They are described as lacking in all the virtues and possessing innumerable vices and as being constant offenders against the law. In fact, the law itself stamps them as criminals for it provides penal servitude for anyone having the drug in his possession unlawfully and naturally the addict has it in his possession daily. This provision of the law, while appearing excellent at first glance, acts at times as a boomerang."

He further states:

"An examination of these cases at close range does not bear out the statement often made that drug addicts belong to the so-called criminal class. It is true that when the drug has come to be a necessity for the addict, the importance of obtaining enough of it every day overshadows everything else in his life, and in order to obtain the drug he has little hesitancy in lying or stealing. These traits are developed and become engrafted in the direct proportion that they become necessary to secure the desired relief and are not the result of inherent criminal tendencies. In other words, the individual is not an addict because he has criminal tendencies but rather he develops criminal tendencies because he is an addict."

"It is a psychological fact that a habit once firmly established over a number of years cannot be uprooted and thrown aside by treatment. covering a period of weeks or months. It has become engrafted upon the individual and constitutes a part of his very being. His resistance to this act has been broken down and it is not only easy but it is the natural thing to happen that he should go back to this habit upon the slightest provocation."

C. B. Pearson-1918-1919.35 36

Pearson apparently considers as equally important and indicative of the nature of chronic opium intoxication both the pyschic and somatic manifestations. He states:

"Many of the medical profession rightly regard morphinism as a disease. A few laymen arc of the same opinion. Unfortunately, not a few physicians and the majority of the laity regard morphinism and opiumism as faults. When an organ of the body or portion of an organ is changed in structure or fails to properly perform its functions, we have disease. When there is an actual change in structure we call the disease an organic disease. When there is only a derangement of function we call the disease a functional disease.
"Morphinism and opiumism belong in the latter class of diseases. Many medical men look upon morphinism as a disease, but hold the addict responsible for the continuation of the disease because he does not discontinue the use of the drug. If a relatively large minority of addicts discontinued the use of the drug through their own unaided efforts and of their own volition, we might very justly hold the majority responsible for not doing likewise. As a matter of fact, less than one-tenth of one per cent ever thus succeed in freeing themselves from the clutches of the drug.
"There is only one rational explanation of this fact, and that is that the drug itself has certain peculiar properties and effects upon the body and mind of the victim that makes any attempts at discontinuance a matter of intense physical and, more especially, mental suffering. The mental stress and depression are not only horrible in the extreme, but they also unman the addict to such an extent that he is in no condition to bear the physical suffering."

The author further states 36 that some consider morphinism a toxemia, others a neurosis, others a psychosis. It is all three plus other changes; the glands of the body are affected, how much we do not know; metabolism is interfered with; organic functions are interfered with; nutrition is seriously affected and all of these and other changes must be taken into account in the treatment of cases.

George D. Swaine-1918.37

Swaine emphatically denies that chronic opium intoxication is a disease but states rather that it is "a condition, a disorder resulting from chronic narcotic poisoning plus an established toleration for the drug, and complicated by an ever present dominating fear."

C. L. Dana-1918.38

"In drug addiction there is a morbid condition of metabolism which arouses a very uncontrollable need for opium. This may be called a disease or not according to one's fancy in the use of words. It may be there is a functional defect or perversion of the endocrine and vegetative nervous system. Drug addiction is a vice, or moral or mental defect, in the sense that the condition is often deliberately or stupidly acquired and persisted in."

Special Committee of Investigation appointed by the Secretary of the Treasury-1918.

The report of this committee, signed by Henry T. Rainey, Chairman, Reid Hunt, B. C. Keith, and A. G. DuMez, but not by the fifth member of the Committee, Pearce Bailey, states:

"In reply to the question relative to the nature of drug addiction, 425 health officials stated that the physicians in their communities regarded it as a disease, while 542 reported that they regarded it as a vice." a

Elsewhere in the report appears the following:

"The constant use of narcotics such as opium, its preparations and alkaloids produces a condition in the human body which is beginning to be looked upon by physicians as a disease. This diseased condition requires the repeated administration of the drug of addiction to keep the body functioning normally or the institution of medical treatment. The mere withdrawal of the drug induces such fundamental disorganization and such painful disturbances that addicts are driven to any extreme to procure more of the drug with which to allay their suffering."

