have admitted, this seems to me quite a remarkable record. Both these patients had tuberculosis with complicating pericarditis.

During the 36 hours in the hyoscine ward the patient is given all the cold water and vichy, or soda water, that he cares to take. There is such marked acidosis that much relief is experienced by the use of alkaline water. No food is given, but the patient may have all the liquid he calls for.

Sometimes the patient has a feeling of great weakness, prostration, with cramps in the legs, and these symptoms will disappear ordinarily with another dose of hyoscine, one two-hundredth or one two-hundredth and fiftieth of a grain. For the after-pains and cramps in the legs, our physicians have found a powder, consisting of one grain of sparteine sulfate, one thirtieth of a grain of apomorphia and one two-hundred and fiftieth of a grain of hyoscine, will make the patient entirely comfortable. One dose within the first 36 hours after the completion of the treatment will suffice usually to relieve cramps and pains.

For the nervousness experienced, bromides and trional for the women, and chloral for the men, are used in exceptional cases. In alcoholic addiction complicating, paraldehyde has been found useful in doses of 1 to 2 drams. This is used for a night or two after the treatment. Usually a 2-dram dose is given on the first night and a 1-dram dose for 2 nights following.

I have visited the wards and have been able to converse with every patient. There is no active delirium. Occasionally, a patient picks at the bedclothes. He may say the chandelier looks like the “old boy," but not more than 1 patient in 15 has to be restrained. During this treatment we have 1 nurse to every 2 patients, but most of the time they are not actively engaged except in keeping the patients covered with bedclothes.

The first 24 hours the patient is in the hospital, he may be somewhat miserable. He comes in intoxicated with the drug and when he is dropped off from 30 grains to the normal amount, he complains for a few hours. But from this time forward, he is exceedingly comfortable.

We find that most of the addicts are excessive cigarette smokers. One of the first things we undertake is to reduce the number of cigarettes to 4 or 5 in 24 hours. These patients make more fuss over the deprivation of tobacco than over all the remaining features of the treatment.

During the last stage our patients are employed about the island. They have been rebuilding the roads, leveling the grounds, painting the buildings, repairing the boats, operating the laundry and doing a thousand and one things that make for their physical restoration and rehabilitation.

The ultimate result.-The patients are now being discharged from day to day and are being returned to the community sound in body, if not regenerated in mind and soul. Society has a very important problem to meet in the reception and placing of these deserving persons. The department of health, with the cooperation of various religious and social organizations, is attempting to aid in this process of regeneration.

I am laboring under no delusions as to the ultimate fate of many of our discharged patients. There can be no doubt that a large number of them will return to the drug. The first time sickness comes, or social disaster, there will be recourse to the narcotic. Until this community and every other is freed from the possibility of obtaining the drug clandestinely, we will have addicts to deal with. It is imperative that there shall be worked out some system of international control of crude opium. It is my opinion that in every country there must come ultimately centralization of narcotic distribution in some governmental agency. So long as it is possible for American manufacturers to prepare the derivatives of opium, ship them to nearby foreign countries and have them smuggled back across our borders, the drug evil will persist. So long as the bootlegger is permitted to operate, so long will there be addiction. Certainly it is incumbent upon the Federal Government, upon the officials of other governments, upon the League of Nations, upon every official body that can be considered in this connection, to move forward toward the realization of some plan for the control of the narcotic evil. There must be intense activity and alertness, otherwise all the efforts of health departments will fail. It is possible to cure a patient of malaria, but if he return to a district abounding in infected mosquitoes, he will have another attack of malaria. The physician and the department of health can heal these poor victims and restore them to physical health, but without moral regeneration or such strict governmental control as to prohibit the possibility of illicit possession of narcotics, the problem will not be solved.

EXHIBIT No. 4

[From Monthly Bulletin of the Department of Health, City of New York, February 1920] THE NEW YORK CITY NARCOTIC CLINIC AND DIFFERING POINTS OF VIEW ON NARCOTIC ADDICTION

By S. Dana Hubbard, M. D., Acting-Director, Bureau of Public Health Education. The problem of narcotic addiction has been in the public eye for some time, and the differing points of view regarding narcotic addiction have been provocative of some very interesting discussion.

In the spring of last year, the Federal authorities having made several raids on trafficking physicians and druggists, an acute emergency was created whereby it was feared by some that a panic of these miserable unfortunates would ensue. These conditions caused the New York City Department of Health to open a narcotic relief clinic in order to study and examine into the subject of narcotic drug addictions.

The problem of narcotic drug addiction is somewhat to be compared with village gossip-but few know the actual facts-and it is extremely interesting to find how many peculiar and extravagant opinions are expressed regarding such mysteries. This is very applicable to the facts regarding drug habits.

