Effect of addiction on health.-The committee is forced to conclude from its investigations that the habit-forming drugs herein mentioned produce a marked physical and mental deterioration in individuals addicted to their use.

The constant use of narcotics, such as opium, its preparations and alkaloids produces a condition in the human body which is beginning to be looked upon by physicians as a disease. This diseased condition requires the repeated administration of the drug of addiction to keep the body functioning normally or the institution of medical treatment. The mere withdrawal of the drug induces such fundamental disorganization and such painful disturbances that addicts are driven to any extreme to procure more of the drug with which to allay their suffering. For years individuals addicted to the use of opiates may appear quite normal to the ordinary observer, but close attention will usually reveal signs of diseased conditions as evidenced by variability of moods, waxy complexion, emaciation, diseased condition of the respiratory organs, heart, and kidneys. Continued addiction brings about sexual sterility and thus reduces the birth rate among this class. If impregnation occurs during a period of abstinence from the drug, and the mother later begins using the drug again, the child when born becomes addicted through the mother's milk.

The effect of cocaine is somewhat different. While it causes a more rapid physical and mental deterioration than the opiates, the changes produced are not as profound, and the drug may be completely withdrawn without danger of serious results following. In addition to the systemic effects of the use of cocaine, individuals addicted to this drug often show a perforation of the nasal septum as a result of the local action of the drug when it is used as a snuff. This condition has also been observed in heroin addicts, this drug being usually taken in the same manner. The committee also finds that insanity is not infrequently a result of the use of cocaine in the case of addicts.

In cases where any of these drugs are taken hypodermically, there is frequently noticed abscesses, scarring, and disfiguration of those parts of the body in which the needle was inserted. In general the physical deterioration which results from the continued use of any of these drugs brings about a diminution in the power of resistance so that the addict falls an easy prey to some other ailment, and thus very seldom reaches old age.

Effect of addiction on morals.—From information in the hands of the committee, it is concluded that, while drug addicts may appear to be normal to the casual observer, they are usually individuals weak in character and will, and lacking in moral sense. The opium or morphine addict is not always a hopeless liar, a moral wreck, or a creature sunk in vice and lost to all sense of decency and honor, but may often be an upright individual except under circumstances which involve his affliction, or the procuring of the drug of addiction. He will usually lie as to the dose necessary to sustain a moderately comfortable existence, and he will stoop to any subterfuge and even to theft to achieve relief from the bodily agonies experiences as a result of the withdrawal of the drug. There are many instances of cases where victims of this disease were among the people of the highest qualities morally and intellectually, and of the greatest value to their communities, who, when driven by sudden deprivation of their drug, have been led to commit felony or violence to relieve their misery. Addiction to the use of cocaine produces a much more rapid deterioration of mental powers and moral sense. It is this class of addicts that most frequently commit moral wrongs and crimes of violence.

Among the addicts of the underworld, practically all show a low mentality, a lack of decency and honor. This condition, however, is not entirely due to the effect of these drugs as might be inferred, but is largely the result of degeneracy due to environment and association.

Relation of drug addiction to crime.-The committee finds that the drug habit has some bearing on the question of crime. Reports from officials of prisons and reformatories show that a number of the inmates are drug addicts. In 1916, the addicts in the city prison (Tombs) at Manhattan constituted 5 per cent of the total number of prisoners. There is, however, a great variety of evidence on this subject which has not yet been made clear.

The users of opium and morphine are seldom seen in the courts for brutal crimes. The offenses committed by them in the order of their frequency as indicated by replies to questionnaires sent out by the committee are larceny, burglary, vagrancy, forgery, assault, and violation of the drug laws. They are frequently aiders or abettors of crimes, but less commonly the leading actors in criminal conduct.

In cases where addicts have committed violent crimes, it is reported that they were users of cocaine or heroin. These are also the drugs which are most frequently used by prostitutes and those engaged in the "white-slave traffic." These drugs appear, therefore, to be the most obnoxious.

