In general, what is said of the use of morphine and its derivatives in surgery applies equally well to the practice of gynecology. For the postoperative pain and abdominal symptoms morphine is indispensable, and the narcotic often saves life by its sedative influence on the bowel. For the treatment of chronic gynecologic diseases morphine has only limited uses and should be dispensed with as much as possible with the exception of incurable cancer.

NARCOTICS IN LOCAL ANESTHESIA

The ideal method of performing operations on a conscious patient without mental or phyiscal discomfort requires a balanced use of sedatives, analgesics, and anesthesia. Premedication to local anethesia aims to diminish psychic reactions and painful sensations. In minor ambulatory procedures it is not necessary; before major surgical operations the restless night, fear, and anxiety not only exhaust the patient but may cause definite bodily changes. Ordinarily sedatives of the barbituric acid series are sufficient for this purpose. The most frequent causes of toxic symptoms after local anesthesia are excessive premedication, error in the concentration of the solution of local anesthetic used, inadvertent intravenous or intraspinal injection and an individual hypersensitivity to cocaine, procaine hydrochloride or other local anesthesia.

ABUSES OF NARCOTICS AND ADDICION

The problem of narcotic addiction merits the attention of physicians for many reasons and at this time in particular results in an enormous diversion of narcotic drugs from their field of proper employment.

Narcotics may be defined as agents that lessen the relation of the central nervous system to external as well as internal conditions of the body. They act by freeing the mind more or less from the thraldom of the senses, and therein lies their value as well as their danger. It is the "ease and ignorance" with which one may be relieved of a great multiplicity of symptoms by means of narcotics that makes their use an ever present temptation to patient and physician alike; and it is only by patients forswearing self-medication and by physicians adopting certain definite rules regarding their employment that the abuse of narcotics can be guarded against.

Thus, narcotics should never be employed to remove a diagnostically indispens able symptom. As an illustration, the old and well-worn warning against the use of opium in appendicitis at once comes to mind. In a case of appendical colic, for instance, in which operation may or may not be required, the administration of an opiate may, by the comfort it gives, create the impression that the patient is getting well and obscure the fact that inflammation is setting in and perforation is threatening or has occurred, and immediate operation is required to save life. One may relieve the pain of a strangulated hernia or an intussusception by an opiate and even check the vomiting, so that it may seem that all is well when, as a matter of fact, the patient's death is commencing with necrosis of the bowel. Nothing is easier than to remove the results of fatigue-headache, backache, nervous irritability, insomnia-by narcotics; nothing is worse, unless the fatigue is due merely to temporary overexertion. When the excessive strain is habitual and the demand for the relief of its ill effects also becomes habitual and is gratified, one is driving head on to a serious wreck. A rest treatment is needed, not dope. It is unfortunate that the term "rest cure" has become so intimately associated with the famous Weir Mitchell prescription. It should be recognized that there may be all sorts and degrees of rest treatment. For instance, a regular afterdinner nap is one of these and it will often do the distracted and harassed housewife or businessman more good than any amount of medicine.

Formation of habit should be the ever-present specter to inspire fear of prescribing narcotics in chronic or recurring ailments, unless there are malignant conditions or limited tenure of life to make the habit relatively unobjectionable. Especially should physicians, dentists, nurses, and pharmacists make it their inviolable rule never to prescribe narcotics for themselves for from among these classes is recruited a large contingent of those who become afflicted with the habitual use of narcotics. Some narcotics, as opiates and alcohol, are intrinsically habit producing. They operate in creating the notorious craving, partly by being most efficient antagonists to the disagreeable aftereffects produced by the agent itself, and partly by causing mental deterioration. But all narcotics are liable to be habit forming, by reason of their very efficiency in relieving symptoms and

their inability really to cure any disease. Therefore, as soon as the effect of the agent wears off, the original condition asserts itself, demanding relief. Whenever, therefore, a narcotic is employed it should merely be as an adjunct to the real curative treatment. It is only when cure is impossible that the narcotic habit may be a lesser evil than unrelieved suffering. In any case, an extensive range of knowledge of the many available narcotics should permit a choice of the least objectionable and yet most efficient agent for the particular patient to be relieved; and opiates should be appealed to only as a means of last resort.

