exception of 2 or 3, all of these cases relapsed within a very short time after their discharge as cured, and I realized more than ever that here was indeed a medical problem and I began to harbor my first doubts as to the wisdom of blind restrictive legislation. And by this I mean legislation based upon the ⚫habit and vice theories of drug addiction and upon the assumption that satisfactory methods of treatment are generally available.

In the passage of the Harrison Act and other antinarcotic laws we have a further example of being partly right. Splendid in its objective, praiseworthy in its intent to control or remedy the abuse of narcotic drugs, this law nevertheless fails to appreciate the true nature of the condition sought to be controlled.

While my active health administrative work ended in January 1917, membership on the committee on habit-forming drugs of the American Public Health Association made it necessary to continue to keep in touch with the problem and situation, and it was not a far call to a determined effort to find all that medical literature offered.

Here again is recalled an unpleasant chapter when I found that for 4 years I had been attempting to administer this problem in an American city through the workings of what I believed to be a modern health department without having really made any earnest effort to inform myself as to the true nature of narcotic drug addiction. I knew nothing of the work of Gioffreddi, Hirschlaff, Rubsamen, Valenti, Bishop, and but very little of that of Petty and Jennings, nor had I any conception that a host of others had made valuable observations upon this subject. It was only after reviewing this literature that I have been able to explain to my complete satisfaction my own failures in Jacksonville and the foredoomed failure of every law or administrator that does not take into account the true disease nature of narcotic drug addiction. I have seen practicing physicians when urged to assist, try one routine method after another without avail. I had heard neurologists and psychiatrists expatiate upon the many and varied nervous and mental stigmata. I had seen judges convict for possession of the drug, and I had seen patients die under treatment, and yet I had never fully realized that all these things were happening to men and women old and young of all classes and social groups who were just as truly sick as they would have been had Bright's disease or typhoid been the diagnosis.

One feature which my experience in Jacksonville taught me was that a large proportion of narcotic drug addiction cases owed their origin to the therapeutics of the medical profession, to the ignorant or unavoidable prescribing of narcotic drugs for prolonged periods. In 54 percent of my cases this etiologic factor appeared, and the figures of other observers are even higher than mine, in this respect. Yet it is well known that the average member of the medical profession will shun in every possible way the treatment of drug addiction. That there must be some reason for this attitude of the profession and for the profession's ignorance in the handling of narcotic drugs I felt sure.

In reviewing my own medical training I realized that I had never been shown a case of narcotic drug addiction, that I had never been given the opportunity to observe the symptoms of drug withdrawal, and that the only lectures to which I had listened in connection with opium and its derivatives dealt with its therapeutic properties, while its addiction-forming properties were mentioned in but the most casual manner. Was not my own ignorance directly attributable to this lack of medical instruction?

That my experience was not unique was determined by the committee on habitforming drugs of the American Public Health Association, through a questionnaire submitted to the medical schools of the country. The following paragraph quoted from the committee's report of 1919, summarizes the findings as follows: "Of the 85 institutions queried, 37, or 43 percent, replied. Among these replies were included the leading schools of this country. A brief review of the data so obtained indicates that the time devoted to the physiologic, clinical, and therapeutic consideration of opiate drug addiction averaged about 2 hours, and that in several institutions the subject was not considered at all. In 25 of these schools the subject was taken up only under materia medica or therapeutics in the second year's course and, in 9 schools under the consideration of mental and nervous diseases. Clinical material was woefully lacking, none at all being available in 13 of these schools, while in the others the replies stated that opportunities to observe these cases were rare, infrequent, or limited to an occasional case seen in the insane asylum or jails.

"The textbooks used were, with one exception, those which teach the old habit and vice theories, and in which medical treatment is confined to routine procedure

and specific formulas. None of the more recent experimental or clinical work was mentioned."

With the above facts confronting us; with our graduates in medicine almost totally unprepared to treat this condition; with habit, vice, degeneracy, and other similar descriptive characterization employed by writers of medical textbooks for the last half century, is it any wonder that the profession as a whole has refused to seriously consider the matter, that moralists and reformers and penologists have seized the opportunity to stimulate the passage of laws, which, however well intentioned, have almost entirely overlooked the medical and physical needs of the sufferer, or have left them to the interpretation of lay administrators?

