Drug Abuse

 

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The number of individuals involved is probably what first brings any problem to the attention of the public. It bears a definite relationship to control and if it is demonstrated that a problem is confined neither to a community nor to a section of tile country, neither to one social group nor even to one race, but is widespread and common to all, such facts should be used as the basis for eliciting interest, for pointing out the need for remedial measures, and for framing such measures. Likewise the converse is true. A knowledge, therefore, of the extent of tile problem with which we are concerned is a matter of importance and should receive early consideration.

The attempts which we have made to secure an accurate estimate of the number of chronic opium users in the United States at the present time emphasize an unusual situation. We find estimates varying all the way from a few thousand individuals to several millions. One states that one hundred thousand to two hundred thousand is the outside limit while another states that two million or more is a conservative figure. The lay press, popular magazines, and even scientific journals vary so widely in their estimates of the number of sufferers from this condition that one is justified in accepting none of them unreservedly and in analyzing afresh all available means for the determination of the actual facts.

It will be seen not only that no one is possessed of an accurate knowledge as to the exact number of individuals regularly using opium in this country today, but also that under present conditions it is impossible to obtain such a figure. There are several reasons why this is true. In the first place, the fact that opium-using in any form is regarded by the general public as alone a habit, vice, sign of weak will or dissipation undoubtedly has caused the majority of users to conceal their condition. This attitude presumably attributes to the individual either a physical or mental inferiority the concealment of which is quite natural. This factor applied before the problem ever became a matter for official and legislative action and undoubtedly became intensified when it was taken up officially and the individuals desirous of solving it made their views the basis of propaganda for control. With the advent of prohibitory legislation and the consequent fear of legal involvement, it is natural that even greater efforts were made by individuals affected to conceal their condition.

Quite aside from this individual point of view is the fact that only in cases where large doses of the drug are being consumed can casual observation or even a fairly careful examination determine the existence of the condition. There is a popular belief extant that practically anyone can detect the so-called "dope fiend," that he is a miserable, emaciated, furtive individual with pinpoint pupils, trembling hands, sallow complexion and characterized by a varied group of moral attributes, needing only to be observed to render identification of the condition complete. As a matter of fact not even one of these alleged characteristics need be present and it is safe to say that in many cases only one or another of them exists and by no means would suffice to give the ordinary observer an idea of the true situation. It has been reported that for many years husbands and wives, to say nothing of other members of a family, have lived in complete ignorance of the existence of this condition in one or the other and that quite possibly the average physician, unaccustomed to dealing with the condition, might have difficulty in determining its existence.

In view of what has been said it would seem quite evident that there is no accurate knowledge as to the exact number of chronic opium users in the country today, as it is apparent that, if the condition is considered a physical, mental, or moral stigma and if it is possible to conceal it from any but the most scrutinizing examination unknown cases inevitably must exist. This may be expected to continue as long as the present attitude toward the user of these drugs exists with the social and economic damage resulting from exposure, and the illicit traffic offers a means of supply. That the illicit traffic exists to a very marked degree we know; to suppose that the dangers of disclosure are not appreciated by individual sufferers would be to consider them lacking in ordinary intelligence. However, in spite of the obvious difficulties in the way of an accurate determination of the number of cases of chronic opium intoxication, startling statements constantly are being made.

Although it is apparent that under present conditions the difficulties in the way of arriving at exact knowledge or even an estimate known to approach the number of opium users in the United States are insurmountable, on a superficial examination there would appear to be two methods available for attaining at least a minimal figure. As it is common knowledge that opium is not produced in this country and that therefore all opium used must be imported, it is possible to secure through the proper Government bureaus the quantity of opium legitimately imported. By suitable calculations apparently it should be possible to arrive at the total number of users, excluding those supplied by the illicit traffic. Theoretically this could be accomplished by subtracting from the amount imported for a given period the amount exported and the amount used for therapeutic purposes not connected with chronic opium intoxication and dividing the resulting figure by the average amount consumed by the chronic user for that period. This method has been used by some authors, but there are several factors which vitiate the totals arrived at. First, some writers have neglected to distinguish between general importation figures and the figures dealing with importations for consumption.* This at once makes for very different totals as will be seen when it is stated that, for the period of ten years 1911-1920 inclusive, these amounts differed by about 400,000 pounds of opium.

*'General imports" embrace imported articles entered at the customs houses for immediate consumption and imported articles entered for warehouse. "Imports entered for consumption" embrace imported articles entered for immediate consumption and imported articles withdrawn from warehouse for consumption.

Another source of error enters in any attempt to allow for the amount of opium and its derivatives employed for therapeutic purposes not connected with chronic, opium intoxication. The estimates as to the proportion of imported drug required for such purposes have varied very widely and obviously where such large figures are dealt with the resulting estimates vary considerably. These allowances always seem to have been reached either in an arbitrary fashion or upon a basis of incomplete facts.

Further so far as we know there has been made no study of a sufficiently large and representative number of individual cases under suitable conditions to permit of any definite statement as to an average daily dose. For instance, it is well known that certain cases continue for years on one or two grains or even a fraction of a grain daily while others take such almost unbelievable doses as eighty to one hundred or more grains a day. Also, among a certain type, the amount stated as habitually consumed by an individual may include the ration of one or more other individuals unknown to the investigator.

As far as we know then there are two obstacles to the determination through importation figures of a minimal figure for the number of chronic opium users in this country at the present time:-(1) the fact that the so-called "legitimate therapeutic needs" are unknown and (2) the wholly speculative nature of the "average dose." In view of these facts, all estimates as to the extent of this condition based on importation figures however used are potentially fallacious to such a great degree as to be practically valueless.

The second method of determination is the employment of some means for the taking of a census of opium users in a given locality and adjusting it to the population of the country as a whole. Aside from the fact that it would not include those users who, by reason of their desire for concealment and consequent dependence on illicit traffic for supply, could not be recorded by such a survey undoubtedly would possess a value not found in estimates based on importation figures in an attempt to reach a minimal figure, inasmuch as it would be definite and positive as far as it went. Of course, there is possibility of error to a greater or less degree in this method. The floating population, for example, cannot be disregarded, yet this is a source of error common to every method of census-taking. Further, local conditions such as population composition, climate, race distribution, occupation, etc., are influencing factors which tend to lessen the value of the individual surveys as applied to the country as a whole. Unfortunately, there have not been enough of these surveys made in various sections to determine by comparison the degree to which these factors operate. In what follows, the surveys which we have reviewed and which represent investigations made in different localities at different periods will be analyzed and the features which tend to vitiate their application to the country as a whole, for the period in which they were made, will be pointed out.

'This factor does not enter into the early surveys which were carried on when illicit traffic was unknown or practically negligible.

Before examining the first definite figures of which we have knowledge, contained in a survey reported by 0. Marshall in the Annual Report of the Michigan State Department of Health of 1878, it will be interesting to quote from some of the earliest authors who refer to the extent of chronic opium intoxication in this country. Their statements, however inexact, at least show that the problem is by no means one of recent development but the result, as we know it today, of a continuous growth probably since Colonial days. What effect the war of the American Revolution and that of 1812 had upon its spread we have not seen indicated in any record we have consulted, but that the Civil War gave it a considerable impetus seems definitely established.

Fitzhugh Ludlow-1867.3

3 Ludlow, Fitzhugh-Harper's Magazine. August, 1867.

"The habit is gaining fearful ground among our professional men, the operatives in our mills, our weary serving women, our fagged clerks, our former liquor drunkards, our very day laborers, who a generation ago took gin. All our classes from the highest to the lowest are yearly increasing their consumption of the drug."

Horace Day-1868 .4

4 Day, Horace-The Opium Habit. 1868.

"The number of confirmed opium-eaters in the United States is large, not less, judging from the testimony of druggists in all parts of the country as well as from other sources, than eighty to one hundred thousand . . . The events of the last few years (Civil War) have unquestionably added greatly to their number. Maimed and shattered survivors from a hundred battlefields, diseased and disabled soldiers released from hostile prisons, anguished and hopeless wives and mothers, made so by the slaughter of those who were dearest to them, have found, many of them, temporary relief from their sufferings in opium."

Alonzo Calkins-1871.5

Calkins calls attention to the increased use of opium in this country from the year 1840. Basing his computations on the importations of opium and the population figures for those years, he reaches the following ratios of advance:

He gives in some detail the method by which he reaches these figures which include "a comparison of opinions given by eighteen prominent apothecaries of New York City."

"Such statistics," he asserts, "fully presented bear no equivocal interpretation."

Independent and collateral evidences, he believes, show that "opiummania, far from being restricted . . . to our cities . . . is fast pervading the country-populations."

In the evidence he presents he quotes the following:

"Thus addresses the writer, a physician and druggist of a New England city, Dr. S. S.: 'In this town I began business twenty years since. The population then at 10,000 has increased only inconsiderably, but my sales have advanced from 50 pounds of opium the first year to 300 pounds now; and of laudanum four times upon what was formerly required. About 50 regular purchasers come to my shop, and as many more, perhaps, are divided among the other three apothecaries in the place. Some country dealers also have their quotas of dependents.' Such is no solitary record.

"In the Portland Press, IM, a correspondent sounds the alarm-note in these words: 'Very few of our people are aware how many habitual consumers of opium among us a careful scrutiny would disclose. In the little village of Auburn (of the neighborhood) at least fifty such (as counted up by a resident apothecary) regularly purchase their supplies hereabouts; and the country grocers, too, not a few of them, find occasion for keeping themselves supplied with a stock.' Corroborative accounts dome in from New Jersey and Indiana, from Boston at one extreme and from St. Louis at another, and from the impoverished South as well. In the Mississippi Valley particularly the use of stimuli of every name is fearfully on the increase (Pitcher, Comstock)."

F. E. Oliver-1871.

In the third Annual Report of the State Board of Health, Massachusetts, for the year 1871, there appears a chapter on the use and abuse of opium written by this author. The writer addressed the following questions to the physicians of Massachusetts:

1. Are preparations of opium used by the people except for the relief of Pain?

2. We would like to know whether the injurious use of opium has increased of late years, and if so, the causes of such increase?

Unfortunately, these questions were not so framed as to elicit the information which the author desired to obtain and, as he himself states, the data secured are most incomplete although suggestive. Less than one-half of the physicians addressed were heard from, representing a little more than one-third of the physicians of the state. In all 125 physicians replied, 40 of these stating in answer to the first question that they knew of no case of opium eating. The remaining 85 stated that the drug was used to a greater or less extent in their respective circuits. In many of the smaller towns where the "habit" existed, the number of users was reported where it could be ascertained, while in the returns from others such terms as "few," "many" and "several" alone were given. In others again no mention was made of numbers, so that the author was not able to arrive at anything like an accurate computation. From the fragmentary data so obtained the author states that the inference is unavoidable that the "opium habit" is more or less prevalent in many parts of the state and while it is impossible to estimate it the number of users must be very considerable.

