By Dr. Lazaros Vladimiros (Department of History of Medicine, Faculty of Medicine, Athens University), Dr. Aristidis Diamantis (Department of History of Medicine, Faculty of Medicine, Athens University), Dr. Apostolos Beloukas (Office for the Study of History of Hellenic Naval Medicine, Naval Hospital of Athens, Greece) and Dr. Emmanouil Magiorkinis (Office for the Study of History of Hellenic Naval Medicine, Naval Hospital of Athens, Greece)
The aim of this study was to elevate from obscurity the results of Demetrios Kouretas’ research on the drug addicts in the Hellenic Armed forces during the mid-war period. Demetrios Kouretas, gifted with exceptional discernment, undertook a pioneering study regarding the use of addictive substances in the Greek Armed forces. Kouretas did not stick to the epidemiological parameters of the use of narcotics, but also tried to look into the reasons that led to drug addiction and to give an outline of the mental outlook of the drug addicts. Demetrios Kouretas brought forward the problem of drug addiction, which was considered as taboo. His study, based on a strict scientific basis, is considered a byword for the psychiatric research in Greece.
The history of drug use goes back many centuries. Narcotics were known to ancient people and their civilizations not only for religious reasons but also for medical purposes . Drugs were used at the oracle of the ancient world and also during initiation ceremonies. Many scholars believe the prophetic delusions of the Oracle “Pithia” were the result of drug use . Opium is surely the most famous medicine in the history of our world. The ancient Greeks knew of the drug since the prehistoric and Minoan years . Opium was a basic component of an ancient greek remedy called the “Thiriaki” (Θηριακή) which was considered as an exceptional therapeutic drug for more than 4,000 years . There is considerable evidence that opium-based medicines found use since the pre-historical and Minoan times . The drug became part of the therapeutic tools of doctors all over the world for many centuries including the 20th century pharmaceutical companies. As Marios Marcellos professor of pharmacology at the University of Ioannina notes, many European doctors from the medieval ages through the 17th century were called Doctor Opiatus, due to their frequent prescription of opium . Cannabis is also a well-known drug for its psychotropic qualities since the ancient times .
Since narcotics were in use ever since the ancient years, they played an important role in religious ceremonies, therapeutics, commerce and the history of civilization. Two cases exemplify the influence of drug use in the social life throughout history: The exclusive production of “Thiriaki” belonged to the Venetians because mainly of financial reasons and due to the Opium War during the first half of the 19th century between China and England.
Many of the narcotics that currently create serious social problems were legally distributed in many countries for centuries. Their use was socially accepted with drug users facing no social exclusion or out casting. Scientists, artists and writers used various narcotics for their psychotropic qualities. Whereas the use of narcotics in the Exotic East was exceptionally widespread, on the other hand, all kind of narcotics have also met their days of glory in the Western civilizations. In mid-19th century Paris, artists and scientists joined an elite club called The Hashish-Users Club . The French writer Charles Pierre Baudelaire (1812-1867) wrote two works, Les Paradis Artificiels and Les Fleurs du Mal, which were used as anthems for the use of narcotics . Hashish, cocaine and heroin are today considered illegal substances. The use of narcotics for long periods of time lead many individuals to addiction and toxicomania. And for this huge and rather unresolved issue one should limit to mention just one example: To explain the meaning of the word “theriaklis” (excessive user of something) and its similar “theriakliki” (excessive use of something). In his dictionary, Stamatakos, professor of ancient Greek philosophy at the University of Athens (1896-1968), notes the word originates from the Turkish word “tiriaki” and the Persian word “tiriak,” while the Greek synonym is the word “thiriaki.” The dictionary meaning of the word is: the one who uses thiriaki, the opium-user, the one who uses it with mania .
Obviously, the drug was well known enough to society and the world of science since a word existed that described addiction to the substance.
The Use of Narcotics during the Beginning of the 20th Century
Several high-profile cases of addiction were noted among the social elite in the early 20th century. Addiction to morphine and ether was first observed in doctors, nurses or people of their close environment [9,10,11]. Addiction to cocaine was also often noted in the world of arts. Opium and cannabis were widely used by people of lower income levels and the underworld.
The use of narcotics gradually emerged as a serious social problem in the 20th century. Toward the end of the 1920s and early 1930s, drug use, addiction and toxicomania in Greece emerged as not just as an individual problem restricted to socially excluded users or between people of a small group, but as a problem for the entire society.