Again, in speaking of the growth of the problem and the public indifference to it, the report states:

"In many cases it is no doubt partly due to the more or less general acceptance of the old theory that drug addiction is a vice, or depraved taste, and not a disease, as held by modern investigators. This attitude has had the effect of holding these unfortunate creatures up to public scorn, and thereby lessening any interest in their welfare."

S. E. Jelliffe and W. A. White-1919.4°

"The habitual use of opium in some form has become common among all classes of society. The same thing may be said with reference to the reasons for taking opium as has been said with reference to alcohol. The opium habitué is a person primarily of neuropathic taint, the mere opium taking or the symptoms it produces being but surface indications of the real trouble."

C. F. J. Laase-1919.41

"It is no longer justifiable to speak of drug addiction as being a habit, a vice, a degeneration or perversion of the mind. It is a distinct, definite physical disease condition with definite uniform manifestations and phenomena and a definite understandable causation."
He says, reviewing the tolerance of these cases, that in balance they are normal in every respect but that withdrawal may lead to collapse and death.

"These signs and symptoms are as constant, uniform and recurring as those of any other disease."

He states that the old views of vice and habit do not explain these happenings or the fact that a baby born of an addicted mother is addicted and will die unless an opiate is administered. He accepts the theory that the continued administration of the narcotic drug causes the establishment of a protective mechanism or certain antidotal substances in the blood, and that these are poisonous when not antagonized by the drug itself.

American Medical Association, Council on Health and Public Instruction-1920.42

The report of the Committee on the Narcotic Drug Situation in the United States appointed by the Council on Health and Public Instruction of the American Medical Association and, according to our best information, composed of Drs. E. Elliot Harris, Chairman, A. T. McCormack, Paul Waterman, and Alexander Lambert, ex-officio, states:

"We think it is also apparent that the habitual users of narcotic drugs may be divided into two classes. In Class 1 we shall place all those who suffer from a disease or ailment requiring the use of narcotic drugs, such as cancer, and other painful and distressing diseases. Patients in this class are legitimate medical cases, and the physician should be ever mindful that his patient should protect him by not sharing the drug with others.       
"After excluding Class 1, we have left for consideration those who are addicts—those who use narcotic drugs for the comfort they afford and continue their use solely by reason of an acquired habit. In this class we have those who are suffering from a functional disturbance with no physical basis expressed in pathologic change."

"We turn to the consideration of the persons classified as addicts after excluding all those who suffer from a disease calling for the use of narcotic drugs, and with the conviction that we are dealing with functional conditions for which the remedy is the withdrawal of the drug. On the basis of the testimony we have submitted in this report we suggest the following subdivisions of Class 2, in which we include addicts as just defined:

1. Correctional cases       
2. Mental defectives       
3. Social misfits       
4. Otherwise normal persons."

J. H. W. Rhein-1920.4s

Rhein does not agree with those who claim that mental deficiency is a cause of chronic opium intoxication or that the proportion of mental defectives is high among such cases. He believes that the cause of the development of the condition is inherent in the individual, who, he says, is a psychopath who cannot face unassisted painful situations, who resents any suffering either physical or moral, and who has not adjusted himself to his emotional reactions.

E. S. Bishop-1920.44

"We find that we are dealing fundamentally with a definite 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 recognition and appreciation of causative factors; forming a clean-cut symptom-complex peculiar to opiate addiction."       

"My present definition of narcotic drug addiction is as follows: a definite, physical disease condition, presenting constant and definite physical symptoms and signs, progressing through clean-cut clinical stages of development, explainable by a mechanism of body protection against the action of narcotic toxins, accompanied if unskillfully managed by inhibition of function, autotoxicosis and autotoxemia, its victims displaying in some cases deterioration 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 administration of opiate drugs has established a physical reaction, or condition, or mechanism, or process which manifests itself in the production of definite and constant symptoms and signs and peculiar and characteristic phenomena, appearing inevitably upon the deprivation or material lessening in amount of the narcotic drug, and capable of immediate and complete control only by further administration of the drug of the patient's addiction."

. . the tendency and effect of legislative, administrative, police and penological activities 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 his 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, 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 a good basis for their opinions in some cases;—the addict has physical grounds for his statement in all cases—he is always sick, sick with addiction-disease."

