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DR. BROMBERG: To start with, my interest in this Marihuana problem began in 1933 when I reported at Bellevue Hospital a group of 11 cases of mental reactions induced by smoking Marihuana and I reviewed the literature and medical knowledge at that time. Also, the experience which I obtained was at the Psychiatric Clinic of the Court of General Sessions
over a period of six years. Persons showing overt mental symptoms were brought to the hospital by interested relatives and occasionally on a magistrate's order. For that reason, the vast majority of Marihuana smokers did not reach the hospital. Cases which came before the Clinic had passed through the Court of General Sessions and had been arraigned, indicted and convicted of a felony.

There has been considerable literature on the intoxication and insanity-producing effect of Cannabis, in papers from Asia, Europe, and the United States. To sum up this material concisely, it can be said that the several types of syndromes recognized fall into three groups: (a)
intoxication, (b) toxic psychosis with or without admixture of other types of mental reactions (schizophrenia, manic-depressive) and (c) according to Eastern European and Asiatic observers, chronic dementia and deterioration following prolonged use of the drug. Apparently this latter type of deteriorating process has not been observed in American clinics.

Our experience with mental conditions following Marihuana indicate to us that there are two categories of mental reaction. The following classification is suggested:

Acute intoxication (Marihuana Psychosis) Containing sensory, motor and subjective elements, lasting hours to several days, often with anxiety or hysterical reactions, and panic states and depressions of transient nature.
Toxic Psychoses (a) in which there are many admixtures of disturbed sensorlum, delusional and emotional reactions amounting to psychosis, but with the common characteristic toxic signs and (b) functional psychoses of a typical variety, initiated by Marihuana or colored by Marihuana in their symptomatology, but which continue in the form of the underlying psychosis. In these cases Marihuana represents an incipient stage in the psychosis, apparently.

There were 14 cases of Acute Intoxication and 17 of Toxic psychosis.

The point at which the line is drawn between acute intoxicating due to Marihuana and psychosis due to Marihuana depends on the degree and severity of the symptoms. Acute intoxications, induced by smoking one to four cigarettes, bring about after an interval varying from one-half to five hours in the individual one or all of the following symptoms: an increase in motor activity, a feeling of excitement, mental confusion, disorientation, crowding of perception, elementary visual illusions and hallucinations, euphoria and talkativeness. In addition to these symptoms, numerous subjective experiences occur, such as increased speed of thought processes, a feeling of intellectual brilliance, change in time perception, various somatic feelings, dizziness, hunger, a feeling of swelling of the head, lightness of the extremities, a sensation of walking on air, lengthening of the limbs and sexual illusions. More often sex excitement consists in the fact that the possible sexual objects in his environment become extraordinarily desirable. There is abundant evidence in our clinical and experimental material to show that the stimulus for sexual
interest and activity derives from the aesthetic enhancement of objects in the environment. It is not so much a matter of increased potency on the part of the user as increased reaction to sexual fantasies and illusions. One of our patients said: "I saw black and white women lying in bed with legs separated, as if expecting men . . . some women in the park with nothing on, doing nasty dances, moving their hips. I chased after them." Others state women appear amazingly beautiful. Another patient said: "In the subway I felt very sexy. I wanted to touch every woman that passed."

The speeded-up physical motility has its counterpart in rapid speech. There is a feeling on the part of the individual that he is witty, even brilliant; his ideas flow quickly and words come readily to the tongue. Conclusions and answers seem to come to mind ready-formed and surprisingly clear, without the effort of thinking. This feelings of clarity is, of course, spurious. Actually the productions of the intoxicant are hard to follow, for when he wishes to explain what he has thought there is only confusion. The rapid flow of ideas gives a subjective impression of brilliance of thought and observation. The sense of increased speed of thinking apparently has an effect on memory - hence the confusion that appears on trying to recall what was thought during the intoxication.