Economic aspect of drug addiction.—While the committee has been unable to secure sufficient data to enable it to formulate a statement which will convey exact knowledge of the economic phase of drug addiction, it is believed some idea of the economic loss to the country sustained through addiction may be gained from the cost of the drugs used by addicts and the loss through unemployment of those addicted. It has been computed by the State food and drug commissioner of one of the States having stringent regulatory laws that the average annual expenditure for an addict to satisfy his addiction amounts to $61.18. Upon this basis of cost of drugs alone, the addicts of this country annually pay over $61,000,000 for the satisfaction of addiction. The figures obtained by the committee vary as to the average percentage of addicts regularly employed, employed part of the time, and not employed at all. But it is concluded from a careful analysis of these figures, as well as those obtained by other investigators who have made a study of this problem, that at least 25 per cent of the addicts are not steadily employed in gainful occupations. This would represent at least 250,000 unemployed addicts in the United States. At a conservative estimate this would represent the loss in wages of $150,000,000 annually. These figures, however, do not include the cost of drug addiction to individuals as a result of loss through theft and burglary, nor the cost to the States and municipalities in the suppression and punishment of crime, and the care and treatment of those who eventually become a charge upon the community.

CONCLUSIONS AND RECOMMENDATIONS.

From the data obtained the committee is convinced that there is a nation-wide use of narcotic drugs for other than legitimate medical needs, and that such use for the satisfaction of addiction has materially increased in certain sections of the country despite the vigorous efforts exerted in the past four years in the enforcement of the Federal antinarcotic law, and in the enforcement of the laws of the States and municipalities which have enacted such for the control of habit-forming drugs. Furthermore, it is apparent from the replies to questionnaires sent out that there has been no definite or concerted action on the part of the majority of the State and municipal governments to suppress the illicit traffic and use of habit-forming drugs, and that there has been little, if any, attempt made to secure accurate information concerning the problem of drug addiction as a basis for the enactment of proper legislation and regulation. The replies to the questionnaires sent out to State, county, and municipal officials show that a great majority of these officials kept no records and therefore had no information upon the subject. This condition is believed to be due principally to a lack of knowledge of the seriousness of the situation. In many cases it is no doubt partly due to the more or less general acceptance of the old theory that drug addiction is a vice, or depraved taste, and not a disease, as held by modern investigators. This attitude has had the effect of holding these unfortunate creatures up to public scorn, and thereby lessening any interest in their welfare. Records having a bearing on any and all phases of drug addiction are of sufficient importance to warrant immediate action for the purpose of remedying these conditions.

Excerpts from address by James A. Hamilton, Ph. D., secretary of state and former commissioner of correction of the State of New York on drug addicts on Riders Island. (New York Medical Journal and Medical Record for December, 1922.)]

All students of drug addiction are grouped into two schools: First, those who believe drug addiction to be a disease and those who believe with us that it is merely a pernicious habit. The laity have criticized the medical profession for their failure to produce a real cure (as they term it) for drug addiction. This criticism has resulted from a misconception of drug addiction and also from the use of the word cure, which is undoubtedly a misnomer and gives an erroneous impression.

If we regard drug addiction as a disease we must not expect the cure to produce any immunity to a recurrence. There are only a few diseases that produce any immunity and this immunity is but relative, never absolute. In a great many diseases one attack predisposes to a recurrence. If we regard drug addiction as a disease it is among those where a recurrence is possible that we must place drug addiction.

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It is interesting to be behind the scenes in a drug addict ward and watch them unobserved while they are rioting. If no attention is paid to them, those who are complaining that they can not sleep, go to bed: if they hear footsteps outside the ward, the ringleaders wake up all the patients who "could not sleep," so that all will join in the appeal for more drug. When the ringleaders are taken out of the ward and placed in separate rooms, everybody goes to sleep.