I. H. Neff-1921.45

"It has often been asked whether drug inebriety can be considered a disease. This has been questioned, as the term disease has never been accurately defined; whether we accept the theory that drug addiction once established is due to an antidotal toxic substance in the blood, or whether we regard it as a manifestation of an inherent defect with an unknown pathology, is foreign to our present consideration; it is sufficient to recognize drug addiction as the name of a clinical syndrome, requiring an accurate differentiation and a specialized and distinctive treatment directed to the individual case. . . .
"For clinical purposes we may consider that drug addiction is a symptom complex, not a clinical entity, the drug taking episodical and precipitated by exciting causes of physical or mental origin, given a susceptible subject, crises,: may develop after any marked departure from ordinary routine (mental) or any disturbance of organic nature (physical). By the acceptance of this theory as a working basis we can readily appreciate the vagaries and inconsistencies which are so pronounced in the drug user and we will be able to meet the symptoms with a better understanding as to the underlying causes. If we recognice this description of the drug addict we are prepared to oppose those who would conveniently label the syndrome a 'habit' which can be corrected by the patient; there can be no argument as to the habit of mannerism, however; the believers in such theory are faulty in their reasoning, as they fail to recognize the importance of valuing the neurotic state responsible for the habit."

W. P. Butler-1921.46

"Morphinism is the same everywhere, yet opinion differs as to what it really is. It is variously considered as a vice, a crime, a disease, a purely mental,' condition, a pathological condition, something that can voluntarily and easily be quit by the user if he wants to quit it, and some say it is a sociological and legal problem, while still others contend it is a medical problem primarily, No matter what different persons may call the condition, the patient is a sick person, and as such is entitled to and should have proper consideration, care,: and treatment, either for the causes that are responsible for his being an addict, or for the addiction itself."

Eugene Gelma-1922.46

This author's conception of the nature of chronic morphin poisoning is covered in what follows:

"Morphinism is the psychosomatic state of an individual given to the continued use of morphin or opium; no poisoning from habitual use is comparabl to morphinism ; while tobacco, alcohol, ether, and even cocain habits may be controlled with relative ease and quickly, or at least without causing serious consequences of any kind, the special state in which the morphinist fin. himself and which is more than a habit, cannot be remedied in a day. The morphinist acquires a new state of being, his organic personality is changed; the equilibrium of certain functions of the vegetative nervous system is disturbed' the patient, so to speak, is out of accord with his normal biologic status; he i to use a figure of speech, remonte d'un ton, (keyed up) and if he does n' wish to suffer, often beyond all description, by the change to normal tone he must remain on the ration of morphin or opium that has become necessary The general health, the visceral functioning, the psychic faculties of acquisition and assimilation, disposition, affectivity, emotion, and the possibility of intellectual work and habitual activity, cannot be maintained in the morphinist except with his usual dose of poison, accustomed as he is to the abnormal condition which in reality in his case constitutes an indispensable stimulant, a support of all of his organic, neuro-sympathetic and cerebral functions.
"Morphin therefore is a necessity for the morphinist, a vital necessity. This statement is not too strong. It does not constitute an .emotional satisfaction, the gratification of a pleasure, as those unacquainted with this unfortunate condition state; it only gives a feeling of support to the vital forces, to the maintenance of the equilibrium of cenesthesia, that is to say, to the harmony of the many feelings, vague or definite, connected with the viscera, the bony structures, the skin, etc., which emanate from all tissues and of which the total is the foundation of obscure consciousness and of instinct.
"Morphinism therefore is an inexorable need of morphin. Privation of morphin, the diminution of the accustomed ration, puts the patient into an indescribable state of discomfort which is called `morphin hunger.' Then appear signs of morphinism which are completely unperceived by others as long as the dose is maintained in the necessary and sufficient quantity."