The writer further gives the following extract from a letter received from Mr. S. Dana Hayes, one of the State Assayers:

"'In reply to your inquiries, it is my opinion that the consumption of opium in Massachusetts and New England is increasing more rapidly in proportion than the population. There are so many channels through which the drug may be brought into the State, that I suppose it would be almost impossible to determine how much foreign opium is used here; but it may easily be shown that the home production increases every year. Opium has been recently made from white poppies, cultivated for the purpose, in Vermont, New Hampshire and Connecticut, the annual production being estimated by hundreds of pounds, and this has generally been absorbed in the communities where it is made. It has also been brought here from Florida and Louisiana, while comparatively large quantities are regularly sent east from California and Arizona, where its cultivation is becoming an important branch of industry, ten acres of poppies being said to yield, in Arizona, twelve hundred pounds of opium."'

"'That which is not used where it is produced, including the shipments from California and the West, together with inferior and damaged parcels of foreign opium received and condemned at this port, is sent to Philadelphia, where it is converted into morphis. and its salts, and is thus distributed through the country! Pt a

In his letter Hayes comments further on the use of opium and morphin in family remedies such as cough mixtures and liniments and in the dangerous so-called "cures" or "Relief for Opium-Eaters" preparations.

'D. M. R. Culbreth in his "Materia Medica and Pharmacology", 3rd edition, 1903, states:

"During the Civil War opium was cultivated in Virginia, Tennessee, South Carolina, Georgia, being planted in September and collected in May."

In the 6th edition of the same work the author states that this opium was of high narcotic content.

Oliver also quotes extracts from letters replying to his question as to the increase in tile use of opium, some of which are reproduced below:

"Clarksburg-'I think it on the increase, because doctors prescribe it more indiscriminately now than formerly, thus establishing the habit with the patient!

Eastham-2 I think the use of opium has slightly increased, mostly among females.'

Swampscott-2 The use of opium in its various forms has materially increased within the last ten years!

Westfield---I have reason to believe this practice exceedingly common among certain classes of people, who crave the effect of a stimulant, but will not risk their reputation for temperance by taking alcoholic beverages.'

Worcester-2 I have talked with some of our most intelligent apothecaries, who tell me that the use of opium has greatly increased, especially among women. The reasons which one gave are these: The doctors are prescribing it more to their patients, and thus the habit is acquired. There is also the desire for Some form of stimulant. Alcoholic stimulants being prohibited, many have resorted to the use of opium.'

Another gave it as his opinion that 'the use of opium in its various preparations is increasing among the people as a stimulant, and is now being used to an alarming extent. I believe this to be due largely to the unpopularity and restricted use of alcoholic liquors. I believe there is a natural craving for some artificial stimulant with almost every human being, which is greatly increased by the cares and perplexities of life, and therefore is more apparent as age advances. This desire should be satisfied by the milder and least injurious drinks, as beer, light wines, etc.'

Another states: 'I think opium and its preparation are used to a considerable extent as stimulants, and am inclined to the opinion that such use is increasing and that such increase is due, in some degree, to the excitements, suffering and mental disquietude resulting from the late war!

Boston-Among 20 or 30 druggists consulted there was a diversity of opinions many of them not selling opium without a physician's order. The following statements are among the most important:

'Believes the habit of opium eating diminishing, as he has fewer calls than formerly!

'Has one customer who buys half an ounce at a time. The number of calls is less than formerly. Has observed that veteran soldiers who contracted the habit in army hospitals are still addicted to opium.'

'In the experience of twenty-five years has observed no decided increase in the habit of opium eating. Recognizes the correlation in the abuse of opium and of alcohol. The opium habit frequently begins in the use of opium medicinally. Veteran soldiers, as a class, are addicted to it . . . '

'Thinks the abuse is not uncommon in the community but that it is les,9 in Boston than elsewhere. Would look for it rather among professional men threat among the poorer classes.'

'From his own experiences, believes that the habit of opium eating has increased within the last five years from 50 to 75 per cent. Never sells the drug without physician's prescription but has on an average five or six daily applications for some one of its preparations. It is largely taken by prostitutes.' 'Has but one customer and that a noted temperance lecturer.'

S. F. McFarland-1877.7

' McFarland, S. F.-Opium inebriety and the hypodermic syringe. Trans. New York State Medical Society, 1877.

"If cases of opium inebriety occur as frequently in the private practice of other physicians as they have in my own, it is coining to be a serious matter, and a few words of caution, against the indiscriminate use of so active a drug, may be pardonable.

"Since the introduction of the hypodermic syringe, especially, there has been a noticeable increase in the frequency, as well as the severity, of these cases; and I wish to enter a protest against its imprudent use, and particularly against leaving it in the hands of patients or their friends, to be used at their discretion, or even allowing them to know that they can use it, except in the greatest emergencies; for once in their possession, and used for any considerable length of time, they will seldom discontinue it, and will soon be inquiring where they can get 'one of those things'. It is certainly a most valuable instrument in the hands of the discreet practitioner, and will reach cases which nothing else will, with a certainty and promptness which is very satisfactory; but it is too potent for evil, as well, to be trusted beyond his grasp.

"By the hypodermic use of opium the habit is much more rapidly produced than by taking it into the stomach, or by any other method-a fact which should not be lost sight of."

0. Marshall-1878.8
'Marshall, O. The opium habit in Michigan. Annual Report Michigan State Board of Health. 1878.

Turning to a consideration of the early surveys, the one already mentioned by 0. Marshall deserves first consideration, as it was the earliest of which we have knowledge. While these figures are obviously quite incomplete, they represent at least a minimal extent and apparently can be depended upon as comprising positive information as far as they go. For these reasons they are of great importance to us today in seeking to arrive at a true conception, first, of the probable influence of factors other than illicit traffic and, second, of their possible relationship to conditions of today.

Marshall begins his report with the following paragraph:

"At a meeting of the State Board of Health in January, 1877, by a written communication, I called its attention to the large number of opium-eaters in the vicinity of North Lansing, giving many particulars relating to the opium habit as it exists here. In complying with the request of the Board to prepare an article for publication, I have extended the investigation to other parts of the State, the result of which investigation is here given."

From further observations the author realizes how impossible it is to obtain complete and perfectly reliable information concerning this condition. He states:

"Those beat acquainted with its extent are the physician and druggist. As a rule, the physician, although originally responsible for many of the cases in his vicinity, is only aware of them through his business relation with the druggist. The latter, from whom the drug is obtained, from the fear of low of trade, or, as some of them term it, a violation of confidential business, are often unwilling to furnish any information with regard to it."

Marshall sent two hundred circulars to prominent physicians throughout the state asking for information in regard to the opium "habit" in their localities and enclosing a postal card with printed form for report of the number of men and women using opium and morphin in each place. Marshall took care to eliminate duplication of cases by addressing only one physician in each locality and where reports from a physician included figures from two or more druggists the lists were compared and repeaters eliminated. To those, ninety-six replies were received giving the number of morphin and opium users in ninety-six cities, villages, and townships of the state. He says in this connection:

"From the supposed impossibility of getting reliable information of the numbers in the larger cities, no circulars were sent to Detroit, Grand Rapids or East Saginaw; and probably from this cause no answers were received from many of the larger cities of the State where circulars were sent."

The majority of the reports received by him include only those persons with whom the physician personally was acquainted. This, he points out, resulted in obtaining less complete information than had the druggists themselves been addressed. This, he says, is noticeable in the reports from two neighboring cities, one of which gives the large number of one hundred sixteen, which number was obtained after considerable effort by particular request, while the other reports only one case. A druggist, however, formerly in business in the latter city estimated the number of opium users in that city at not less than sixty. From such facts as these Marshall comes to the conclusion that only the minimal number was obtained and that the actual number was probably greater in many instances.

We are including the complete table given in Marshall's report. It is of peculiar interest because of the fact that urban, rural and semirural communities were included and that the larger cities of the state, in which the underworld and vicious element naturally would be supposed to exist in the greatest degree, were absent. The assumption therefore is that, whatever the cause for the original use of the drug, the influence of vicious association was relatively negligible. It is significant that throughout his whole report no mention is made of illicit traffic or of any source of supply other than that through physician and druggist.

Marshall summarizes his findings as follows:

"The total number of opium caters reported in the places given is 1313; of these 803 are females, and 510 are males ... The population of the cities and villages including the townships in which they are situated, according to the State census of 1874, was 225,633. The population of the whole State at the same time was 1,334,031. If the number of opium eaters, including morphine eaters, in proportion to the population in the places given holds good for the entire State, the total number of opium caters, all classes, in the State would be 7,763. Taking every degree of the habit into consideration, this estimate of the number is probably not too large."

The smallest community from which figures were obtained had a population of but 315, the largest a population of 10,235, the average population of the 96 towns being 2350. In other words, whatever the prevalence of the use of narcotic drugs obtained by Marshall was, his facts were derived from small hamlets and towns which scarcely could be dignified by the name of city even in the time in which he wrote. These communities covered every section of the state and presumably gave a true picture of it as a whole. Obviously, as alreadk stated, underworld influences such as prostitution, gambling, etc., largely can be eliminated. At the time of this investigation communication was much more difficult and less rapid than it is today; news was not so widely disseminated and in an area of such an extent as that of the state of Michigan, one must conclude that a situation of this nature was caused by factors of common occurrence, by influences shared alike by all communities rather than by artificial or unusual influences operating in selected localities. If, therefore, we find that Marshall's figures were based on representative conditions common to all sections of the state, it is reasonable to assume that they may be applied also to the country as a whole. We may not assume, for instance, that the distribution of painful disease, of insomnia, of nervousness, or even of certain social proclivities and curiosity was peculiar to Michigan and that in 1877 through some mischance its people, more than those of other states, were subjected to pernicious influences of this nature. Nor may we assume that the practice of medicine was conducted along widely different lines in Michigan from those elsewhere or that the druggists of Michigan were more careless in the conduct of their business, less prone to make a profitable sale or more blind to the harm resulting from this traffic than those of other states. In other words, there would seem no valid reason for not applying to the country as a whole such figures as Marshall gives us in depicting the extent of chronic opium intoxication in his state. Also the resulting estimate for the country would be a minimal figure not only because of the incompleteness of Marshall's returns but also because of the absence in Michigan of certain influences which would tend to increase the use of opium. At that time, as we know from other sources, there were operating on both the Atlantic and Pacific coasts influences that did not operate in Michigan, an inland state. On the west coast there were such influences as the maritime traffic with the Orient and the coolie labor imported for railroad and other construction undertakings, while in New England we have already seen poppy culture already was being indulged in and shipments were being made to other states.

