As far as we have been able to ascertain the first federal attempt at legislation to control the use of opium in the United States was made on February 9, 1909, when the act known as "An act to prohibit the importation and use of opium for other than medicinal purposes" was approved. This law was passed as the result of investigations made in the United States during the summer and autumn of 1908 by the American Opium Commission appointed under the Act of Congress approved May 27, 1908.
It is true that according to the treaty of 1880 with China the importation of opium to Chinese subjects in the United States was prohibited, but Wright' says that only Chinese subjects were affected and that in fact American citizens "continuously imported the drug in a form prepared for smoking," and "handed it over to Chinese subjects who distributed it throughout the country, not only to Chinese, but to any and all" who had "become addicted to the opium smoking habit." Further, it is true that before 1909 there existed tariff and internal revenue laws governing the admission of opium into the United States but the aim of these laws was the production of income.
Wright summarizes the tariff laws and their effect as follows:'
"The first mention of opium in our tariff acts was in that of July 14, 1832, section 3, where, amongst other articles, it was exempt from duty. In the tariff act of March 2, 1833, section 5, opium is again mentioned and placed in the free list.
"In the tariff acts that followed, the duty on opium frequently changed."
"In the tariff act of August 30, 1842, opium for the first time is made to pay a duty. In section 8, paragraph 2, of that act an impost of 75 cents per pound was placed on the drug. It will be noticed . . . that, in anticipation of the change of opium from the free list to the dutiable list, there was, during the year 1841, a large speculative importation of the drug. In the tariff act of July 30, 1846, Schedule E, opium, amongst other articles, was put in the ad valorem list and made to pay 20 per cent. The price of the drug about that time was in the neighborhood* of $5 a pound, and there seems to have been some difficulty in regard to invoicing under an ad valorem tax, so that by the tariff act of March 3, 1857, a specific tax of $1 a pound was placed on the drug. In the year 1861 there were two tariff acts—that of March 2, imposing a duty of $1 and that of August 5, imposing a tax of $2 a pound on the drug. By the tariff act of June 30, 1864, the impost on crude opium was raised to $2.50 a pound. This increase in the rate on crude or medicinal opium appears to have been for revenue purposes. The duty of $2.50 per pound remained in force until the tariff act of July 14, 1870, when the impost on this form of the drug was reduced to $1 per pound. The latter rate was retained in the tariff act of March 3. 188.3; but in the tariff act of October 1, 1890, the drug was again placed in the free list. It remained in the free list in the tariff act of August 27, 1894; but on the passage of the tariff act of July 24, 1897, it was again made to pay .$1 a pound.
"The taking of crude or medicinal opium from the free list of the immediately preceding tariffs and the imposition of $1 a pound upon it in the Dingley Act seems to have been due to the fact that the manufacturers of morphia have succeeded in securing a duty of $1 an ounce on this alkaloid, a duty that was practically prohibitive.
"It will be noticed that, in anticipation of the transfer of crude or medicinal opium from the free to the dutiable list, there was in 1897 a large speculative importation of the drug. This speculative importation has slightly changed the relative values of the total of importations in ten-year periods. . . .
"It became clear in the early fifties that a large percentage of the opium imported in previous years was not crude opium for medicinal purposes but smoking opium imported into San Francisco and other Pacific ports with the primary intention of supplying the Chinese. Several volumes have since been published on the misuse of opium in this country, and in them it has been stated on what appears to be good authority that the habit of smoking opium began about 1860 to spread from our Chinese to the vicious elements of our white and black population. This was more particularly true of the Pacific coast."
"Since 1860 it may be said that we have a fairly complete record of the importations of this form of the drug, and in some measure it may be calculated what the effect of the admission of it to this country has had on our population as a whole.
"Just what the object was in placing a heavy ad valorem tax on smoking opium has not been determined. It was known in the early sixties that the use of the drug was demoralizing even to the Chinese, and it is probable that the heavy ad valorem taxation was with the object of excluding it from the country. Be this true or not, the heavy tax had one effect—the customs returns for this form of opium began to decline, and the collectors of customs on the Pacific Coast found themselves confronted with serious smuggling operations. In spite of this, a still heavier ad valorem tax (100 per cent) was placed on it by the act of June 30, 1864. The customs returns for this form of the drug continued to recede, and smuggling operations were extended to a vast scale.
"Taking into consideration the cost of producing and carrying to our shores a pound of smoking opium, it was concluded by the collectors of customs that the drug could not bear a higher rate of taxation than $6 a pound; so that in the tariff act of July 14, 1870, it was taken from the ad valorem list and for the first time taxed specifically at $6 a pound. Under this rate it was admitted until the tariff act of March 3, 1883, when the specific tax was raised to $10 a pound. In the tariff act of October 1, 1890, the rate of smoking opium was increased to $12 a pound.
"It will be observed . . . that as the result of the high specific rate of $10 and $12 a pound the importation of smoking opium apparently fell off. But this was only apparent, for again collectors of customs on the Pacific coast were confronted with huge smuggling operations. In addition a large quantity of crude medicinal opium was turned into smoking opium in all parts of the country where Chinese had settled. The result of all this was a considerable correspondence between the Treasury Department and the collectors of customs as to the rate that smoking opium would bear without leading to clandestine operations.
"So vital had this question become that, on the 12th of January, 1888, Mr. C. S. Fairchild, the then Secretary of the Treasury, was impelled to write to the then Speaker of the House of Representatives, Mr. Carlisle, recommending the passage of a bill to prohibit the importation of the drug."
In his letter Mr. Fairchild states: 2
"Sir: Under existing law the importation of opium containing less than 9 per cent of morphia is prohibited. Such opium may, however, be re-exported under the provisions of section 2937 of the Revised Statutes. The practical effect of this law is to induce the clandestine introduction of the drug in this form for use in the preparation of smoking opium.
"It is assumed that the object of the law in prohibiting the importation of opium in that condition was to prevent its use for the purpose mentioned, it being understood that smoking opium is chiefly prepared from the drug below the standard of purity named. In order to make this prohibition effective the privilege of re-exportation should be withdrawn.
"This prohibition should, in my opinion, be extended to opium prepared for smoking, on which the rate of duty was increased by the tariff act of 1883 from $6 to $10 per pound, presumably with the object of restricting its importation and use. Such has not, however, been the effect of the law, which has served rather to stimulate smuggling, extensively practiced by systematic organizations on the Pacific coast. Recently completed facilities for transcontinental transportation have enabled the opium smugglers to extend their illicit traffic to our Northern border. Although all possible efforts have been made by this Department to suppress this traffic, it is found practically impossible to do so.

"If, however, Congress is not disposed to prohibit or restrict the importation of opium for smoking, and desires to obtain revenue therefrom the tax should be materially reduced so that the inducement to smuggling and attendant difficulties and expense of administering the law may be lessened."
Wright continues:
"However, no effective action to prohibit importations of this form of opium resulted from the recommendation of Secretary Fairchild. On the contrary, the duty rate was raised to $12 per pound in the tariff act (October 1, 1890). Smoking opium continued to be imported through the customs houses, but in decreasing amounts as the result of the higher impost. The larger part of the market was now supplied by clandestine smoking opium or the same form surreptitiously manufactured from high-grade medicinal opium.
"By the Dingley Act of July 24, 1897, the duty on smoking opium was again placed at $6 a pound, experience having at last taught that it could not bear a higher rate without begetting an extensive surreptitious manufacture or serious smuggling operations. The amount that passed through the customs houses under the latter act progressively increased from the time the act went into effect to the period we are reviewing."
The Internal Revenue Act of 1890 provided for a tax of $10 on all opium manufactured in the United States for smoking purposes and restricted the manufacture of such opium to citizens of the United States. Wright states that the Commissioner of Internal Revenue reported that no license was ever taken out under it.
The National Food and Drugs Act of 1906 also is of interest as an influence on the opium problem in the United States through its prohibition of the introduction of adulterated or misbranded drugs according to the following paragraph. It reads:
"Sec. 2. That the introduction into any State or Territory or the District of Columbia from any other State or Territory or the District of Columbia, or from any foreign country, or shipment to any foreign country of any article of food or drugs which is adulterated or misbranded, within the meaning of this act, is hereby prohibited."
As Wright remarks, "the effect of this Act in diminishing the use of proprietary or patent compounds containing opiates has ever been extensive."
But as Wright concludes:
"It seems clear as it concerns the continental United States that neither treaty, tariff, excise, nor other laws bore so heavily on the opium traffic, or on those engaged in it, as to regulate the importation and confine the use of crude or medicinal opium to legitimate medical channels. On the contrary, vast amounts of this form of the drug have poured in ever-increasing quantities into the United States, while the opium-smoking habit, outlawed by nearly every State and municipality in the Union, appears to have been encouraged by the tariff and excise laws permitting its importation and manufacture."
Wright says in connection with the origin of the Act of 1909:
"Another aspect of the opium question loomed large and was most important to our government, considering that it had convened an International Opium Commission to study and report on the opium problem as it is seen in the Far East. While the diplomatic correspondence proceeded it became apparent to the Department of State that there was a large misuse of opium in the continental United States. When this had been sufficiently demonstrated by the opium commission, it became the bounden duty of our Government to take some steps to clear up the home problem before the American delegates to the International Opium Commission should be brought face to face with the delegations of the other powers. Otherwise the American people stood to be accused of living in a glass house that no doubt would have been shattered on their heads."
As a result of the investigations made in this country in 1908 the attention of the Government was called to two facts that had been disclosed,—first, that the federal government was legalizing the importation and manufacture of smoking opium contrary to the laws of most states and many municipalities and that this anomalous situation should be taken care of by legislation before the meeting of the International Commission at Shanghai; second, that state and municipal laws must necessarily be ineffective while there is unrestricted importation of crude or medicinal opium. It was contended that the manufacture and distribution of these drugs in interstate commerce should be controlled by the federal government through the Bureau of Internal Revenue.
As a result of this, Congress on February 9, 1909, approved an act which made it " . . . unlawful to import into the United States opium in any form or any preparation or derivative thereof" except "for medicinal purposes only, under regulations which the Secretary of the Treasury is hereby authorized to prescribe. . . . " The law further provided penalties for violations in the form of fines or imprisonments, defined the various preparations of opium, and designated certain ports—Baltimore, Boston, Chicago, Detroit, Honolulu, New Orleans, New York, Philadelphia, San Juan, San Francisco, Seattle and St. Louis at which the drug might be imported. The law further provided for the making of necessary regulations and the keeping of records of importations.

As to the results obtained by the act of 1909, Wright states:
"In the practical working of this act and the regulations issued under it, legally imported opium is almost immediately lost sight of on leaving the customhouse; for, although the importer may import in good faith and sell to the manufacturer or jobber in equally good faith, it is not possible for any of them to guarantee that the ultimate receiver or seller of the drug in interstate commerce is handling it for strictly medical purposes. Importers have made a genuine attempt to comply with the provisions of the act and the regulations issued under it, but there can be no doubt that the regulations impose too heavy a responsibility on those who in good faith import the drug for the declared purposes. A proposed bill to supplement this defect in the act by placing the interstate traffic in opium and other habit-forming drugs under federal control will be submitted in a moment. But the glaring defect of the February act is that it contains no provision against the possible intrastate manufacture of smoking opium. It does no more than exclude this form of the drug from the United States. If all of the States had uniform laws, which, in addition to forbidding the sale and use of smoking opium, also prohibited its manufacture, and if such laws were effective, there would seem to be no need for action on the part of the National Government to prevent the manufacture of this form of the drug in the United States. But only a minority of the States have such laws, and they are not always effective. This lack of general and uniform state laws to prohibit the manufacture as well as the sale and use of opium prepared for smoking is a question for the urgent attention of the States and the national conference of commissioners on uniform state laws. But until uniform and effective state legislation is an accomplished fact, it would seem to be the duty of the National Government to devise a measure to supplement and complete the law of February 9, 1909, which governs the importation and the proposed measure about to be submitted to govern the manufacture and interstate traffic in this and other habit-forming drugs.
"The opium problem in the United States as it now stands needs to be confined by a triangle. One side of that triangle has been laid down by the act of last February. The importation of opium prepared for smoking and of other forms of opium except for medicinal purposes is prohibited by that act. If the proposed act about to be submitted, or sthne other act of Congress to control the manufacture and interstate traffic in the drug passes and is approved, the second side of the triangle will have been laid down. The third side may be made from an internal-revenue act that will prohibitively tax the manufacture of smoking opium within the United States. It would seem that this third side could be had by amending the act of Congress of October 1, 1890, (26 Stat., 567), governing the manufacture of smoking opium in the United States."
Bills incorporating the ideas suggested in Wright's report as to the control of the opium problem in the United States were introduced in Congress in 1910 and several hearings were held before the Ways and Means Committee of the House. At that time Mr. Wright explained the proposed bills as follows: 3
"The proposed bills, as I have said to you, informally, Mr. Chairman, were drafted in the Department of State to correct the abnormal use of habit-forming drugs that has been laid bare by the investigations of the American delegates to the International Opium Commission. The American opium delegates were appointed two years ago under the authority of Congress (H. R.-21260, public, No. 141.). They were instructed by the Secretary of State to study the opium question as it appeared in the Far East, and in the United States, and in the Philippines. Before the meeting of the International Opium Commission at Shanghai, sufficient evidence was secured on which to draft a measure that would deal with one aspect of the question. As a result of investigations made in the summer of 1908, a bill was drafted in the Department of State, passed by Congress,. and approved on February 9, 1909 (public, No. 221, H.R. 27427). That bill aimed to prohibit the exportation of opium in the United States except for medicinal purposes, and more especially to prohibit the importation of opium prepared for smoking.
"Since the meeting of the international commission at Shanghai, further investigation has been carried on in connection with the preparations for the forthcoming opium conference to be held at The Hague in the near future to complete the work of the Shanghai commission. A wide personal investigation has been made, and importers and manufacturers of opium and other habit forming drugs have been consulted, together with the state boards of pharmacy, representatives of state and national medical associations, some 1,200 leading physicians and surgeons, and many others; as the result the bills that are now before the committee have been drafted. It would seem from the advices that I have had from all sources that if the bills are passed and approved they would meet the abnormal conditions known to exist in the United States, and several measures besides the ones under review are before Congress aimed to correct the abuses that have been uncovered. But after a thorough study of all measures that have been proposed it has seemed to the American Opium Commission that the abuse can be best reached by the measures now under review, which placed the entire matter in the hands of the Treasury Department, acting through the Bureau of Internal Revenue. The first bill—H.R. 25240—is designed to amend a statute which provides for the manufacture of smoking opium within the United States under an internal revenue tax of $10 a pound (Act of Oct. 1, 1890 . . .) . . . This proposed admendment . . . imposing a prohibitory tax' on the manufacture of smoking opium in this country is designed to supplement the February act."
"The second bill, H. R. 25241, is all supplementary to the February act of last year. It is designed to place the entire interstate traffic in the habit-forming drugs under the administration of the Treasury Department. It is the opinion of the American Opium Commission that it would bring this whole traffic and the use of these drugs into the light of day and thereby create a public opinion against the use of them that would be more important, perhaps, than the act itself."
"Now in regard to H. R. 25242. . . . This bill is designed as an amendment, to make more effective the opium-exclusion act of February 9, 1909. Since that act was passed, several things have occurred that make it necessary to amend the law. That act prohibits the importation of opium except for medicinal purposes, and it is aimed especially at the importation of opium prepared for smoking. Since the passage of the act the Attorney-General has given. an opinion, so I am informed by the Secretary of the Treasury, that importation of opium, in this case opium prepared for smoking, for immediate transshipment by sea does not constitute an importation under the act. The effect of this opinion is that importers at San Francisco are bringing large quantities of this obnoxious form of the drug to San Francisco, where it is immediately transshipped by sea to Mexico and then smuggled into the United States over the Mexican border. It has been a most trying task for the customs authorities to detect and prevent this smuggling. To correct the defect in the February act, an amendment has been drawn, the one under discussion, H. R. 25242, prohibiting any vessels, foreign or domestic, from bringing to the United States the substance or article known or designated as opium prepared for smoking. . . .
"A further amendment to the February act is necessary, as the result of certain conclusions reached by the International Opium Commission at Shanghai. That commission made a declaration to the effect that it was the duty of opium-producing countries to prohibit the exportation of all opium to a country prohibiting its entry. In conformity with this declaration, the Hongkong government has prohibited the exportation of opium prepared for smoking to the United States and the Philippines and has asked this Government to reciprocate.
"The typewritten amendment accompanying H. R. 25242 is designed to conform with the declarations of the Shanghai commission. It declares that it shall be unlawful to export or cause to be exported any opium or cocaine to countries prohibiting or regulating their entry, provided that these drugs may be shipped to a regulating country if the exporter conforms with the regulations in force in the importing country."
"We have a law prohibiting the importation of Smoking opium—the act of February 9, 1909. What we need now is a federal law regulating the importation of medicinal opium, cocaine, etc., and the interstate traffic in these drugs, one that will bring the entire traffic into the open, one that will make it easy for the Federal officials to effectively execute it, and will be an aid to the State authorities in enforcing state laws. One good effect of the February law of last year has been to prevent the legal importation of opium prepared for smoking."