In the unread articles of the authors mentioned above and others, in the descriptions of Hirschlaff's rabbits and Valenti's dogs, in Petty's cases of addiction in the newborn, in Bishop's clinical observations, etc., lies the real solution of the narcotic drug addiction-disease problem. That it is a medical problem becomes apparent. That it is also an administrative problem no one will deny. So is tuberculosis. So is typhoid. But with these two diseases pathology is recognized and medical treatment considered a sine quo non. Why then in the case of another disease just as real, far more serious, and involving a larger number of sufferers than both the preceding, should we leave to the judge, the dope squad, or the revenue agent the determination of its proper management? By all means let us have administration, and let that administration carry as it does in other health problems, help and understanding. Let it seek both to protect the well and to heal the sick. Let it seek to determine etiologic factors and where possible control them. Let it study the modes of extension of the disease and combat them by rational procedure. Let it teach whenever the lesson is needed the true nature of this condition. We have had part truths and lies long enough. The exploiter, the reformer, the quack, and the criminal trafficker have all benefited by them, and today with all our laws and all our moralists we are informed by the committee appointed by the Secretary of the Treasury to study the extent of drug addiction in this country that the illegitimate supply at least equals that which passes through legal channels.

It would seem unnecessary to state that the narcotic drug addict must be supplied with his drug in doses physically necessary until such time as he may receive treatment which will leave him in at least as good condition as that in which it found him. That to supply this drug is not only necessary, but is vital, that to deny it is to cause a physical and possibly a moral wreck, while to heap contumely upon narcotic drug addicts as a whole is to drive them to the underworld for their supply. It never must be lost sight of that among the sufferers from this disease are numbered many of the highest intellectual types of men and women in the business and professional worlds, and that individuals of this type may not contemplate the indignities which many administrators seek to heap upon them, through their ignorance of the true nature of this condition and their apparent misconception of the character of its victims.

The above statements must not be interpreted to mean favoring or recommending the indefinitely prolonged supplying of narcotic drugs to addicts. They mean only that such supply is at present a temporary necessity designed to tide over a period of medical education after which an enlightened profession will easily relieve their condition. There is no disease known to medicine that offers greater hope of cure than does narcotic drug addiction-disease, when once practitioners shall have come to study the drug reactions and the symptom-complex of the malady in the same spirit of scientific investigation that they accord the other clinical entities.

Narcotic drug addiction-disease will never be solved by forcible measures only. There is a place and a great need for such measures and they should be limited to this field alone, namely to the control of traffickers, exploiters, charlatans and quacks.

Yet even here police measures to be successful must go hand in hand with intelligent medical services. If anyone doubts this let him try to extinguish the underground traffic in narcotic drugs by police measures alone. Experience has shown this to be impossible during the 4 years' enforcement of various restrictive legislative and administrative experiments. The only way that peddling will ever be controlled is through the intelligent application of our medical knowledge of the needs of the situation in such a manner as to make peddling unprofitable. By this I mean that the moment it is realized by officials and the public that narcotic drug addicts must be supplied with the drug of their addiction until

such time as successful and satisfactory treatment is available, that moment is the first step taken to undermine the profits of the peddler. This person must be met upon his own grounds as it were, by intelligent administrators, by honest physicians and humane consideration. He is only in it for the money. Yet today one of the most prolific causes of narcotic drug addiction is the activity of drug traffickers in extending the scope of their operations.

In addition to these temporary measures there must be instituted and carried through a widespread program of education which shall begin in the medical schools and spread broadcast throughout society generally.

EXHIBIT No. 6

[From the Medical Record, July 23, 1921]

SOME OBSERVATIONS ON THE NARCOTIC SITUATION 1

By Edward Huntington Williams, M. D., Los Angeles, Calif.

About 10 years ago the use of narcotics became the subject of popular agitation in the United States. There were good reasons for this agitation. The responsibility for a series of spectacular crimes occurring in the South was attributed to narcotic addiction. And criminal acts in varying degrees of atrocity occurring everywhere through the country, and with apparently increasing frequency, were laid at the door of drug habitues. Thus public attention was focused upon the evils of the abuse of narcotics, and the inadequacy of our legal measures for controlling the situation. As a result, the Harrison narcotic law was enacted by the Federal Government on December 17, 1914. This law was not a hastily conceived statute rushed through as an emergency measure. On the contrary, it was the result of the mature deliberation of persons intimately familiar with the narcotic situation. It was formulated with the knowledge and assistance of medical men, and of medical associations, thus bearing the stamp of approval of the very persons who, next to the narcotic users themselves, were most vitally affected by its provisions. For this law placed restrictions upon members of the medical profession and, in effect, dictated the manner of practicing the profession of medicine to an extent scarcely approached by any legislation in recent years.