The smoker finds it pleasant to be with others and to impart his experiences to them. This is reflected in the fact that Marihuana is ordinarily smoked at parties or in groups. It is felt that this need for a social setting is a reaction to an inner anxiety arising from the threat of bodily destruction implied in somatic illusions induced by Marihuana In the ordinary case of smoking Marihuana, especially with one who is used to the drug, this threat becomes converted to euphoria which develops to uncontrollable fits of laughter. Nevertheless inquiry shows that almost every smoker is aware of definite uneasiness at the outset of the intoxication. The description from smokers in Harlem and from experimental subjects agrees on this point. In the words of a user of two years' standing, initiates "shrink together, feel tight inside and get
frightened." After they smoke it more than once, the reality of these frightening somatic illusions becomes less. In occasional instances, and these are the cases which are apt to come to medical attention, the fear of death, of insanity, of bodily deformity and of bodily dissolution are startling. These patients are tense, nervous, frightened, they may develop a state of panic. Often
suicide or assaultive acts are the result of these emotional states. The anxiety state is so common in patients admitted to the hospital for uncomplicated Marihuana psychosis, that it can be considered part of the intoxication syndrome.

Notes taken on experimental subjects who were psychologically trained illustrate these points:

Subject l. Two cigarettes were smoked within 40 minutes. Immediately after the second a feeling of lightness in vertex of head was felt. Head was expanding; there was a feeling of mild excitement. Now the head felt heavy and there was a definite feeling of lengthening in the legs
and a tension in the back muscles of the thigh. Head felt alternately light and heavy. There was a sensation as though the top of the head were lifted with about four inch increase in height, accompanied by optic images of skulls and skeletons. Feeling of the arms rising up in the air.
Subject was aware of a feeling of confusion. Suddenly he saw images of legs and arms in a dissecting room which were terrifying.

Subject 2. "I felt a little euphoric at first, but with the first draw my heart feels faster, my eyes a little heavier. I feel myself perspiring all over, and shaking. I can feel a slight dizziness. I feel weak; the dizziness has left and I am perspiring (Asked to walk around the room. Refuses to do
so and becomes negativistic). On looking back I remembered that I had sexual thoughts during the time of the experiment. Time seems to pass in a peculiar way, there being a combination of fastness and slowness. I took my first inhalation a few minutes after 9 and when I looked at the clock and saw it was 10 after 9. I was very much surprised because it seemed like hours. The whole experiment seems now as if it lasted much longer than it did. Walking home I walked slowly in front of oncoming cars and felt a sense of recklessness connected with not being able to walk faster and not caring."

It is remarkable how much anxiety is developed when one looks for experimental subjects among laymen. The drug is popularly supposed to release aggressive and sexual impulses beyond the point of control; it is also regarded as being habit-forming. The legendary history and social connotation of hashish smoking may help to develop in those who have had no experience with the drug, a series of anxieties masking sexual fantasies and aggressive impulses. This has come almost to the point of mass hysteria. Some public officials are unwilling to allow the use of Marihuana cigarettes for experimentation purposes, on the ground that it may be "immoral," tending to foster the development of drug addiction among the public. This frequent anxiety concerning Cannabis may have as its source the feeling of dissolution and other somatic changes induced in smokers which is communicated somehow to the non-smoking public.

In clinical material as indicated, Marihuana effects may range from mild intoxications to transitory psychoses which require psychiatric aid. The effects vary and not all the symptoms occur in every case. Illustrative of the Marihuana psychosis with anxiety reactions, and somatic sensory distortions:
A 31 year old white man, admitted March 27, 1934, with a history of having smoked just one cigarette. On admission the patient was depressed, retarded, apprehensive. He admitted smoking Marihuana. Was oriented and memory showed no defects. Physical examination was negative. The patient states, "My hand began to feel blue all of a sudden. I felt like laughing and I felt funny in my head. it was the queerest feeling I ever had. I felt like I was kind of fainting away like. I sweat and then I'd get kind of chilly. I got the scare of my life. I thought I was going to die and everything else. I knew what was happening all the time. I thought my hands were beginning to get blue. My throat began to get kind of dry. It was a little better than getting drunk. I did not want to step down from the curb—it seemed to be so high. I was sitting down and was afraid to get up." Patient improved and on the second day was less apprehensive, was pleasant and cheerful. He was discharged as recovered, after two days.