Several hearings were held on these bills, but they were not passed.
It was not until January, 1914, that any bill on the subject was passed and on the seventeenth of that month two were approved.
One of them entitled "An Act to amend an Act entitled 'An Act to prohibit the importation and use of opium for other than medicinal purposes', approved February ninth, nineteen hundred and nine," covers practically the same material as H. R. 25242 above discussed.5
The second passed on January 17, 1914, corresponds in the main to H. R. 25240 except that the tax is $300 per pound instead of $200 and Section 5 of the old bill prohibiting interstate commerce in smoking opium is omitted('
The bill regulating the production, manufacture, distribution, etc., of the drugs was finally passed as H. R. 6282 and approved on December 17, 1914. This Act—the so-called Harrison Narcotic Act—and amendments included in the Revenue Acts of 1918 and 1926, and the act of March 3, 1927, are briefly digested as follows: 7

HARRISON ACT AND AMENDMENTS
DRUGS INCLUDED— Opium and coca leaves, and compounds, manufactures, salts, derivatives or preparations thereof.
Exceptions-1. Certain preparations containing not more than two grains of opium, one-fourth grain of morphin, one-eighth grain of heroin or one grain of codein or any preparations of them in one ounce.
2. Liniments or preparations for external use except those which contain cocain or its preparations.
Providing: 1. That such preparations are manufactured and distributed for medicines and not for the purpose of evading the act;
2. That a record be kept by all parties handling these drugs of purchases and sales and that they shall register and pay a tax.
3. Decocainized coca leaves and other preparations which do not contain cocain are excepted.
PERSONS AFFECTED-1. Every registered person who handles in any way any of these drugs.
2. Any person not registered under the provisions of
this act who has these drugs in his possession.
Exceptions—I. Employees of registered persons acting within the scope of their employment.
2. Nurses under the supervision of a physician, dentist or veterinary surgeon.
3: Possession of these drugs upon a prescription given in good faith.
4. United States, state, county, municipal, district, territorial or insular officer or official having possession of these drugs by reason of his official duties.
5. Warehousemen holding these drugs for a registered person.
6. Common carriers engaged in transporting such drugs.
DUTIES OF PERSONS AFFECTED—Group 1.—That they be registered, pay a tax and
keep such records as may be required. Group 2.—Possession unlawful.
TAXES--    The law provides for both special and stamp taxes,
graded according to the class of individuals concerned.
PURCHASE, SALE, ETC., OF DRUGS—    The law also provides ways in which these drugs
may be purchased and held in possession by registered persons. It makes exceptions as follows for unregistered persons:
1. Persons possessing these drugs when they have been obtained upon the prescription of a physician from a registered dealer providing the prescription is for a legitimate medical use and providing the container shows certain records.
2. The dispensing or administration of these drugs to a patient by a physician, dentist or veterinary surgeon in the course of his professional practice and for legitimate medical purposes.
Unstamped packages shall be subject to seizure except as herein provided.
The drug may be sold only on written order of such person to whom such article is sold on a form'to be issued in blank for that purpose by the Commissioner of Internal Revenue. Nothing in this paragraph shall apply to
1. Dispensing or distribution to a patient by a physician registered under the act in the course of his professional practice providing he keep a record.
2. Sale by a dealer to a consumer upon a written prescription providing the prescription be recorded.
3. Sale or shipment by a person within the United States to a person in a foreign country.
4. The sale or giving away of these drugs to an officer of the United States, of a state, territory, district, county, municipality or insular possession.
It is unlawful for any person to obtain by means of order forms any of these drugs for use other than that comprised in the conduct of a lawful business or the legitimate practice of a profession. The law provides certain detailed regulations for the transportation of these drugs.
ADMINISTRATION— Commissioner of Prohibition with approval of Secretary of Treasury shall make needful rules and regulations for carrying out the provisions of this act. The inspection of records by agents of the Bureau of Prohibition is provided for as are penalties for violation of the law and the disposition to be made of seized drugs.
In compliance with the provisions of the Act of December 17, 1914, and amendments, regulations have been made by the Commissioner of Internal Revenue and later the Commissioner of Prohibition with the approval of the Secretary of the Treasury for carrying the provisions of the Act into effect. In what follows these regulations as adopted from time to time are digested briefly.
The main object of the law is to provide certain definite, legitimate channels through which the proscribed drugs shall pass from the time of their importation to that of their ultimate consumption and, further, to permit the verification of this object through certain ma-
chinery which shall permit a checking and tracing of the drugs in question.
With these ends in view certain individuals are selected as qualified to handle these drugs and all others are outlawed from such handling. Through registration, taxation, the making and reporting of inventories, the outlining of specific methods applicable to the different groups involved, such as importers, wholesale dealers, retail dealers, practitioners, and institutions in which the participants are held severally and jointly responsible, the machinery for carrying out the purpose of the law is developed. The details of these regulations, while essential to the enforcement of the law, have no direct bearing upon the problem under consideration and, therefore, will not be presented here. Those regulations having to do directly with the practice of medicine and hence involved intimately with the development and control of the problem follow in greater detail.
One of the latter regulations is contained in Treasury Decision 2809, dated Mar. 20, 1919, and M-Mim. 2212, dated July 31, 1919, reported in Regulation 35 as follows:
"An order purporting to be a prescription issued to an addict or habitual user of narcotics, not in the course of professional treatment in an attempted cure of the habit, but for the purpose of providing the user with narcotics sufficient to keep him comfortable by maintaining his customary use is not a prescription within the meaning and intent of the act; and the persons filling and receiving drugs under such an order, as well as the person issuing it, will be regarded as guilty of violation of the law. (See T. D. 2809, dated Mar. 20, 1919.)
"Exceptions.—Exceptions to this rule may be properly recognized (1) in the treatment of incurable disease, such as cancer, advanced tuberculosis, and other diseases well recognized as coming within this class, where the physician directly in charge of a bona fide patient suffering from such disease prescribes for such patient, in the course of his professional practice and strictly for legitimate medical purposes, and in so prescribing, indorses upon the prescription that the drug is dispensed in the treatment of an incurable disease; and (2) where the attending physician prescribes for an aged and infirm addict whose collapse from the withdrawal of the drug would result in death and in which case he indorses upon the prescription that the patient is aged and infirm, giving age, and that the drug is necessary to sustain life. (See M.-Mim. 2212, dated July 31, 1919.)"
The next regulation of interest here, as having to do with the practitioner of medicine, the retail dealer, and the patient or consumer is Pro-Mimeograph No. 217 issued October 19, 1921, outlining the treatment of "narcotic drug addiction" permissable under the Harrison Narcotic Law as follows:
"In accordance with the recent decisions of the courts . . . and the attitude of the medical profession on the subject generally, as indicated below, the provisions of M-Mim. 2212, dated July 31, 1919, are hereby amended and the following provisions as to the proper procedure to be followed in the prescribing and dispensing of narcotic drugs are issued for the guidance of narcotic agents in charge and others concerned.
"It should be borne in mind that these instructions must necessarily be general in their nature, as it is impossible to lay down an inflexible rule which will cover all cases; and that they are subject to modification through further interpretation of the law by the courts:
"1. Use of Narcotics in the Treatment of Disease Without Reference to the Question of Addiction.