Historic medical records strongly note this change. The most widely abused drug is heroin, as opposed to hashish, the drug more traditionally used by lower social levels. Ploumpidis, professor and historian of the Hellenic Psychiatry, based on medical statistics published during the period between the two World Wars, notes that between 1928 and 1930, 55 patients were admitted in the Psychiatric Hospital “Dromokaitio” for drug addiction therapy. Of those 55, 40 were heroin addicts .
This increase of heroin addicts during the same time frame was also mentioned by Dr. Fokion Kopanaris (1883-1975) in 1933 . While the number of heroin-addicted patients at the General Psychiatric Clinic of Athens was 10 in 1928, it increased to 51 in 1929, to 99 in 1930, and 113 by 1931. This dramatic increase of heroin use at that period of time is closely connected with the history of this narcotic. Heroin, was initially produced by Bayer as a non-addictive morphine substitute and cough suppressant, which could be used as a treatment for morphine addiction and was widely used between 1898 and 1910. However, it was soon proved that it was quickly metabolized to morphine. The sale of heroin was banned in 1924 by the US congress, and since then manufacture of heroin became illegal. During the period after the war the Italian Mafia, as well as the pre-communist China were actively involved in producing and selling heroin illegally and, therefore, the drug become extremely popular during the 1920’s and 1930’s .
Georgiadis (1876-1960), professor of forensic medicine and toxicology at the University of Athens at the time, wrote that in the 1930s “dozens are the cases every year at the coroners’ lab of deaths due to drug abuse and mostly of heroin” . He also saw the the drug affected all classes: “Heroin poisoning is noted throughout all social categories and ages of people, unemployed and criminals, as well as wealthy and developed” . Georgiadis blamed the increase of heroin-addicted individuals on the use of heroin as a medicine, specifically as a therapy for morphine addiction.
Narcotics in Greece – Demetrios Kouretas: A Pioneer in Psychiatry
The problem of narcotics – not just on the individual level but as a major social issue – appeared in Greece during the period of 1928-1930. In 1930, a military medical doctor, psychiatrist Demetrios Kouretas, realized the medical, social, and military importance of the problem of drug addicts in the Armed Forces. On 3 December 1930, Kouretas gave a lecture on the dangers, to the officers of the Department of Medical Services and in the presence of the Greek Prime Minister, Eleftherios Venizelos. The lecture, “Drug addicts in the Armed Forces,” was published in a Greek medical journal in 1932 . This study focuses on and analyzes this publication.
Dr. Demetrios Kouretas (1901-1984) was widely considered one of the best military medical doctors of his time. After graduating from the University of Athens, he studied at the famous Military Medical School of Lyon, France, on a military scholarship. At Lyon, he received many commendations for his medical excellence. Many of the Greek military medical doctors that studied during that time at the Medical School in Lyon helped the scientific evolution of the Greek nation . Kouretas served in several distinguished positions including Director of the Neuro-psychiatric clinic of the Military Hospital in Thessaloniki (1927-1930), Director of the Neuro-psychiatric clinic of the 6th Military Hospital in Athens (1931-1942), instructor at the University of Athens (1933-1942), Professor of the Department of Neurology and Psychiatry at the University of Thessaloniki (1942-1948). In 1964, he became Professor of Neurology and Psychiatry at the University of Athens where he introduced Psychoanalysis in Greece and authored numerous scientific papers. Kouretas was one of the few people that influenced the evolution of psychiatry in Greece. His numerous students founded a scientific school and many became university professors and important members of the scientific community .
As mentioned above, the lecture on drug addiction in the Armed Forces took place in Athens in the beginning of December, when he was reassigned from Thessaloniki to Athens. Of course, the published article that followed in 1932 was enriched with more of his observations. Later, he published more research papers after studying the issue further . To fully study and analyze drug addicts in the Armed Forces, he collaborated with neurologist-psychiatrist Dr. Skouras (1904-1953), a famous doctor and fellow graduate of the Medical School in Lyon.
A wise man is not the one who knows a lot, but the one who realizes things around him that other people don’t “see.” The Goddess of Wisdom for the Ancient Greeks was called “glafkopis,” meaning the owl. The word referred not to the large size of the eyes, but due to their quality – the bird that can see in the dark when all the other animals can’t see. Dr. Kouretas had the wisdom to see the problem in the military as well as its social aspect, when others around him ignored it or tried to profit from it .
The Study by Demetrios Kouretas
The 1930 lecture and the later publication are considered the first study in bibliography on drug addiction. The author started his work by stressing that the issue of drug addicts in the troops needs special attention by the officers for two reasons. The first reason was the increased use of narcotics during that period. More in detail, he wrote : “the propagation of toxic and narcotic substances, for reasons of pleasure, has increased during the last few years dangerously threatening the balance of the military troops” .