This case demonstrates visual illusions, which recall the megalopsia (perceiving objects larger than they are), and more common micropsia, which has been reported experimentally and clinically. It is this type of illusion, induced by hashish, that may have been the basis for the story of Aladdin who saw the tremendous genie emerge from his lamp spout in the Arabian Nights' tale.

A 32 year old Irish-American, admitted September 17, 1937, with a history of smoking Marihuana cigarettes two hours prior to admission. He felt dizzy, wanted to commit suicide by jumping out of windows, bumping head on the wall, floor, etc. On admission was uneasy, apprehensive, impulsive. Said, "I feel sick. I'm going through hell. I saw trucks coming at me getting larger and I wanted to open the door of the cab and jump out." He was discharged as improved in his own custody about 12 hours after admission.

A common type of intoxication is indicated in the following case:

A 38 year old Negro, admitted April 13, 1934, with history that he had run out of the house poorly clad and that he had smoked "artificial" cigarettes. He was confused on admission, was dazed in appearance and disoriented. He described a lightness of the head, dizziness and seeing
star-shaped figures before his eyes after smoking a "doped" cigarette. He was apprehensive on examination. On the second or third day after admission, apprehension had disappeared and he was discharged as recovered, being clear, composed, but unable to account for his earlier excitement.

It is not uncommon to find the history of admixture of other drugs or alcohol in Cannabis intoxication. Frequently alcohol intensifies the Cannabis symptomatology.

A 27 year old man of old American stock, admitted on June 18, 1933, at his own request. He had been a chronic alcoholic and displayed definite evidences of psychopathic makeup; had marked inferiority because of his eyes and body structure. On admission he appeared to be apprehensive, a little excited, spoke coherently and relevantly. His experiences were rather clearly set forth--"I was down on the water-front. A fellow gave me an Egyptian cigarette to smoke . . . it was hashish. About an hour afterwards I began to see things. I'd see things flying in the air. This made me laugh and I'd laugh at things not worth laughing at. Then I began to see green and other colors flowing before my eyes. Then things got black. I imagined people were
following me and I screamed in my hotel and got kicked out. I still see red lines in front of my eyes and other different colors all stuck together.

Then I began to hear bells that would get fainter and fainter and then start again. Imagined someone was after me all evening. I thought I heard footsteps and saw people ducking in and out of doorways behind. me. At the time I said to myself maybe it all affect my eyes. I seen a big splotch in front of me — it was scarlet— very bright, exceptionally bright. It contracted, then faded away. I knew all the time it was due to hashish."

The second group comprises cases of toxic psychosis due to or initiated by Cannabis. There may be other toxic agents present, as alcohol, other drugs, infective or other endogenous elements. Disordered sensorium, excitement and agitation, retardation, blocking with emotional rigidity, hallucinations, sensations of somatic change, delusional experiences may appear in the toxic psychosis. The psychosis lasts from weeks to months. Often the mental picture crystallizes out into a schizophrenic or manic depressive psychosis after several weeks or months (see paradigm). At the onset of the illness what can be considered characteristic Cannabis symptom-
atology is discernible. As the underlying functional psychosis develops, the toxic elements recede.
A boy of 16, admitted February 27, 1934, with statement from the family that for two months he had been depressed, apprehensive, worried, scratching his hands in a nervous manner, prayed constantly. He complained that somebody read his thoughts. On admission was well
developed and showed no physical signs. Patient was agitated, depressed, talked constantly in a bizarre manner about the devil influencing him, etc. Said: "I felt lightly when I was walking - as if I weighed only 10 pounds. I felt like running my whole body was light. I felt like jumping. As if I was walking on air. I felt happy. Then I saw yellow lights all around me. I saw blue and green too. The colors were more bright than usual. There are just masses of colors - sometimes I see a black cross with everything red behind it. That means there is a God. He is helping me. The devil knows the evil thoughts in me." This agitated condition improved and patient was discharged about 3 weeks after admission as a psychosis due to drugs; acute hallucinatory