"Without reference to the question of addiction, a physician acting in accordance with proper medical practice may prescribe or dispense narcotics for the relief of acute pain or for any acute condition, such as influenza, pneumonia, renal calculi, broken limbs, etc.
"2. Use of Narcotics in the Treatment of Incurable Disease.
"A reputable physician directly in charge of bona fide patients suffering from diseases known to be incurable, such as cancer, advanced tuberculosis, and other diseases well recognized as coming within this class, may in the course of his professional practice, and strictly for legitimate medical purposes, dispense or prescribe narcotic drugs for such diseases, provided the patients are personally attended by the physician, that he regulates the dosage, and prescribes no quantity greater than that ordinarily recognized by members of his profession to be sufficient for the proper treatment of the given case. Physicians will be held accountable if through carelessness or lack of sufficient personal attention the patient secures more narcotic drugs than are necessary for medical treatment, and devotes part of his supply to satisfy addiction. The physician should clearly set forth on each prescription the date issued, and the full name and address of the patient, and describe in indisputable terms the exact nature of the ailment for which issued. It would not be lawful under any circumstances to place in the hands of an addict, through prescription or otherwise, a sufficient quantity of narcotic drugs to last a week. In incurable and aged and infirm cases, geographically isolated, where it would otherwise work extreme hardship, and where there is no danger of maladministration or diversion to illegitimate use, the physician in charge may, at his own risk, upon obtaining permission from the narcotic agent in charge of the district, prescribe or dispense a week's supply or more, safeguarding the same by placing it for administration in the custody of a responsible nurse or attendant. Accurate records must be kept of such prescribing and administration.
"3. Use of Narcotics in the Treatment of Addiction Only.
"Mere addiction alone is not recognized as an incurable disease. It seems necessary, however, to divide the addicts not suffering from an incurable disease into two classes: (a) Those suffering from senility, or the infirmities attendant upon old age, who are confirmed addicts of years standing, and who, in the opinion of a reputable physician in charge, require a minimum amount of narcotics in order to sustain life ; and (b) those whose addiction is not complicated either by incurable disease or by the infirmities attendant upon old age.
"(a) Aged and infirm addicts.—Addicts suffering from senility, or the infirmities attendant upon old age, and who are confirmed addicts of years standing, for all intents and purposes, may be treated in the same manner as addicts suffering from incurable disease. In such cases, where narcotic drugs are necessary in order to sustain life, a reputable physician may prescribe or dispense the minimum amount necessary to meet the absolute needs of the patient. As in the treatment of those addicts suffering from incurable diseases, physicians will be held accountable if through carelessness or lack of sufficient personal attention the patient, by securing more narcotic drugs than necessary for his medicinal treatment, is able to devote part of his supply merely to satisfy addiction. In this class of cases the physician issuing the prescription should make a statement on the prescription to the effect that the patient is aged and infirm, giving age, and certifying that the drug is necessary to sustain life.
"(b) The ordinary addict—It is well established that the ordinary case of addiction yields to proper treatment, and that addicts will remain permanently cured when drug taking is stopped and they are otherwise physically restored to health and strengthened in will power. This bureau has never sanctioned or approved the so-called reductive ambulatory treatment of addiction, however, for the reason that where the addict controls the dosage he will not be benefited or cured. Medical authorities agree that the treatment of addiction, with a view to effecting a cure, which makes no provisions for confinement while the drug is being withdrawn, is a failure, except in a relatively small number of cases where the addict is possessed of a much greater degree of will power than that of the ordinary addict. The good faith of the physician and the bona fides of his treatment in a given case will be established by the facts and circumstances of the case and the consensus of medical opinion with regard thereto, based on the experience of the medical profession in cases of similar nature. The following resolution passed by the Council on Health and Public Education of the American Medical Association at its meeting on November 11, 1920, is pertinent in determining the period over which narcotic treatment should be extended in purely addiction cases:
" 'Be it resolved, That the Council on Health and Public Education of the American Medical Association indorse the principle expressed in the California law which forbids the use of opium and its derivatives in the withdrawal treatment of those addicted to the use of these drugs for a period of more than thirty days after the commencement of the withdrawal treatment.'
"This bureau can not under any circumstances sanction the treatment of mere addiction where the drugs are placed in the addict's possession, nor can it sanction the use of narcotics to cover a period in excess of 30 days, when personally administered by the physician to a patient either in a proper institution or unconfined. If a physician, pursuant to the so-called reductive ambulatory treatment, places narcotic drugs in the possession of the addict who is not confined, such action will be regarded as showing lack of good faith in the treatment of the addiction, and that the drugs were furnished to satisfy the cravings of the addict.
"Doubtful cases, or those not falling within any of the above instructions, upon request, will be investigated and special instructions based upon the recommendations of the inspecting officers will be issued."
"Note.—Synopsis of court decisions referred to in paragraph 1.
"Prescribing for 'Dope Fiends.'
"The United States Supreme Court has determined that a physician who sells, dispenses, or distributes narcotic drugs, not in the course of his regular professional practice, and not for the treatment of any disease, but to a person popularly known as a 'dope fiend,' for the purpose of gratifying his appetite for the drug as an habitual user thereof, violates the provisions of the Harrison Narcotic Law, and thereby becomes subject to punishment as provided therein. It was also determined that an order issued by a practicing and registered physician for morphine to an habitual user thereof, the order not being issued by him in the course of professional treatment, in the attempted cure of the habit, but being issued for the purpose of providing the user with morphine sufficient to keep him comfortable by maintaining his customary use, is not a physician's prescription within exception (b) of section 2 of the said act. (U. S. v. C. T. Doremus; W. S. Webb and Jacob Goldman v. U. S. T. D. 2809.)
"Guilty Knowledge of Druggists.
"The Circuit Court of Appeals for the Fifth Circuit has determined that the undisputed facts (1) that the physician issued prescriptions only for narcotics; (2) that many of the alleged patients were described in his prescriptions as addicts and had the physical appearance of such; and (3) that the prescriptions were issued to the same person repeatedly and over long periods of time and without diminution in the quantity prescribed, indicating that no cure by reduction was intended by the physician, warranted the conclusion that the druggists must have known when they filled such prescriptions that they had been issued merely to satisfy addiction. In the same case it was further held that an instruction erroneously authorizing a conviction on a trial for abetting a violation of the Harrison Narcotic Law by a druggist, though the druggist had no actual knowledge that a prescription was wrongfully issued, was not ground for reversal, where reasonable men could have drawn but one inference, that the druggist had such actual knowledge. (C. T. Doremus v. U. S., T. D. 3085.)
"Intervening Agency Does Not Affect Guilt.
"The United States District Court, Southern District of New York, recently determined that where for consideration the defendant issued an order or `prescription' for opium not in the course of his regular professional practice, but to an 'addict' for a prohibited use which was as intended presented to and filled by a dealer, who had no reason to believe it had been wrongfully issued, the defendant committed an indictable offense, although the offense was consummated through an innocent agency, that the injunction of the statute had been violated by the defendant's willful procurement and participation and the quality of his act is not affected by the fact that another agency innocently cooperated. (U. S. v. Emil H. Keidanz, unreported to date.)
"When Prescribing and Selling are Synonymous.
"The Supreme Court of the United States has determined that an indictment was sufficient which charged that defendant, a practicing physician, did feloniously, etc., sell, exchange, barter and give away a specified quantity of morphine sulphate to a person named, not pursuant to an order form issued by the Commissioner of Internal Revenue, by issuing and dispensing a prescription to such person, not a patient of the physician, which morphine was dispensed and distributed by the physician not in the course of his professional practice only; that 'selling' in the criminal sense is not confined to the parting with one's property; and that under section 332 of the Criminal Code, and section 2 of the Harrison Act, one may take a principal part in the prohibited sale of an opium preparation by unlawfully issuing a prescription to a would-be purchaser; hence there is no necessary repugnance between prescribing and selling. (Jin Fuey Moy v. U. S., T. D. 3127.)
"Moral Purpose of Law.
"The Circuit Court of Appeals, Eighth Circuit, in explaining the object of this law, stated that although enacted under the taxing power of Congress, it no doubt was intended to prevent the growing use of narcotics, deemed by Congress a menace to the Nation, and that the act has a moral end, as well as revenue in view. This decision further held that a physician who dispenses narcotics not in good faith for the purpose of securing a cure of one suffering from an illness, or to cure him from the narcotic habit, violates the law, and affirmed the conviction of a physician who was charged with furnishing narcotics to an addict in decreasing quantities, claimed to be in an attempt to cure addiction, where it was shown that such physician did not personally attend the addict or give him personal attention sufficient to show that he was practicing in good faith. (Bascom C. Thompson v. U. S., T. D. 2887.)
"Selling Exempt Preparations to Addicts.
"The Circuit Court of Appeals, Fourth Circuit, has determined that the sale of a so-called exempt preparation under section 6 of the Harrison Narcotic Act, as amended, to wit, paregoric, not as a medicine, but for purpose of evading the intentions and provisions of the aet by supplying addicts with said preparation to satisfy addiction, is unlawful, and that an indictment substantially in the language of section 6 was not only sufficient, but was unnecessarily specific in negativing the exceptions of sale for medicinal purposes by alleging the sale was not as medicine, but for purpose of evading the act. It was also determined that in a prosecution for the sale without a license of a preparation containing opium contrary to the Harrison Narcotic Act, section 6, evidence that sales were knowingly made to drug addicts was sufficient to go to the jury on the question of intent by defendant to evade the provisions of the act and that a charge that the purposes of the act were, first, to obtain a license tax, and incidentally to prevent sales being made to addicts, was not error. (Oliver v. U. S., 267 Fed. Rep. 544.)
"Prescriptions for Regular Patients.
"The United States Circuit Court of Appeals, Fourth Circuit, determined that when a physician is charged with unlawfully selling or prescribing drugs under the Harrison Act, the case turns largely upon his good faith in prescribing drugs to his regular patients, for maladies requiring the administration of the drug, or whether he prescribed for persons seeking his professional aid merely to procure the drug. It further stated that in the latter case the physician might perhaps in a single instance afford temporary relief for one whose condition demanded immediate treatment, but to go further than this would enable every doctor to do just what the defendant in that case did, furnish drugs to addicts, or afford opportunity to them to procure all the narcotics they desired, as unrestrained they would go from one physician to another and thus quickly destroy the whole purpose of the act in question. (Louis D. Barbot v. U. S., No. 1839, U. S. C. C. A., 4th Circuit, unreported to date.)"
On January 12, 1923 a regulation was passed and approved amending the original article 117 of the regulations as to the wording of the "Exceptions" paragraph. It permits physicians to use on their prescriptions for narcotics given to patients suffering from incurable disease the phrase "Exception (1) Art. 117" instead of the phrase "incurable disease" or the name of the disease and in cases of aged and infirm patients the phrase "Exception (2) Art. 117" instead of "Aged and infirm" with the age and the statement that the drug is necessary to maintain life.
The next regulation is Pro. Mini. Pro. No. 316, dated May 21, 1923, as follows:
"Pro-Mimeograph Pro. No. 217, dated October 19, 1921, is hereby revoked, and the following outline of procedure to be followed in prescribing and dispensing narcotics is issued for the guidance of narcotic agents in charge, and others concerned. This pamphlet is intended to be advisory only and to anticipate and answer questions arising in the minds of practitioners in regard to the law and regulations governing the prescribing and dispensing of narcotic drugs as interpreted by the courts.
"The regulations governing this subject are contained in article 117, Regula• tions 35, as amended by Treasury Decision 3426, and read as follows:
" 'Purpose of issue—A prescription, in order to be effective in legalizing the possession of unstamped narcotic drugs and eliminating the necessity for use in order forms, must be issued for legitimate medical purposes. An order purporting to be a prescription issued to an addict or habitual user of narcotics, not in the course of professional treatment in an attempted cure of the habit, but for the purpose of providing the user with narcotics sufficient to keep him comfortable by maintaining his customary use is not a prescription within the meaning and intent of the act; and the persons filling and receiving drugs under such an order, as well as the person issuing it, will be regarded as guilty of violation of the law. (See T. D. 2809, dated Mar. 20, 1919.)
" 'Exceptions—Exceptions to this rule may be properly recognized (1) in the treatment of incurable disease, such as cancer, advanced tuberculosis, and other diseases well recognized as coming within this class, where the physician directly in charge of a bona fide patient suffering from such disease prescribes for such patient, in the course of his professional practice and strictly for legitimate medical purposes, and in so prescribing, indorses upon the prescription that the drug is dispensed in the treatment of an incurable disease (or if he prefers he may indorse upon the prescription "Exception (1) article 117") ; and (2) where the attending physician prescribes for an aged and infirm addict whose collapse from the withdrawal of the drug would result in death and in which case he indorses upon the prescription that the patient is aged and infirm, giving age, and that the drug is necessary to sustain life (or if he prefers he may indorse upon the prescription "Exception (2), article 117").
"General.
"It is impossible to state an inflexible rule which will cover all cases, and this outline must, therefore, be general in nature and subject to modification through further interpretation of the law by the courts. The bureau is not charged with the duty of laying down any fixed rule as to the furnishing of drugs or the frequency of the prescriptions in any particular case.' This responsibility rests upon the physician in charge of the case." While the primary responsibility rests upon the physician in charge, a corresponding liability also rests upon the druggist who knowingly fills an improper prescription or order whereby an addict is supplied with narcotics merely for the purpose of satisfying his addiction.1° Caution should be exercised to avoid being imposed upon by unscrupulous persons, and too much credence should not be given to the unsupported statements of the addict himself, because the confirmed addict will go far beyond the truth in an attempt to secure an ample supply of narcotic drugs with which to satisfy his cravings.
"The good faith of the physician and the bona fides of his treatment in a given case will be established by the facts and circumstances of the case and the consensus of medical opinion with regard thereto, based on the experience of the medical profession in cases of similar nature." Physicians will be charged with violation of the law if through carelessness or lack of sufficient personal attention the patient secures more narcotic drugs than are necessary for medical treatment and devotes part of his supply to satisfy addiction."

"Use of Narcotics in the Treatment of Disease Without Reference to the Question of Addiction.
"Without reference to the question of addiction, a physician acting in accordance with proper medical practice may prescribe or dispense narcotics for the relief of acute pain or for any acute condition, such as influenza, pneumonia, renal calculi, broken limbs, etc.

"Use of Narcotics in the Treatment of Incurable Disease.
"A reputable physician directly in charge of bona fide patients suffering from diseases known to be incurable, such as cancer, advanced tuberculosis, and other diseases well recognized as coming within this class, may in the course of his professional practice, and strictly for legitimate medical purposes, dispense or prescribe narcotic drugs for such diseases, provided the patients are personally attended by the physician who regulates the dosage, and prescribes no quantity greater than that ordinarily recognized by members of his profession to be sufficient for the proper treatment of the given case." The danger of supplying persons suffering from incurable diseases with a supply of narcotics must be borne in mind, because such persons may use the narcotics wrongfully, either by taking excessive quantities or by disposing of a portion of the drugs in their possession to other addicts or persons not lawfully entitled thereto." The physician should indorse upon the prescription that the drug is dispensed in the treatment of an incurable disease, or if he prefers he may indorse upon the prescription 'Exception 1, article 117.'