The second reason was the effect of drugs on the mental status of the soldier, making him incapable of adjusting to the military environment and unable to perform his duties. Kouretas mentions that the data for these observations were collected from examining patient soldiers from the Army of Athens the Army of Thessaloniki, civilians, prisoners and patients in mental institutions. Kouretas study was not just a collection of cases of addicts, but it was rather a systematic, epidemiological study based on a questionnaire examining all social and psychological aspects of addiction.
Heroin was the most commonly drug used followed by hashish, cocaine and morphine. The doctor remarked that the preferences differed greatly from higher social classes. The social elite most often used morphine and cocaine, while the lower levels preferred heroin and hashish. He also suggests different reasons that might drive people to the search and use of drugs. He separates these reasons to internal (predisposition) and external (by chance). Internal factors include the psychological temperament. People with a personality disturbance and with severe psychological problems usually find a haven in “artificial paradises” to deal with problems in their lives. External factors include depression, imitation, the social circle of the drug addict and medical treatment, which implicates the use of narcotic substances. For morphine he wondered that many morphine addicts begun from a single dose from a medical recipe”.
Dr. Kouretas strongly states his opinion, a view widely accepted today, that the military environment leads itself more to drug abuse than civilian life. He wrote: “Military day life that claims total subjugation of individuality to obligations that arise from military discipline at all other inferiors, as well as abdication from all quirks and/or behaviors out of military habits, creates opportune environment for drug use, especially to military prisons”.
Kouretas also describes in detail the symptoms that drug addicts of different substances show, analyzing in parallel the reasons for the spread of heroin, hashish and cocaine. Kouretas notes the illegal production and circulation of those drugs across Europe. Heroin in Kouretas’ time and in contrary with modern use of heroin, was received through the nasal epithelium. Headache, nausea and muscle relaxation are among the most usual symptoms that the addict experiences after the first use of heroin, whereas after prolonged use heroin causes constipation, anorexia and stupefaction. Kouretas characteristically describes heroin addicts to have an extremely pale face, “their head falls like lead, their eyes are completely incommunicable when the addict talks or laughs he gives the impression that he will die soon”.
Another symptom, as Dr. Kouretas notes, is the lack of sexual urge in heroin addicts. In his study, Kouretas describes in detail the need of the heroin addict to gradually increase the heroin dose, as well as, the symptoms of the withdrawal syndrome, which, according to Kouretas, can lead to death if left untreated. Hashish as referred by Kouretas is being received through smoking in the form of simple cigarettes or with the use of special smoking devices. Compared to heroin, hashish provokes stronger stimulation of the nervous system. Symptoms caused by hashish use, according to Kouretas’ study, are cough, thirst, facial paleness, nausea and vomiting. It is also notable Kouretas’ description of the symptoms of chronic use of hashish resembling a form of ‘primitive dementia’ which include exhaustion and stupefaction, anorexia and paranoia. Finally, cocaine according to Kouretas’ study is not that popular within the Armed forces. Dr Kouretas characteristically states that “the victims of cocaine are mainly members of aristocracy” . Cocaine as heroin is also received by the nasal epithelium, and its main symptoms include anorexia, increase of muscular strength and tactile delusions. As with heroin addicts, cocaine addicts gradually increase the receiving dose in order to attain similar levels of euphoria.
Kouretas also discuss the different ways that relatives of drug addicts in prisons have in order to pass drugs in prisons. He mentions in more detail that the relatives of drug-addicted prisoners are being pressured so much to provide them with narcotics that “they become the executioners of these poor creatures16. Among the various ways used to pass drugs in prisons are listed the constructions of shoes, the use of neckerchiefs or bed sheets, the mix of heroin with tobacco, even the insertion of small packs of heroin in private parts of female body. Despite 70 years of elapsed time, today’s prison population largely resembles Kouretas’ observations. Dr. Kouretas appears despondent about the situation: “The descendents of cunning Odysseus do their best to spoil the reputation of this famous hero” .
In his study on the drug addicts in the Armed Forces, Dr. Kouretas does not limit himself in a couple of cases, but examines a large swath of them. He “set from the beginning a specific” questionnaire . He handled and approached the soldiers’ drug addiction problem with humanity and understanding. Through this specific questionnaire and his discussions with the military personnel he gained solid knowledge about the `drug addiction issue in the Armed Forces.