The staging of "fits of all kinds" by the drug addicts when official visitors are present is of frequent occurence. It is not uncommon for a drug addict to stimulate a state

of collapse in court, although they received the drug in sufficient amount from the authorities. A very zealous citizen seeing a preformance of this kind requested and received premission to visit the correction hospital, as she was sure this inmate would be dead before she reached there. Imagine her surprise to find the patient walking around the ward as though nothing had happened. **

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All drug addicts received in our institutions are committed there for a crime. Much has been written about the so-called respectable drug addict. The experiences of our general hospitals have led us to question whether there is such a thing as a respectable drug addict. Realizing that drug addiction is a menace to the community and that it is a degrading habit, degenerating a person mentally, morally, and physically, these individuals if they persist in this habit when the cure is so easily obtained are certainly by continuing, not only their own destruction, but by the bad example that they give make themselves highly undesirable citizens.

The aim of all treatments is to take the patient "off the drug" and to keep him off until there is no physical craving and to place the individual in as near a perfect physical condition as possible. The treatment must be carried on in as humane a manner as possible. *

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Lately it has been suggested that a congressional investigation of the entire subject of drug addiction be made with a view to determining what treatment is the best. All debates or discussions relative to the control of drug addiction sooner or later become acrimonious disputes between medical men as to the merits of their respective treatments. In this way the doctors have unintentionally befuddled the real issue, which is not treatment but the prevention of drug addiction. Treating drug addicts bears the same relation to the broad problem of drug addiction as the treatment of drunkenness bears to the broad problem of inebriety. Men were formerly treated again and again for drunkenness, and at the time no one believed there was any permanency in the cure. Everyone expected there would be a relapse. Treating drug addicts is a very small item when it comes to the real problem.

Drug addiction will never be eradicated by treatment. Prevent the drug addict from getting supplies and there will be no necessity to worry about what kind of treatment is the proper one. The department of correction stands firmly and squarely on the assumption that all drug addicts are a menace to the community, and to be taken off the drug they need custodial care.

It would be interesting, of course, to have a nonpartisan and fair review of the treatment and handling of drug addiction; but the interest probably would be more from a medical viewpoint. The importance of the treatment is far outshadowed, however, by the larger problem of how to prevent drug addiction, and how to prevent the drug addict from obtaining the drug.

In 1921 the municipal farm, Rikers Island, received and treated 2,197 drug addicts.

[Excerpts from tariff information surveys on the articles in paragraph 47 of the tariff act of 1913. Opium, cocaine, and their derivatives. (Revised edition.)

SOURCES OF SUPPLY.

The principal opium-producing countries are Turkey, Persia, India, and China. Turkish opium is the highest grade, and has been the chief variety consumed in America. The war has naturally resulted in cutting off the supply of Turkish opium and its place has been taken to some extent by Persian opium.^ Indian and particularly Chinese opium are comparatively low in morphine content, have been used chiefly in the preparation of smoking opium, and are not imported into the United States. A large proportion of Turkish opium arrives via England.

HISTORY OF OPIUM.

The opium poppy is probably indigenous to southern Europe and western Asia. The medicinal properties of the juice have been known for a very long period. It was mentioned by Theophrastus (372-287 B. C.). From the first to the twelfth centuries the opium of Asia Minor appears to have been the only kind known in commerce. Reference to the production of opium in India is found early in the sixteenth century. The spread of the poppy thence is said to have been connected with that of Mohammedanism. In the seventeenth century Persian opium is described; the best sorts were flavored with spices and called "theriaka," and greatly prized during the Middle Ages. The poppy has been known in China some 12 centuries and its medicinal uses for 9. Opium, however, was not extracted in China till about the sixteenth century.