"Use of Narcotics in the Treatment of Addiction Only

"Mere addiction alone is not recognized as an incurable disease. It seems necessary, however, to divide the addicts not suffering from an incurable disease into two classes: (a) Those suffering from senility or the infirmities attendant upon old age, who are confirmed addicts of years standing, and who, in the opinion of a reputable physician in charge, require a minimum amount of narcotics in order to sustain life ; and (b) those whose addiction is not complicated by incurable disease or by the infirmities attendant upon old age.
"(a) Aged and infirm addict.—Addicts suffering from senility or the infirmities attendant upon old age and who are confirmed addicts of years standing may be, for the purpose of enforcing the law, treated as addicts suffering from incurable diseases. In such cases, where narcotic drugs are necessary in order to sustain life, a reputable physician may prescribe or dispense the minimum amount necessary to meet the absolute needs of the patient. In this class of cases the physician issuing the prescription should make a statement on the prescription to the effect that the patient is aged and infirm, giving age, and certifying that the drug is necessary to sustain life, or, if he prefers, he may indorse upon the prescription 'Exception 2, article 117.'
"(b) The ordinary addict.—It is well established that the ordinary case of addiction yields to proper treatment, and that addicts will remain permanently cured when drug taking is stopped and they are otherwise physically restored to health and strengthened in will power. This bureau has never sanctioned or approved the so-called reductive ambulatory treatment of addiction, however, for the reason that where the addict controls the dosage he will not be benefited or cured, Medical authorities agree that the treatment of addiction, with a view to effecting a cure, which makes no provision for confinement while the drug is being withdrawn, is a failure, except in a relatively small number of cases where the addict is possessed of a much greater degree of will power than that of the ordinary addict,
"Special advice to cover cases not falling within these instructions will, upon request, be furnished by this office."
An Act of Congress, approved March 3, 1927,15a created a Bureau of Prohibition and a Commissioner of Prohibition, and transferred from the Commissioner of Internal Revenue to the Prohibition Commissioner the enforcement of the Harrison Narcotic Act as amended. Under this new arrangement the Bureau of Prohibition of the Treasury Department issued, effective January 1, 1928, "Regulations No. 5 Relating to the Importation, Manufacture, Production, Compounding, Sale, Dispensing and Giving away of Opium or Coca Leaves, their Salts, Derivatives or Preparations thereof under the Act of December 17, 1914, as amended."
These regulations included the substance of previous regulations herein considered, except those which have been revoked as already noted. In addition, new regulations included under Article 105 of Regulations No. 5 were adopted as follows:
"Prescriptions unnecessary.—Preparations or remedies which are within the exemption may be sold with or without prescriptions, and a prescription for such a preparation may be refilled, provided, of course, the preparation is furnished in good faith for medicinal purposes only. The filling or refilling of narcotic prescriptions calling for more than one exempt preparation or a mixture consisting of an exempt preparation or remedy further reduced or diluted by the addition of non-narcotic medicinal agents is authorized, provided, of course, the preparation is furnished in good faith for medicinal purposes.
"Extemporaneous prescriptions.—An extemporaneous prescription calling for narcotic drugs not in excess of the amounts specified in section 6 may be refilled in the same manner as a prescription calling for ready-made preparations or remedies, provided the mixture is sold in good faith for medicinal purposes only, and a record is kept of the sale in the manner indicated in article 107."
Under Article 108 of Regulations No. 5 the following is given:
"Compromise.—Section 3229, Revised Statutes, provides in part:
"The Commissioner of Internal Revenue, with the advice and consent of the Secretary of the Treasury, may compromise any civil or criminal case arising under the internal revenue laws instead of commencing suit thereon; and, with the advice and consent of the said Secretary and the recommendation of the Attorney General, he may compromise any such case after a suit thereon has been commenced.
"Under the provisions of section 3229, R. S. the act of March 3. 1927, and Prohibition Treasury Decision No. 1, dated April 1, 1927, as amended, the Commissioner of Prohibition, with the advice and consent of the Secretary of the Treasury has authority to compromise any civil or criminal cases arising under this act instead of commencing suit thereon ; and, with the advice and consent of the said Secretary and the recommendation of the Attorney General, he may compromise any such case after suit thereon has been commenced. Forms 656, which must accompany any offer submitted, may be obtained upon request from the narcotic agent in charge or the collector and must be forwarded with the amount tendered to the collector. Offers in compromise in order to receive consideration must be voluntarily made. It is not the policy to compromise violations of this act where willful intent is shown."
The next natural step would be a recital of the results of the legislation passed and designed to exert a favorable influence in retarding the growth of the problem. While at first sight this may appear a simple procedure, as a matter of fact, a proper evaluation of the Harrison Narcotic Law as interpreted and administered would require a very exhaustive sociologic and scientific study such as heretofore has never been made and which the Committee on Drug Addictions has not been in a position to make. The difficulties attending the sociological aspects of such a study are apparent when it is noted, as has been pointed out in a preceding chapter, that there is no accurate knowledge for purposes of comparison as to the extent of chronic opium intoxication in the United States at any given period. Further the very nature of the illicit traffic is such as to handicap to a considerable degree any investigations, inasmuch as it has removed from legitimate channels of distribution very considerable amounts of the proscribed drugs. Furthermore, due to the interpretation placed on "legitimate medical purposes" by certain regulations, it is apparent that an accurate determination of the nature of the condition, about which there is at the present time considerable difference of opinion, must precede any attempt at evaluation of the operation of the law and its regulations. It will be seen readily, for example, that if the act itself, the regulations, and the administrative policies are based upon the assumption that chronic opium intoxication once thoroughly established constitutes a pathologic entity which is beyond the individual's power to control, they cannot result in solving the problem if this assumption is wrong and if, on the other hand, the nature of the condition proves to be little more than the expression of a vicious habit or desire. Likewise the converse is true. For if the problem really consists of a very complex mingling of etiologic influences and physiologic and psychical reactions, it will be seen that no policy of administration which does not take these factors into consideration, which is in itself inelastic and which does not give to the administrator the utmost latitude for dealing with individual cases and does not provide for the appointment of experienced and intelligent enforcement officers can possibly operate effectively.
However, it may be of interest to the reader if we point out the features of the law as enforced to which objections of one kind or another have been raised. The following are the principal ones concerning which discussions and difference of opinion have arisen.
Section 2, paragraph "a" of the act permits a physician to dispense or distribute the proscribed drugs to a patient "in the course of his professional practice only," providing record is kept, except when the physician personally attends the patient. Further section 8 permits the possession of the drug if prescribed "in good faith" by a registered physician, dentist, or veterinary surgeon. As the act does not define "professional practice" and "in good faith," many critics claim that the interpretation of these phrases in the regulations promulgated by the Bureau of Internal Revenue have been unwarranted and that the indictment and prosecution of reputable physicians for exercising their judgment in this connection have been unjust.
In other words, the attitude of many physicians is that the law prevents members of the medical •profession and pharmacists from legally supplying these cases with the drug which they are accustomed to using and for the use of which they are not responsible, in that this use was acquired and developed through medical treatment, and yet no provision is made for their care. It is pointed out that there is a very general lack of provision by states and municipalities for the medical treatment of these cases; that general hospitals as a rule will not accept them; that special hospitals have not been provided, and that in many instances individuals of small means have no choice of treatment except in hospitals for the insane and those connected with prisons to both of which not unnaturally they hesitate to have themselves committed. It is also claimed that even in cases where abundant means are available the patient already has learned from past experiences that treatment in a great many private and public institutions is incompetent and by no means free from risk to health and even life, and that the results obtained are such as to discourage repetition.
This has resulted, it is claimed, in strongly deterring physicians from handling these cases with the result that large numbers of honest and reputable men and women have been forced to seek relief through the only means available to them, namely, the illicit traffic.
It must be borne in mind that members of the medical profession who hold this attitude claim that "professional practice" and "legitimate medical purposes" both are subserved fully by the supplying of opium preparations to selected individuals accustomed to their use for many reasons that should be left to the judgment of the individual practitioner and not made the subject of an arbitrary ruling.
An instance of disagreement between this group of critics and the Bureau of Internal Revenue as to what constitutes "professional practice" and "in good faith" is brought out by a consideration of article 117 of Regulations 35, 1919.
There is a group of physicians who do not agree that all cases of chronic opium intoxication except those with an incurable, intercurrent malady such as cancer, tuberculosis, etc., and aged and infirm users can be treated successfully. They claim that there are certain cases who, although not suffering from such a malady, nevertheless suffer intermittently or periodically from certain painful conditions which of themselves would necessitate a return to the use of the drug at more or less frequent intervals and certain other cases who have reached such a state of dependence on an opium preparation as to preclude—perhaps because of constitutional factors, perhaps because of our incomplete knowledge—the possibility of successful treatment except at the risk of chronic invalidism. Even the plainly curable cases, according to this group, have certain rights and should be entitled to a legal supply of their drug for varying periods of time until their physical condition, domestic, economic, or other affairs may render it convenient for them to undergo treatment directed at permanent cure. To force such cases to take treatment is, they state, bad medical practice and as long as the use of the drug is carried on without interference with the rights or privileges of others, it should be considered a matter of individual liberty, with the physician as the sole judge as to the desirability of undertaking curative treatment.

It has been pointed out also that to attempt any differentiation through the age of the patient and the length of the period during which he has been using the drug is neither scientific nor warranted by known facts.
This regulation was amended on October 19, 1921 in Pro. Mimeograph Pro. No. 217, which further outlined the "treatment of narcotic drug addiction permissible under the Harrison Narcotic Law." In addition to criticism of the features similar to those contained in the previous regulation, objection to the treatment permitted under this regulation has been raised by some physicians. They claim that, if a physician is sufficiently skillful and the patient is possessed of average honesty and perseverance, the so-called "ambulatory treatment" may be successful at least for the major part of the treatment. It has been claimed also that one of the longest known and well recognized forms of treatment, namely, that involving gradual reduction, may not be concluded successfully within the space of thirty days as required by the regulation. Indeed, according to some of its chief advocates, in gradual reduction it is sometimes necessary temporarily to cease the reduction and even to increase the amount of the drug given, of which individual needs the regulation takes no cognizance.
Criticism has been made also of that portion of this regulation which reads: " . . . provided the patients are personally attended by the physician, that he regulates the dosage, and prescribes no quantity greater than that ordinarily recognized by members of his profession to be sufficient for the proper treatment of the given case. Physicians will be held accountable if through carelessness or lack of sufficient personal attention the patient secures more narcotic drugs than are necessary for the medical treatment, and devotes part of his supply to satisfy his addiction." This, according to certain physicians, is an incongruous and impossible situation. They claim that as the continued administration of opium preparations causes the development of so-called addiction, once this condition is established it may be eliminated only by curative treatment which alone would permit the complete cessation of the administration of the drug. The fact that an individual patient is suffering from an incurable malady such as cancer in no way militates against the development of this addiction and to require the physician to give only as much of the drug as is necessary to relieve the cancer or other pain and not enough to relieve what they claim is a need arising from the addiction alone is impossible. In other words, the development of tolerance to increasing doses of the drug used for the relief of the painful cancer condition also results in a dependence on the drug. This regulation apparently overlooks this fact and also the fact that as tolerance for the drug develops its analgesic effect is correspondingly lost, and if enough of the drug is given to relieve the pain incident to the intercurrent malady the dependence or addiction is of necessity automatically "satisfied," i.e., the patient is comfortable. In other words when, as a result of continued administration in increasing doses, tolerance and dependence —addiction—have developed it is no longer possible to relieve the pain from the intercurrent malady alone.
Under these circumstances, according to certain physicians, the risks involved are so great as a result of the interpretation of this regulation that practitioners of medicine hesitate to administer opium preparations even to individuals suffering from conditions which the regulation apparently exempts, with the result that these cases as well as those who do not suffer from an intercurrent malady requiring the use of opium become dependent upon the illicit traffickers. In other words, a physician treating cases of this nature is not safe from unwarranted indictment and may be called upon at any time in court to prove his innocence to the detriment of his social, professional, and economic standing and to bring equally disastrous notoriety to his patient, all for the reason that the local inspector charged with the enforcement of the law is apparently not conversant with its requirements, with the rights of the physician, or with the needs of the case.
In the paragraph above partially quoted it is also stated that the patients must be "personally attended by the physician." In Regulations 35, Art. 126, issued by the Bureau of Internal Revenue the phrase "in personal attendance" has been interpreted as meaning that the physician shall be in attendance upon the patient away from his office, i.e., presumably in the patient's home or in a hospital or other institution. It is well known that cases of cancer, tuberculosis, and other diseases requiring the continued use of opium for the relief of pain or other symptoms still may be able to visit the physician's office or even to pursue an occupation or profession over long periods of time. To require that these patients be visited away from their physicians' offices would entail upon them an additional expense, residence in an institution, or at least serious personal inconvenience which, it is claimed, in no way assists in the proper administration of the law.

It should be noted that the regulation above referred to was revoked and superseded by the regulation dated May 21, 1923, entitled Pro-Mimeograph Pro-Number 316. The intent of this regulation appears to be more liberal than that of the preceding one in that it omits the statement to the effect that in the use of narcotics in the treatment of incurable diseases and in the treatment of aged and infirm cases "physicians will be held accountable if through carelessness or lack of sufficient personal attention the patient secures more narcotic drugs than are necessary for medical treatment, and devotes part of his supply to satisfy addiction," and reference to the period of time in which treatment of addiction alone must be completed. In view of the omission of these objectionable features from the latest regulation, several of the criticisms above noted become invalid as far -as the present administration of the law is concerned. However, during the period in which the earlier regulations operated, if the above-named criticisms were justified, they deterred unwarrantably members of the medical profession from the handling of the cases involved. As a result the patients were driven to the illicit trafficker for their supplies and to this extent the regulations themselves contributed to the ever-increasing complexity of the problem. Also there still remain the original objections which have been advanced by certain physicians as outlined above.
In general it is the contention of these critics that no patients are so hedged about with arbitrary restrictions as are those suffering from chronic opium intoxication and that in relation to no other condition are the judgment of the physician and his methods of procedure, the result of his medical training and education, brought so unwarrantably into discussion and controversy with the risk of indictment for illegal practice.
However, others claim that the regulations are sound and well-conceived and work no undue hardship; that the continuation of the use of opium preparations by those accustomed thereto is without necessity; and that physicians who supply such cases are no better than the drug peddlers. They further claim that the so-called "ambulatory treatment" must in all cases be a failure; that the methods of treatment available are good; that thirty days is a sufficient length of time for the successful treatment of all curable cases; that the public institutional provisions already in existence are sufficient and that if discharged patients return to the use of their drug it is the fault of the patient and not the fault of the treatment.
With presumably honest, highly intelligent and well-equipped practitioners holding these different points of view, it seems fair to assume that more than a mere matter of opinion is involved and that the sharp division of opinion must be the result of misunderstanding or incomplete knowledge as to the fundamental nature of the condition known as narcotic addiction. It would appear, therefore, that medical and sociologic studies as above indicated are needed before any complete evaluation of the law and its enforcement may be made.
As a meta of the enforcement of the law and its regulations a number of cases of alleged violation have been brought to trial. The court decisions rendered in relation to these cases have been used by the Bureau of Internal Revenue as the basis for a revision of the earlier regulations and the promulgation of new ones. For a study of the relation of these decisions to the regulations involved, the reader is referred to the synopsis of the decisions included with the text of the regulations given in the preceding pages.
A more recent court decision not included in those just mentioned is comprised in the following: le
"Mr. Justice McReynolds delivered the opinion of the Court.
"The court below affirmed the conviction of petitioner by the District Court, Eastern District of Washington, under the following count of an indictment returned therein June 26, 1922. As to all other counts the jury found him not guilty.
" `Count II. And the Grand Jurors aforesaid upon their oaths do further present: That Charles 0. Linder, whose other or true name is to the Grand Jurors unknown, hereinafter in this indictment called the defendant, late of the County of Spokane, State of Washington, heretofore, to-wit; on or about the first day of April, 1922, at Spokane, in the Northern Division of the Eastern District of Washington, and within the jurisdiction of this Court, did then and there violate the Act of December 17, 1914, entitled "An Act to provide for the registration of, with Collectors of Internal Revenue, and to impose a special tax upon all persons who produce, import, manufacture, compound, deal in, dispense, sell, distribute, or give away opium or coca leaves, their salts, derivatives, or preparations, and for other purposes," as amended February 24, 1919, in that he did then and there knowingly, wilfully and unlawfully sell, barter and give to Ida Casey a compound, manufacture and derivative of opium, to-wit: one (1) tablet of morphine and a compound, manufacture and derivative of coca leaves, to-wit: three (3) tablets of cocaine, not in pursuance of any written order of Ida Casey on a form issued for that purpose by the Commissioner of Internal Revenue of the United States; that the defendant was a duly licensed physician and registered under the Act; that Ida Casey was a person addicted to the habitual use of morphine and cocaine and known by the defendant to be so addicted; that Ida Casey did not require the administration of either morphine or cocaine by reason of any disease other than such addiction; that the defendant did not dispense any of the drugs for the purpose of treating any disease or condition other than such addiction; that none of the drugs so dispensed by the defendant was administered to or intended by the defendant to be administered to Ida Casey by the defendant or any nurse, or person acting under the direction of the defendant ; nor were any of the drugs consumed or intended to be consumed by Ida Casey in the presence of the defendant, but that all of the drugs were put in the possession or control of Ida Casey with the intention on the part of the defendant that Ida Casey would use the same by self-administration in divided doses over a period of time the amount of each of said drugs dispensed being more than sufficient or necessary to satisfy the cravings of Ida Casey therefor if consumed by her all at one time; that Ida Casey was not in any way restrained or prevented from disposing of the drugs in any manner she saw fit and that the drugs so dispensed by the defendant were in the form in which said drugs are usually consumed by persons addicted to the habitual use thereof to satisfy their craving therefor and were adapted for consumption. Contrary to the form of the statute in such case made and provided and against the peace and dignity of the United States.'
"The Harrison Narcotic Law, approved Dec. 17, 1914, c. 1, 38 Stat. 785— twelve sections—is entitled: 'An Act to provide for the registration of, with collectors of internal revenue, and to impose a special tax upon all persons who produce, import, manufacture, compound, deal in, dispense, sell, distribute, or give away opium or coca leaves, their salts, derivatives, or preparations, and for other purposes.'
"Sec. 1 provides—That on and after the first day of March, nineteen hundred and fifteen, every person [with exceptions not here important] who produces, imports, manufactures, compounds, deals in, dispenses, sells, distributes, or gives away opium or coca leaves or any compound, manufacture, salt, derivative, or preparation thereof, shall register with the Collector of Internal Revenue,' and shall pay a special annual tax of one dollar. Also, 'It shall be unlawful for any person required to register under the terms of this Act to produce, import, manufacture, compound, deal in, dispense, sell, distribute, or give away any of the aforesaid drugs without having registered and paid the special tax provided for in this section. . . . The Commissioner of Internal Revenue, with the approval of the Secretary of the Treasury, shall make all needful rules and regulations for carrying the provisions of this Act into effect.'