C. E. Sandoz-1922.4T

"Enough has been said to show that the morphine habitue having withdrawal symptoms feels very miserable and is sick. Nevertheless, it will be useful to dwell on this point, because a certain skepticism towards this sickness is often met with. Even if the sickness is acknowledged, the idea is too often expressed that it is due simply to a desire for the drug which could be overcome by the display of will-power. This error is based partly on ignorance of the facts, but there is another source for it. There are all degrees between the cases in which the symptoms do not go beyond a certain discomfort and those in which they are so severe that death ensues. Furthermore, any case begins with light symptoms. Now, as long as the suffering is moderate, the patient can pull himself together and refrain from exhibiting too much distress. He does so, too, if it is in his interest, as when it is a question of not betraying that he is a morphine habitue. It is also true that the average case is a weakling who has a tendency to whine and to exaggerate his symptoms, especially if he knows that by so doing he will obtain relief or pity. This being granted, it should not blind us to the fact that most withdrawal symptoms cannot possibly be created by a mental attitude. The wildest desire or craving for anything else has never been observed to cause a condition resembling that of a person suffering from withdrawal symptoms from morphine. Besides, the following facts show clearly that we have to deal with a disease condition which has its root in bodily changes:
"1. In every case, the symptoms are in the main the same, so much so that from these symptoms alone, provided one is familiar with them, the diagnosis can be made.
"2. People who have acquired the morphine habit and do not know about withdrawal symptoms sometimes do not realize that the latter are due to the want of the drug when they try to stop its use, but will attribute them to some other cause and perhaps consult a physician. Ocassionally, in these cases, the physician himself does not suspect or recognize morphinism and interprets the symptoms as due to some other disease condition.
"3. Certain animals can be chronically intoxicated by morphine and, when injections are discontinued, they develop withdrawal symptoms similar to those in men.
"4. When a pregnant woman uses morphine, the drug circulating in her blood goes over into the child's, so that babies of morphinist mothers show, some hours after birth, withdrawal symptoms identical with those of adults and which are often so severe that they die. Furthermore, cases are on record in which morphine, habitually taken by the mother after the birth of the child, has created in the latter a condition of morphinism which manifested itself by withdrawal symptoms when feeding at the breast was discontinued.
"5. Whatever may be the intensity of the withdrawal symptoms, no matter how long they have lasted and whether they are recognized as such or not by the patient (as in the case of newly born babies), a sufficient injection of morphine will bring about their prompt cessation and a feeling of well-being. The relief, and especially the duration of the relief, is roughly proportional to the dose given. One does not succeed in deceiving the patient by an injection of some indifferent solution.
"This possibility of removing at any time any withdrawal symptoms by means of a new dose of morphine is a further point which should always be kept in mind when the question of morphine addiction is discussed. It is a well-nigh irresistible inducement for the addict who suffers from withdrawal symptoms to give up his decision to leave the drug alone."

"The question, 'Is morphinism a vice or a disease?' is often raised, but is obscured or its issues are confused by the moral feelings involved. Now the definition of morphinism, not only in medical parlance but according to Webster', is a 'morbid condition produced by the habitual use of morphine; morphine habit.' In the first meaning, morphinism is by definition a 'morbid condition,' i.e., a disease. In the second, we must realize that when there is a morphine habit, i.e., when morphine is taken regularly, the disease condition described before necessarily develops. The more inveterate the habit, the more marked, as a rule, the disease condition will be. Morphinism, then, is always a disease and must be considered as such. The only question which can logically be asked is: 'Is it a vice besides?' Vice means, among other things, 'indulgence of degrading appetites,' state of being given up to evil conduct or habit,' a physical taint' It is plain that, in all these acceptations, morphinism is a vice as well. We can, then, say that morphinism is necessarily both a disease and a vice at the same time. But vice has, also, the meaning of 'moral failing' or 'wickedness,' Is morphinism a vice in this sense? If it is, is it always so and in the same degree? This is a moot point closely linked with another question: 'Is morphinism brought about by a vice or by a disease?'"

Medical Society of State of New York—Committee on Narcotic Drugs-1922.48

"Your Committee does not consider drug addiction as a disease entity, but
' rather as a habit similar to the excessive use of any other stimulant or sedative, as coffee, tobacco, etc. The question is the character of the stimulant or sedative used by the habitue. Functional disturbances of the internal organs follow acute excesses or prolonged use of these drugs. These conditions can be cured, but the fundamental psychopathic state is not cured by cutting off the drug, hence a relapse to the former habit when opportunity offers."

The members of this Committee were E. D. Fisher, Chairman, E. B. Angell, E. A. Sharp and W. Timme.