Patient was readmitted August 1st of that year with a picture of a depression with schizoid features. On this admission there were no evidences whatever of the sensory illusions and somatic feelings that he had previously when he smoked Marihuana. He was transferred to the state hospital, where he remained four years, being diagnosed as Paranoid Schizophrenia with Catatonic Features. There he was restless and overactive. He had a marked push of speech, expressed ideas of reference and religious delusions and was manneristic. Said: "I figured the devil was trying to pull me away from God so I cut a cross on my arm. Physically I am the same, but mentally I am another person. ...I feel that people influence me by touching me - like injecting dope." Later he was manneristic, grimaced, was untidy, repeated practically all questions asked, answered briefly and usually vaguely and would say, "I don' know exactly," or "I don't know." He remained dull, apathetic, indifferent and mute until the present time.

The personality factor is of undoubted importance in this group of individuals. After the toxic state passed off in these patients in whom the intoxication reaches deeply enough into the personality, a basic psychotic state developed. At times, the toxic features are in the background, the personality reactions being pre-dominant. What the inner relationship is
between Cannabis and the onset of a functional psychotic state is not always clear. From our observation, the inner reaction to somatic sensation seems to be vital. Such reactions consisted of panic states which disappeared as soon as the stimulus (effects of the drug) faded. It
is generally known in psychopathology that when the perception of our own bodily sensations is disturbed we are liable to be profoundly affected psychologically. Disturbances in perception of the body-model (Korperschema), which is built up of kinesthetic, tactile, visual and other
stimuli, and integrated into the core of the personality, elicit some type of reaction. Such disturbances act as a blow to the ego, invoking defensive reactions of anxiety, apprehension, projection, etc., which approach or are schizophrenic in their clinical manifestations. The following case illustrates these points:

A 20 year-old colored man admitted February 22, 1936. He is said by his mother to have been "nervous" for some time, said he wanted to die, wanted to kill himself. Prior to admission his mother caught him with a bottle of lysol. He had been depressed and despondent. He was a boy of superior intelligence as measured by the Army Alpha test. On admission he stated that he used Marihuana for several months and during this time he had heard people talking about him They said' "Oh, what an ugly boy. How mean-looking he is." For four months, August to October, 1935, he smoked three to four cigarettes a day until he began to feel ill. At first Marihuana made him happy. Then he felt that he made a peculiar noise in his throat; ate once a day; was unable to sleep; and experienced auditory hallucinations. The hallucinations started four months ago and increased gradually. He thought his face was changing. He looked thin, mean, and ugly; he became self-conscious. He felt that every-one in the neighborhood knew it. He stated at times he seemed speeded up, but his mind was keenly alert with the development of the ideas of reference, he became self-reproachful, apprehensive and fearful.

He was then transferred to a state hospital on March 13, 1936, where he stated his hallucinations had disappeared and his emotional reaction improved. After three months he was discharged to his home; within five months he was readmitted to Bellevue Hospital, where he had gone in a state of panic, and from where he was re-committed to a state hospital. He was tense, uneasy, still retained ideas of reference, acted oddly at home apparently in response to his delusions. Diagnosis on second admission to State Hospital was Dementia Praecox Paranoid Type, which was made about two years after the onset of the original illness.

Some cases showed the manic-depressive reactions, but these were in the minority. It is perhaps to be expected that schizophrenic-like psychoses are more common because individuals who take to drugs have some deep inadequacy to start with. The cyclothymic personality is less prone to require the drug.

A man of 28 who was brought to the hospital by his mother on February 13, 1938, with the history that he had been smoking reefers for some time. A year ago he had an episode, was not hospitalized and improved from it. On admission patient was confused, restless, apprehen-
sive. He engaged in violent daydreamings. At times he appeared to be reacting to hallucinations. He said he "had a big head." He became talkative, euphoric, elated and overactive after a day or so. He said: "The best thing for me to do is. . . you look fine. I've got to look like you . I know what it is . . . when a Buick and a Packard get together." His speech was distinctly flighty, his behavior panicky; was constantly restless. Would cry, sing, talk.