NUMBER OF DRUG ADDICTS IN NEW YORK CITY

Many opinions regarding the prevalence and frequency of drug addiction have been expressed. No doubt many of these statements are far from true. We do not know who the addicts are, nor how many there are of them, either here or elsewhere in this country. Why? From opinions expressed, and from the literature on this subject, we have been led to believe that addiction was allocated with certain definite physical stigmata: pallor, emaciation, nervousness, apprehension, snuffing, needle puncture markings, and tatto skin evidences; but in actual experience with hundred of acknowledge drug addicts, persons actually seeking their drug supply, we find, like the weather indications, all such signs failing. There are drug addicts constitutionally inferior, and superior; feebleminded, and strong minded; physically below, and above par; morally inferior, and superior. No one clase of society seems, in our experience, to enjoy a monopoly in this practice. Our opinions, therefore, regarding the number of drug addicts, here and elsewhere about this country, have very naturally had to be revised. While it was the current opinion to think that they existed in vast numbersestimated by some as 1 percent of the community, and even 2 and 3 percent by others-we, today, think that this is greatly overestimated.

It was formerly held that drug addiction was so general and so frequent that if the law-the Harrison Act-was enforced, as it should be, a panic would be created by the immense numbers of addicts who would seek relief.

The efforts of the New York City Department of Health, actuated and urged by the commissioner of health, Dr. Royal S. Copeland, showed that this fear of the production of a panic was a false one. Our efforts were given wide publicity, and the cooperation of medical and scientific societies earnestly and zealously sought to help solve this problem. It might be added also that the raids initiated by the Federal authorities-arresting illicit prescribers and dispensers-together with the New York State Narcotic Commission requiring registration of all addicts in this locality have not occasioned any undue excitement among these individuals. We, naturally, must infer that the enormous numbers of drug addicts supposed to exist, in this vicinity at least (and it was supposed to be greater here than anywhere else) are mythical and untrue and that therefore the fear of a panic of these miserable unfortunates was negative.

From our experience with narcotic relief and registration in New York City, we now are of the opinion that the present law-the Harrison Act—should be strictly and uniformly enforced. To do so would bring these tipplers in drugs to the front, and would hurt no one, not even the users themselves. These opinions, while radical, are not given to belittle the opinions previously expressed by persons supposedly well-informed on this matter, but are the results of an actual practical and intimate working knowledge of this subject.

CHARACTER OF ADDICTS

It has been said that the experience in the department of health emergency narcotic clinic was unique; that the character of the addicts visiting this service was very exceptional. Possibly our experience dealt with an unusual feature of this problem, but from personal consultations with many acknowledged addictsin all walks of life-journalists, ministers, writers, physicians, clergymen,

teachers, businessmen, etc., seeking interpretation of the law's requirements as it affected them individually-they being addicts—we naturally had an opportunity for firsthand information.

The arrest of several trafficking physicians and druggists for violating the narcotic laws caused the department of health to open a relief clinic, which began as an emergency and was expected, naturally, to be only a temporary expedient, but the necessity was so acute, and attracted so much attention from those interested, that the commissioner of health decided to continue it for some time, in order to study this subject and obtain data regarding this problem.

The Narcotic Clinic, 145 Worth Street, New York City, was opened April 10, 1919. The clinic ministered to those willing to become its patients. The acute enforcement of the narcotic law by the Federal authorities made trafficking physicians and druggists fearful to prescribe and dispense for their addicts, and this factor sent these persons to this public emergency clinic. They appeared to come from all stations of society, and seemed to represent a fair average of these habitues.

We feel that we have had an unusually wide and peculiarly general experience with drug addicts of all classes-classes so large as to make us think that others' experience in this form of prctice has not been nearly so extensive.

The public narcotic clinic is a new thing. In fact there are only a very few in existence and, if we may judge from our experience, they are not desirable, and do not satisfactorily deal with this problem. We have given the clinic a careful and thorough as well as a lengthy trial and we honestly believe it is unwise to maintain it longer.

The clinic has been found to possess all the objectionable features characteristic of the so-called ambulatory treatment, as practiced by the trafficking physicians, except one, the financial profit to a few physicians (about one-half of 1 percent of the doctors of this city) performing this character of service.

LENGTH OF TIME USING DRUG

The average duration of our patients on the drug was 6 to 7 years-79 percent being under 10 years' duration. This is interesting, because, when they drift from drug using, where next do they go?