L. C. Scott-1923.49

"Pertinent to both the legal and medical viewpoints of the narcotic problem is the question which is so often asked and so often evaded—`Is drug addiction merely a habit or is it a disease?' The confusion and difficulty in answering this question is due to lack of definition of terms, what is meant by 'habit' and what is meant by 'disease.' According to the Century Dictionary a 'habit' is a cu. tomary mode of action which is instinctive, unconscious and uncontrollable. 'Disease' is a deviation from the healthy or normal condition of any of the functions or tissues of the body.
"Huxley's definition is even more broad and comprehensive. He says 'Disease is a perturbation of the normal activities of a living body.' If we concede the truth of the following premises; viz.: that morphinism or drug addiction is a customary mode of action and that furthermore it is uncontrollable, we must also accept the conclusion that it is a habit and, secondly, we must agree that inasmuch as disease is deviation of the normal functions of the body, and that the manifestations of drug addiction indicate at once that these functions are disturbed, we must conclude that it is a disease. Therefore, it is both a habit and a disease; but arguing by analogy we can easily prove that habit may readily act as the provocation of disease. For instance, epithelioma of the lip or carcinoma of the tongue are assuredly diseases. It is possible that they may owe their origin to pipe smoking. But pipe smoking is a habit, therefore, lip and tongue cancers are habit diseases. Again, overeating may lead to a long series of organic defects including arteriosclerosis and an apoplectic stroke. Overeating is surely a habit, and an unnecessary one. Its logical outcome is arteriosclerosis and apoplexy, that is disease and its manifestations—ergo, habit diseases.
"Another point of view which seems equally as logical is that the state called `morphinism' or 'drug addiction' is one in which the body finds itself when its physiology is disturbed, without the administration of some foreign substance not normally necessary. In the sense of the above definition this constitutes disease, for without morphin, which is beyond doubt an abnormal substance in the metabolism of the human body, there is 'a deviation from the healthy and normal condition.' Let any one look at an individual suffering from withdrawal symptoms and argue that the bodily functions are intact.
"Another contention that morphinism is not a disease is that there are no pathological changes visible. In short, it is a habit because the microscope does not reveal cellular alterations. Has any one detected cellular alterations in the earlier stages of hebephrenic dementia or paranoia, or hysteria? But who will question for one moment that they are manifestations of disordered bodily functions, and therefore disease entities?
"Then we come to the conclusion that it is neither flesh nor fish, yet sometimes one, sometimes both; either a habit or a disease or finally a disease condition caused by a habit which has become fastened upon the body because of disease. We argue in a circle, grasp fallacy after fallacy and in the end are little wiser than when we commenced."

Sir W. H. Willcox-1923.5°

"The taking of a narcotic drug of addiction for a few doses may be termed a vice, but if the administration is continued for a month or so a true disease condition becomes established, with a definite pathology and symptoms.
"The drug addict, provided that he has a certain allowance of his drug, is an individual on a low plane of physical health. The complexion is sallow, he is emaciated, and there is evidence of a general lack of function of the secretory organs. The mental symptoms are shown by weakness of character and will, and lack of moral sense.
"In some cases a drug addict may show even to an experienced observer few, if any, abnormal signs. The opium or morphine addict, if having his necessary allowance of the drug, may conduct himself normally from the moral and social point of view; and where the daily amount is small he may, for extensive periods, carry on his work in life. The cocaine addict undergoes a more rapid deterioration, both mentally and morally, and is apt to perform criminal acts.
"The 'withdrawal symptoms' of addiction disease are most characteristic. The sudden stoppage of the drug leads quickly to characteristic symptoms which are both physical and subjective or mental. These have been well described by Dr. Harry Campbell in his recent able paper on morphine addiction read before this Society (April, 1923).
"The objective symptoms—feebleness of the heart's action, tremors, vomiting, purging, and sometimes actual collapse—are unmistakable. In addition there are subjective symptoms, such as pains in the limbs and body of a distressing character. The mental symptoms experienced by the patient are those of restlessness and extreme mental suffering.

"The withdrawal symptoms are at once relieved by a dose of the drug of addiction. The prevention of withdrawal symptoms in a confirmed morphine addict can be worked out with almost mathematical accuracy. Thus in a given ease a minimum amount of morphine can be determined which will, for a certain 'number of hours, prevent the development of withdrawal symptoms. Such symptoms are usually less marked with cocaine than with morphine and heroin, but in severe cases of cocaine addiction of long standing it is a mistake to
assume that withdrawal symptoms do not occur; they may be quite marked and even serious.

"Withdrawal symptoms of addiction disease are now accepted as forming a definite symptom-complex of characteristic type. They are not symptoms which are purposely assumed by the patient with the object of obtaining a further dose of the drug. The objective symptoms described are a sufficient proof of this.