The law not only transgressed ancient customs heretofore held sacred to the judgment of physicians alone, but made it necessary for every physician to engage in irksome details and exacting clerical work quite foreign to the usual medical régime. All this with the approval and cooperation of the members of the medical profession, who appreciated the importance of and the difficulties involved in stemming the rapidly rising tide of opiate addiction.

Nor was it alone those most directly affected who approved the new statute. Popular approval was almost universal. And, as would be expected in the case of any law having such a background and such a backing, this statute became actively operative from the day of its enactment. Never for one moment has its enforcement been neglected. On the contrary, a veritable army of specially appointed officials-Federal, State, county, and city officials-have devoted their energies to the law's rigid enforcement.

From time to time the various courts have interpreted certain points in the law. And almost without exception these rulings have tended to tighten the net about the narcotic law breakers. There has been no trend toward leniency. So that at the present time practically every prescription written by a physician for a narcotic comes under the careful scrutiny of a competent inspector; practically every grain of narcotic dispensed by every pharmacy in the land must be accounted for to Federal and State inspectors; and a majority of the habitual narcotic users are known to the authorities even to the extent of knowing approximately the amount of drug they are taking and the length of time they have been taking it.

Nor is this narcotic knowledge a mere formality. Prosecutions of offenders who have broken the Harrison narcotic law, or are suspected of having done so, fill the calendars of the Federal courts. And other courts are equally well patronized.

1 Read before the Los Angeles Society for Neurology and Psychiatry, April 20, 1921.

In short, the Harrison narcotic law has been a popular measure for something like 5 years, and as actively enforced as is humanly possible.

What is the result of these years of almost unprecedented legislative activity? The question cannot be answered in a sentence. But it seems to be the consensus of opinion of Federal, State, and county officials who are most closely in touch with the situation, that the number of drug takers and the amount of drug consumed today, after 5 years of this active legislation, is just as great as, if not, indeed, considerably greater than it was 5 years ago.

There is, however, a radical change in the method of obtaining opiates by the drug addicts. The closure of the legitimate channels for obtaining narcotics has brought into existence an illicit traffic of tremendous proportions. The elusive underworld "peddler," well supplied with drugs, now exacts his pound of flesh from his helpless victims, and tempts guileless "prospects" with free samples for the sake of future profits. Thus, without vitally affecting the actual evil, we have added criminality to what was formerly simply immorality.

With this situation existing after 5 years of active legislation it behooves us to take inventory of our weapons and fighting equipment against the narcotic evil. Why has the Harrison Narcotic Act failed to accomplish the purpose for which it is formulated? Certainly this failure cannot be laid at the door of inactivity on the part of officials, or lack of interest and cooperation by the public. Wherefore, it appears that there must be something fundamentally wrong with the inception of the law itself. A law that fails to effect its purpose when vigorously enforced, and after a sufficient length of time to give it fair trial, must be lacking in something not visualized in its original conception. There seems to be no other logical conclusion.

From a medical viewpoint the law has the fundamental defect of not giving sufficient consideration to the underlying cause of opiate addiction. In effect, it regards narcotic addiction as a purely criminal act willfully indulged in by normal individuals, with only scant consideration to the possibility that disease may be a cause as well as a result of the condition. Stated in another way, the law emphasizes the legal aspect of the problem and subordinates the medical features.

Now, in point of fact, the vast majority of opiate addicts present an abnormal mental and physical condition closely akin in many respects to the condition known as insanity. And our present narcotic legislation presents many features similar to the older legislation for the control of mental diseases.

It is not medical men alone, however, who believe that narcotic addiction is often the result of an abnormal mental state, not merely a "bad habit." The veteran officers of the law eventually reach this conclusion, almost without exception. In the beginning, when their duties first bring the officers in contact with this class of persons, they usually regard the drug addict as a self-willed and responsible criminal offender. Their opinion is based on the popular conception of addiction, not upon practical experience. But later, after they have been closely in touch with every phase of drug habituation, their viewpoint changes almost invariably. Their original conception was based on ignorance; their later point of view is the result of experience. And no one will question that experience is a better teacher than ignorance.

A precisely similar change in mental attitude occurs in persons who are brought closely in contact with the insane. The novice in insane hospital work invariably thinks that a high percentage of his patients are not insane-that "there is nothing wrong with them." But as he gains in experience his viewpoint changes, just as in the case of the officers who are brought closely in contact with narcotic addiction. And thus we find the experienced narcotic officer inclined to deal leniently with the noncriminal type of drug addicts, because he realizes that he is dealing with persons who are not wholly responsible for their shortcomings.