EXHIBIT No. 22

Following are the records of the various actions of the House of Delegates, Medical Society of the State of New York, and the American Medical Association, committee on narcotics, which constitute the present policy on the narcotics problem of the American Medical

Association:

[Minutes of the Annual Meeting, New York State Journal of Medicine, pt. II, September 1, 1953]

PROCEEDINGS OF THE HOUSE OF DELEGATES, MEDICAL SOCIETY OF THE STATE of NEW YORK, 147TH ANNUAL MEETING, MAY 4 TO 6, 1953, BUFFALO, N. Y.

SECTION 73 (SEE 109)-LEGALIZING OF DISTRIBUTION OF NARCOTICS

Dr. Walter T. Heldmann, Richmond: I have two resolutions to introduce at the request of the Richmond County Medical Society. The first concerns legalizing of distribution of narcotics:

"Whereas the medical profession, in its traditional role as guardian of the public health, has been distressed by the narcotic problem and its apparent increase; and

“Whereas the average user of narcotics must spend from $15 to $100 per day to keep himself supplied with drugs; and

"Whereas the crime in drug addiction stems from the inability of persons of moderate means to purchase drugs at present illegal prices; and

"Whereas the most serious of these crimes is the conversion of each addict into a salesman, with consequent formation of new addicts; and

"Whereas the use of morphine and heroin in themselves do not incite these unfortunate people to crime, since both drugs are depressants; and

"Whereas the narcotic trade exists only because of the huge profits involved (for example, 2 pounds of heroin can be bought for $10 in China and sold after cntting and packaging for $80,000 or more) : Therefore be it

“Resolved, that the Medical Society of the State of New York favors the legalizing of the distribution of narcotics free of charge with proper safeguards, as follows:

"1. Establish narcotics clinics in all cities, as the need appears, under the aegis of the Federal Bureau of Narcotics;

"2. Register and fingerprint all who apply (to prevent reregistering in other clinics);

"3. Do not demand that these addicts be forcibly confined, as they are now; "4. Determine the smallest amount of pure drug that will relieve the patient of his symptoms;

"5. Administer this uncut material by the doctor or under his supervision and under sterile precautions;

"6. Keep accurate records of dosages;

"7. Never give any supply to the addict, dosage to be given only at the clinic; "8. Nominal charge for the actual cost of the drug, possibly 15 to 30 cents; "9. Make an effort to effect a cure, where possible, using hospitalization if the patient acquiesces; and be it further

"Resolved, That the Medical Society of the State of New York instruct its delegates to the American Medical Association to work actively for the enactment of Federal legislation embodying these principles."

Speaker HOLCOMB. This will be referred to the Reference Committee on Miscellaneous Business B, of which Dr. E. Dean Babbage is the chairman (p. 47).

REPORT OF REFERENCE COMMITTEE ON MISCELLANEOUS BUSINESS B: LEGALIZING OF DISTRIBUTION OF NARCOTICS

Dr. E. DEAN BAGGAGE, Erie. Two, a resolution was introduced by Dr. Walter T. Heldmann, of Richmond County. It is a lengthy resolution, and all members of the house of delegates have been sent a copy.

Dr. Herbert Berger, president of the Medical Society of the County of Richmond, was present to discuss the resolution. His views are that addiction is an illness, the present system of treatment of addiction is a failure, and that the medical profession should take the lead in presenting some constructive program rather than allowing the legal profession to assume the task. He presented two bills that have been introduced in Congress, one by Miller of Nebraska and one by Bailey of West Virginia, the latter being a member of the Kefauver committee. Both bills embody the contents of the resolution presented by Dr. Heldmann for your action.

This reference committee discussed the resolution for some time and arrived at the following conclusions: This is a complicated subject and one that would have to be studied at great length. There are so many ramifications of the problem that this house of delegates could debate on them the rest of this session. Your reference committee unanimously approves of the resolution in principle and recommends it be referred to the council for further study.

I recommend that adoption of this portion of the report.

Dr. CHARLES A. ANDERSON, Kings. I second it.

Vice Speaker WILLIAMS. Is there any discussion? Are you ready for the question? Every delegate is fully aware that the recommendation of the reference committee is to adopt the resolution in principle and refer it to the council for further study.