Origin of use of opium.-Opium smoking appears to have originated with the Dutch in Java, and by them taken to Formosa, whence it spread to the mainland about the middle of the seventeenth century. The drug was not then, as now, smoked by itself, but as a mixture with tobacco. Probably it was not smoked alone till near the end of eighteenth century. Something of its deleterious effect was early recognized, for opium smoking was first prohibited by the Chinese Emperor Young Cheng, in 1729. At that time opium was imported in small amounts from India, as well as produced locally. The early opium trade with China was in the hands of the Portuguese, but the East India Co., who had secured a monopoly of Indian opium in 1757, took charge of the Chinese-Indian trade in 1773. Chinese imports increased from 150,000 pounds in 1776 to 758,000 pounds in 1790. The Chinese Imperial authorities, alarmed by the rapid spread of the vice, in 1796 again prohibited opium smoking, and followed this with a prohibition of importation in 1800. Although infractions of these edicts were punishable with severe penalties and even with death, the trade continued, and during 1820-1830 increased to some 2,527,000 pounds per year. In 1839 the first serious attempts were made by the Chinese authorities to stop the trade; 3,030,000 pounds of opium, valued at $9,740,000, was destroyed by the Chinese commissioner at Canton. This was the property of British traders. The traders still sought to smuggle opium ashore, and the result was the so-called "Opium war," between Great Britain and China. This ended by the treaty of Nanking, in 1842. Opium was not mentioned in this treaty, but its importation continued and was legalized under certain restrictions in 1858. In this year some 10,430,000 pounds were imported into China. The status of the opium question at this period was a marked proof of the inherent weakness of the Chinese Government; while the central authorities were honestly striving to discourage production and trade, several of the provincial viceroys were actively encourgaging it. By the beginning of the twentieth century opium was produced in every province in China. The total amount produced in China in 1906 was estimated at 44,000,000 pounds, of which two-thirds was produced in Szechuan. About 7,230,000 pounds were imported, chiefly from India, and about 631,000 pounds exported, chiefly to Indo-China.

Early Indian-Chinese trade.--During the latter part of the nineteenth century and the first years of the twentieth the opium trade was the chief source of Indian revenue. The total net receipts from the export trade of India for the years 1900-1909 never fell below £3,000,000, and in one year (1904-05) exceeded £4,000,000. The gross revenue from opium excise (for consumption within India) varied in this period from £676,000 to £986,000. Repeated efforts by persons in India and England to bring about the discontinuance of the trade on moral grounds were for a long time without effect. In 1893 an extensive inquiry was made into all phases of the Indian opium question by a commission appointed by Parliament. This commission rendered a voluminous report in 1895, which in substance stated that the evils attending the opium traffic had been much exaggerated; that it was not necessary, advisable, or demanded by the Indian people that the growth of the poppy and manufacture of opium except for medicinal purposes should be abandoned in India; that the finances of India were not in a condition to bear the cost of the preventive measures and the loss of revenue which would be entailed by prohibition; and that they found "no evidence of extensive moral or physical degradation" resulting from the use of opium. A single member filed a dissenting report, in which he disagreed especially with the last-cited conclusion of the commission, and sharply arraigned the administrative methods of the Indian government and its attitude toward the inquiry. The report of the commission put an effectual quietus on the antiopium movement for a number of years.

Opium in the Philippines.-The next important era in the history of opium may be said to have opened with the acquisition of the Philippines by the United States. While the United States, in its "Chinatowns," and in its treaty and trade relations, had encountered the opium traffic and adopted certain policies with regard thereto, it now for the first time came seriously into contact with the problem. In the Philippines were about 70,000 Chinese, the majority in the larger towns, Manila alone containing 40,000. A large proportion of these were opium addicts. Under the Spanish law the sale of opium was farmed out, and smoking resorts licensed for the Chinese only. It was unlawful for a Filipino to use opium in any way. Under American occupation the Spanish law was not continued in force. A duty was placed on opium, and towns were enjoined to forbid the establishment of opium dives. Under this system the use of the drug spread rapidly among the Filipinos.