TABLE I

Showing the number of Opium and Morphine Eaters, with the Number of Each Sex, Reported in 96 Cities, Villages and Townships of the State, with the Population of Each Place, Including the Township in which it is Situated, according to the State Census of 1874.

As a preliminary to the application of Marshall's figures to the State of Michigan as a whole, three things must be borne in mind-first, the total omission of returns from the larger cities, second, the fact which he himself brings out, that information secured from the stated source, namely, physicians, was less complete than would have been information secured from druggists, and, third, the use by Marshall of population figures for the year 1874 instead of 1877.

From the ninety-six communities heard from, as we have seen, there were reported 1313 users of opium or morphin. For some unknown reason Marshall employs in his computation the state census figures of 1874 rather than an estimated figure for the year 1877 in which the survey was made. The population of Michigan, according to him, was in 1874, 1,334,031. Employing this figure he comes to the conclusion that if the number of opium and morphin users holds good for the entire state the total number in the state would be 7,763. Taking into account the natural rate of increase in population between the years 1874 and 1877, this figure would represent a slight overestimate, all other things being equal. However, this is offset by other factors such as the relative incompleteness of the information received from physicians as compared with that received from druggists and it is fair to assume that this is a minimal figure. How great the error on the side of underestimation is, we have no means of telling.

The fact that in one town, Monroe, the physician addressed reported but one case while a druggist stated that there were about sixty, is indicative possibly of a very great error in Marshall's total figure and it must be remembered that the druggists were in a much better position to know the truth than were physicians. They supplied the drugs used and as a rule, especially at the time of Marshall's investigation when counter sales were legal and a matter of common practice, physicians were called upon only by those opiate users seeking curative treatment for their condition. It is, therefore, doubtful if the medical profession at any time has been in a position to supply anything like a complete list of these cases while the druggists from the very nature of things in the past could have furnished this information.

It is probable, therefore, that Marshall's figures are very much more incomplete than even he himself believed and it is quite possible that the actual number of cases in the towns and cities of Michigan from which Marshall received his returns were several times larger than his figures indicated. Be this as it may, his total of 1313 cases represents definite and positive information indicative of the widespread use of these drugs in the State of Michigan over fifty years ago, long before the development of an illicit traffic in opium and its preparations with its resulting artificial impetus to the formation of new cases. If applied to the country as a whole for the year in question, 1874, this figure gives a total of 251,936. This is a startling figure for the period in question and yet in all probability well below the actual one and deserving of the most careful consideration on the part of those who today, with the undoubted existence of new and increasingly powerful factors at work in the stimulation of the use of these drugs, seek to become familiar with the extent of our present narcotic problem.

Further on in his report, Marshall introduces the importation figures from 1850 to 1877. From these he estimates an average importation figure for the year 1877. From information secured from drug store sales he comes to the conclusion that the average user consumes about three pounds of opium during the year. Allowing one-fifth of the total importation for "legitimate therapeutic use" and dividing the remainder by three he arrives at a figure of 93,654 as the number of users in the country as a whole. From this figure by suitable calculation he obtains for the State of Michigan about 25.50 users.

Elsewhere we have pointed out some of the dangers of calculating the number of users upon such a basis as this and in Marshall's effort we have a good illustration of the fallacies that enter. If we take Marshall's figure of 2550 for the State of Michigan we obtain, as the proportion of the ninety-six towns and cities from which lie received definite information as to the number of opium users, the figure of 421 or but one-third of the actual number of users positively known to exist in these ninety-six communities. It is quite evident that in (Calculations based on importation figures there enter very large errors which it is impossible to determine or correct. It seems, therefore, we repeat, that little or no dependence can be placed on estimates arrived at in this manner and that fragmentary as have been the various actual surveys they furnish data of far greater value for purposes of generalization.

C. W. Earle-1880.9

'Earle, C. W.-Tile opium habit. Chicago Med. Rev. 1880.

Earle made a study of the extent of the use of opium in Chicago by interviewing a number of druggists in that city. Although the figure of the number of users he obtained may not be used in a statistical analysis, his work is a distinct contribution as an indication of the prevalence of the use of the drug at the time. The following is a quotation from his report:

"In an article entitled 'The Impending Danger,' Dr. Mattison, of Brooklyn, states that he is assured by both dealers in the crude drug and manufacturers of the alkaloids, that importation of opium is increasing rapidly every year, and that the supply may become insufficient for the demand. The question naturally suggesting itself is: What becomes of the vast amount yearly brought to our shores?"

Earle investigated fifty drug stores, asking questions as to the number of customers, their age, nativity, kind of narcotic used, quantity, etc. He reports:

"The three divisions of the city were visited, and localities inhabited by the different classes and nationalities were thoroughly canvassed. I was greatly surprised to find that druggists on the West Side were patronized to a greater extent (excepting a few on Clark Street) than in any other part of the city. Foreign druggists (German and Scandinavian), seem to exhibit more conscientious scruples in regard to the trade than our own nationality. I learned from some of these gentlemen that in Denmark, and, if I mistake not, in Norway and Sweden, the trade is absolutely forbidden. Fifty druggists have 235 customers, or an average of nearly five to each store."

J. M. Hull-1885.

An account of Hull's findings appears in the Biennial Report of the State Board of Health of Iowa for 1985. This Biennial Report covers a period of two years ending June 30, 1885, and it is not quite clear from his article whether the investigation was made in the latter half of 1883, during 1884 or in the first half of 1885. In using his figures, therefore, we shall choose the middle period and base our computations on the population figures of 1884.

Hull begins his report with the following:

"Although my paper on the opium habit is brief, and but a small part of the sad story told, yet I am inclined to believe it contains some facts regarding this rapidly increasing evil that cannot fail to astonish even those who are well informed, and far more those who have given the subject little or no attention.

"Opium is today a greater curse than alcohol, and justly claims a large number of helpless victims, which have not come from the ranks of reckless men and fallen women, but the majority of them are to be found among the educated and most honored and useful members of society; and as to sex, we may count out the prostitutes so much given to this vice, and still find females far ahead so far as numbers are concerned. The habit in a vast majority of cases is first formed by the unpardonable carelessness of physicians, who are often too fond of using a little syringe, or of relieving every ache and pain by the administration of an opiate."

To fifteen hundred circulars sent to druggists in the state of Iowa, requesting information on the subject, Hull received 123 replies reporting 235 users of opium in some form. Of these 86 were men and 129 women.10 The form of drug used was morphin, 129; gum opium, 73; laudanum, 12; paregoric, 6; Dover's Powder, 3; McMunn's Elixir, 4. As to the method of using the drug he states:

"While the drug is used less frequently by the hypodermic method than by the mouth, the former method is gaining ground. The habit may be formed about as readily one way as the other. Those who use it by the mouth as a rule make the most rapid progress, as the drug is easier taken, is free from pain, and larger than the hypodermic dose."

He states that there were about 3,000 stores in Iowa where opium was kept for sale and that if reports had come from all in the same ratio it would have shown the number of users to have been about 6,000. By actual computation on the above basis we get 5,732. Hull states, however, that his reports were mostly from the small villages, very few coming from the cities where, he states, the "habit" was far more common. He states further:

"From reliable information which I have been able to secure from various sources, I feel safe in saying that there are in this state over 10,000 people who are constantly under the influence of an opiate and who are wholly unable by any effort of the will to break the habit or even to abstain for 72 hours."

The estimated population of continental United States for 1884 was according to the U. S. Bureau of the Census 55,379,154 and that of the State of Iowa for the same year was 1,742,084.

Using the lower figure of 5,732 obtained in the manner described above, as the actual number of users in the State of Iowa, we get 182,215 chronic users for the country as a whole for the year 1884. This must be by far an underestimate as Hull himself states that he had good reason to believe that there were over 10,000 in the state.

In considering estimates based on Hull's figure several points should be borne in mind. First, Hull does not indicate the population served by the 123 stores reporting the 235 cases. Although he does state that there were about 3,000 stores in Iowa where opium was kept, in assuming that the sales averaged the same in different stores, there is the possibility of error. Second, according to Hull's own statement most of the cases reported were from small villages with very few coming from the cities, where he states the "habit" was far more common. With the usual vicious elements of city life eliminated, one may assume that Hull's figures represent a minimal extent.

It is worthy of note that here again no mention is made of illicit traffic.

B. H. Hartwell-1888.11

' Hartwell, B. H. The sale and Use of Opium in Massachusetts. Annual Report, Massachusetts State Board of Health, 1889.
Hartwell made a survey in the State of Massachusetts, in the report of which, unfortunately, he failed to give the population figures on which the study was based. If these figures were available it might be possible to compute the per capita consumption. Although this cannot be done, we are giving below a summary of that part of his survey dealing with extent as an interesting side-light on conditions obtaining in that period.

Hartwell states that the investigation was undertaken in accordance with the following "resolve" adopted by the Legislature of 1888:

"Resolved, That the State Board of Health be requested to make an investigation concerning the sale and use of opium, in various forms and preparations, with a view to ascertaining the extent of the evils arising therefrom; whether such use and evils are increasing, and, if so, the manner and cause thereof, and what remedies for such evils may be proposed; and to report the result of such investigation to the General Court."

Hartwell continues his report as follows:

"This resolution was presumably an outcome of the prevalent belief that the use of opium is increasing very rapidly. An expos6 of the opium joints in Boston appeared in one of the leading dailies in 1885; there have been frequent allusions to the habit in other papers; a recent article, claiming to be the result of years of study of the opium habit in Boston, was published in one of our popular magazines, in which the writer says that the habit 'is increasing rapidly! In these and numerous other ways the public has been taught to believe that the evil is widespread and extending. The large number of opium habitues which seem to be among us, the novelty of this form of stimulation, its secret character, the strong hold which it has upon its victims, the horrible results arising therefrom, especially from the habit of opium smoking,-all tend to keep the subject prominently before the people, and to magnify the evil in the public mind. To get at the facts concerning the use of opium (the term opium will include all of its preparations), as far as possible, is the object aimed at in this inquiry. This is beset with many difficulties, from the very nature of things. There can be no reliable statistics of the amount of opium used by the medical profession, the laity, or by habitues, or the proportion used by each. The most rigid inquiry into a habit as secret and as easily practised as is this form of inebriety could not be sufficiently accurate for mathematical calculation; approximation only can be attained.

"That a great deal of opium is used besides that legitimately required for the relief of pain and treatment of disease, is unquestionably true. The unwillingness of people to bear pain, the habit of self-prescribing, the many facilities for obtaining opium and its preparations from the regular dealers as well as by means of proprietary medicines containing it, the numerous ways by which a knowledge is gained of the method of obtaining and taking the drug-all extend its use in the most dangerous manner.