He was transferred to a state hospital on February 24, 1938. There his condition persisted and he became somewhat depressed, but showed promise of recovery a few months after admission. Diagnosis at State Hospital was Manic Depressive Psychosis, Manic Type.

Mixed reactions merge with the toxic psychoses. These reactions vary clinically, some occurring in chronic alcoholics, some in schizophrenics and some in psychopathic personalities, and in all of them Marihuana usage was a factor. It can be clearly seen that aside from the direct toxic effect of the drug, the personality of the patient plays a tremendous role in psychotic states following Marihuana usage.

A Cuban, age 34, who was admitted on March 6, 1938, to Bellevue Hospital. He had been taking Marihuana for one and a half years. He had jumped in front of a south-bound subway train without injury. He was very depressed, dull, lackadaisical, despondent in attitude.

He was definitely under productive but still strongly suicidal. He described taking one cigarette every day of Marihuana for a year and a half because it took his worries away. For some time he had been conscious that people were looking at him He feels that his body is heavy all the
time. Sometimes he hears deceased persons talking to him. He sees lights at times. At times he sees a photograph of a strange person.

His friend corroborated the history, stating that he had been in this depressed condition for 3-4 years. He had a work-house sentence for 2-3 months for Marihuana. He was transferred to a state hospital March 18, 1938. At that time he was dull, preoccupied, but lost his hallucinatory and delusional trends. The State Hospital diagnosed him as Schizophrenia, Hebephrenic Type (?) and he was released after two months.

In some cases the drug makes relatively little difference in the content of the psychosis. It is for the clinician to determine how much Marihuana influences the clinical picture. In South Africa, where dagga (equivalent of Marihuana) smoking is very widespread, a diagnosis of Marihuana psychosis is made in any "toxic psychosis where there are very good grounds for assuming addiction to dagga smoking." It is felt that there should be more exact criteria, as we outlined above, for a diagnosis of Marihuana psychosis, by which we mean the presence of disordered
sensorium, characteristic colored visual hallucinations, time changes, subjective and somatic feelings. One is apt to over-estimate the place of Marihuana in the causation of a psychotic picture.

A white man of 28, admitted January 23, 1938, to Bellevue Hospital with a history that he was in a state hospital in Arizona for 3 months about two years ago and one in Indiana for 9 months four years ago. "I was smoking this Marihuana weed (at time of admission to State Hospital in
Arizona). I ran around the desert for a time, ran out nights and one day knocked on a door and told a woman I was Dillinger. I tried to see how much water I could walk in. I was just like hypnotized and walking in my sleep. Sometimes I feel like something's controlling me. Sometimes I feel just like I'm talking to somebody with my mouth closed. I just ask them a
question with my brain and they answer. Sometimes it's a man, sometimes it's a woman's voice; it just works in my temple. I think it's imagination. It's just like a dream. People stare at me. Sometimes I see different colors. I had that years ago - just like a light coming towards me; it's not a light, it's an arc. His effect was flat and he was dejected and slow-speaking. Showed
blocking and evasiveness on. sex experiences. Had ideas of reference and persecutory ideas.

He was transferred to a state hospital, where he was noted as being preoccupied, under productive and somewhat dissociated. He stated that he had some sort of seizures that were not really fits, but that when he had them if he had a sword he would not mind cutting everybody's head off. He also believed if anybody got killed near the place where he worked he would be blamed for it. Said that when he looks in bright lights he sees visions like all sorts of different colors, blues, whites, and these seem to blind him. A diagnosis was made of Dementia Praecox, Paranoid Type, and he was still in State Hospital after five months.

In psychopathic personalities, those with deep inferiorities, use of drugs is a method of supporting the ego. In these cases Marihuana does not always produce the desirable effect. Apparently it is not strong enough to affect the problems which have involved deeper layers of the personality. Such individuals adopt heroin or morphine very soon after a short experience with Marihuana. The experience of drug addicts seen at the Court of General Sessions confirms this. Persons addicted to heroin, morphine, cocaine or opium never return to Cannabis. Such
individuals are admittedly psychopathic in that they need an increment of drug to make their lives tolerable, In the next case, the use of Cannabis represented the attempt of the patient to overcome his sexual inadequacy. In this respect the social psychology of the drug is a factor, since Marihuana is popularly supposed to free sexual inhibitions.

