Read before the Society of Medical Jurisprudence and State Medicine,
June 14, 1888.
“All men are liars,” said the writer of ancient days, and the revised
version of modern times is, “All men—who take opium—are liars.”
The writer—whose initial acquaintance with this question dates back
nearly two decades, and whose professional experience for several years
has been exclusively devoted to a large and enlarging clientele of this
class—has long held this opinion to be a mistaken one. Years ago he
wrote—“Clinical Notes on Opium Addiction,” read before the Kings Co.
Med. Soc., 16th January, 1883—“Nor do we share in the opinion, largely
held, that no reliance is to be placed on the word of opium habitués.
That the habitual use of opium, in many cases, does exert a baneful
influence on the moral nature we are well aware, but we also know that
in the ranks of these unfortunates are those who would scorn to deceive,
and whose statements are as worthy of credence as those upon whom has
not fallen this blight.” Increasing attention to this topic has only
confirmed that belief, and the recent statement—unwarranted and
untrue—of a medical writer and teacher, that “no morphia habitué can be
depended on to tell the truth,” with the courteous invitation of your
honored President to present you a paper, has prompted me to offer some
thoughts on this subject—the result of observation, reflection and
applied common sense.
Putting the query—why do men take opium?—the answer to-day is that made
nearly twenty years ago by Dr. Joseph Parrish, Pres. Amer. Assoc. for
the cure of Inebriates—“men take it for a physical necessity.” In an
experience covering the history and treatment of hundreds of cases, I
have noted only two exceptions.
Let it be distinctly understood that my remarks apply only to the better
class of habitués, who have become such by force of conditions beyond
control. With those who, viciously indulgent and lacking alike in
principle and purpose, take opium from mere sensual desire, we have
nothing to do.
This physical necessity, the great genetic factor in an opiate using, it
need scarcely be said, has its rise in painful disorder of body or mind.
For this opium in some form is given, which, when the legitimate need
for its action is ended, entails a demand for continued taking that will
not be denied.
The larger share of responsibility then rests on the medical man who
prescribes—very properly it may be—this valued drug, though the main
measure of his responsibility depends not on the initial using, but upon
the case being dismissed without full thought as to the ultimate result
of the opiate taking, and with a neglect to warn the patient against the
danger of continued using, and insisting upon—giving to this his
personal attention—the entire narcotic disusing when the proper need for
its taking is ended. Vide “The Genesis of Opium Addiction,” _Detroit
Lancet, 1884_, and “The Responsibility of the Profession in the
Production of Opium Inebriety,” _Med. and Surg. Reporter, 1878_.
Granting this correct, on what principle of equity or right can one be
held accountable, and so culpable, for his use of the drug when, unaware
of its ensnaring power, and, confiding in the counsel of his medical
adviser he avails himself of the relief it affords?
Another and most important auxiliary factor obtains in these cases—one
of which the laity knows little or nothing, and the profession
appreciates less than it should—and that is the power opium possesses to
create a necessity of its own. Of this, I venture to assert that no one,
other than the subject of a painful personal experience, or of large
observation, can form a fully adequate idea. The writer has been
studying opium and opium habitués for more than sixteen years, with an
annual experience, of late, as regards number of cases, that is probably
unequalled in this country, and yet he stands more and more in awe of
this peculiar power with every case that comes under his care.
Granting a painful physical necessity, and the daily or semi-daily use
of opium—especially morphia, subcutaneously—for a few weeks or months,
and there are few, if any, who can withstand the ensnaring, enslaving
power of this drug. Men stronger of brain and brawn than we have gone
down before it. I have known a superbly athletic specimen of physical
manhood, able to resist the wintry rigor of a polar expedition, succumb
to the power of morphia in less than a month. I have seen a man so
generously endowed that he survived the horrors of Salisbury when the
death rate averaged eighty per cent., go down before the same resistless
power in four weeks. It was my pleasure to see this gentleman recover,
and take the lecture platform to tell of his bondage and escape, and
this is what he said:
“I proclaim it as my sincere belief that any one afflicted with neurotic
disease of marked severity, and who has in his possession a hypodermic
syringe and morphia solution, is bound to become, sooner or later, if he
tampers at all with the potent and fascinating alleviative, an opium
habitué. The first dose is taken, and mark the transformation. This
overmastering palliative creates such a confident, serene, and
devil-may-care assurance, that one does not for once think of the final
result. The sweetness of such harmony can never give way to monotony.