"Sec. 2 provides—That it shall be unlawful for any person to sell, barter, exchange, or give away any of the aforesaid drugs except in pursuance of a written order of the person to whom such article is sold, bartered, exchanged, or given, on a form to be issued in blank for that purpose by the Commissioner of Internal Revenue.' [The giver is required to retain a duplicate and the acceptor to keep the original order for two years, subject to inspection.] 'Nothing contained in this section shall apply—
"'(a) To the dispensing or distribution of any of the aforesaid drugs to a patient by a physician, dentist, or veterinary surgeon registered under this Act in the course of his professional practice only: Provided, That such physician, dentist, or veterinary surgeon shall keep a record of all such drugs dispensed or distributed, showing the amount dispensed or distributed, the date, and the name and address of the patient to whom such drugs are dispensed or distributed, except such as may be dispensed or distributed to a patient upon whom such physician, dentist, or veterinary surgeon shall personally attend; and such record shall be kept for a period of two years from the date of dispensing or distributing such drugs, subject to inspection, as provided in this Act.
"(b) . . (c) . . (d)
"The Commissioner of Internal Revenue, with the approval of the Secretary of the Treasury, shall cause suitable forms to be prepared for the purposes above mentioned. . . It shall be unlawful for any person to obtain by means of said order forms any of the aforesaid drugs for any purpose other than the use, sale, or distribution thereof by him in the conduct of a lawful business in said drugs or in the legitimate practice of his profession. . .
"Sec. 8. 'That it shall be unlawful for any person not registered under the provisions of this Act, and who has not paid the special tax provided for by this Act, to have in his possession or under his control any of the aforesaid drugs; and such possession or control shall be presumptive evidence of a violation of this section, and also of a violation of the provisions of Section One of this Act: Provided, That this section shall not apply to any employee of a registered person, or to a nurse under the supervision of a physician, dentist, or veterinary surgeon registered under this Act, having such possession or control by virtue of his employment or occupation and not on his own account; or to tha possession of any of the aforesaid drugs which has or have been prescribed in good faith by a physician, dentist, or veterinary surgeon registered under this Act; or to any United States, State, county, municipal, District, Territorial, or insular officer or official who has possession of any said drugs, by reason of his official duties, or to a warehouseman holding possession for a person registered and who has paid the taxes under this Act;' or to common carriers engaged in transporting such drugs: Provided further, That it shall not be necessary to negative any of the aforesaid exemptions in any complaint, information, indictment, or other writ or proceeding laid or brought under this Act; and the burden of proof of any such exemption shall be upon the defendant.'
"Sec. 9. 'That any person who violates or fails to comply with any of the requirements of this Act shall, on conviction, be fined not more than $2,000 or be imprisoned not more than five years, or both, in the discretion of the court.'
"Section 1 was amended by the Act of February 24, 1919, c. 18, 40 Stat. 1057, 1130. This increased the special annual tax to twenty-four dollars on importers, manufacturers, producers and compounders, twelve dollars on wholesale dealers, six dollars on retail dealers, and three dollars on 'physicians, dentists, veterinary surgeons and other practioners lawfully entitled to distribute, dispense, give away, or administer any of the aforesaid drugs to patients upon whom they in the course of their professional practice are in attendance.' It also added a provision requiring that stamps—one cent for each ounce—should be affixed to every package of opium, coca leaves, any compound, salt, derivative or preparation thereof, produced in or imported into the United States and sold or removed for consumption or sale, and then, the following paragraph-
" 'It shall be unlawful for any person to purchase, sell, dispense, or distribute any of the aforesaid drugs except in the original stamped package or from the original stamped package; and the absence of appropriate tax-paid stamps from any of the aforesaid drugs shall be prima facie evidence of a violation of this section by the person in whose possession same may be found; and the possession of any original stamped package containing any of the aforesaid drugs by any person who has not registered and paid special taxes as required by this section shall be prima facie evidence of liability to such special tax: Provided, That the provisions of this paragraph shall not apply . . . to the dispensing, or administration, or giving away of any of the aforesaid drugs to a patient by a registered physician, dentist, veterinary surgeon, or other practioner in the course of his professional practice, and where said drugs are dispensed or administered to the patient for legitimate medical purposes, and the record kept as required by this Act of the drugs so dispensed, administered, distributed, or given away.'
"Manifestly, the purpose of the indictment was to accuse petitioner of violating Section 2 of the Narcotic Law, and the trial court so declared. Shortly given the alleged facts follow. Petitioner, a duly licensed and registered physician, without any official written order therefor, knowingly, wilfully and unlawfully did sell, barter and give to Ida Casey one tablet of morphine and three tablets of cocaine; he knew she was addicted to habitual use of these drugs and did not require administration of either because of any disease other than such addiction, and he did not dispense them for the treatment of any other disease or condition; they were not administered by him or by any nurse or other person acting under his direction, nor were they consumed or intended for consumption in his presence; the amount was more than sufficient to satisfy the recipient's cravings if wholly consumed at one time; petitioner put the drugs into her possession expecting that she would administer them to herself in divided doses over a period of time; they were in the form in which addicts usually consume them to satisfy their cravings; the recipient was in no way prevented or restrained from disposing of them.
"Petitioner maintains that the facts stated are not sufficient to constitute an offense. The United States submit that, considering United States v. Behrman, 258 U. S. 280, the sufficiency of the indictment is clear.
The trial court charged-
" 'If you are satisfied beyond a reasonable doubt that defendant knew that this woman was addicted to the use of narcotics, and if he dispensed these drugs to her for the purpose of catering to her appetite or satisfying her cravings for the drug, he is guilty under the law. If, on the other hand, you believe from the testimony that the defendant believed, in good faith this woman was suffering from cancer or ulcer of the stomach, and administered the drug for the purpose of relieving her pain, or if you entertain a reasonable doubt upon that question, you must give the defendant the benefit of the doubt and find him not guilty.'
"In effect, the indictment alleges that the accused, a duly registered physician, violated the statute by giving to a known addict four tablets containing morphine and cocaine with the expectation that she would administer them to herself in divided doses, while unrestrained and beyond his presence or control, for the sole purpose of relieving conditions incident to addiction and keeping herself comfortable. It does not question the doctor's good faith nor the wisdom or propriety of his action according to medical standards. It does not allege that he dispensed the drugs otherwise than to a patient in the course of his professional practice or for other than medical purposes. The facts disclosed indicate no conscious design to violate the law, no cause to suspect that the recipient intended to sell or otherwise dispose of the drugs, and no real probability that she would not consume them.
"The declared object of the Narcotic Law is to provide revenue, and this court has held that whatever additional moral end it may have in view must 'be reached only through a revenue measure and within the limits of a revenue measure.' United States v. Jin Fuey Moy, 241 U. S. 394, 402. Congress cannot, under the pretext of executing delegated power, pass laws for the accomplishment of objects not entrusted to the Federal Government. And we accept as established doctrine that any provision of an Act of Congress ostensibly enacted under power granted by the Constitution, not naturally and reasonably adapted to the effective exercise of such power but solely to the achievement of something plainly within power reserved to the States, is invalid and cannot be enforced. McCulloch v. Maryland, 4 Wheat. 316, 423; License Tax Cases, 5 Wall. 462; United States v. DeWitt, 9 Wall. 41; Keller v. United States, 213 U. S. 138; Hammer v. Dagenhart, 247 U. S. 251; Child Labor Tax Case, 259 U. S. 20. In the light of these principles and not forgetting the familiar rule, that 'a statute must be construed, if fairly possible, so as to avoid not only the conclusion that it is unconstitutional but also grave doubts upon that score,' the provisions of this statute must be interpreted and applied.
"Obviously, direct control of medical practice in the States is beyond the power of the Federal Government. Incidental regulation of such practice by Congress through a taxing Act cannot extend to matters plainly inappropriate and unnecessary to reasonable enforcement of a revenue measure. The enactment under consideration levies a tax, upheld by this court, upon every person who imports, manufactures, produces, compounds, sells, deals in, dispenses or gives away opium or coca leaves or derivatives therefrom, and may regulate medical practice in the States only so far as reasonably appropriate for or merely incidental to its enforcement. It says nothing of 'addicts' and does not undertake to prescribe methods for their medical treatment. They are diseased and proper subjects for such treatment, and we cannot possibly conclude that a physician acted improperly or unwisely or for other than medical purposes solely because he has dispensed to one of them, in the ordinary course and in good faith, four small tablets of morphine or cocaine for relief of conditions incident to addiction. What constitutes bona fide medical practice must be determined upon consideration of evidence and attending circumstances. Mere pretense of such practice, of course, cannot legalize forbidden sales, or otherwise nullify valid provisions of the statute, or defeat such regulations as may be fairly appropriate to its enforcement within the proper limitations of a revenue measure.
"United States v. Jin Fuey Moy, supra, points out that the Narcotic Law can be upheld only as a revenue measure. It must be interpreted and applied accordingly. Further, grave constitutional doubts concerning Section 8 cannot be avoided unless limited to persons who are required to register by Section 1. Mere possession of the drug creates no presumption of guilt as against any other person.
"In United States v. Doremus, 249 U. S. 86, 93, 95, a registered physician was accused of unlawfully selling, giving away and distributing five hundred one-sixth grain tablets of heroin without official written order. Another count charged selling, dispensing and distributing five hundred such tablets not in the course of regular professional practice. The trial court held Section 2 invalid because it invaded the police power of the State. This court declared: 'Of course Congress may not in the exercise of Federal power exert authority wholly reserved to the States. . . . If the legislation enacted has some reasonable relation to the exercise of the taxing authority conferred by the Constitution, it cannot be invalidated because of the supposed motives which induced it. . . We cannot agree with the contention that the provisions of Section 2, controlling the disposition of these drugs in the ways described, can have nothing to do with facilitating the collection of the revenue, as we should be obliged to do if we were to declare this Act beyond the power of Congress acting under its constitutional authority to impose excise taxes.' The sharp division of the court in this cause and the opinion in Jin Fuey Moy's Case clearly indicated that the statute must be strictly construed and not extended beyond the proper limits of a revenue measure.
"Webb v. United States, 249 U. S. 96, 99, came here on certified questions. Two were answered upon authority of Doremus' Case. The third inquired whether a regular physician's order for morphine issued to an addict, not in the course of professional treatment with design to cure the habit, but in order to provide enough of the drug to keep him comfortable by maintaining his customary use, is a 'physician's prescription.' The answer was that `to call such an order for the use of morphine a physician's prescription would be so plain a perversion of meaning that no discussion of the subject is required.' The lower court had sought instruction in order that it might decide the particular cause. The question specified no definite quantity of drugs, nor the time intended for their use. The narrated facts show, plainly enough, that physician and druggist conspired to sell large quantities of morphine to addicts under the guise of issuing and filing orders. The so-called prescriptions were issued without consideration of individual cases and for the quantities of the drugs which applicants desired for the continuation of customary use. The answer thus given must not be construed as forbidding every prescription for drugs, irrespective of quantity, when designed temporarily to alleviate an addict's pains, although it may have been issued in good faith and without design to defeat the revenues. This limitation of the reply is confirmed by Behrman's Case, 258 U. S. 280, (infra) decided three years later, which suggests at least that the accused doctor might have lawfully dispensed some doses.
"In fin Fuey Moy v. United States, 254 U. S. 189, 194, doctor and druggist conspired to sell opiates. The prescriptions were not issued in the course of professional practice. The doctor became party to prohibited sales. 'Manifestly the phrases "to a patient" and "in the course of his professional practice only" are intended to confine the immunity of a registered physician, in dispensing the narcotic drugs mentioned in the Act, strictly within the appropriate bounds of a physician's professional practice, and not to extend it to include a sale to a dealer or a distribution intended to cater to the appetite or satisfy the craving of one addicted to the use of the drug. A "prescription" issued for either of the latter purposes protects neither the physician who issues it nor the dealer who knowingly accepts and fills it.'
"The quoted language must be confined to circumstances like those presented by the cause. In reality, the doctor became party to sales of drugs. He received a fixed sum per dram under guise of issuing prescriptions. The quoted words are repeated in Behrman's Case, which recognizes the possible propriety of prescribing small quantities.
"United States v. Balint, 258 U. S. 250, 253, 254, hold—qt is very evident from a reading of it [Sec. 2] that the emphasis of the section is in securing a close supervision of the business of dealing in these dangerous drugs by the taxing officers of the Government and that it merely uses a criminal penalty to secure recorded evidence of the disposition of such drugs as a means of taxing and restraining the traffic.'
"United States v. Behrman, 258 U. S. 280, 287, came up under the Criminal Appeals Act. The indictment charged that Behrman, a registered physician, did unlawfully sell, barter and give to one King, an 'addict,' one hundred and fifty grains of heroin, three hundred and sixty grains of morphine and two hundred and ten grains of cocaine, by issuing three prescriptions. Further, that the drugs were not intended or required for treatment of any disease or condition other than such addiction, but for self-administration over a period of several days. The question was, `Do the acts charged in this indictment constitute an offense within the meaning of the statute?' And replying, this court said-