Dr. IRVING J. SANDS, Kings. I should like to say a word about this resolution. I would urge you to be cautious in what you do with it. In 1920 you recall the name of Royal Copeland, who was quite a national figure, mayor of New York, Senator, and what have you. He established then the very same thing that is proposed in these resolutions. It was a miserable failure. The treatment of narcotics drug addicts from a medical standpoint of view is a very simple one, but you cannot cure them because the so-called economic factors, not the medical, are too powerful to prevent addiction. You can cure a drug addict within a month. There are no difficulties at all. I was at that time in 1920 in charge of the Bellevue ward for narcotics. The trouble is that we fail to recognize there is too much money as far as drug addiction is concerned. It is a social and economic question. When you say that we approve in principle the idea that we should open clinics and treat them, it is a very serious and, I am afraid misguided step. We doctors can cure the addict but can't keep him off the drug. It is not within our policy to do so; it is not without our reason. I should like to have a vote against the entire proposition.

Vice Speaker WILLIAMS. I would like to call to the attention of the house that by this recommendation the principle is approved, and they are referring it to the council for further study and action.

** The question was called, and the motion was put to a vote and was carried (p. 64).

PROCEEDINGS OF THE HOUSE OF DELEGATES OF THE AMERICAN MEDICAL ASSOCIATION, THE 103D ANNUAL SESSION HELD AT SAN FRANCISCO, JUNE 21, 1954

NO. 63-RESOLUTION ON LEGALIZATION OF DISTRIBUTION OF NARCOTICS

Dr. Andrew A. Eggston, for the New York delegation, introduced the following resolution, which was referred to the reference committee on hygiene, public health, and industrial health: (50)

"Whereas the medical profession, in its traditional role as guardian of the public health, has been distressed by the narcotic problem and its apparent increase; and

"Whereas the average user of narcotics must spend from $15 to $100 per day to keep himself supplied with drugs; and

"Whereas the crime in drug addiction stems from the inability of persons of moderate means to purchase drugs at present illegal prices; and

"Whereas the most serious of these crimes is the conversion of each addict into a salesman, with consequent formation of new addicts; and

"Whereas the use of morphine and heroin in themselves do not incite these unfortunate persons to crime, since both drugs are depressants; and

"Whereas the illicit narcotic trade exists only because of the huge financial profits, such as are obtained by purchasing 2 pounds of heroin in China for $10 and selling it after adulteration and packaging for $80,000: Therefore be it "Resolved, That the American Medical Association favors the legalization of distribution of narcotics at cost or free under the following safeguards: (1) establishing narcotic clinics in cities where needed under the aegis of the Federal Bureau of Narcotics (2) registration and fingerprinting of narcotic addicts; (3) keeping of accurate records; (4) administering the optimal doses at regular intervals to addicts at cost or free; (5) prevention of self-administration; (6) attempt cures through voluntary hospitalization, if possible; and (7) avoidance of forceable confinement" (p. 46).

REPORT OF REFERENCE COMMITTEE ON HYGIENE, PUBLIC HEALTH, AND

INDUSTRIAL HEALTH

"7. Resolution No. 63 on legalization of distribution of narcotics: Your reference committee believes that, because of the complexity of the problem involved. this matter should be referred to the board of trustees for further reference to an appropriate group for detailed consideration by experts, the results of such study to be reported at a subsequent meeting of the house" (46) (50) (pp. 49–50).

1954]

[Minutes of the Annual Meeting, New York State Journal of Medicine, Pt. II,
September 1, 1954]

PROCEEDINGS OF THE HOUSE of Delegates, MEDICAL SOCIETY OF THE STATE OF NEW YORK, 148TH ANNUAL MEETING, MAY 10 To 12, 1954, NEW YORK CITY

MATTERS REFERRED FROM THE HOUSE OF DELEGATES, 1953

5. Legalizing the distribution of narcotics (sec. 109).-Dr. Herbert Berger, author of the resolution, was granted a conference with Dr. Ernest Gruenberg, executive director of the Mental Health Commission of New York State. It was Dr. Gruenberg's feeling that narcotic addicts should be treated in mental health clinics and that separate clinics may not be necessary. Since the passage of the mental hygiene bill it seems likely that clinics may be established throughout the State where addicts could apply for treatment.