Those who have studied and followed carefully the chronic alcoholic addict, know very accurately that he goes down, down, down, drifting from usefulness to idleness, from good to bad conduct, finally from health to disease, and indulgence foreshortens the life period by a high percentage. The earmarks of chronic alcoholic indulgence are not pathognomonic, yet they are generally recognized in our precociously advanced cases of poverty, disease, and early death; in these there are indications, in very many instances, where the history of chronic alcoholic indulgence and the clinical phenomena correlate cause and effect. This, in our study of narcotic drug addiction, is not so obvious. In our institutions for the poor, the aged, and the feebleminded, drug addicts are exceptional, in fact it might be safe to state that they are rare. Now, what becomes of these drug habitues? Our dead, found in public places, and our deaths by suicide, as well as our pauper dead, fail to indicate, as the cause of such endings, any connection with the habit of drug addiction. This drug indulgence must leave a mark on the system, in many instances, especially in the cases of those addicts using hypodermic needles-here the tattoo and abscess cicatrizations, while perhaps in many instances not positively indicative, yet, are so characteristic that it is felt certain that if one of these cases was found dead, the drug addiction marks would be quickly determined by either the coroner or city examiner, or last attending institutional physician, and these complicating facts noted in the final record. Dr. Charles Norris, chief medical examiner of New York City, advises us regarding such instances as follows:

Deaths from overdose of narcotics, New York City-Jan. 1–Dec. 1, 1919

Total number of deaths from all causes reported to medical examiner, 10,828.

The doctor also states: "There is one thing that has impressed me in the morgue work in Manhattan, namely, the relative infrequency of finding marks of hypodermic areas of cicatrizations. I cannot tell you at the moment how many of the 43 cases had marks but they are comparatively few." In our experience at the clinic-where we permitted the addict, when he had obtained his supply, to administer his dose to himself—the unmistakable markings on the person appeared to be quite frequent, and of a permanent character. These, without doubt, would be easily discoverable upon a corpse.

Most-in fact 70 percent-of the addicts, in our clinic, are young people; they have had no really serious experiences-surely none sufficient to occasion a desire to escape all of life's responsibilities by recourse to the dreams of narcotic drugs; therefore the one and only conclusion that we can arrive at, is that the acquirement of this practice-drug addiction-is incident to propinquity, bad association, taken together with weak vacillating dispositions, making a successful combination in favor of the acquirement of such a habit. Being with companions who have those habits, they, in their curiosity, give it a trial (similar to the acquirement of cigarette smoking in our young) and soon have to travel the same road to their own regret.

"FREE MASONRY" OF THE ADDICT.

Another remarkable concomitant of which we knew but little, heretofore, was shown-the free-masonry of the drug addict. They know one another by association; but by name, not at all, perhaps a nickname, or abbreviated first name, being the only appreciable recognizable fact of a connection between them. "May” knows "Ike," and "Shorty" knows "Whitey"; while "Smoke" pals with "The Duke"; and, as for homes, they have none. They meet in places convenient for secret conference, toilets being the most often selected, and in such dens of iniquity as will tolerate such lounging and loafing. Their hours are as irregular as those of a stray cat, and neither day nor night is of any particular consequence, save that the cover of darkness suits their convenience for obtaining a renewed supply of their drug. As for meals, they depend on the effect of the drug most often to assuage any hunger, but they will eat candy, particularly nut chocolate bars. For these, addicts all display a fondness, and when offered to them, will never be refused.

All that this class of drug addicts-the confirmed habitue-appears to care for is to have a supply of dope, and a place where it can be obtained. Having this, he is as happy and contented, and as apparently comfortable as any blessed mortal on earth desires. Thirst he knows not. When a sensation develops, he regards that as a need for another "shot," and so every thing that would be natural in the usual daily life of the ordinary man, to him, is unnecessary.

Addicts confide in one another-they are loyal, in their own way, stealing from the weak or those that have it, to be in turn imposed upon by others in similar fashion. From their pals, in their set-for there is caste-and the hangers-on of such a group or tribe, they borrow even to the last cent, and it appears to be loaned willingly, even though knowing it may never be returned. If one loans to another, he, in turn, borrows from others more fortunate than himself. They are typical human parasites. The following is interesting as relating to this fellowship: A young fellow, unclean, ragged, and apparently in abject pain and misery, applied, got his "script" (slang for prescription) but on going to the pharmacy of the clinic found that the amount of money required to fill it was beyond his financial abilities; he dropped out of the waiting line, mingled with his more fortunate companions, borrowing a penny here and another there, until he made up the required amount. He then returned to the line and secured his supply. Then, as he went toward his retreat to take a "shot," he was accosted by one in lower depths, bent on borrowing; he gave his precious all and returned to borrow enough of the drug from his pals to meet his needs until he could secure another prescription, on the day following.