" 'The District Judge who heard this case was of the opinion that prescriptions in the regular course of practice did not include the indiscriminate doling out of narcotics in such quantity to addicts as charged in the indictment .. . In our opinion the District Judge who heard the case was right in his conclusion and should have overruled the demurrer. Former decisions of this court have held that the purpose of the exception is to confine the distribution of these drugs to the regular and lawful course of professional practice, and that not everything called a prescription is necessarily such. [Webb v. United States and Jin Fuey Moy v. United States, supra, are cited.] ... It may be
admitted that to prescribe a single dose, or even a number of doses, may not bring a physician within the penalties of the Act; but what is here charged is that the defendant physician by means of prescriptions has enabled one, known by him to be an addict, to obtain from a pharmacist the enormous number of doses contained in 150 grains of heroin, 360 grains of morphine, and 210 grains of cocaine'—three thousand ordinary doses!
"This bpinion related to definitely alleged facts and must be so understood. The enormous quantity of drugs ordered, considered in connection with the recipient's character, without explanation, seemed enough to show prohibited sales and to exclude the idea of bona fide professional action in the ordinary course. The opinion cannot be accepted as authority for holding that a physician, who acts bona fide and according to fair medical standards, may never give an addict moderate amounts of drugs for self-administration in order to relieve conditions incident to addiction. Enforcement of the tax demands no such drastic rule, and if the Act had such scope it would certainly encounter grave constitutional difficulties.
"The Narcotic Law is essentially a revenue measure and its provisions must be reasonably applied with the primary view of enforcing the special tax. We find no facts alleged in the indictment sufficient to show that petitioner had done anything falling within definite inhibitions or sufficient materially to imperil orderly collection of revenue from sales. Federal power is delegated, and its prescribed limits must not be transcended even though the end seems desirable. The unfortunate condition of the recipient certainly created no reasonable probability that she would sell or otherwise dispose of the few tablets entrusted to her; and we cannot say that by so dispensing them the doctor necessarily transcended the limits of that professional conduct with which Congress never intended to interfere.
"The judgment below must be reversed. The cause will be remanded to the District Court for further proceedings in harmony with this opinion."
The Harrison Nareotic Law and regulations have been the subject of a considerable amount of medical editorial comment. The bearing of the act upon the practice of medicine and upon the treatment of cases of chronic opium intoxication, its probable effect in decreasing or increasing the unnecessary use of the proscribed drugs, as well as the attitude and activities of administrators all have been discussed freely from practically every possible angle. While these editorial comments are of interest and value in that presumably they furnish a rough cross-section of the medical opinion of the act in question, they are too numerous to be included here. For the benefit of the reader, however, and to assist him in quickly locating this material, we are giving a partial bibliography in Appendix IX.
In 1919 a bill "to provide aid from the United States for the several states in prevention and control of drug addiction and the care and treatment of drug addicts" was introduced in Congress. This bill, however, was not passed.
The next attempt at control through national legislation is embodied in what is known as the "Narcotic Drugs Import and Export Act." After earlier efforts to pass legislation regulating the importation and exportation of narcotics had failed the bill introduced by Mr. J. F. Miller on April 11, 1921, was reported from the Committee on Ways and Means, to which it had been referred, on March 27, 1922, with amendments.17 The report states:
"The defects in the existing law governing the importation and exportation of narcotic drugs and the remedies therefor proposed by the committee may be summarized as follows:
"(1) Restrictions on exports—The United States has, in compliance with article 7 of the International Opium Convention of 1912, prohibited the exportation of smoking opium, but as to other narcotic drugs within the scope of the opium convention, section 6 of the narcotic drugs import and export act .. . merely requires that the exportation be in accordance with the laws of the foreign country importing the narcotic drug. For more than six years after the United States adopted this narrow limitation upon exportation no regulations were issued by the Secretary of State, the Secretary of the Treasury, and the Secretary of Commerce, as authorized by section 6, for carrying even the limitation into effect. The result has been that the exportation of narcotic drugs was permitted to countries which had not ratified the opium convention, and therefore maintained no system of control of narcotic drugs within its borders; and also to countries which had ratified the opium convention, but had failed to make and enforce effective regulation of narcotic drugs. Exportations were not limited to consignee's authorized by the foreign Government to receive the narcotic drugs and the consignees who required the narcotic drugs for actual present medical or scientific uses. (See Treasury Decision, Customs No. 38033.)
"In consequence it was found that large amounts of our exports of narcotic drugs, as, for instance, exports to Japan, had been reexported by the consignee (either by in-transit shipments through the country of destination or transshipment at the port of destination) to Chinese consumers, or had been smuggled back into the United States. This is due to the fact that in-transit shipments and transshipments are not deemed 'imports' subject to Japan's strict import regulations. In the case of the Chinese consumer the narcotic drug usually reached him in violation of the laws of China, aided in many instances by the postal agencies maintained by foreign powers in China. The four powers having these agencies, however, have agreed under resolution No. 5 of the Conference on the Limitation of Armament to withdraw the agencies under certain conditions. The above situation, however, has resulted in facilitating violation of our import laws and evasion of the Harrison Act, for the protection of residents of the United States; and it has also resulted in affecting China's purchasing power to the serious injury of our trade in China, and in tending to place China politically under foreign control. The injury to China's purchasing power is brought about by the consumption of narcotic drugs unlawfully brought to China, such consumption lessening the productive power of the nation and causing wasteful expenditures which compromised the profit of the Japanese and other foreign importers upon the resale of our manufacture of narcotic drugs.
"On May 1, 1920, the Secretary of State, the Secretary of the Treasury, and the Secretary of Commerce put into effect regulations (see Treasury Decisions, Customs No. 88381) which have greatly minimized the evils just described. The policy contained in these regulations is much the same as that proposed by the committee in its amendment to section 6 of the narcotic drugs import and export act. But whatever may be said of the effectiveness of these regulations, the committee believes it highly desirable that the policy contained in them should in great measure be made a part of our permanent law, in order that it may be given a firmer legal basis and that our law, may be as broad as our obligations under the convention and wholly consistent therewith. At the hearings hereinafter referred to the Assistant Solicitor of the Department of State made this pertinent statement:
"As the law now stands, it provides that the goods may be exported to countries regulating their entry under such regulations as are prescribed by such country for the importation thereof into said country. Where the country regulates it in any way, whether effectively or not, under this act of Congress I think the officials of the Government would be bound to permit the exportation; yet we know that some countries, while they have regulations and laws on the subject, administer them very loosely, and in order that this illicit traffic might be controlled to a greater extent it was thought that the administrative officials should have greater discretion with respect to the exportation, and if they should find that the regulations of a particular country were not being properly administered, so as to carry out the spirit of The Hague convention, they should be authorized to refuse a permit to export'
"(II) In-transit shipments.—The United States and England are the two countries producing the greatest amount of manufactured opium and coca-leaf products. Regulation of our exports, therefore, deals with but half of the problem of preventing manufactures of narcotic drugs from reaching foreign hands which may make illegitimate use of them. England, while maintaining drastic export restrictions by licenses issued under the British dangerous drugs act, 1920 (see hearings, p. 162 ff), has, by our previous faulty legislative treatment of in-transit shipments, been unsupported by this country in enforcing the British law. The United States has thereby suffered in two ways, first, by smuggling into our domestic trade narcotic drugs contained in in-transit shipments, originating in Great Britain and destined, for the most part, to Japan; and, second, by permitting shipments in-transit through the United States to foreign countries of destination, where the drugs are diverted, as previously described, from legitimate and scientific uses and reexported to China, to the injury of ourselves and China. The committee therefore believes it very important that the present prohibition upon in-transit shipments and the transshipments of smoking opium should be coupled with a similar restriction upon other opium products, such as morphine, and upon coca leaves and its derivatives, such as cocaine.
"(III) Imports.—The existing law in section 1 of the narcotic drugs import and export act . . . prohibits the importation of smoking opium, but permits the importation for medical purposes of other opium products, and places no restraint whatever upon the importation of coca leaves and their derivatives. The United States manufactures more than a sufficient amount of narcotic drugs for domestic medical and scientific uses. The committee therefore believes it desirable to restrict our importation to raw opium and coca leaves, and to admit these only in amounts found by the Secretary of State, the Secretary of the Treasury, and the Secretary of Commerce to be sufficient to provide our manufacturers with enough of the raw products for the domestic and scientific uses of this country, and for foreign exportation as required by the opium convention for medical and scientific uses of legitimate foreign consumers. This restriction will also aid in enforcing our export restrictions and in minimizing the injury to China and ourselves previously described. It will also aid in preventing evasions of the Harrison Act, by means of the unlawful importation into this country of narcotic drugs previously imported by us and sent into the export trade, and will close the legitimate domestic market to foreign manufacturers. By proper action in authorizing the importation of the raw products, it is believed that the three Secretaries can curb any tendency to increase the price of the manufactured narcotic drugs which might otherwise result from the prohibition of their importation, and by such action also take account of increased domestic consumption beyond the ordinary needs for medical and scientific uses, due either to diversion of drugs into illegitimate domestic channels in violation of the Harrison Act, or to epidemic or war conditions."
This bill as amended was adopted and approved on May 26, 1922. The Federal Narcotics Control Board, created under this Act, have made the following regulations: 18
"Pursuant to the provisions of the narcotic drugs import and export act, approved May 26, 1922, published in T. D. 39154 of June 12, 1922, the Federal Narcotics Control Board hereby prescribes the following regulations:
"Regulation 1. Definitions.—(a) The term 'crude opium' shall be understood to mean the spontaneously coagulated sap obtained from the soporific poppy (papaver soniniferum and related species), and which may or may not have been subjected to further drying or other treatment, thus covering all forms of opium known to the trade, such as gum opium, granulated opium, powdered opium, and deodorized (denarcotized) opium, except 'smoking opium' or 'opium prepared for smoking.'
"(b) By coca leaves shall be understood .the leaves of Erythroxylon Coca, known commercially as 'Huamuco Coca,' or the leaves of Erthroxylon Truxillense, known commercially as `Truxillo Coca,' or the leaves or any other species of Erythroxylon yielding cocaine.
"(c) The term 'cocaine' shall be understood to cover all forms of cocaine or its salts known to the trade.
"(d) The term 'derivative' shall be understood to mean any alkaloid, or salt of an alkaloid, or combination thereof, or any chemical compound prepared either directly or indirectly fro the alkaloids of opium or from cocaine. It shall include morphine, rodent, ethylmorphine hydrochloride (known as dionin), or diacetylmorphine hydrochloride (known as heroin), their salts or combinations and any new derivative of morphine or cocaine, or of any salts of morphine or cocaine, or any other alkaloids of opium.
"(e) The term 'preparation' shall mean any product, mixture, or compound containing or representing any quantity of opium or coca leaves or any derivative thereof.