Subsequent to this meeting Dr. Gruenberg took up with the mental health commission Dr. Berger's request that it endorse the resolution. Dr. Gruenberg has reported that the commission did not consider it their function to form conclusions regarding proposals which are under consideration by medical societies or similar bodies.

SECTION 165 (SEE 15)-REPORT OF REFERENCE COMMITTEE ON REPORT OF COUNCIL, PART IV: SUPPLEMENTARY REPORT OF COUNCIL COMMITTEE ON PUBLIC HEALTH AND EDUCATION (LEGALIZING THE DISTRIBUTION OF NARCOTICS)

Dr. Alfred Angrist, Queens: I am sorry, there is another resolution. The resolution of Dr. Herbert Berger which was referred to the reference committee from the supplementary report of the council committee on public health and education.

It was noted that the cause of crime in addiction resides in the illegal acquision through the underworld. Further, addicts are patients with mental disturbance and should be treated by physicians, presenting a medical problem with, very often, the legal and criminal problem appearing secondarily. There was good reason to have existing mental health clinics or established narcotic clinics handle such patients with every prospect of a cure rate superior to what now is recorded. An equivalent resolution has been adopted in the States of California, Michigan, and Illinois.

It was the considered opinion of your reference committee that there is distinct merit in the purpose, objectives, and recommendations included in the resolution, and that this matter be referred to council for the establishment of a committee to make special recommendations for its formal endorsement and implementation. I move the approval of this resolution. * *

The motion was seconded. * *

Vice Speaker Williams: Any discussion? If not, all in favor will say "aye;" contrary "no." It is carried and so ordered.

RESOLUTION ON LEGALIZATION OF DISTRIBUTION OF NARCOTICS

DECEMBER 1, 1954.

Dr. Andrew A. Eggston, for the New York delegation, introduced the following resolution, which was referred to the reference committee on hygiene, public health, and industrial health:

"Whereas the medical profession, in its traditional role as guardian of the public health, has been distressed by the narcotic problem and its apparent increase; and

"Whereas the average user of narcotics must spend from $15 to $100 per day to keep himself supplied with drugs; and

"Whereas the crime in drug addiction stems from the inability of persons of moderate means to purchase drugs at present illegal prices; and

"Whereas the most serious of these crimes is the conversion of each addict into a salesman, with consequent formation of new addicts; and "Whereas the use of morphine and heroin in themselves do not incite these unfortunate persons to crime, since both drugs are depressants; and

"Whereas the illicit narcotic trade exists only because of the huge financial profits, such as are obtained by purchasing 2 pounds of heroin in China for $10 and selling it after adulteration and packaging for $80,000: Therefore be it "Resolved, That the American Medical Association favors the legalization of distribution of narcotics at cost or free under the following safeguards: (1) establishing narcotic clinics in cities where needed under the aegis of the Federal Bureau of Narcotics; (2) registration and fingerprinting of narcotic addicts; (3) keeping of accurate records; (4) administering the optimal doses at regular intervals to addicts at cost or free; (5) prevention of self-administration; (6) attempt cures through voluntary hospitalization, if possible; and (7) avoidance of forceable confinement."

REPORT OF REFERENCE COMMITTEE ON HYGIENE, PUBLIC HEALTH AND INDUSTRIAL HEALTH

Dr. Charles L. Farrell, chairman, submitted the following report, which was adopted:

Resolution No. 63 on legalization of distribution of narcotics: Your reference committee believes that, because of the complexity of the problem involved, this matter should be referred to the board of trustees for further reference to an appropriate group for detailed consideration by experts, the results of such study to be reported at a subsequent meeting of the house.

[Excerpts from the Journal of the American Medical Association, dated December 25, 1954, vol. 156, No. 17]

PROCEEDINGS OF THE MIAMI CLINICAL MEETING

Abstract of proceedings of the house of delegates of the American Medical Association at the clinical meeting in Miami, Fla., November 29-December 2, 1954

REPORT OF REFERENCE COMMITTEE ON REPORTS OF BOARD OF TRUSTEES AND SECRETARY

Your committee is grateful that the nuisance of the $1 certified check for the payment of the Harrison Narcotic Act tax has been eliminated through the efforts of this bureau and trusts that the appropriate regulation will soon be issued.

Volume 5 of the abstracts of medicolegal decisions was issued during the fall of 1954. It will continue to act as a reference source along with the previously published volumes.