In 1903 the Philippine Commission appointed an opium committee, authorized to visit the various oriental countries to investigate the methods taken by the different Governments toward the regulation of opium use and traffic. This committee investigated conditions in Japan, Formosa, Shanghai, Hongkong, Saigon, Straits

Settlements, Burma, and Java, and rendered a report in 1904. The recommendations of this report were based largely on the experience and methods of the Japanese upon their acquisition of Formosa in 1895. The most important recommendations were: Immediate Government monopoly of the traffic in opium to become prohibitive, except for medical purposes, after three years. The partial adoption of these suggestions are seen in an act of Congress entitled "An act to revise and amend the tariff laws of the Philippine Islands, and for other purposes," approved March 3, 1905. This act provided duties on crude and manufactured or smoking opium, but left the Philippine Commission free to prohibit or regulate the use of the drug, and provided further "That after March 1, 1908, it shall be unlawful to import into the Philippine Islands cpium, in whatever form, except by the Government, and for medicinal purposes only, and at no time shall it be lawful to sell opium to any native of the Philippine Islands except for medicinal purposes.' The Government monopoly plan was not adopted.

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Inception of Chinese antiopium movement. The rather voluminous report of the committee gave a new life to the antiopium movement in all countries affected by the drug, and it is not unreasonable to attribute to it the sudden renewal of activity by the Chinese Government, which, while officially discountenancing the use of opium, derived a large revenue from it and had appeared to feel itself unequal to a vigorous opposition to what had become probably the gravest internal menace ever faced by any nation. It has been estimated that 27 per cent or over of Chinese adult males were opium smokers. On September 20, 1906, the central Government of China issued an edict forbidding the consumption of opium and the cultivation of the poppy. In October of the same year the American Government in the Philippines suggested a joint conference of the powers interested with a view to united action against the opium traffic. In 1907 the British Government offered to reduce the export of Indian opium 5,100 chests, i. e., one-tenth of the amount then taken by China each year till 1910, and offered, further, if the Chinese Government should proportionately decrease opium production in China, and its importation from the other sources, to continue this annual reduction till the trade should be extinct in 1917. This proposal was gratefully received by the Chinese Government, which vigorously carried out its part of the agreement.

First international opium conference. In 1909 the first international opium commission, convening on the initiative of the United States Government, met at Shanghai. The powers represented were the United States, Austria-Hungary, China, France, Germany, Great Britain, Japan, the Netherlands, Persia, Portugal, Russia, and Siam. Each of these countries presented a report embodying the regulations and describing the status of the opium traffic within its territories. The most extensive report was that submitted by the Chinese delegates, who, in addition to statements regarding opium proper, called attention to the recent rapid increase in the vicious use of morphine and cocaine, both of which had been widely introduced, both openly and as recent ingredients of opium "cures" and "remedies" with which the country had been flooded, chiefly by foreign agents.

The commission adopted nine resolutions for presentation to the respective Governments concerned. In these the commission recognized the sincerity of the Chinese Government in the antiopium movement. It urged each Government concerned to take measures toward the suppression of opium smoking, to prevent the shipment of opium and its derivatives to countries prohibiting their import, and to take drastic measures in regulation of the manufacture and use of morphine and other habitforming opium derivatives. It further recommended that antiopium remedies and opium and its derivatives be subjected to scientific inquiry, that opium shops and divans in foreign concessions in China be closed, and that the sale of antiopium remedies containing opium or its derivaties be prohibited, and that the pharmacy laws of the governing nation be applied in such concessions.

Continuance of Chinese antiopium movement.-During the years 1906-1910 the Chinese antiopium movement continued with variable but, on the whole, unlooked-for success. În 1911 an agreement was signed between China and Great Britain, ratifying and completing the tentative arrangement of 1907, and furthermore providing for the extinction of the Indian trade with different Provinces of China as fast as each Province should suppress local production. China also prohibited the import of Turkish and Persian opium after 1911. To conclude the history of opium as regards China, it may be said that the prohibitory movement received a serious setback during the revolution, but by 1914 the new Government has apparently full control of the situation and was carrying out systematic and progressive prohibition as planned by the old régime. As an aid to the new Government in the suppression of the opium traffic, the Indian Government in 1913 prohibited the export of opium to China. A considerable amount of smuggling, however, still takes place across the national boundaries.