"As the best means for forming an opinion of the amount of opium used, and whether or not its use is increasing, circulars were sent to many of the druggists and physicians of the State; the questions asked and a synopsis of the answers returned are given below. Some allowance must be made in considering the returns, for the reason that opium habitues, from fear of detection or a desire for secrecy, scatter their purchases as much as possible; so that a druggist may easily get an impression of an increased or decreased use of the drug, while in reality the sales are going on elsewhere or have returned after the rounds have been completed. So also the same habitual users might be seen by different physicians, and counted several times, or escape notice altogether, and thus convey a false idea of the actual number. A circular containing five questions was sent to druggists. Replies were received from about 600 druggists, representing 190 cities and towns, and embracing nearly every city and town in the State where a druggist is located. (There are about 150 towns in which no druggists reside.) About one-fourth of the answers came from Boston, the rest from other parts of that State. Many of the returned circulars contained answers to all of the questions, others to only part of them; hence the number varies in the different questions. The questions and answers were as follows:-

"I. What amounts of opium are sold by you per month, not on the advice and prescription of a physician?"

The answers numbering 512 to 541 showed the following:

(a) Crude opium, opium in pill or other solid form?

Sixty per cent. none-the remainder a few pills to 4 pounds.

(b) Liquid preparations; Tincture?

Twelve per cent. none; the remainder one gram to 32 pints; other liquid preparations none to 40 pints.

(c) Morphia and its salts, in bulk, pill or powder?

Thirty-three per cent. none; the remainder % gr. to 8 oz. morphia 2 to 500 morphia pills, mostly 1/8 grs.

(d) Other preparations very little.

"2. Is the demand for opium and its salts increasing? 535 answers: 85 per cent., no; 8 per cent., yes; 5 per cent., decreasing; 2 per cent., do not know."

"For obvious reasons, circulars were also sent to many of the physicians of the State who commenced practice before 1875. About 260 replies were received, from 100 cities and towns out of about 250 in which physicians reside. Eight questions were submitted, which with the number and character of the answers, were as follows:

"1. From your own observation, is the use of opium and its preparations increasing in the community in which you live? 225 answers: 66 per cent., no; 28 per cent., yes; 6 per cent., do not know.

"2. If such be the case, what is the probable cause of such increase; this question called for answers only from those who had answered the first question affirmatively; consequently, but 75 of a miscellaneous character were received. Twenty per cent., give the use of opium by physicians as the sole cause; 11 per cent., give this as the cause in part. Ease of obtaining opium from druggists, duplication of prescriptions containing opium, increased knowledge of its effects, excessive brain work, desire for stimulation, fast living, comprise most of the remaining answers.

"3. Are diseases calling for the use of opium increasing? 209 answers: 84 per cent., no; 16 per cent., yes."

Although he believes, as can be seen from the above, that a great deal of opium "is used besides that legitimately required for the relief of pain and the treatment of disease," on the basis of his study, Hartwell concludes that

" . . . the use of opium is not increasing in Massachusetts. In the large centres of population there may be a slight increase from year to year. It is here that excesses and crime of all kinds, if not increasing, are much more common than in less populous districts. The better knowledge of the uses and effects of the drug, by means of the greater intercommunication of the people; the many facilities for obtaining it; the general practice of writing prescriptions, followed by unrestrained reduplication of them; the excitement of business, leading to overwork and overtaxing of the mental powers,-are conditions which are favorable to the increased use of opium."

A. P. Ginnell-1900.12

'Grinnell, A. P.-A review of drug consumption and alcohol as found in proprietary medicine. Med. Leg. Jour., 1905.
This author made a study of the consumption of drugs in the State of Vermont and while he made no attempt to estimate the number of opium users from it, a report of his study is interesting as an indication of the use in Vermont at that time. There appears to be no reason to believe that this report covers a community influenced by any unusual factors but rather it represents a normal distribution of drug users.

The author states:

"Few people are aware of the enormous consumption of narcotics or stimulating drugs. With the development of pharmaceutical science and the consequent improvement and facility in preparing drugs and alkaloids the market has grown accordingly. More widespread knowledge concerning the effects and special uses of opium, cocaine, quinine, Cannabis Indica, Chloral and Heroin, ha's further stimulated the demand for these drugs, until today the American people are confronted by a problem which is only equaled in its magnitude by its terrible and appalling aspects.

"When we pause to consider the fearful inroads the excessive and habitual use of these drugs make on the mentality, physical health and general existence of those addicted to them, we can easily appreciate what a serious menace to society a rapid increase of drug habitues must inevitably mean.

"It is hardly necessary to speak of the results of the habitual and excessive use of narcotic drugs. Physicians, more than any other class, realize the fearful ravages made on the human system; and the large number of physical, moral and mental wrecks they are constantly meeting who owe their condition entirely to drug addiction, tells eloquently how extensive and far-reaching the drug evil has become. Every alienist is daily being brought face to face with the growing influence of certain drugs on psychic abnormalities and degenerations, and the insidious onset and progress of such conditions, when so produced, cannot fail to impress us with the Medico-Legal importance of the drug habit."

In order to secure information as to the consumption of certain drugs, Grinnell wrote the druggists of the State asking them for estimates of their monthly sales of the following drugs and preparations:

"Opium (gum or powder)

Morphine sulp. (powder or pills)

Dover powder

Paregoric (tinct. opii. camph.)

Laudanuin (tinct. opii)

Cocaine

Chloral

Indian hemp (Cannabis Indica)

Quinine (powder or pills)?"

Of 130 druggists addressed 116 were heard from. He also addressed 172 general stores which sold drugs in localities where no drug stores existed and three wholesale druggists, but obtained no satisfactory information from the latter.

He states that ninety per cent. of the physicians of Vermont dispense their own drugs and that sales of these drugs to physicians were not included in the figures supplied by druggists.

He also states that the figures he secured could be multiplied by five and be below the actual consumption inasmuch as they include "nothing in the composition of patent medicines or cough medicines; nothing dispensed by physicians; nothing dispensed by these three large manufactories-simply the regular retail drug store businesses and the sales of the 160 general stores."

From these two sources lie estimated 3,300,000 doses of opium were sold every month-enough to supply "one and one-half doses of opium to every man and woman in the State of Vermont above the age of 21 years, every day in the year."

The actual amounts sold by druggists as compiled by Grinnell were as follows:

The above figures cover reports from 69 out of 344 towns, and from 116 drug stores out of 130, but do not include amounts sold in the general stores.

American Pharmaceutical Association-1902 13-1903. 14

A committee of this organization, H. F. Hynson, Chairman, reported on the replies received from pharmacists and physicians in certain localities in response to queries sent by the committee. The conclusion arrived at was to the effect that at least five users of certain drugs, commonly known as "habit-forming" but not opium alone, were known to every pharmacist. From this it was estimated that there were at least 200,000 in the country.

'Hynson, H. P.-Report of Committee on Acquirement of the Drug Habit. Amer. Jour. Pharm. November, 1902.

In the following year the same Committee with E. G. Eberle as chairman made a more extensive canvass of the situation through letters to all sections of the United States and Canada. As a result of the information so gathered, which dealt with cocaine and other drugs as well as opium preparations, the Committee came to certain conclusions, the most suggestive of which follow:

Eberle, E. G. Report of Committee on Acquirement of Drug Habits. Amer. Jour. Pharm. October, 1903.

"General reports indicate that the sale of narcotics is not restricted to any section of the country, nor confined exclusively to the fallen and lower class. Information comes from several sources that in callings which demand many hours' work at a time or the hours of night, cocaine is resorted to for stimulation."

"We are confident that the use of narcotics is increasing and that evil effects from it will come to succeeding generations. While the increase is most evident with the lower classes, the statistics of institutes devoted to the cure of habitues show that their patients are principally drawn from those in the higher walks of life."

"Careful study of data personally collected and from reliable sources forces the conclusion that the habitual use of opium in its various forms is increasing and that this increase is confined to no one class or occupation."

"While it has not been practicable to obtain exact figures, it can be stated that the drug habit is alarmingly increasing among the men of our army and navy. The number of men using opium in the army has greatly increased since the occupation of the Philippines, many 'opium smokers' acquiring the habit there from Chinese or natives. The smoking of opium by the men of the navy does not seem to be as prevalent as in the army, gum opium 'pills' or morphine being the way in which the drug is mostly used by sailors. Quite a number of enlisted men have been discharged from both army and navy during the last year because of their being detected as habitual users of opium or morphine-probably several hundred per cent. more during the last five years than for any ten years previous. To the best of the writers knowledge-and he has carefully inquired into facts -practically all the cases of drug habitues in both army and navy arise from the men learning the habit from natives of foreign countries or from lewd women and men in this country. Not a single case of drug habit coming from the prescribing of an opiate by a medical officer can be recalled, opium and allied drugs being very guardedly and carefully used by army and navy medical officers. A goodly percentage of the cases are men who have acquired some drug habit prior to enlistment while a few-sad to say-are from men of the hospital corps who drifted into the habit from constant opportunity and handling of the baneful drug.

"At the present, it is calculated that there are over a million opium smokers in the United States, the importation of opium for smoking purposes being double that for medicinal uses, amounting to more than 500,000 pounds last year, valued at $3,000,000 1 "

1 -C. E. Terry-1913.15
'Terry, C. E.-Annual Report Board of Health, Jacksonville, Fla., 1013,

In 1913 Terry, Health Officer of Jacksonville, Florida, collected data relating to the extent of the problem in his city. The figures were not dependent upon voluntary cooperation as in the case of previous collections of such material, but were secured through the operation of a local law which required, besides the usual prohibition of sale of opium preparations by druggists without physicians' prescriptions and the keeping of records of all sales, two procedures which resulted in bringing to the health office specific information relating to the extent to which opium preparations were employed. The first of these required physicians writing prescriptions containing more than three grains of morphin or its equivalent in alkaloids or salts of alkaloids of opium to send to the office of the health department copies of such prescriptions together with the names and addresses of the individuals for whom they were intended. Second, it provided that the city health officer or other physician in the employ of the city designated by him might give to any user, upon the furnishing of satisfactory evidence of habitual use, a prescription for as much of such drug as might be deemed expedient.

Records were kept of all duplicate prescriptions sent in and of all those issued at the health office. These prescriptions were free and were designed to remove from druggists the temptation of making counter sales on the plea that indigent users or those of small means could not afford to pay for the writing of a prescription in addition to the cost of the drug. The law was enforced actively and both druggists and physicians were watched carefully for violations.

No effort was made at this time to limit the use of these drugs in the case of habitual users nor were they subjected to such treatment as might be calculated to discourage them from coming to the health department for a prescription. On the contrary, during the operation of this law-a period of over two years-they were supplied upon application. Treatment was offered them from time to time and furnished to such as accepted the offer.