He set a specific dictionary with words and phrases that heroin addicts used such as: “junkie”, “fix”, “sniff”, “and getting high”. For the hashish users he noted the following phrases: “black”, “snort”, “whiff”. He also mentioned that the nargile used by hashish addicts in prison, was called by inmates “Thanasis”, a Greek name, when the guards were around. Kouretas asked the reader to excuse him for using “these vulgar and bad words,” but he intended to assist medical doctors to understand the language drug addicts used and to recognize these terms among the troops. The thorough recording of all the phrases and words used by drug addicts shows how unconventional and original his work was. These drug addicts and military inmates must have respected Dr. Kouretas greatly to share with him their problems and their language .
Dr. Kouretas mentioned the measures (administrative and medical) that the service would take during his time to deal with drug addicts in the Armed Forces. The administrative measures, which he deemed restrictive and intimidating, included various punishments, imprisonments and relocations to other units. The medical measure was primarily a simple discharge of the military personnel via the Board of Discharge. Until that period “the cases of drug addicts in the Armed Forces were rare” and the above-mentioned administrative and medical measures were enough to handle single cases. But, in the 1930’s the cases of drug addicts “increased and from single cases, became an epidemic” . The measures described above were clearly not adequate, and he proposed the change of the corresponding article of the Military Law and the establishment of special military treatment facility for drug addicts. He warned that if the administrative and medical measures did not change, then “there would only be a cover up of the problem and not a solution of it”.
The contribution of Dr. Kouretas work is of great value not only to the Armed Forces, but also to medicine and nursing in the field of drug addiction and rehabilitation.
Psychiatric and mental health nursing is an important field dealing with people with mental illness or distress, and, as such, drug addiction is an important mental disorder. Nurses in this area receive additional training regarding psychological therapies, building a therapeutic alliance, dealing with challenging behavior and the administration of psychiatric medication. Treating mental illnesses have improved dramatically over the last century. Basic goal for psychiatry is, as Indira Ghandi outlined in 1981 ‘to go home instead of large numbers gravitating towards centralized hospitals’. Nursing interventions in hospital settings include physical and biological interventions (administration of medication and monitoring of side effects, preparation and recovery of patients from electroconvulsive therapy, physical care), as well as psychosocial and spiritual interventions.
However, the role of mental health nurses is equally important regarding primary, secondary and tertiary intervention in community settings, as projections based on the basic model of Gerald Caplan. In a globalizing world, advanced practice nursing need to be confined to direct individual and in family services, whereas the main goal is prevention. Mental health nurses in primary prevention aim to reduce the incidence of mental disorders (including addiction) within the general population, targeting both individuals and the environment. Mental health nurses assist the individuals to increase their ability to cope effectively with stress, whereas they target and diminish harmful factors that act as stressors within the environment. In secondary prevention, mental health nurses aim to reduce the prevalence of psychiatric illness by shortening the course (duration) of the illness. Secondary prevention is mainly accomplished through the early and on-time identification of problems and the prompt initiation of effective treatment. Nurses specialized in mental health problems focus on the recognition of symptoms of drug addiction and provision of, or referral to, treatment by experts. Tertiary prevention include services that are mainly associated with severe or chronic mental illness by preventing the complication of the illness and promoting rehabilitation that is directed toward achievement of each individual’s maximum level of functioning. Nursing in that level focuses on helping the drug addicts to learn or re-learn socially appropriate behaviors so that they may achieve or re-gain a satisfying role in the community. The role of the nurse in mental health care and especially in drug addiction is, therefore unique; nurses have the ability to bridge the gap between the hospital and the community, between the psychiatrist and the community care given, as well as, between the public and other health care providers.
Kouretas study, overall, set the basis of prevention in drug addicts care in Greece. Being an expert clinician, Kouretas had already realized from the early 30s the psychological and social implications of drug addiction and the impact of this clinical situation in every day medical and nursing practice. Kouretas initially focused on informing and educating the medical and nursing staff of Armed Forces about the problem and its implications. Afterwards, Kouretas published his results in a prestigious medical journal, in order to put wise the doctors and the nurses of the entire country about the arising medical problem of drug addiction in the contemporary hospitals and nursing facilities. Beyond any doubt, he was a pioneer at his time and his work should still be considered a reliable source of information.
Finally, the study of Demetrios Kouretas poses the importance of the study of History of Medicine and Allied Sciences for the modern nurse. The quality of the data and the methodology that Kouretas followed in his study prove the high standards of military medicine and nursing during his time, and show the way that pioneering studies, which change the face of Medicine and Allied sciences, should be conducted.
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