"Imports.
"Regulation 2. Ports designated for imports.—Crude opium and coca leaves (which are the only 'narcotic drugs' as defined in the act that are admissible) may be imported only at the ports of Detroit, Michigan; Indianapolis, Indiana; New York, N. Y.; Philadelphia, Pennsylvania; St. Louis, Missouri; and San Francisco, California.
"Regulation 3. Who may import.—Crude opium and coca leaves may be entered only by manufacturers actually engaged in manufacturing from such crude opium or coca leaves products for the wholesale trade for medical or other legitimate uses.
"Regulation 4. Applications required.—Applications in triplicate for permission to import crude opium or coca leaves shall be made under oath on an approved form, stating all material facts, and addressed to the collector of customs at the proposed port of immigration, who, after careful consideration thereof and any investigation deemed necessary, shall forward the application with his recommendation to the Federal Narcotic Control Board, care of Division of Customs, Treasury Department, Washington, D. C. Such application must state the amount of the stock on hand, the usual requirements for the ensuing six months, and the necessity for the proposed importation.
"I'pon request, the collector of customs may furnish to the applicant a certified copy of the approved application for use under the laws or regulations of the exporting country.
"Regulation 5. Procedure on arrival and delivery from the appraiser's warehouse.—Immediately upon the unlading of crude opium from the importing vessel, the customs officer shall carefully examine the packages, note their condition, seal the packages, and cause them to be transported under customs guard and by bonded cartmen to the appraiser's warehouse where they shall be placed in a separate and specially protected inclosure.
"The appraiser shall issue such special regulations to his employees as will insure the safekeeping of the packages while in the warehouse.
"No delivery of crude opium to the importer from the appraiser's warehouse shall be permitted until the deputy collector of customs in charge of the building and an assistant appraiser shall be satisfied and so note on the delivery permit after personal examination that the importer has taken all proper precautions for the safe transportation of the crude opium from the appraiser's warehouse to the importer's premises or to the premises of the common carrier if shipment is to be made.
"Until otherwise ordered, however, the procedure now followed in the case of shipments of crude opium in bond between the ports designated in regulation 2 for imports will not be disturbed.
"Except as specially provided in these regulations, the procedure in the case of coca leaves shall be the same as in the case of merchandise generally.
"Regulation 6. Entries.—Crude opium may be entered only for consumption or for transportation in bond between the ports designated in regulation 2 for imports. Entry of either crude opium or coca leaves shall not be permitted unless the application to import has been approved by the Federal Narcotics Control Board nor unless the merchandise has been properly described in the manifest of the importing vessel or carrier.
"Coca leaves, however, may be entered either for consumption or warehouse, or for transportation in bond to any of the ports designated in regulation 2.
"Regulation 7. Importations of unusual amounts.—No amount of crude opium or coca leaves which may be imported within any certain period as necessary to provide for medical And legitimate uses only will be fixed by the board at present, but special explanation of importations of unusual amounts of such articles either in single shipments or in the aggregate will be required and carefully investigated by the board.
"Regulation 8. Reports of stocks on hand and probable future requirements. —Importers shall render to .the board, as soon as practicable after December 31 of each year, or oftener if especially required, a report of the stocks of narcotic drugs on hand and an estimate of the probable requirements for medical and legitimate uses for the next year or any other period that may hereafter be specially designated.
"Exports.
"Regulation 9. No exportation without Previous approval.—No persons shall take out of the United States on his person or in his baggage or offer to any carrier for transportation out of the United States, nor shall any carrier receive for exportation or export out of the United States any narcotic drug unless and until an application for permission to export shall have been approved by the Federal Narcotics Control Board.
"Regulation 10. Applicationd.—Applications in triplicate for permission to export narcotic drugs shall be made under oath on an approved form, stating all the material facts, and addressed to the nearest collector of customs sufficiently early to permit of orderly procedure and any necessary investigation. With this application, the shipper's export declaration in due form shall also be submitted, together with any import license (and a translation thereof if in a foreign language) or a certified copy of any such license, that may have been issued by the country of destination, or other evidence that the merchandise is consigned to an authorized permittee.
"Verification by an American consular officer of signatures on foreign import licenses will not be necessary if such licenses bear the official seal of the officer signing them.
"After careful consideration of such application, and after any investigation deemed necessary, the collector shall forward the application to the board with his recommendation.
"Regulation 11. Labeling of packages.—In lieu of the marking on the outside of the packages required in the previous regulations (T. D. 38381), the inner packages shall be labeled in a legible and conspicuous manner to show the narcotic character of the contents.
"Regulation 12. Opening and inspection of package.—The collector of customs may require packages offered for export to be opened and may inspect the contents thereof.
"In-Transit Shipments.
"Regulation 13. In-transit shipments transferred in the United States or remaining on board the transporting vessel.—Each in-transit shipment under section 2 (subsec. 5) of the act, will be considered by the board on its individual merits, but in general the regulations governing exports will be applied so far as practicable, except that the collector of customs may permit narcotic drugs, other than smoking opium or opium prepared for smoking, to be retained on board a vessel arriving from a foreign port which are shown on the manifest to be destined to another foreign port.
"Articles in transit manifested merely as drugs, medicines, or chemicals, without evidence to satisfy the collector that they are non-narcotic, shall be detained and subjected at the carrier's risk and expense to such examination as may be necessary to satisfy the collector whether they are of narcotic character. With a view to avoiding such inconvenience, the carrier should not accept in-transit shipments of such articles unless accompanied by properly verified certificates of the shippers, specifying the items in the shipment and stating whether narcotic or not.
"General.
"Regulation 14. Importations or exportations by mail prohibited.—The importation or exportation of narcotic drugs in the regular mails or by parcel post will not be permitted.
"Regulation 15. Vessels' stores.—Collectors may permit narcotic drugs in reasonable quantity and properly listed as medical stores of vessels to remain on such vessels if satisfied that such drugs are adequately safeguarded and used only for medical purposes. Smoking opium or opium prepared for smoking shall be seized, however, whenever and wherever found.
"Regulation 16. Custody and disposition of narcotic drugs forfeited or not claimed.—All narcotic drugs which are forfeited in proceedings for condemnation, or not claimed as provided by law, or which are summarily forfeited as provided in subdivision (d), subsection 2, section 1, of the act, shall be reported to the secretary of the board on a form provided by the Treasury Department for that purpose, and retained by the officer reporting the same as custodian for the board pending their disposition. Two committees, each consisting of three employees of the Treasury Department, shall be appointed by the secretary of the board, the duties of each of which shall be to examine, weigh, inventory and destroy such drugs as he may direct. Each committee shall make report to the secretary of the board of all such drugs destroyed immediately upon completing such destruction.
"Regulation 17. Violations of the law to be reported.—Collectors of customs shall report to the United States attorney and to the board any violations of the law which they may discover.
"Regulation 18. Compliance with other laws and regulations applicable is necessary.—All regulations of or action by the board is subject to the provisions of the customs, internal revenue, and other laws and regulations applicable.
"Regulation 19. Emergency regulations superseded.—These regulations supersede the emergency regulations published in T. D. 39154 of June 12, 1922.
"Regulation 20.—Previous licenses valid.—Authorizations to import or export issued prior to the taking effect hereof by the Division of Customs, Treasury Department, under the provisions of the regulations published in T. D. 39154 of June 12, 1922, will continue valid.
"Regulation 21. Secretary and assistant secretary of the board.—Under date of March 10, 1923, the board designated Col. L. G. Nutt, Head of the Narcotic Division, Bureau of Internal Revenue, Treasury Department, as its secretary, with authority to act upon applications and conduct correspondence for and on behalf of the board. Mr. M. R. Livingston, Chief of the Returns Section of said division, is hereby designated as assistant secretary of the board to perform such duties in connection therewith as the secretary of the board may direct.
"Regulation 22. Time of taking effect.—These regulations shall take effect October 15, 1922."
An amendment to the act above referred to was passed by Congress and approved June 7, 1924. This amendment reads as follows:
"Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled, That subsection (b) of section 2 of the Act of February 9, 1909, as amended by the Acts of January 14, 1914, and May 26, 1922, entitled 'The Narcotic Drugs Import and Export Act,' be further amended by the addition of the following sentence:
`Provided, That no crude opium may be imported for the purpose of manufacturing heroin.'"
In connection with limiting the amount of opium imports to the so-called "medical needs" of the country, Lambert after referring to the statement often quoted that 90% of the amount of these drugs imported is used for other than medical purposes, gives the following method for determining the amount needed "in the legitimate practice of medicine:" 19
"Since the Harrison law requires a record to be kept in each hospital of the amount of opium and its alkaloids purchased and the amount consumed, it would seem possible, by calculating from the number of patients treated in the hospitals and the amount consumed, to obtain a fairly accurate idea of the amount of opium and its alkaloids used in the legitimate practice of medicine. From previous investigations it is known that from 2 to 225 per cent of the population are sick in the year, and that from 18 to 23 per cent of these patients are sufficiently ill to be in the hospital. On the basis, therefore, of 23 per cent of 0.0225 per cent, that is, that 0.005175 per cent of the population are hospital patients, one obtains an approximation of the amount of opiates used in the practice of medicine. If, therefore, without taking any account of the illness or the injury which brought the patient to the hospital, without discussing the therapeutics, and scattering the hospitals over a sufficient area in the United States to prevent local peculiarities from coming in, it would seem that a fair estimate can be obtained. This has been done, and the statistics here presented are from the records of hospitals for the years 1920 and 1921, and these hospitals are scattered from New England to the Pacific coast; from the populous Middle Atlantic states; from the Northwest and Great Lakes down the Mississippi Valley to the Gulf and the border of Mexico, and along the Rocky Mountain states to complete the area covered. They are from hospitals dealing with general medicine and surgery; special hospitals devoted to the care of children and maternity cases; industrial hospitals of large industries, and hospitals caring for cancer cases, in which the use of the opiate is a necessity in large amounts; so that they comprise hospitals using a minimal amount of opiates, hospitals using a maximal amount, and large hospitals in general medicine and surgery using average amounts.

"TABLE 2.-HOSPITAL PATIENTS
No. of    Grains of    Grains of    Grains of    Grains of
patients    morphin    heroin    opium    codein
1920..         412,196    148,448.22    11,708.12    109,073.76    176,438.80
Aanountperpafient             0.3600    0.0281    0.2646    0.4280
1921..         442,921    140,603.18    8,730.48    173,169.36    220,262.64
Amountperpatient         ,    0.3174    0.0197    0.3909    0.4995
Totals        855,117    289,052.40    20,438.6    282,143.12    396,701.44
Amountperpatient             0.3387    0.0239    0.3277    0.4637

"The intention, at the beginning, was to calculate only from hospital patients; but the statistics of some of the hospitals have made it impossible to separate hospital bed patients from the ambulatory dispensary patients. This seemed, at first appearance, a disadvantage; but on second thought it proved the reverse, as it gives the difference between the amounts used among all patients and the amounts used solely for bed patients. There is an interesting difference between the two in that the amounts of morphin, codein and heroin are less among the dispensary patients, but the amount of opium is more per patient. This agrees with the rational therapeutics that one would expect to find for the morbid conditions usually presented.
"In Tables 2 and 3 the variation between the two years is averaged up in the total. We see, therefore, that in caring for the hospital patients there is prescribed during the year an amount equivalent to giving each patient 1/3 grain of morphin, 1/42 grain of heroin, 1/3 grain of gum opium, and practically 1/2 grain of codein.

"TABLE 3.-HOSPITAL AND DISPENSARY PATIENTS
No. of    Grains of    Grains of    Grains of    Grains of
patients    morphin    heroin    opium    codein
1920        780,428    80,372.175    5,350.84    367,419.545    228,799.215
Amountperpatient             0.1030    0.0068    0.4607    0.2932
1921        920,494    115,372.03    5,129.46    383,601.257    295,288.91
Amount per patient             0.1253    0.0056    0.4167    0.3208
Totals        1,720,922    195,744.205    10,480.30    751,021.302    524,088.125
Amount per patient             0.1137    0.0061    0.4365    0.3045