Through the operation of this law there were recorded at the health office during the year 1913, 541 persons using opium or some preparation thereof or about .81 per cent. of the population of Jacksonville. These were divided into 228 men and 313 women. Of the men 188 were white and 40 colored; of the women 219 white and 94 colored. The population of Jacksonville for 1913 as estimated by the U. S. Bureau of the Census was 67,209. Of this number 32,998 were whites and 34,211 colored. Applied to continental United States on the basis of the estimated population for 1913 of 97,163,330, the Jacksonville incidence gives as the total for the country 782,118.

In interpreting these figures, however, it should be borne in mind that while the percentage of whites using opium in Jacksonville is much greater than that of blacks, the black population in Jacksonville is very high compared to that of the country as a whole. If, as is indicated by the Jacksonville figures, the white race is more prone to use opium than the negro, suitable correction will be necessary in generalizing from the Jacksonville figures. As will be seen later, this same predilection of the whites appears in Brown's figures of the Tennessee studies. These two studies, however, are not sufficient in our judgment to assume the establishment of such racial tendencies as many other factors quite possibly may have influenced these findings.

If, however, such racial tendencies as the Jacksonville and Tennessee findings seem to indicate do exist, then in computing the distribution of opium use in the country as a whole it will be necessary to correct for the different race distribution existing in Jacksonville as compared with continental United States by applying the figures obtained in Jacksonville to the white and black populations separately.

In 1913, the white population of continental United States was 86,580,278 and colored 10,583,052. Applying the Jacksonville figures to the country as a whole, therefore, we get 1,109,340 total opium using population. This naturally is a larger figure than the original crude figure of 782,118.

One source of possible error in figures of this kind exists in the increase which may take place over the normal population of users through the registration of transients. In the case of Jacksonville, however, it would not seem that this was a large factor inasmuch as the registration required either through application to the health office or through the sending of duplicate prescriptions by physicians was not required in nearby states and cities at that time so that it was more difficult for strangers to obtain the drug in Jacksonville than in other nearby points. Whatever this error was, however, it is very much more than offset by the omissions in registration which occurred in the following ways. It was known to the health officer, for instance, that certain business and professional men and other individuals in high social standing who used the drug were never registered but secured their supplies either by mail order from distant points or through friendly physicians or druggists who were willing to risk violating the law for them. Others through the nature of their employment in drug stores or drug manufacturing concerns were able easily to supply themselves, while still others went to nearby points outside of the city limits and hence beyond the operation of the ordinance to secure their supply.

What part differences in race composition (other than negro), economic, occupational and other sociologic factors may have played in vitiating the Jacksonville figures for purposes of generalization no one is in position to say at the present time, as enough studies of the prevalence of this condition in other sections of the country have not been made to justify claims either for or against the existence of such influencing factors. In view, however, of the facilities at hand for the collection of the Jacksonville data, it is believed that they represent very complete information. As in a consideration of Marshall's figures for Michigan, it may be assumed that the distribution of painful maladies and the methods of medical practice in Jacksonville did not differ widely from those of other sections. In 1913, however, the influence of prostitution and what is generally termed the underworld obtained much more prominently in Jacksonville than in the localities of Michigan with which Marshall's figures deal as these were, it will be remembered, all small towns and villages. In the case of the Jacksonville figures, therefore, we may assume that the influence of vicious association was a more marked factor than in the Michigan figures.

The illicit traffic in these drugs was practically negligible in Jacksonville in 1913. One or two peddlers, it is true, supplied certain women in the restricted district more as a matter of convenience to these customers than because of any large profits involved. The traffic could not have been lucrative as free prescriptions were available to any user asking for them and the price of the drug in the drug stores was in the neighborhood of 60 cents for a drachra of morphin when sold in original bottles or large fractions. With this price it is evident that peddlers could not compete with profit.

Lucius P. Brown-1915.16

' Brown, L. P.-Enforcement of the Tennessee Anti-Narcotic Law. Amer. J. of Public Health, 1915, Vol. 5, No. 4.

Brown, the State Food and Drugs Commissioner of Tennessee, reported on the results of the enforcement of the Tennessee Anti-Narcotic Law passed in 1913. The law provided for the refilling of prescriptions for persons using opium products habitually "in order to minimize suffering among this unfortunate class, and to keep the traffic in the drug from getting into underground and hidden channels." The law provided that upon application to the Secretary of the State Board of Health and the Pure Food and Drugs Inspector and upon presentation of a certificate from the attending physician, the name and address of the druggist and certain other data, an individual might be granted permission to have a prescription for an opium product refilled. This system brought a considerable mass of data to the officials concerned. It should be noted in explanation that an effort was made at every renewal of permit to lessen the amount of the drug allowed.

After twelve months of operation there were on January 1, 1915, 2370 individuals registered under this system in the state of Tennessee. Of these 784 were men and 1586 women.

In commenting on the accuracy of the registration Brown states:

"As to what proportion of the total addicts of Tennessee are registered under this permissive system, guesses only can be given. It seems safe to say that not over one-half of the addict population is registered-possibly not over one fourth. Taking, however, the lower figure, it would appear that there are in the neighborhood of 5,000 addicts in Tennessee. The state has about 2.3 per cent. of the whole population of the United States. It is an agricultural state, and consequently, living conditions appear to be not so exhausting as in more thickly settled communities, nor life as a rule, so intense. In order to get the whole number in the United States, we may multiply our figure of 5,000 by 43. This gives us about 215,000 addicts. Probably, however, in order to allow for conditions in cities and, industrial communities, we ought to add 25 per cent. to this number, giving not less than 269,000 addicts in the whole United States. In my opinion this is a very conservative calculation. It shows by no means so many as sensational writers appear to want us to believe, and while it thus shows better conditions it is bad enough."

Brown points out that according to figures which he believes to be fairly accurate not over ten per cent. of the cases were colored. He says:

"This is due in part to the fact that the average negro avoids as far as possible any contact with an official, and to the fact that the negro appears to use relatively less morphine, and more cocaine than the white man."

This agrees with the race distribution in Jacksonville. If we should take Brown's estimate of 5000 cases and distribute them according to what he believes to be a race incidence actually existing, namely 9070 white and 1070 negroes, we should reach a different total for the country from that reached by Brown. Making this correction and applying, on the basis of Brown's estimate for Tennessee, the race incidence obtaining to the country as a whole, we get 221,818 white users and 11,518 black users or 233,336 as a total in the United States for 1913. If we now add, as Brown suggests, 2517c "in order to allow for conditions in cities and industrial communities," we obtain a total of 291,670 for the United States. Whether or not this correction should be made has already been considered in our discussion of the Jacksonville figures. We give it for what it is worth with no claim that the race distribution of opium use in these two localities typifies racial characteristics.

Such a generalization from the Tennessee figures indicates a very much smaller total for the country than is obtained on the basis of the Jacksonville figures, although these two investigations were made within a year of each other. The territory covered by the Tennessee law was very much larger than in the case of Jacksonville and the machinery for enforcement doubtless was less adequate. In Jacksonville, it must be remembered, every physician and every druggist personally was known to the health officer as were most of the opium users and it is to be expected that on these accounts more complete information could be secured than where, for the most part as in the case of Tennessee, it was necessary to rely on correspondence without the close personal touch possible in the smaller territory. Brown himself questions the completeness of his figures, stating that in his opinion they comprise a very conservative estimate.

Which of these estimates is nearer the truth for the period in question no one may state with certainty. It is noteworthy, however, that Brown's figures applied to the country as a whole give a figure but little in excess of that obtained on the basis of the Michigan figures of 1877, about thirty-five years before Brown's work. It scarcely is to be expected that with the influences at work, which we shall note in the next chapter, during this period of thirty-five years, there could have failed to be a greater increase than is indicated by these two sets of figures.

The estimates resulting from studies heretofore quoted represent conditions of opium usage freer from artificial influences of one kind or another than any that have been or will be compiled dealing with later periods. Prior to this time there was no federal law relating to the distribution of the drug and but very few state laws which were at all rigidly enforced, so that peddling of the drugs was not a marked factor in extending their use. The usual causes mentioned, such as the employment of opium and its products in medicine and self-prescribing for the relief of pain and discomfort, the effect of education through ill-considered articles in the lay press and magazines, fiction, vicious or ignorant associations, and the influence of natural tendencies to dissipation or to seek refuge under stress and strain, were operating alone without the additional stimulation of the illicit traffic which was a later development. Wherever, therefore, the exact truth lies as to the number of chronic opium users in the United States prior to the passage of the Harrison Narcotic Act it represents what might be termed the normal for the United States in contradistinction to an artificial or fortuitous figure resulting in addition to the forementioned causes from the perniciously active propaganda of the commercial trader in opium preparations.

'The federal anti-narcotic law passed December 17, 1914.

Special Committee of Investigation appointed by the Secretary of the Treasury-1918P

'Traffic in Narcotic Drugs--Report of Special Committee of Investigation appointed March 25, 1918, by the Secretary of the Treasury, June, 1919. Washington. 1919.

This Committee was unable to determine the exact number of addicts in the United States, 'owing, as stated in the Report, "to the lack of laws and regulations making it compulsory for the registration of addicts throughout the country or the keeping of any records as to their identity."

The Committee believed, however, that a fairly accurate estimate of their number can be made from the information which it has obtained.

One source of information was a questionnaire addressed to all physicians registered under the Harrison Narcotic Act, requesting data as to the number of chronic users under treatment by them at the time. The Committee reports as follows:

"Replies were received from approximately 30 2/3 per cent of the physicians registered in the different States, and these showed that there were under treatment at that time a total of 73,150 addicts. On the basis of 100 per cent replies, if the same average was maintained, there were under treatment at the time this questionnaire was sent out a total of 237,655 addicts. The following table" shows in detail by States the number of addicts reported under treatment, the percentage of replies received from physicians, and the estimated number on the basis of 100 per cent replies."

Another questionnaire was addressed to state, district, county and municipal health officers, the results of which are given as follows:

"Questionnaire No. 4 was addressed to 3,023 State, district, county and municipal health officers. To this questionnaire 983 replies were received, or 33 per cent of the total number sent out. Only 777 of these, or 26 per cent of the total, contained any information of value to the committee."

The Report summarizes as follows:

"The number of addicts reported by the health officials replying to questionnaire No. 4 was 105,887. As this number represents the addicts reported by only 26 per cent of the health officials, from which this information was requested, it may be assumed that had all the health officials replied the total number would have amounted to approximately 420,000. This number, however, appears to be much too low, in view of the fact that the physicians of the country are estimated to have had about 237,000 addicts under treatment during this same period, and only a small portion of the total number of addicts present themselves for treatment. Addicts of the "underworld," for instance, secure most of their supply through illicit channels and rarely, if ever, consult a physician.