"The experimental production of morphine addiction disease in dogs, and the manifestation of a similar symptom-complex of withdrawal symptoms, have furnished additional evidence that drug addiction is a true disease condition. A most interesting case of symptoms of morphine withdrawal in a newly born infant has been published by Dr. L. A. Van Kleek in America."

"In this case it was clear that the child suffered from withdrawal symptoms addiction disease on the second, third, and fourth days of life. It also peered evident that the addiction disease was transmitted from mother to :Id. Sufficient morphine to prevent withdrawal symptoms was present in the k of the mother, who continued to have her usual daily allowance of mor-.1e. The above case is strong evidence that drug addiction is a real pathoical condition or disease."

C. C. Wholey-1924.51

The observation of a routine series of approximately 1,500 narcotic drug .'cts, many of whom were persons of superior intelligence, convinces me that is essentially a neuropsychiatric problem. The greater number of habitues e drifted into narcotism because of inherent mental instability; the majority all addicts have become victims during adolescence, before character, even normal youth, could become stabilized. A small minority have succumbed <ugh therapeutic necessity. The acquiring of the habit is only in rare aces a matter of individual responsibility. Such facts, viewed in connection the deep-seated and intricate invasion of the personality by the drug, make ar that decisions as to curability and as to treatment are for the physician. addiction is at present an outstanding social problem. It is only through <tific and unprejudiced understanding of the matter that society can be ted against this insidious menace, with its increasing army of inadequates their train of poverty and crime. Society will have to approach this problem end as other disease problems have been approached; we eliminate typhoid, not by putting responsibility up to the individual, but by abolishing the source of infection. Drug infection, as well, will have to be attacked at its source, whether that source lies in the greed of individuals or in that of governments."

William G. Somerville-1924."

"We now know that drug addiction is a disease, a pathological condition, just, as much as the psychoneuroses of any of the various toxic states. To be more exact, I would say that drug addiction, or the craving for opium or its derivatives, is as much a symptom of disease as pain is of peritonitis and pleurisy, and as headache is of meningitis.
"While physical or mental pains are the most frequent causes of one's beginning the habit, yet the drug addict has a disease per se, separate and distinct from the disease or condition for which he sought relief in drugs. He has become, so to speak, infected, just as a simple wound may be infected with tetanus bacilli. In one who has used morphin for a month or more in increasing doses, anti-bodies are produced. These morphin anti-bodies, then, constitute the disease, which has been aptly designated by some authors as addiction disease, the only immediate antidote for which is opium or one of its derivatives. This is clearly proved by the fact that when the drug is suddenly discontinued in an habitue, there occur acute and characteristic symptoms. It is, perhaps, a Utopian prophecy to state that future research workers may discover some antidote for the anti-bodies."

Ministry of Health of Great Britain—Departmental Committee on Morphine and Heroin Addiction-1926.53

In September, 1924, the British Ministry of Health appointed a Committee 54 to consider certain matters relative to the prevalence of addiction, the Dangerous Drugs Acts and regulations in reference thereto, to suggest administrative measures that might seem expedient' as a result of their investigation, and to consider the advisability of, bringing preparations containing morphin and heroin of a percentage. lower than that specified in the Dangerous Drugs Acts within the provisions of the acts and regulations. The Committee, for the purposes' of its investigation and report, defined the word "addict" as "a person who not requiring the continued use of a drug for the relief of the symp-, toms of organic disease, has acquired as the result of repeated administration, an overpowering desire for its continuance and in whom withdrawal of the drug leads to definite symptoms of mental or physical distress or disorder."

The Committee further defined the nature and causation of addiction as follows:

"The nature and causation of morphine and heroin addiction are so closely associated that they are most conveniently considered together. While there were differences of opinion among the medical witnesses whom we heard as to the importance of the parts which different causes may play in the production of addiction, there was general agreement that in most well-established cases the condition must be regarded as a manifestation of disease and not as a mere form of vicious indulgence. In other words, the drug is taken in such cases not for the purpose of obtaining positive pleasure, but in order to relieve a morbid and overpowering craving. The actual need for the drug in extreme cases is in fact so great that, if it be not administered, great physical distress, culminating in actual collapse and even death, may result, ur less special precautions are taken such as can only be carried out under close medical supervision, and with careful nursing. It is true that there is a certain group of persons who take the drugs in the first instance for the sake of a new and pleasurable sensation, e.g., the 'underworld' class, who often use heroin for this purpose as a snuff. But even among these a morbid need for the drug is acquired and the use is maintained not so much from the original motive as because of the craving created by the use."