Volition is suspended. You may not think of it when the pain for which
it was taken subsides. But when distress supervenes you go at once for
the only balm that abounds in Gilead, and every additional dose is but
another thread, however invisible, of which the web is made that binds
us fast as fate.”
If this be true—and it is true—what justice is there in the charge that
these unfortunates continue the use of opium from an innate propensity
to evil, or a merely vicious desire? What right have we to set ourselves
up in judgment to note the beam in our brother’s eye, when the only
reason it is not in our own—when the only reason you and I are not opium
habitués—is because a kind Creator has so conditioned us that this
physical necessity, and consequent opiate need, does not, with us,
obtain?
Having thus touched upon the etiology of this disorder, let us reason
together regarding the special ethical point involved, and note the
reason—if reason there be—for the commonly accepted idea that all men
who use opium are liars. While admitting that the habitual need and use
of this drug does, in many cases, warrant such assertion, I hold that
the leading factor in this moral obliquity is the principle of self
protection—the habitué’s desire to shield himself from that censure
which the prevalent opinion—uncharitable and untrue—that he is simply
the victim of his own vicious indulgence, involves.
There are various proofs that this holding is correct, and, too, without
resorting to the opinion held by Lahr, Fiedler, and some others, that
opium habitués are the subjects of a mental alienation, both in the
creation and continuance of their addiction, and therefore absolved from
culpable wrong—an opinion in which I do not share. Nor do I believe, for
reasons given, with another German observer, that “the morbid craving
for morphia ranks among the category of other human passions, such as
smoking, gambling, greediness for profit, etc.,” for if this were true,
the impulse to protect one’s self would not so largely prevail.
The opium habitué realizing that he is looked upon as one who has given
himself up to a vicious habit, a habit in which he persists from mere
desire to enjoy the pleasures of opium—pleasures which, be it ever
remembered, soon give place to its pains—and so liable to the censure
which a vicious indulging involves, is impelled—by a feeling common to
us all of guarding our good repute—to yield to the protective temptation
to untruth.
But to this there are numerous exceptions, for many a captive to this
drug, though well nigh crushed by his captivity, and that “cruelty of
ignorance,” which the unjust reproaches of should-be friends entails,
still refuses to seek refuge behind such subterfuge, and scorns to tell
a lie.
And do we not note this same impulse to deceit in most non-habitués who,
lapsing from the right, make effort to avoid the sequence of their sin?
Does the swindler always confess his swindling? Do the thieves, the
forgers, the rascals of any degree, never deny their wrong doing? And
while, in these cases, such double wrong may be the outcome of a general
depravity, that, of itself, tends to prove that if the pernicious effect
of opium in this regard were due solely to its baneful effect upon the
morale in general, we should note the same tendency to lying along the
various lines of life, whereas, it is a fact that on any question other
than one involving his opiate taking, and consequent accountability, the
habitué may be, and often is, a very prototype of truth.
What is the bearing of this question on the medico-legal status of these
cases? If they be held culpable for the inception and furtherance of
their condition, whatever outcome there may be affecting the
jurisprudence of their action, must, from such erroneous view of the
situation, fail of that legal justice which a correct appreciation of
their case demands.
The writer was recently called upon to testify in the case of a
physician who had been under his care for treatment of narcotic
inebriety. This gentleman was the subject of delusions and
hallucinations, so marked, that, in my opinion, he was not accountable
for his conduct. Suit for separation was brought against him, and the
referee’s remarks during the trial, and his final decision, were in
keeping with the belief that the defendant was responsible for the
consequences of his alienation.
Again, a right appreciation of the status of such patients will lessen
the labors of the doctor and the lawyer in their legal aspect, and
remove the risk of failure to determine the true physical condition of
the habitué where the question of narcotic taking is the leading issue
in the case. To illustrate. Granting a general acceptance of my
assertion that the class to which this paper pertains are the subjects
of a disturbed organism, beyond their control, and for which they are
blameless; and granting an appreciation of this belief by the patients
themselves, then their main motive for concealment will be removed, and
no more reason for untruth exist than if they were the victims of any
other functional disease.