"It appears that a more accurate estimate of the total number of addicts may be obtained from the data secured by those investigators who have made an intensive study of drug addiction in certain restricted communities. For example, the health officer of Jacksonville, Fla., reported 887 1 addicts in that city in 1913. This number represents 1.31 per cent of the population. Upon this basis the total number of addicts in the United States, in 1918, taking the estimated population as 106,000,000 would be 1,388,600.

"In reply to questionnaire No. 4 sent to health officers of States, counties, and municipalities, the health officer of New York City reported a total of 103,000 addicts, which is equivalent to 1.8 per cent of the population. On this basis, there would be 1,9W,000 addicts in the United States.

"Information in the hands of the committee indicates that drug addiction is less prevalent in rural communities than in cities or in congested centers. It would, therefore, be unfair to estimate the number of addicts in the entire country on the basis of the figures obtained for New York City. Furthermore, it is the opinion of the committee that an estimate based on the number of addicts in a small city like Jacksonville, Fla., would not be representative for the entire country. Taking these facts into consideration, the committee is of the opinion that the total number of addicts in this country probably exceeds 1,000,000 at the present time."

' This figure includes 346 cocaine users.

In reviewing the estimates arrived at on the basis of the replies received to these questionnaires, there arises a question as to what is meant by "treatment." From a later statement in the Report "treatment" here means presumably the supplying of the drug by physicians, but we believe that in replying to this question the average physician would report only such cases as were under curative treatment. Be this as it may, the propriety of estimating the number of cases on the basis of 100% replies from physicians registered under the Harrison Narcotic Act is open to question. It is stated in the Report that thirty and two-thirds per cent. of the registered physicians queried replied and that 73,150 cases were reported by them as being under treatment. To assume that the resulting figure of 237,655 calculated on -such a basis is a correct estimate, is still not warranted. For such an estimate to be accepted as a logical conclusion on the basis of 100% replies 'it would have to be assumed that all groups of physicians registered under the Harrison Narcotic Law answered in like proportion. But it is natural to assume that nose and throat specialists, oculists, obstetricians, gynecologists, surgeons and others not occupied with general practice would not be interested to the same degree in replying to the questionnaire. In all probability the thirty and two-thirds per cent. physicians reporting include a relatively greater proportion of those treating addiction cases than those not reporting. Under these conditions the estimated 237,655 addicts is too high a figure. As a matter of fact, however, the Committee appears not to accept this figure, anyway, inasmuch as it ultimately reaches a speculative figure of 1,000,000, inclusive of cocaine users.

As to the estimates based on replies received from state, county and municipal health officers of which the Committee states only twenty six per cent. replied, we would call attention to the fact that 103,000 were reported by the health commissioner of New York City, with a balance of the twenty-six per cent. reporting only 2887. This material was gathered in 1918. At that time also nothing in the nature of a survey of chronic opium users in New York City had been made. The narcotic clinic was not opened until 1919 and this clinic disclosed but 7464 cases of opium users. It is manifest therefore that the 103,000 reported by the health commissioner in the previous year was wholly speculative. It is also of interest to note that the health commissioner of New York City a year or two later stated that 20,000 was an outside estimate for cases of chronic opium users in New York City.

Here again, however, the Committee admits dissatisfaction with the resulting estimate of 420,000, stating that the figure is too low and ultimately arrives at an approximate figure of 1,000,000 including users of cocain. It is not apparent in the Report how this figure is reached.

New York City Health Department Narcotic Clinic-April, 1919, to January, 1920.

'Hubbard, S. D@The New York City Narcotic Clinic and differing points of view on narcotic addiction. Monthly Bulletin, Dept. of Health, City of New York, February 1920.

Hubbard 21 reports on the findings resulting from the data gathered during the operation of this clinic over a period of approximately nine months. This clinic was conducted in co-operation with the New York State Department of Narcotic Drug Control. In regard to the extent of opium usage in New York City, Hubbard states:

"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 addiction.

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, sniffing, needle puncture markings, and tattoo skin evidences; but in actual experience with hundreds of acknowledged 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; feeble-minded, and strong-minded; physically below, and above par; morally inferior, and superior. No one class 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 numbers estimated by some as one per cent. of the community, and even two and three per cent by others--we, today, think that this is greatly over-estimated.

"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 co-operation 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 number 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."

In his conclusion, Hubbard states:

"The estimate of 1% of our population addicted to the use of narcotic indulgence as a habit-addiction-is very likely greatly exaggerated."

In his general statistics Hubbard gives as the number of users registered during the operation of the clinic (about nine months), 7464 of which 5882 were men and 1582 were women. Applying the incidence indicated for New York City by the number registered at the clinic, we obtain for the country as a whole 140,554 for the year 1919.

A number of factors combined to make the registration at the New York City clinic incomplete. In the first place attendance was voluntary. Further in New York City it was required that not more than a twenty-four hour supply be furnished the addict, so that it was necessary for individuals to visit their physicians or the clinic daily in order to secure the drug legitimately. This requirement tended to influence those for whom it was impossible or too inconvenient to leave their business or work to seek their supply from the illicit traffic or from legitimate sources outside of the jurisdiction of this ruling. The number registered, therefore, represents only those who, because of difficulties in securing their supply by reason of the cost of prescriptions or because the drug was sold more cheaply at the clinic than at the retail drug store in spite of the twenty-four hour ruling chose to attend the clinic.

Also there were several other factors operating, to keep certain classes of users away from the clinic. First there was the inconvenience of the crowded condition of the clinic where applicants were required to stand outside in lines a block or more long in any weather waiting their turn to be examined and otherwise attended to. Second, there was the fixing of an arbitrary dosage and then the enforced reduction by an arbitrary amount. Third, it was required that a considerable amount of personal information having nothing to do with their addiction, such its the name of their employers and their addresses, be supplied and that the photograph of the patient be attached to the registration card.

Drug peddling in New York City was very rife at the time of the operation of the clinic, and every opportunity was offered those who could afford to pay the prices charged by the illicit traffickers in drugs to secure their supplies without submitting to the requirements of the twenty-four hour supply provisions or registration at the clinic.

Narcotic Drug Control Commission-New York-1920 .22

'Second Report of the Narcotic Control Commission. 1920.

Referring to the number of users in New York State, Commissioner Herrick says:

"I think a safe and conservative approximation would be 39,000. The records of the Department show in round numbers 13,000 registered addicts. This number is composed of those who obtain habit-forming drugs through legitimate sources, that is, directly from a doctor or on prescriptions issued by a doctor, filled by a druggist, or from the different clinics established throughout the State. To these figures should be added twice the number, which is an approximation of the users who obtain drugs from peddlers, or other illicit sources. Of course, this latter figure, as I have stated, is only an approximation. I base it on the percentage of addicts among the great number with whom I have personally conferred, who have admitted that they obtained their drugs from peddlers or other illicit sources. Between four-fifths and two-thirds of the registered addicts are located in the city of Greater New York, and the remaining fraction is scattered throughout the rest of the State. The larger the center of population the greater the percentage of addicts."

When applied to the country as a whole, Herrick's estimate of 39,000 addicts in New York State yields a figure of 396,978.

If Commissioner Herrick's statement that between four-fifths and two-thirds of the registered users were located in the city of Greater New York is correct, we have from 10,400 to 8,666 in the Greater City by using his figure of "in round numbers 13,000" for the state as a whole or several thousand more than were registered at the clinic.

It should be pointed out that however far Hubbard's figure falls short of the actual number of users in New York by reason of the forementioned factors, it is at least 500 too low if our interpretation of the Commissioner's report is correct. According to his statement, the Department of Narcotic Drug Control issued exemptions for certain individuals who were not required to register. The number of these exemptions was 500 in the beginning, but later was reduced to 300. In attempting to generalize, therefore, from the New York City clinic figures we must bear in mind the apparently marked incompleteness of these figures. The figure of 7,464 however, as a minimum, is a figure of importance and of itself presents a serious problem, however far it may come from indicating the actual conditions.

Los Angeles Clinic-1920.

In Los Angeles a narcotic clinic was operated from March 8 to August 17, 1920-a period of a little over five months-at which time, according to the report of the medical head, W. H. Bucher, the clinic was closed by federal orders. During this brief period there were registered at the clinic 582 persons-389 men and 193 women. In addition, knowledge was had of 37 individuals who were not registered and given the drug because they were not working, had previous undesirable records or gave insufficient evidence of being chronic users. The exact number, therefore, of users was unknown to the clinic authorities. In the case of Los Angeles as in New York all opium users were not required to come to the clinic and register nor were records kept of cases handled by outside physicians. Another factor which tended to influence the situation in Los Angeles and which did not obtain in like degree in other localities where clinics were operated was the proximity of this city to Mexico. Tile constant smuggling of the drug furnished easy sources of supply to those who wished to avoid registration at the clinic.

Taking, however, the Los Angeles figures as indicated by the clinic registration for what they are worth, we find at least a minimum of 564 known chronic opium users, giving an incidence rate of about .1 70'. On the basis of the Los Angeles figure there would be in the United States a total of 102,005 for 1920. It will also be remembered that the Los Angeles clinic was in operation for but five months, while in Jacksonville and Tennessee registration of narcotic users covered a much longer period.

'In using the phrase "normal incidence" as indicating the cases of chronic opium usage caused through medical practice, self-medication and constitutional make-up but exclusive of cases stimulated by such artificial influences as underworld association, illicit traffic, etc., we would not be understood as meaning that the normal as at present existing is an irreducible figure. We believe only that it is an actual figure existing as of this time-the present period in medical practice and lay knowledge-that with better medical education and a more widespread dissemination among the laity of the facts of chronic opium intoxication this "normal" in the future materially will be lessened.

Shreveport, Louisiana, Clinic-1919-1923.

In many respects the next figures to be considered possess a unique value. They were supplied by W. P. Butler, medical director of the narcotic clinic at Shreveport, Louisiana, and include the cases of chronic opium intoxication in the city of Shreveport and Caddo Parish in which Shreveport is located, comprising thus a territory including both urban and rural population. Further they represent only resident cases. Transients, non-residents or those who were induced possibly to seek Shreveport because of the opportunity for attending a clinic and profiting by treatment have all been eliminated by Dr. Butler through his intimate personal knowledge of the circumstances surrounding each case. The size of Shreveport, its relative isolation from populous centres, the absence of large industries and manufactories would all tend to minimize underworld influences as etiologic factors of importance. For the most part these cases represent those arising from the prescribing of these drugs by physicians, from self-medication and that element which everywhere, even without unusual opportunity or artificial incitement, tends to seek adventure, stimulation or solace through the use of narcotics. In other words, Butler's figures represent more nearly than any others in our possession what might be termed a normal incidence 23as existing in a community where unusual exciting causes have not existed.

