The LaGuardia Report

THE CLINICAL STUDY

PLAN AND SCOPE

Interest in the effects of marihuana on the human subject follows two main lines: first, concerning what may be called pleasurable effects which account for its widespread use- and second, regarding undesirable effects, including those leading to criminal and other antisocial acts.

In his monograph on marihuana, Walton has reviewed at length the literature on hashish experience. He has grouped these descriptions as retrospective accounts by professional writers and physicians who have taken the drug through curiosity or scientific interest, reports by physicians concerning patients who have taken excessive doses, and observations by psychiatrists on subjects under marihuana influence. In all of these instances a dose toxic to the individual had been taken and the effects described correspond to psychotic episodes of greater or less degree.

In the literature there are commonly described two basic types of effect, one of excitation, psychic exaltation, and inner joyousness, with divorcement from the external world; the other a state of anxiety with fear of consequences, such as death or insanity. Either one of these types of reaction may be experienced alone, but usually both are present during the intoxication. They occur in no regular sequence but replace each other in rapid succession. The euphoric and anxiety states are generally accompanied by mental confusion, a rapid flow of dissociated ideas, and a feeling of prolongation of time and spatial distortion. Sexual desires or phantasies may also occur.

The detailed descriptions of the experience vary. Those given by trained writers, such as Ludlow and Bayard Taylor, are vivid and dramatic, embodying sensual, visual, and auditory illusions-phantasies of overpowering splendor and beauty, on the one hand, and intense suffering and horror on the other. The authors, familiar with stories of hashish effects and gifted with strong imaginative powers, undoubtedly were expectant of much that happened. The account given by the eminent Philadelphia physician, H. C. Wood, while following the same general pattern, has much less embellishment. He describes a feeling of well-being and inner joyousness and buoyancy and the performance of antics which he knew to be foolish but was unable to control. He was able to recall no illusions or hallucinations. Later a state of anxiety came on, developing into an overpowering fear of death.

A number of studies by psychiatrists on selected subjects have been reported. An excellent example is that of Kant and Krapf. Each acted as subject for the other and the effects of marihuana are described and analyzed at length. In general, the objective in such studies is the interpretation of the reactions in terms of disturbances in psychological processes and functionings. The descriptions referred to have been given by persons of a higher social class, well educated and accustomed by training to act in conformity with conventional social behavior. Although a state of irritability may occur and threats of suicide be made by individuals of this type under toxic doses of marihuana, it is noteworthy that in none of the descriptions is there found an expression of antagonism or antisocial behavior which led to acts of violence or what would be called criminal conduct.

Of more direct interest are the publications of Walter Bromberg, psychiatrist, Bellevue Hospital, Psychiatrist-in-Charge, Psychiatric Clinic, Court of General Sessions of New York County. Marihuana users who are brought before the court or admitted to the hospital come under his observation and he has reported at length on the psychiatric observations of 29 of these who showed psychotic reactions. He describes two types of reactions, one an acute marihuana intoxication with a psychotic syndrome, the other a toxic psychosis. Acute intoxication occurs in any individual if the marihuana is taken in sufficiently large doses. It comes on promptly and passes off some hours later. In marihuana psychosis, the symptoms are much more severe and of longer duration. He describes a number of cases in which the psychotic state continued for a number of days and required hospitalization.

The toxic psychosis seen in marihuana users occurs at any time and is of indefinite duration. Bromberg states that the relationship between cannabis and the onset of a functional psychotic state is not always clear. The personality factor is of undoubted importance and other toxic agents, such as alcohol and other drugs, as well as endogenous elements, may be involved. The symptoms, except for the longer duration, resemble those observed in persons under marihuana intoxication, but often take on the characteristics seen in schizophrenic or manic- depressive psychosis.

A description of 11 cases admitted to Bellevue Hospital is given for illustration. The marihuana was taken in the form of cigarettes. In this group were 5 Negroes, 2 of whom were women, 1 Puerto Rican, and 5 whites, one of whom was a Mexican and another a boy of 16. Except for one of the whites, a homosexual, they were all of a low intellectual and social order. One of the Negroes was arrested for following women in Central Park. The others were admitted at their own request, or were sent in by the police or family. Three of the group had definite sexual stimulation but in none was there an outburst in the form of an attack on women. The Puerto Rican became confused and excited and began chasing people with an ice pick. Shortly after his discharge he was readmitted to the hospital, was diagnosed as definitely psychotic, and was transferred to a state hospital as a schizophrenic. The majority of the group, 8 in fact, had psychopathic personalities and 3 of these were transferred to state institutions for further care. The group as a whole is representative of those who come into the hands of the police because of abnormal conduct and who are the source of the sensational newspaper and magazine stories.

Bromberg's findings concerning the lack of a positive relationship between marihuana and crime are described in the sociological section of this study.

In marihuana literature, the action of the drug is usually described from retrospective observation of the effects on a single individual. Relationship to varying dosage, to the subject's personality and background, to environmental conditions when the drug was taken, is given little if any attention. It is the lack of information concerning these and other factors involved in marihuana reaction which has given rise to the present confusion regarding its effects.

The clinical study here described was designed to afford information not found in marihuana literature but necessary for any comprehensive view of marihuana action. For obtaining this information there were these requisites: an adequate number of subjects for the study, a clear understanding of the mental and physical make-up of each subject, a uniformity of environmental factors, accurately graded dosage of marihuana, and standardized methods of obtaining and recording marihuana effects. In addition to defining the usual and unusual effects of marihuana, as shown by subjective and objective symptoms and alterations in behavior and in physical reaction, the study was expected to answer questions which must arise in consideration of the problem as a whole. Of special importance are these: Do marihuana users show fundamental traits differentiating them from non-users? Do users present evidence of psychological or physical damage directly attributable to the drug? What are the pleasurable effects which account for the widespread usage of marihuana? To what extent does it lead to antisocial or dangerous behavior?

The sections covering the clinical study are under the following headings:

A. Medical Aspects

1. Symptoms and Behavior

2. Organic and Systemic Functions

B. Psychological Aspects

1. Psychophysical and Other Functions

2. Intellectual Functioning

3. Emotional Reactions and General Personality Structure

4. Family and Community Ideologies

C. Comparison Between Users and Non-Users from the Standpoint of Mental and Physical Deterioration

D. Addiction and Tolerance

E. Possible Therapeutic Applications

Organization for the Study

The clinical studies were carried out at the Welfare Hospital (1) a New York City hospital for chronic diseases on Welfare Island. The quarters assigned to the study consisted of a ward of eight beds for the group to be studied at any one period, an adjoining ward of two beds for the study of individuals of the group, three additional rooms with equipment for special examinations, and a diet kitchen for the preparation of the subjects' meals.

Four female nurses were employed and the subjects in the larger ward were under constant supervision. In addition to routine records, each nurse reported the behavior of the subjects while she was on duty. Guards were assigned from the Department of Correction and the New York City Police Force for the subjects drawn from the Riker's and Hart Island penitentiaries and the House of Detention for Women.

The facilities of the Third Medical Division laboratory were used for general clinical laboratory examinations and for more detailed study of organ functioning. For measurement of psychological reactions, special apparatus was provided. A description of equipment used for each division of the study is given under its proper section.