A white man, age 23, admitted to Bellevue Hospital on March 31, 1938, with a history that he felt unworthy and thought he had a venereal disease. He held ideas of infidelity against his wife and was assaultive. Threw a four month old baby across a room. He turned gas jets on. On
admission he was rambling, talkative, evasive, depressed, self-absorbed and had somatic complaints. He said: 'I was sentenced to the Workhouse for 4 months for smoking Marihuana. I knew then I was not satisfying my wife and I thought it might help. A year ago some friends gave me the weed, I smoked several. I felt calm and liked to listen to music - very happy - exhilarating feeling - that's all."

In the hospital he was talkative, discussed his problem in detail and showed some depression, which improved. The infidelity ideas and his sexual inadequacies concerned him most. He was transferred to a state hospital with a diagnosis of Psychosis with Psychopathic Personality; Cannabis usage a factor.

Often Cannabis intoxication represents a stage in the incipiency of a psychosis. The patient who is developing a functional psychosis strives in the incipient stage to overcome the unconsciously perceived difficulties. In this sense Marihuana usage represents a healthy reaction tendency, even though the mechanism may be unknown to the patient. The next case illustrated this problem. A boy who had made a successful adjustment on a moderate level of social attainment began to show schizoid behavior shortly after the usage of Marihuana. The process continued to a psychotic state. What role did the drug play? Could the psychosis have begun without the drug? Was the use of Cannabis the patient's attempt to cure his developing psychosis? These are problems needing careful judgment and study and wide clinical experience.

A young Negro, 20, admitted October 2, 1936 to Bellevue Hospital with a history of having been dull, indifferent for some time. Insisted upon keeping the windows closed, would not leave the house, but denied he heard voices. Would masturbate openly and made sign with fingers, and actions were decidedly peculiar. Mother states she caught him. smoking a sweet-smelling cigarette with a white man and soon after got a history from his playmates that he had been smoking Marihuana cigarettes for a long time.

Observation in the hospital confirmed his withdrawn, retarded attitude. Psychometric gave an IQ. of 75 with rating of Borderline to Dull Normal Intelligence. Was pre-occupied on ward; difficult to obtain his attention; evasive; offered many excuses for closing window and putting
out lights. About 10 days after admission he appeared a little more alert and cheerful. He was discharged in custody of mother as Incipient Schizophrenia (?) or Psychoneurosis, Reactive State, on October 13, 1936.

He was readmitted a year later, October 15, 1937. At that time mother gave a statement that for past year, since he left hospital, he had been dull, staying in the house in a "deep study." He seems to listen; does not say anything'. At one time he beat up an old man in the house who, he
said, called him names. Prior to admission he had attacked a woman for no apparent reason. Sleeps day and night. Often looks as if he is in a dream, Changed personality reactions for more than a year. For two weeks distinctly worse.

On admission he was sluggish, dull and lethargic, spoke in a quiet, low voice, showed empty affect, but was intact in intellectual functions, memory, comprehension, orientation. He was transferred to the State Hospital on October 20, 1937, where he was evasive and dull. He showed no interest in the surroundings and did not mingle with the other patients. He expressed mild ideas of persecution and of electricity, was evasive and suspicious. He said some people called him bad names across the street. Believes that an attempt was made to harm him. "I sometimes have a funny feeling in my legs (electricity)." Their diagnostic impression included the possibility of Dementias-Praecox, Paranoid Type.

Gradually he acquired an interest and socialized with other patients. At all times he was neat and tidy in personal appearance and habits. He improved after five months and was ready for parole.

Now, so much for the psychopathic. We now come to the criminology.

COMMISSIONER ANSLINGER: I thought we would cover that in another subject.

We will now adjourn for lunch and come back at 1:30.

(Thereupon at 12:20 o'clock p.m., a recess was declared, the conference to resume discussions at 1:30 p.m.)

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