After one of these borrowing excursions, one of these less fortunate individuals approached one more fortunate and asked "for a part of a shot." The poor addict had his little outfit ready to take a dose; he was pale, anxious, and apparently suffering keenly. He pinched up his skin, turning and twisting the needlepoint, sent it home, slowly injecting the solution, and when about half accomplished, noticing the despair on his companion's face, he withdrew the needle, and turned his syringe over, half filled, to his pal in misery. The poor chap had felt that he needed a little, but also that he could divide with one who appeared to need it more than he, so he took sufficient to "set" him, and willingly passed over the

outfit to his beseeching companion in misery. This beggar seized the outfit, jabbed the needle through clothing and all into his belly skin and slowly shot the contents, to the last drop, home.

Having witnessed this charitable and brotherly act, I waited and, when the outfit was returned, I had it refilled and returned to its owner. This chap dropped to his knees and kissed my shoes. I tried to restrain him, and told him the clinic was intended to aid and comfort those in need. Imagine my chagrin, to observe, on the following day, the same game practiced by others, clearly stamping this as a ruse, a frameup, to obtain the drug without paying, by playing upon the emotions of those in charge. Persons that practice such deceptions to serve their selfish purposes are not "on the square," and cannot be trusted because they incite others to practice further impositions.

Another similar instance of imposition played upon the volunteer workers was the following: Early on opening the clinic, there appeared a lad, surely not over 20 years of age, who had the great misfortune to have had both legs cut off at the hip. He propelled himself by having a board strapped to his torso and attached to the bottom of this board was a pair of roller skates. In his hands he had a pair of wooden handles, like dumbbells, which he would place on the ground and with a shove he would send himself rolling along faster than one could walk. He was alacrity itself, and agile as a cat. He got about gracefully, followed always by a white spitz dog of the toy type. Like master, the pump was very, very dirty. The boy in his crippled condition, accompanied by his faithful dog, naturally attracted attention as well as keen sympathy. This boy was not particularly pallid, nor emaciated, and, on examining him later, no needle marks were discovered. The addicts who snuffle the drug have a sniffling respiration-a constant catching of the breath on inhalation through the nose which, with the presence of excessive nasal secretion, gives a mucous rattle. This symptom was also absent in this case. We were certain that this cripple was not an addict. What was he? His connection was developed later. The clinic was always crowded-jammed was a better and more fitting description—but on this occasion it was unusually congested. Suddenly the crowd surged to a corner and, thinking some accident (an addict overcome through an overdose) had happened, the floor captain (a lady volunteer worker) went over to investigate, and returned stating that the roller-skate cripple had had his dog stolen and was crying bitterly. The sympathy of the captain was aroused and, to comfort the boy, she passed the hat about the building and collected a neat sum of money. The money, naturally, consoled the chap, and he left the clinic with his tear ducts dry.

On opening the clinic, the following day, there was our little cripple and, lo! with him was his spitz dog. I approached him and said: "I thought that you had lost your dog?" "I did," he replied. "How did you get him back so quickly?" He said, "I heard a feller had him and I got my pal to go to him and buy him back-it cost me $25." The story seemed honest, but the price to redeem so inconsequential a "mut" was unreasonable. The chap was marked for more careful observation. We permitted the boy to come and go freely, giving him his supply, and, owing to his cripple condition, he was advanced in the several lines, preference being given him at all times. This kindness was his undoing. One day, soon afterward, our detectives brought in our little cripple, charging him with acting as a "bootlegger”-selling drugs. When brought into the consulting room he was searched, and, strapped to his back, resting on his roller skate board, was a dirty bag containing "coke decks" and $60 in silver coinsin fact it was the tinkling of this pile of coin that exposed him. To arrest a cripple, on such a charge, in our quarters, where sanctuary had been proclaimed, would make others think that we had framed the boy and were not playing the game fair. We decided not to arrest him, but to try and get into his good graces, if he had any. The scheme worked. The little chap was not above par when it came to matching wits, so he was quickly and easily caught and confessed to being a coke peddler. Not being an addict, he was excluded from the use of the clinic, and later fell into the hands of the police. In his confession, he said that the dog story had always been successful, and that no one had ever before seen through it. He also told how it had always netted him from ten to twenty dollars a day. He said that, at first, his conscience had bothered him about gulling the ladies, but the money came so easily that, later, he never gave it a second thought, and, when he needed money he would go to some crowded place, hang around until known to have a dog and then a chum, on a signal, would secrete the pup and, the stage being set, he'd break out crying-using glycerine

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