Further it should be remembered in considering these figures that the operation of this clinic continued without interruption for a period of nearly four years, from May 3, 1919, to February 10, 1923. This is a longer period of existence than has been comprised in the life of any other narcotic clinic. The methods employed by Butler, differing in several particulars from those employed elsewhere in similar work and the support from local officials, physicians and public combined to make this unusual period of existence possible in view of the attitude of the Bureau of Internal Revenue in regard to the operation of narcotic clinics.

The local educational influence of the clinic undoubtedly was very great in Shreveport and the adjoining rural districts, which fact must not be lost sight of in attempting to generalize from the Shreveport figures. Not only the very great majority of all cases were handled personally by Dr. Butler and his staff-only a very few remained in the hands of private physicians-but the nature of the work was so thoroughly understood and so widely endorsed by the local medical profession that it could not have failed to have a deterrent effect upon the ill-advised, careless or unnecessary prescribing and administering of opium preparations in the ordinary practice of medicine. Therefore, there must have been an influence during the operation of the clinic tending to lessen rather than to increase the number of new cases usually arising from and attributable to the unwise use of opium by the practicing physician at large. In other words, there appear to have been no artificial stimulating influences toward narcotism but, on the contrary, there were present influences which tended distinctly to lessen the formation of new cases.

Also it should be noted that . during the operation of the clinic the illicit traffic was reduced to the minimum if not wholly eradicated. This matter received the particular attention of the Bureau of Internal Revenue whose agents repeatedly visited Shreveport and noted the conditions under which the clinic operated. According to Butler, they stated to him as their personal opinion that the drug was very scarce on the streets of Shreveport; one agent made several attempts at different times to buy the drug or to have it bought, but was unsuccessful.

It would-appear, therefore, that one may generalize with less chance of error, at least on the side of exaggeration, from the Shreveport figures than from those of any other locality. Further in such generalizations we have a more nearly accurate portrayal of the extent of the use of opium preparations in this country arising from what we may term the more natural causes,-causes inherent in all communities in which medicine is practiced, painful illness is experienced and predisposing constitutional tendencies do not exist in excess or are not influenced unduly by artificial conditions-than in other generalizations.

In other communities, especially in the metropolitan centres and industrial cities where racial, social and economic factors lead to congested living conditions and tend to stimulate the vicious employment of opium preparations for purposes solely of dissipation, where prostitution is considerably more prevalent and where peddling is highly profitable, we should expect a very material increase in the underworld or vicious element among the drug-using population as a whole. In addition to this, where public and professional attention has not been continuously and for a relatively long period directed at constructive effort toward the elimination of this evil, we should not look for n decrease in the drug-using population resulting from an increased caution on the part of members of the medical profession. Whatever the effect of these two influences in the causation of chronic opium intoxication in such large centres as we have referred to here or elsewhere, the cases attributable to them must be considered as an increment in excess of those normally existing in these communities and resulting from such widespread and omnipresent causes as those apparently responsible and chiefly operative in Shreveport.

The Shreveport incidence, therefore, of opium users for the population at large may well be considered a minimum.

Had Butler not eliminated the non-resident and transient cases, the cases recorded at the Shreveport clinic since its inception would be 1,237. This figure, Dr. Butler states, includes transients, residents, non-residents, and all those dispensed to one time or more and comprises all cases handled by the clinic from the date of its opening to February, 1923. In the case of Shreveport, however, where the collection of information has been made with unusual care and over a considerable period, it has been possible for those in charge of the work to eliminate artificial or unusual conditions and to determine with exactness the true resident incidence. Butler reports this figure to be 371, which covers exclusively those residents registered and cared for during a period of nearly four years. This figure, however, cannot be used for the determination of the addiction incidence in Shreveport, and for purposes of comparison with other surveys for three reasons: First, it covers a period of more than one year, while in the Tennessee, Jacksonville, Los Angeles and other figures heretofore considered the numbers dealt with surveys made during one calendar year; second, the figure is a strictly resident figure, whereas the figures of the other cities deal with the crude population; third, in Shreveport the narcotic clinic and the hospital facilities for treatment undoubtedly attracted addicts from other sections of the country, as the figure of 1,237 given above indicates. Therefore, Doctor Butler has supplied us with the number of addicts treated and registered during one calendar year of the clinic, 1920. The total number of cases treated in this year was 542, but into this figure enters the error incident to the fact that numbers of individuals came to Shreveport throughout the period of the clinic because of the clinic and its facilities. In an attempt to correct for this source of error, it was possible for Doctor Butler to subdivide these 542 cases into residents and non-residents, the basis for the former being residence in Caddo Parish for a period of one year prior to registration at the clinic. The resident figure for 1920 is 211, the non-resident figure is 331. None of these figures unfortunately permits of comparison with the figures dealing with addiction incidence in other communities, inasmuch as these latter figures have included the general run of population usually present in a community, residents and transients, but they did not include-and there was no reason why they should include-individuals especially attracted because of a local situation having to do with the special handling of opium addicts. The true number which would be typical of Shreveport lies somewhere between the strict resident figure of 211 and the exaggerated figure of 642. The resident figure gives to Shreveport an opium user rate of .25%. Applied to continental United States it would furnish a total of 264,276 for 1920. From what already has been said of the conditions under which the Shreveport figures were obtained-the elimination of non-residents, transients, drug traffickers-and from the absence of unusual exciting causes which would lead to the formation of any considerable percentage of vicious or underworld cases, it is at once apparent that this figure represents a minimum and must be considerably below the real number. For we may not minimize without danger of serious underestimation what, is so often reported by local and federal authorities throughout the country as a powerful influence in the causation of this condition in the younger age groups of both sexes, particularly of males, namely, the etiologic factor comprised in under-world associations and the instinct of the illicit trafficker.

In the preceding pages we have utilized such figures as we have found available in an effort to show the extent of this problem. These figures have been in sonic cases incomplete, and in others, for one reason or another, subject to doubt or controversy. Unfortunately a sufficient number of local surveys at any given period has not been made to furnish material for a reliable cross-section of the country. Conditions existing in one section may be attacked with at least a show of justice when applied to others. Population composition, occupation, and even climate, to say nothing of many other sociologic influences, tend to vitiate generalizations made from local data of this kind.

For comparison we are giving in the following table the findings of the surveys suitable for purposes of generalization together with certain computations based thereon. The other surveys of which we have record are too incomplete or for one reason or another too inconclusive to warrant their use as bases for general estimates.

A more recent estimate 24 of the number of addicts in the United States is that of Lawrence Kolb and A. G. Du Mez of the United States Public Health Service. While not based on an original survey of a community or section of the country, the estimate of these authors is of interest as a result of their analysis of certain recent surveys and other data. In their introduction they state:

'Kolb, Lawrence, and A. G. Du Mez---'The Prevalence and Trend of Drug Addiction in the United States and Factors Influencing It." Public Health Reports--May 28, 1924.

"It is realized that it is impossible at the present time to make an exact count of the persons addicted to narcotics in the United States in an individual State, or even in one of our larger cities, because of the social and legal factors tending to make addiction a secret practice. It is believed, however, that it is possible, by utilizing all of the information now available, to delimit the number by certain maximum and minimum figures. With this object in view, a number of the more important narcotic surveys made in recent years were analyzed; also the reports made by agents of the Bureau of Internal Revenue and other persons on the narcotic clinics conducted in different parts of the country; statistics on the dose of addiction, world production of narcotics, and the quantities imported into this country were compiled and studied; and numerous physicians in different parts of the country were interviewed in person to ascertain the number of addicts they were treating in the course of their practice. The results of these analyses and studies follow:"

After their analysis of the surveys and clinic reports, they conclude as follows:

"In summing up it may be stated that according to Brown's survey, 215,000 was approximately the number of addicts in the United States in 1915. The New York City, the Treasury Department, and the clinic surveys were made four or five years later. An objection to making a general application of the New York City survey is that the sex and age distribution of addicts shown by it does not obtain throughout the country. This was probably due in part to the fact already referred to, namely, that young addicts are attracted to large cities, and conditions exist in them which cause a delinquent type of addiction; and it is also due in part to the fact that some of the older addicts were being taken care of by physicians and were not counted when the survey was made. Just how far these two factors balance each other is not known, but the 140,600 indicated by the New York City survey in 1920 shows a reduction over the 1915 figures. The clinic surveys made at the same time or a year later took in nearly all sections of the country and comprised a more representative group of population. These surveys show 104,300 addicts.' The Pennsylvania figures, collected over a period of five years and ending about a year after the clinics were closed, show approximately 109,250 addicts in the United States in 1922 when the actual count of 9,000 is used. The Army rate is undoubtedly too low for the particular group surveyed, and for reasons already given for estimating addiction in the population as a whole. The 1918 Treasury Department survey shows 237,655 addicts and apparently contains an indeterminate error of exaggeration, as already pointed out. The highest estimate based on any unrevised survey is 269,000; the lowest, exclusive of the Army survey, is 104,300. These figures may therefore be accepted as the maximum and minimum numbers for the period 1915 to 1922; but from what has been brought out relative to the surveys it would seem that somewhat less than 215,000 is more nearly correct for the beginning and about 110,000 the approximate number for the end of the period."

The second part of their report is a consideration of the estimated number of addicts "based on dosage and available supplies." Using as a basis for their computations an average daily dose of six grains of morphin sulphate, which they state they obtained as a result of their studies, the authors show in tabular form in ten-year periods in the next table the number of addicts who would be supplied if all of the opium entered for consumption were used for addicts.

They state:

"These figures are given for a period prior to the time when restrictions were placed on the traffic in opium, and there was no incentive to the smuggling trade as there is to-day. It is therefore believed that at no time have there been more than 246,000 opium addicts in the United States."

' A press release from the Narcotic Division of the Prohibition Unit, Bureau of Internal Revenue, dated May 4, 1924, states: "It is estimated that there are upwards of 500,000 drug addicts in the United States . . . . ..

Following the same reasoning in regard to the total world production of opium these authors conclude that at this rate "the total annual production of opium, exclusive of that produced in the countries of the Far East, if used entirely for the satisfaction of addiction, would supply only about 566,000 addicts."

It is necessary to emphasize, as the authors themselves have pointed out, how impossible it is to obtain accurate statistics on the world opium production. The data upon which the above estimate of 566,000 was based were obtained from statistics compiled by the Advisory Committee on Traffic in Opium of the League of Nations who the authors state, "admits that the figures given are only estimates in the majority of cases." Further it should- be remembered that the annual production figures vary from year to year and an estimate based on the figures for one year-the above estimate of 566,000 is based on the production figures of 1922-is true for that year alone, granting that the figures are correct, and may be quite different from those based on figures of other years.