It is apparent, therefore, that the comparison between insanity and drug addiction is not overdrawn. And in this connection we should remember that it is only within the lapse of a century that insanity has been legally recognized as a disease. Christian nations, for a period of more than 15 centuries, had regarded insanity as a "possession by demons"-a crime. The unfortunate insane were imprisoned and subjected to every kind of cruelty, just as in the case of the vilest criminal. Yet persons continued to become insane, and usually incurably insane, in the face of the most hideous punishments.

America, the great haven of liberty, offered no sanctuary. Lunatics were beaten, imprisoned, chained in filthy dungeons, and specially maltreated here, just as in monarchy-ridden Europe. And as a culminating touch of persecution

our ancestors burned at the stake that pitiful little group of old mad women at Salem.

But even this did not stop people from "going crazy." And at last even the law itself stood aghast at its futile folly.

Then a great French physician, Pinel, proclaimed the heresy that insanity is a disease, not a crime. And with the courage of his convictions, and, fortunately, with an influence that could not be disregarded, he struck the shackles from the inmates chained in their madhouse hovels. And behold! many of these mad creatures regained normal reason! The era of rational treatment of insanity had dawned. Lunacy had evolved from a state of incurable criminality to the condition of a curable disease.

There is an analogy between our present attitude toward opiate addiction, and the lunacy situation of 100 years ago. Insanity was not thoroughly understood then, and naturally the lunacy laws of that time were inadequate and unjust. The opiate addict, like the psychopath, is an abnormal individual. But in most instances his physical and mental abnormalities are not apparent to casual observation so long as his system is supplied with a sustaining quantity of the drug. When this necessary stabilizing narcotic is withdrawn, however, the abnormal physical and mental conditions quickly assert themselves with absolute certainty.

Yet even when the similarity between insanity and opiate addiction is recognized, our attitude toward the two conditions is utterly different, and is determined by the supposed underlying cause of each condition, rather than by the conditions themselves. We punish the opiate addict because his infirmity is selfimposed, just as formerly lunatics were punished because it was believed that they willfully associated themselves with evil spirits.

But the present legal attitude is not consistent even if we accept the dictum that the result of self-imposed vices should be punished, while unavoidable misfortunes should not. For it so happens that one of the most important and prevalent forms of insanity, general paresis, is the result of venereal vice-a self-imposed condition. At least 10 percent of all cases of insanity are attributable to this vicious cause. Yet the law makes no distinction between paretic patients, with their virtually self-imposed disease, and any other types of insane persons. The paretic is not punished, although in acquiring the specific infection which is the cause of his condition, he gratified a willful indulgence scarcely more compelling, and generally regarded as far more reprehensible, than the craving for a drug.

It is evident, therefore, that the cause of insanity does not influence the legal attitude toward this disease. Such is not the case with opiate addiction. A drug addict is a malefactor in the eyes of the law whether he acquired his habit through pure viciousness, or whether, as is often the case, his addiction was thrust upon him unwillingly, as in the case of many maimed veterans from France.

It is true that there is a somewhat vaguely phrased distinction in the legal attitude toward persons who are criminally insane and other demented individuals. All insanity is disease, but in some States special hospitals are provided for the care of persons suffering from "criminal insanity." But even so, a very great distinction is made between this type of insanity and ordinary criminality. No such distinction is made in the case of drug addicts. Yet we know that there are addicts whose drug taking makes them criminals; and others who regard criminal tendencies and criminal acts with just as great abhorrence as the highest type of normal individual. It is just as inconsistent to put these persons in the same class as it would be to place ordinary criminals and insane criminals on the same level.

The important thing about the existing narcotic laws, however, regardless of inconsistencies, is the fact that they do not appear to be getting adequate results. One modification of the present law that naturally suggests itself is to increase still further the scope and stringency of the statute. But it would seem that this is scarcely possible without curtailing the legitimate use of opium. And opium. bear in mind, is our most useful and most important drug. Curtailing its legitimate use would cause untold suffering among countless numbers of innocent persons afflicted with painful diseases. These persons far outnumber the addicts. So that even the complete elimination of this relatively small handful of drug habitues would be scant recompense for such a sacrifice.

A less objectionable plan would be some slight modification in the existing narcotic laws tending to emphasize the medical side of the narcotic problem. There is nothing novel in this suggestion. Indeed, a practical step in this direc