Again, the present general opinion of these patients is such that once a
case comes into court to settle the question of an opiate using, the
defendant, desirous of protecting himself, by denying his drug taking,
makes it essential that evidence be secured to disprove his statement,
and if certain signs be wanting, the habitué may quite outwit the
medical expert. The writer noted a case of this sort last summer. A
lady, cultured and refined, who had fallen a victim to morphia years
before, and who was party to a suit in court, was examined by two
well-known female physicians of this city, who, failing to apply the one
infallible test of an opiate using, testified that she was not an
habitué. They were mistaken—the lady was taking morphia, though she has
since recovered. The point involved, to spare the chagrin of such an
error, is obvious.
Lastly, what is the trend of a more rational view of this question as
regards the treatment of these cases? Reference has been made to the
statement that “no morphia habitué can be depended on to tell the
truth”—a statement so often at variance with the fact that it must be
the outcome of an experience with the baser class of cases—and I submit
the wrong of regarding _all_ as liars because _some_ fail to tell the
truth; or, added evidence of the “cruelty of ignorance;” or, an
unwarranted libel on a worthy class of unfortunates, who, Heaven knows,
have enough to bear without loading them with the reproach such an
injustice implies.
Nevertheless it is just such an opinion, and consequent lack of
confidence in the honor of these patients that influences their
management by some medical men. Looked upon as the victims of their own
wrong-doing, or as unworthy the sympathy that should ever exist between
physician and patient, or treated on the erroneous belief that such is
the only proper method, they are consigned to the brutal ordeal of
abrupt and entire opiate disusing, which, while it may end in the
desired result, entails such suffering of mind and body as to be utterly
inexcusable—because a more humane method will avail—except under
conditions peculiar and beyond control.
I am well aware that such coercive measures are the only hope of cure in
some cases, but I also know that such patients are not of the better
class, and that, once the drug abandoned, the prospect of continued
recovery is small, because they lack one of the essential requisites for
a permanently good result—that is an earnest desire to be cured.
And the promise of good results from this better way in regarding such
patients is more far reaching than on first thought might appear, for
the ex-opium habitué forced to stem a tide of distrust—special, as to
his cure, and general, as to the permanence of that cure—finds himself
hampered in continued well-doing by the lack of that hopeful trust that
would largely conduce to his good getting on.
In a recent letter from a lady who honored the writer with her care,
nearly three years ago, she referred to the permanence of her recovery,
and added—“but as I found it difficult to make every one believe this,
much less acknowledge it in my favor, I resorted to the best means I
could think of to establish corroborative testimony that _would_ avail,
and during _all_ the time I have been in or near—the past two years, I
have gone regularly every few days to a physician of prominence here, my
old friend and medical adviser of many years’ standing, and had him make
every test he desired, placing on record my exact condition, and showing
the real truth of the matter. I continue to do this, and intend to do
so, and have let people generally know that such a record is being made.
I need not tell you that I am proud of my victory. The struggle against
ungentle and unfair judgment of those around you make a combination of
overwhelming power against the reformed opium taker. It is there that
the _real_ conflict begins.”
The writer’s professional work among this class has long been along the
line here noted. He has extended confidence—very rarely has it been
broken; he has asked for confidence, and the general result can be truly
and tersely stated—increasing satisfaction and success.
And now, gentlemen, what are the conclusions of this whole matter?
These.
Reason and right alike demand a more rational and correct idea as to the
origin of the toxic neurosis we have noted.
This demand complied with—regarding such patients, with certain
exceptions, as creatures of conditions beyond control, and so no more
culpable than the subjects of other functional disorder—will be most
helpful against the protective temptation to untruth.
The medico-legal status of such cases will then be more in keeping with
advanced forensic medicine.
The medical care of these cases will tend to a more humane method, with
a larger promise of good results, both near and remote.
It will, too, be likely to lessen the increase of habitués, and the
number now existing, for a more correct idea as to the genesis of this
disorder will prompt medical men to greater care in avoiding the cause,
while many a patient—who now shrinks from disclosing his
misfortune—feeling he is not denied the charity his case deserves, and
that he can command resources both helpful and humane, will be impelled
to avail himself of the aid that scientific treatment can surely extend.