 

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27 Rubin, Solomon H.—Drug addiction and modern methods for control. Boston M. & S. J. Nov. 30, 1916, 175, p. 792.

28 Crothers, T. D.—Drug Addictions and Their Treatment. Cincinnati Lancet Clinic. October 23, 1916.

29 Seeloth, Charles E.—A rational treatment of the morphine habit. J. A. M. A. March 18, 1916.

30 Vinnedge, W. W.—The ethics and legislation of drug and alcohol addiction. Medico-legal Journal. Vol. 33, May 1916.

31 Hare, H. A.—Practical Therapeutics, Lea and Febiger. 16th ed. 1916.

32 Rogues de Fursac, J. and A. J. Rosanoff—Manual of Psychiatry. 1916.

33 Gordon, A.—The relation of legislative acts to the problem of drug addiction. Jour. Crim. Law and Crim. July 1917. Vol. 8.

34 Bloedorn, W. A.—Studies of Drug Addicts. U, S. Naval Medical Bulletin. 1917.

35 Pearson, C.    morphine "Happy Dust" to the addict? Medical Council. December 1918 and January 1919.

36 'Pearson, C. B.—A study of the etiology and prophylaxis of relapse in morphinism. Med. Rec. June 21, 1919.

37 Swaine, G. D.—Regarding the Luminal Treatment of Morphine Addiction. Amer. Jour. Clinical Medicine. 1918. p. 610-611.
38  Dana, C. L.—Problems of Drug Addiction. Medical Record. Feb. 2, 1918.

39 'It should be noted that cocain users were included in all questions and figures.

40 Jelliffe, S. E. and W. A. White—Diseases of the Nervous System. 1919.

41 Laase, C. F. J.—Practical Application of the Facts of Narcotic Drug Addiction Disease. Medical Record. Aug. 9, 1919.

42 J. A. M. A. May 8, 1920. p. 1324-1328.

43 Rhein, J. H. W.—The Doctor and the Drug Addict—Symposium Philadelphia County Medical Society Meeting, Nov. 10, 1920. J.A.M.A. 1920. Vol. 75. p. 1589-1591.

44 Bishop, E. S.—The Narcotic Drug Problem-1920.

45 Neff, I. H.—The Case of the Drug Addict. Jour. Mich. State Med. Soc. March, 1921. xx. 79-83.

46 Butler, W. P.—Report Louisiana State Board of Health Narcotic D'.. sary and Institutional Treatment Department, January 1, 1921.

47 Gelma, Eugene—De quelques particularites stir la morphinomanie et demorphinisation. Gaz. med. et rev. d'hyg. soc. de Strasbourg. April, l! Vol. 80. No. 4. pp. 143-148.

48 Sandoz, C. E.—Report on Morphinism to the Municipal Court of Boston. Jour. Crim. Law and Criminol. May, 1922.

49 New York Medical Society, E. D. Fisher. Report of the Committee on Narcotic Drugs. Presented at annual meeting of the Medical Society of State .f New York at Albany, April 18, 1922. New York State Journal of Medicine. ay 1922. Vol. 22, No. 5. pp. 221-2.

50 Scott, L. C.—The Case of the Drug Addict. Quarterly Bulletin Louisiana state Board of Health. March, 1923. Vol. XIV No. 1. pp. 14-18.

51 vWillcox, Sir W. H.—Norman Kerr Memorial Lecture on Drug Addiction. Brit. M. J. Dec. 1, 1923. No. 3283, pp. 1013-1018.

52 "Wholey, C. C.—The Mental and Nervous Side of Addiction to Narcotic 4., J.A.M.A. Aug. 2, 1924. Vol. 83. pp. 321-324.

53 Somerville, Wm. G.—Who is Responsible for the Drug Addict? Chairman's, Address, Section on Neurology and Psychiatry, Southern Medical Association, Washington, D. C., Nov. 12-15, 1923. Discussed by Drs. M. A. Bliss, M. L. Graves, E. Bates Block, Beverly R. Tucker, Tom A. Williams and D. Percy' Hickling. Southern Medical Journal. Feb. 1924. p. 108-112.
54 Ministry of Health. Departmental Committee on Morphine and Heroin Addiction. Report. His Majesty's Stationery Office. London, 1926.
55 For the membership of this Committee see page 131 footnote.

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