They continue:

"It has been shown that at no time have the annual importations of narcotic drugs into this country been greater than would be necessary to supply 264,000 addicts, assuming that they were used in their entirety for the satisfaction of addiction. No one contends that they were so used, but it has been asserted that at least 75 per cent of the quantities imported are used for this purpose. It is believed that a fairly accurate estimate of the amounts used for the satisfaction of addiction subsequent to 1909, when the entry of smoking opium was prohibited, can be obtained by using the import statistics given in Tables 2 and 3.

"For the four-year period, 1920-1923, the importations of opium amounted to 144,805 pounds annually. For this same period 5,282 ounces of opium alkaloids were imported annually. The narcotic division of the Bureau of Internal Revenue estimates that not over 15 per cent of these quantities get into illegitimate channels. Making these deductions it may be assumed that 123,084 pounds of opium and 4,490 ounces of opium alkaloids are required annually to supply the legitimate medicinal needs of the country, including the needs of many old and incurable addicts now being supplied by physicians, which number is constantly decreasing. By subtracting these amounts from the amounts imported annually for the decade 1910 to 1919 we obtain 242,971 pounds of opium and 22,653 ounces of opium alkaloids.

"These quantities would supply approximately 100,000 addicts for a year. Making similar computations for coca leaves and coca leaf alkaloids, it is found that approximately 9,000 addicts could be supplied with the quantities which were formerly imported in excess of what has been imported in recent years. This would make a total of 109,000 addicts who, prior to 1915, could have obtained their supplies of narcotics from the quantities imported legally. In view of the limited supplies of medicinal opium available in the world and the rigid control of narcotics exercised by this country, it is highly improbable that the combined quantities available to addicts in 1919 and 1920 from smuggled sources and from leakage through legitimate channels were more than sufficient to supply the number (109,000). This is probably too high, in view of the reduction which has been shown, but if we add to this figure the number of aged and incurable addicts who received their supplies through legitimate channels, the total number of addicts in this country for the period stated was probably somewhere between 120,000 and 140,000, which is in keeping with the figures arrived at from the surveys and clinic reports.

"That the quantities of narcotics smuggled into this country are in all likelihood not as great as is believed by some, is shown by the quantities reported as falling into the possession of the Bureau of Internal Revenue in the enforcement of the narcotic laws. For the year ending June 30, 1922, the total quantity, including opium and coca leaves, preparations containing opium and coca leaves, the alkaloids of opium and cocaine, and preparations containing these alkaloids, was only 4,447 pounds. In 1923 it was 542 pounds."

In connection with the above statements, we should like to point out that in our opinion a decrease in the amount of drug confiscated does not necessarily indicate a decrease in smuggling. The report of the Special Committee of the Treasury Department, 1918, states that

"in recent years, especially since the enactment of the Harrison law, the traffic by 'underground' channels has increased enormously, and at the present time it is believed to be equally as extensive as that carried on in a legitimate manner!" How much of this traffic found its source of supply in smuggling and to what extent the activities of the federal bureau charged with the enforcement of the law have diminished smuggling operations since 1918, we are unable to say. However, we believe that the significance of the above statement should be considered.

Earlier in this chapter we have. pointed out the undesirability of attempting to make an estimate of the number of addicts based on the amount of the drug available for consumption and the average daily dose. We again wish to point out the present lack of data, at least in our experience, which would warrant the acceptance of any figure as a representative average daily dose for addicts.

From their interviews with physicians the authors conclude as follows:

"Confirmation of the estimates based on the supplies of narcotics available and on the findings of the various surveys as to the number of addicts and the trend of narcotic addiction in the United States is furnished by the experience of physicians as related to us. We have interviewed physicians from all parts of the United States and it is unusual to find one who has an addict among his patients. Few besides those who have contact with penal institutions and sanitariums meet any great number. Many physicians still occasionally see a transient addict who drops in and begs for a dose, but this, too, is growing rare. Some of the physicians who have been practicing for years in small towns and rural communities speak of addicts they have cured by the aid of the Harrison law or who have, without outside assistance, cured themselves. Some of them are taking care of one or more old or incurable cases but from the information they give it seems that new cases of addiction are not arising to take the place of the old ones who die.

"The accuracy of our observation is Supported by the findings of Dr. Carleton Simon, special deputy police commissioner in charge of the narcotic division of the police department of New York City, who sent out a questionnaire to the physicians in New York State. Of the 7,599 physicians who replied, only 52 per cent reported that they were treating addicts in 1922."

Two questions arise as to the justification of the above deductions based on interviews with physicians throughout the country; first, were a sufficient and representative number of physicians interviewed to portray a fair picture of existing conditions; and second, is it reasonable to expect that the majority of addicts under present conditions place themselves in the hands of physicians? In regard to the latter question we believe that for reasons pointed out in the following chapter the tendency of the physician is to avoid contact with the problem of addiction.

As a final conclusion in regard to the present number of addicts, the authors state:

"The evidence seems to show that a maximum estimate for the number of addicts in the United States at the present time would be 150,000. The estimates based on actual counts and on the available supplies of narcotics, together with conditions reported by the physicians interviewed, point to about 110,000, which number is believed to be nearly correct."

In general, a review of the material already covered in this chapter will show it in the above study in the first place certain surveys have not been taken into consideration and in the second place, incorrect deductions have been drawn from two of the official reports cited. Among the first may be named the Jacksonville, Fla., survey made in 1913, about a year before the Tennessee study. A consideration of the earlier surveys may have been omitted because of the supposed existence of different influencing factors by reason of time. In regard to this point we believe that however different conditions may be at the present time, the changes have not been great enough to eliminate completely the significance of these early figures.

In regard to the second point, namely the incorrect deductions, it is true that there actually were reported only 73,150 addicts in the survey made by the special committee of the Treasury Department, 1918, which on the basis of 100 per cent replies would yield 237,655 addicts under treatment in the entire country. The report from which they take this figure has already been considered above. The figure which they quote is not given in the original report as the committee's estimate of the total number of addicts in the country, but only as the estimated number of addicts under treatment by physicians during the period when the survey was made, as the report states, I............ only a small portion of the total number of addicts presented themselves for treatment. Addicts of the 'underworld', for instance, secure most of their supply through illicit channels and rarely, if ever, consult a physician." Further, had Kolb and Du Mez employed the figures resulting from queries sent to health officials they would have reached a total for the country of 420,000 addicts, which figure, the committee's report states, "appears to be much too low in view of the fact that the physicians of the country are estimated to have bad about 237,000 addicts under treatment during the same period." Further on the report of the Treasury Department, after considering the errors potentially residing in all of the -figures presented, both from general and local sources, reaches the following conclusion: "Taking these facts into consideration, the committee is of the opinion that the total number of addicts in this country probably exceeds 1,000,000 at the present time,'-a statement which Kolb and Du Mez did not take into account. Again, these authors quoted only the lower figures and lost sight of the final estimate of the number of addicts in the state of New York made by Commissioner Herrick in his report of the work of the Narcotic Control Commission when he states:

"I think a safe and conservative approximation would be 39,000. The records of the Department show in round numbers 13,000 registered addicts. This number is composed of those who obtain habit-forming drugs through legitimate sources, that is, directly from a doctor or on prescriptions issued by a doctor, filled by a druggist, or from the different clinics established throughout the State. To these figures should be added twice the number, which is an approximation of the users who, obtain drugs from peddlers, or other illicit sources. Of course, this latter figure, as I have stated, is only an approximation. I base it on the percentage of addicts among the great number with whom I have personally conferred, who have admitted that they obtained their drugs from peddlers or other illicit sources."

The importance of these estimates in relation to their use as a basis for further estimates or comparisons is obvious.

Finally in view of the various considerations pointed out in regard to the above study, we cannot agree that the ultimate estimate of 110,000 is warranted. While we on the one hand deplore unjustifiable, sensational exaggerations, on the other, we recognize the danger of basing maximal estimates on selected data.

One other method of arriving at a satisfying conclusion as to the extent of this problem exists. It is quite remote from what we may terra the mathematical procedure, and, while neither specific in its application nor concerned with actual numbers, includes presumptive evidence of such importance and brings into consideration such deeprooted human attributes and such well-known characteristics as to render it, perhaps, the most important method of all, while, parodoxical as it may seem, the least definite. We refer to a review of the growth

in the use of opium through the many and varied motives as presented and revealed by available historic record. That there has been a continuous, marked increase in the consumption of opium and its products in the United States, at least through 1915, is shown in the following table of importations. The supply has but filled the demand. Tile conclusion is inevitable that the number of chronic users, for one reason or another, steadily has been increasing, as upon the basis of the therapeutic use of these drugs alone-in the treatment of disease other than that of chronic opium intoxication-such an increase would have been impossible. In 1915 two things occurred simultaneously, the importations decreased and the illicit traffic began to develop. This doubtless was due chiefly to the fact that chronic users, because of the restrictions placed upon physicians and pharmacists in the handling of these drugs, sought their supplies from underworld sources. It does not mean necessarily that the consumption of opium has decreased.

Inasmuch as this comprises a study of the development of the problem of chronic opium intoxication we shall take it up in a separate chapter, tracing its progress through the early unrestricted use and popularity of opium to relieve pain in that period of medical enlightenment when attention was directed at symptoms rather than cause, the ignorance of the dangers of continued use, the discovery of its value for therapeutic uses, the influence of such writings as De Quincey's and others of his day, the introduction and widespread use of the hypodermic syringe, the influence of the Civil War and other wars, the practice of opium smoking, the influence of the patent medicine industry, the discovery and use of heroin, the illicit traffic which has grown up since the enactment of anti-narcotic laws and the general lack of interest and laxness in medical teachings and practice in the employment of opium preparations.

RESUME

The period covered in the foregoing material dates from the earliest time in which this problem in the United States appears to have received individual or public recognition up to the present time. From beginning to end the material is fragmentary. Altogether very few surveys have been made and those that do exist are more or less imperfect due to one or another vitiating factor. Incompleteness seems to be an outstanding feature of practically all surveys. This may be explained by the nature of the problem and the prevailing early and present attitudes toward the individuals affected, as a result of which they are not inclined to reveal their condition. Other influences tending to render the surveys already made inapplicable to generalization are community variations such as race composition, method of conducting survey, method of registration, classes represented in survey, attitude and experience of investigators, etc. Moreover, singularly enough, in spite of a growing interest evinced in the problem as a result of the enactment of the Harrison Narcotic Act, the results of several of the earlier investigations appear better adapted to generalization than most of those made public since the enforcement of this law. In consideration of the above factors it must be concluded that we do not know the total number of opiate users in the United States today.

Whatever their inaccuracies, these surveys and estimates indicate sufficiently clearly the existence of a major medico-social problem to make the denial of the existence of a general situation far more dangerous than its affirmation. As a matter of fact, it is not necessary to know the exact number of users or even the minimal extent, to realize that there are a large number in the country and that the problem is serious.

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