"In hospital and dispensary patients, we find necessary an amount equivalent to giving each patient about 1/9 grain of morphin, 1/164 grain of heroin, 1/2 grain of gum opium, and practically 1/3 grain of codein.
"To obtain the amount of opium necessary to be imported into this country, we must translate these terms of alkaloids into terms of gum opium, and we must therefore consider for a moment the chemistry of their preparation. In every 100 parts of opium, the U. S. Dispensatory states, there are 10 parts of morphin and 3/10 of a part of codein. Cushing gives 5/10 of a part of codein. We will use the 3/10, as it will produce a larger total, and we shall thus obtain an amply sufficient supply. The amount of opium required is therefore governed by the amount necessary to obtain the amount of codein used. Codein, moreover, is obtained from the mother liquor of opium after the morphin is crystalized out. If we, therefore, have enough opium to give us the codein, we shall have an excess of morphin. Heroin is diacetylmorphin, and is made by treating morphin with acetyl chlorid. Dionin, on the other hand, is ethylmorphin, and is made by the action of ethyl iodid in the presence of an alkali on morphin. The necessary amounts of dionin and heroin, therefore, are easily obtainable from the excess of morphin which remains after the demands in medicine are satisfied, since, as we have said, the opium used to obtain the codein contains thirty-three and one-third times as much morphin as codein.
"In calculating, therefore, the amount of opium required on the basis of the amount of codein desired, we are amply providing for the alkaloids here mentioned and usually employed in the medical practice.
"Among the hospital patients, taking 0.4637 grain as the necessary amount of codein for each patient yearly, it must be equivalent to 0.3 per cent of the total amount of opium required for each patient yearly, since gum opium contains 3/10 part of codein per hundred parts of opium. Each pittient, therefore, will require 154.56 grains of opium yearly to make the necessary amount of codein. By adding to this 03277 of gum opium required as opium, we have 154.88 grains. If we add the maximal amount of opium as calculated for the dispensary patients of 0.4384 we get 154.99 grains. In either case it is practically 155 grains of opium that is necessary to produce the amount of codein plus the amount of gum opium necessary to obtain both gum opium and its alkaloids of codein, morphin, and the synthetic heroin and dionin. One hundred fifty-five grains of opium will give 15.5 grains of morphin; and as each patient in the hospitals requires, according to our calculations, only 0.3387 grain yearly, there will each year remain an excessive amount of morphin.
"Two and twenty-five hundredths per cent of all the population are sick in this country each year. At present, the population of the United States is given as being 106,000,000. Two and twenty-five hundredths per cent of this number is 2,385,000. Multiplying this by the 155 grains for each patient and dividing the result by the 413 grains in an avoirdupois ounce, and again dividing that quotient by 16 ounces, we obtain 55,9431/2 pounds of opium. Opium is distributed medically in Troy ounces of 480 grains to the ounce and 12 ounces to the pound, but is bought in avoirdupois ounces of 413 grains to the ounce and 16 ounces to the pound. This is calculating on the basis of every one being as sick as the hospital patients. Taking, however, the amount required by the hospital and dispensary patients combined, which perhaps is a fairer estimate, we find that the amount of codein required is 0.3045 grain; and, adding the amount required of gum opium in the dispensary, 0.4365 grain for each patient, we have 101.9 grains for each person required to give the desired amount. Multiplying, therefore, the 2,385,000 patients by 102 grains, we find that 37,117 pounds will be required.
"Thus, it is seen that the amount of opium required in the practice of medicine depends on whether we calculate by the amount of codein used only among hospital patients, or whether we calculate by the amount of codein required in hospital and dispensary patients together. Somewhere between 37,500 and 56,000 pounds is probably nearer the truth. Calculating from the 77 per cent dispensary patients and 23 per cent hospital patients combined, we have 23 per cent of 2,385,000, or 545,550 patients as hospital patients, requiring yearly, at 155 grains for each patient, 12,796 pounds of opium, and 1,839,451 patients as dispensary patients requiring, at 102 grains each, 28,393 pounds of opium, or a total of 41,189. To assure an ample amount of even an increased demand of codein, 45,000 pounds of opium may well be considered an abundant amount of opium to be imported each year for medicinal use. This is less than one-tenth the actual amount now imported, and supports the statement of the Treasury Report on Traffic in Narcotic Drugs that 90 per cent of the amounts of these drugs entered for consumption is used for other than medical purposes.
"These figures do not include the practice of dentistry and veterinary medicine; but the excess of morphin obtained in making the codein beyond that required in the practice of physicians will be more than ample to supply the legitimate needs of the dentists and veterinary surgeons."
Early in his article, Lambert states that:
"Since the Harrison law requires a record to be kept in each hospital of the amount of opium and its alkaloids purchased and the amount consumed, it would seem possible, by calculating from the number of patients treated in the hospitals and the amount consumed, to obtain a fairly accurate idea of the amount of opium and its alkaloids used in the legitimate practice of medicine."
This paragraph contains a statement which forms the basis for his estimate for all needs of the "legitimate practice of medicine' and which may be questioned. The writer indicates that the use of opium in hospitals is indicative of the use of opium in the "legitimate practice of medicine" generally. It is well-known that well-equipped hospitals contain many facilities for avoiding the use of opium both for the relief of pain and for other therapeutic objects. The close supervision of hospital patients, the constant presence of resident physicians, the care afforded by a competent nursing staff, appliances for hydro-and thermo-therapeutic, electrical, and various mechanical appliances, to say nothing of the influence of constant education of the patients, all tend to lessen the need for opiate administration. In private practice, however, where hospital equipment is not at hand, the physician must depend usually upon untrained members of the family to care for the patient. Further, in small towns and rural districts where the attending physician because of the many demands upon his time may not be constantly within call when advice is needed, where his visits, indeed, may be limited to one, two or three times a week, it is obvious that the need for opium and opium preparations is far greater. Individuals suffering from painful conditions requiring relief or from other conditions where the therapeutic indication is for the use of opium are just as much entitled to assistance as are those fortunate enough to be able to avail themselves of hospital facilities. Without the equipment mentioned above, however, the relief of pain is far more difficult under conditions of private practice unless some preparation of opium may be used. Unfortunately there are no figures available for purposes of comparison but it is extremely doubtful if the above statements will be contested by those familiar with the conditions met in hospital and private practice.
The writer further states that the statistics as to opium use presented are from hospitals dealing with "general medicine and surgery; special hospitals devoted to the care of children and maternity cases; industrial hospitals of large industries, and hospitals caring for cancer cases, in which the use of the opiate is a necessity in large amounts; so that they comprise hospitals using a minimal amount of opiates, hospitals using a maximal amount and large hospitals in general medicine and surgery using average amounts."
That the types of hospitals mentioned by Lambert actually represent the maximal use of opium obtaining in the hospital practice is open to question. There is no mention made in the above enumeration of hospitals caring for cases of tuberculosis where, in the terminal stages at least, it is not uncommon to employ very considerable amounts of opium. Again no mention is made by the author of institutions, either public or private, where cases suffering from chronic opium intoxication are treated. Here probably will be found the greatest therapeutic use of opium of all. As an example might be taken the use of opium in treating cases of addiction according to the method described by Lambert. From his description it will be noted that three or four doses of morphin are employed in treating these cases. The first dose should be, according to the author, two-thirds or three-fourths of the total daily twenty-four-hour dose, the larger amount being better if the patient can take it. The second dose should be one-half of the first dose and the third dose allowed one-half of the second dose. As nearly as can be determined, a fourth dose, one-half of the third dose, is given in about one-half of the cases.
In addition to the morphin used the author recommends in the latter portion of the treatment the use of codein in from one to five grain doses "as may be necessary to quiet him." The total number of doses of codein is not given but left to the discretion of the attending physician. It would appear, however, that two doses of codein would not be an excessive number in the average case.
In order to form some idea of the amount of opium needed in the treatment of a case by this method, it is necessary to assume an average daily dose in cases of chronic opium intoxication. We are aware that there is no accurate information available on this point for reasons stated in a previous chapter. We shall assume arbitrarily, therefore, ten grains to be an average daily consumption. From a figure obtained on this basis the reader easily can calculate the amount of opium that would be required should he deem the average dose either excessive or insufficient.
On this basis of ten grains the amount of morphin required for the first three doses per patient would be 13.125 grains and for the fourth dose given in one-half the cases treated, .4268. This totals 13.59 grains. Assuming that the average dose of codein is 21/2 grains and that two doses are required in the average case we find that five grains would be used.
Lambert states that "in every 100 parts of opium, the U. S. Dispensatory states, there are 10 parts of morphin and 3/10 of a part of codein." Using these percentages and calculating the amount of opium required to produce the morphin and codein needed to treat one patient, we find that
13.593 grains of morphin require 135.93 grains of gum opium
5    "    " codein    di    1666.6    44    id    id
The number of chronic users of opium in the United States is as we have stated unknown. Lambert in other connections, however, quotes from the report of the Special Committee on Investigation appointed by the Secretary of the Treasury 'in 1918 so that it might be well to use the figure given in this report as a basis for determining the amount of crude opium required to treat each patient once according to the method. This figure is one million. Multiplying by one million 135.93 grains of opium and converting the resulting figure into avoirdupois pounds by dividing first by 413 and again dividing the quotient by 16, we get 20,566 pounds. To secure the 5 grains of codein needed for treatment we should multiply 1666.6 by a million. Again converting into pounds, we find that to produce this amount of codein 252,194.3 pounds of gum opium would be required. For the purposes of this discussion we may omit consideration of the crude opium needed for the production of the required amount of morphin inasmuch as a quite sufficient amount would be secured as a by-product of the codein production if as Dr. Lambert states, codein is obtained "from the mother-liquor of opium after the morphin is crystallized out."
As a matter of fact, however, Lambert is mistaken in his assumption that all codein is obtained "from the mother-liquor of opium after the morphin is crystallized out" and that therefore the opium requirements should be calculated on the basis of the amount of the crude drug needed to yield the codein requirements. While it is true that codein may be obtained in this way, it is done so only to the extent of its content in the opium available for all other purposes and the balance of the codein needed is obtained by methylating morphin. Thus the codein requirements influence the total amount of opium needed for all purposes only to the extent of the amount of the crude drug needed for the production of morphin to make the codein not provided in the crude drug available for other purposes.
Be this as it may, if we assume that every case of chronic opium intoxication is entitled to at least one course of treatment, if we further assume that this course of treatment will be successful in 100 per cent of cases and if we still further assume that no new cases will be formed, we find that Lambert's treatment of existing users once requires about five times the amount of opium indicated by him as sufficient for the legitimate therapeutic needs of the country for one year. This amount of opium, however, requires that the million hypothetical patients all be treated at one time or that those awaiting treatment be denied their customary drug until their turns arrive. Any contemplation of the amount of opium required to supply these cases awaiting their turn at the Lambert treatment, leads us into such enormous quantities that we consider it useless to pursue the speculation further. Whether or not the treatment of cases of chronic opium intoxication by this or any one of several other methods constitutes "legitimate practice of medicine" within the meaning of Lambert's article we may not say, as he omits any mention of the opiate needs in the treatment of these cases.
We have given this example of Lambert's method of arriving at the legitimate opium needs of this country in order to point out the manifold difficulties of making such estimates upon such bases as are at present available. The very grave results that might follow arbitrary assumptions are only too apparent as are likewise the dangers of over-estimates. In other words, it would appear that here again we are confronted with such inadequate knowledge as to indicate the importance of far more comprehensive studies of the situation than have yet been made.
It might seem at first sight a comparatively easy matter to determine the so-called "legitimate medical needs" for narcotic drugs.

Years ago it was stated first, we believe, by Dr. Hamilton Wright that 10% of the opium and opium products imported into the United States would serve the therapeutic needs of the country and that 90% was used for other purposes. This statement has been quoted and re-quoted for the last fifteen or twenty years and has come to be accepted by many as authoritative. Certainly it was not based originally upon any comprehensive survey of the country's opium needs as no such survey has ever been made. Whether or not it was based even on local figures is not known but we feel it safe to assume that the statement is erroneous or at the most purely speculative.
To determine accurately the country's medical needs of opium would require an exhaustive study of the actual therapeutic uses to which opium is put under all of the existing conditions. Such a study would take into account variations in medical practice, in disease prevalence, in race composition, occupation, and many other factors which it is unnecessary to mention here.
In the actual compilation of such data accurate methods of determination should be employed and to avoid error they should cover the ultimate consumption of the drug. Therefore, from a practical point of view the nearest approach would be a study of the records of physicians, dentists, veterinarians, scientists and retail pharmacists—the ultimate distributors of the drug.
Although it is obvious that such a study could not be made for the country as a whole, however, it apparently would be possible to arrive at a fairly satisfactory figure through studies made in properly selected localities which together might be taken as representative.
Two studies of this nature were made during 1924. A. G. DuMez of the United States Public Health Service determined the use of narcotics in Allegany County, Maryland for the period July 1, 1922 to June 30, 1923,20 and the Committee on Drug Addictions studied the use of opium and coca leaves in six communities during the period July 1, 1923 to June 30, 1924.21

With regard to the selection of Allegany County, the procedure followed, and his findings DuMez states:
"Allegany County, Md., was selected for this purpose for several reasons, namely, (1) because of its remoteness from the sea coast and boundary lines, where the greater possibility of obtaining narcotics might tend to vitiate the results; (2) because the county is fairly distant from and contains no large cities in which it is thought that abnormal conditions are more likely to prevail; (3) because the occupations of its inhabitants are quite diversified—farming, mining, railroading, and manufacturing being represented; (4) because the county is easily accessible from Washington. In other words, it was thought that Allegany County represents as nearly as possible a normal unit within easy reach of Washington where conditions prevail which can be taken as typical of the country as a whole.
"The actual work of the survey consisted in visiting all the narcotic registrants in the county and compiling from their records the amounts of narcotics dispensed or used during the period of one year. In all there were visited 69 physicians, 12 dentists, 20 retailers (pharmacists), 3 wholesalers (pharmacists), 1 veterinarian, and 5 hospitals and sanitoria. The records of each were examined in detail. These records showed that for the period July 1, 1922, to June 30, 1923, the following quantities of narcotics were dispensed or used:

"Table 1.—Total quantities of opiates dispensed or used.
Grains.
Opium      38,937
Codeine sulphate and phosphate      29,410
Morphine sulphate and hydrochloride     22,284
Ethylmorphine hydrochloride (dionin)      4,724
Diacetylmorphine hydrochloride (heroin)     1,940
Cotarnine hydrochloride (stypticin)      788
Apomorphine hydrochloride      93
Fl. oz.
Exempt preparations (paregoric, Bateman's drops, Godfrey's cordial,
etc.)      10,366
Total cocaine dispensed or used.
Grains
Cocaine hydrochloride      11,485
"The equivalents of the foregoing quantities in terms of crude drugs are given in Table 2. In computing these equivalents the amount of anhydrous morphine present in opium has been taken as 10 per cent, of anhydrous codeine as 0.3 per cent, and of narcotine as 5 per cent. In computing the opium equivalent of the total quantity of opiates 855 grains of codeine sulphate have been subtracted from the 29,410 grains of codeine sulphate and phosphate, as this quantity can be extracted (on the 0.3 per cent basis) from the opium required to manufacture the stated quantities of morphine sulphate and hydrochloride, ethylmorphine hydrochloride, diacetylmorphine hydrochloride, and apomorphine hydrochloride. Likewise, the 788 grains of cotarnine hydrochloride have been omitted, as the quantity of narcotise which can be extracted from the opium required to manufacture the foregoing alkaloids and their derivatives is more than sufficient (on the 6 per cent basis) to yield this amount. In computing the coca leaf equivalent of the quantity of cocaine hydrochloride used, the yield of anhydrous cocaine has been taken as 0.5 per cent.

"Table 2.—Opium equivalents of opiates.
Grains of opium
38,937 grains of opium    38,937
28,555 grains (29,410-855) codeine sulphate    213,219
22,284 grains morphine sulphate    167,130
4,724 grains ethylmorphine hydrochloride    36,560
1,940 grains diacetylmorphine hydrochloride    13,060
93 grains apomorphine hydrochloride    850
10,366 fluid ounces exempt preparation    18,906
Total    488,662
69.81 pounds
Coca leaf equivalent of cocaine
Grains of coca leaves
11,485 grains of cocaine hydrochloride    = 2,051,220
= 293.03 pounds
"The per capita consumption of opium for Allegany County on the basis of a population of 69,938 as found for 1920 by the Bureau of the Census, United States Department of Commerce, would therefore be 6.98 grains. In the case of coca leaves, it would be 29.32 grains. To supply the entire United States on this basis, taking the population to be 106,000,000, would require the annual importation of approximately 105,697 pounds of opium and 443,988 pounds of coca leaves."
DuMez comments on his findings and on local conditions as follows:
"It is thought that the quantities of narcotics dispensed or used in this country represent fairly accurately the medicinal requirements at present, except in the case of cocaine and the exempt preparations. A census taken for the year July 1, 1923, to June 30, 1924, would no doubt show a much smaller quantity of cocaine used, as most of the dentists who used cocaine in 1922 to 1923 reported that they had since discontinued its use in favor of the synthetic local anesthetics. In the case of exempt preparations (paregoric), it is thought that, although they were sold only in small amounts (in quantities not exceeding 2 fluid ounces), they were dispensed too frequently in some cases to the same individuals. It is also realized that some of the residents of the county may have purchased narcotics outside of the county (in near-by counties for instance); but it is thought that any error in the total amounts resulting from this cause would be counterbalanced by that introduced through the purchases made within the county by non-residents."

The studies made by the Committee on Drug Addictions are described as follows:
"The Committee undertook these studies in addition to its other work to make available for use by the. international conference called on invitation by the League of Nations certain data which might prove valuable as a basis of fact for any estimates made in a consideration of the limitation of the production of the drugs concerned.
"Method.—Obviously it was impossible to obtain an exact figure representing the amount of opium and coca leaves and their derivatives and preparations legally used throughout the country as a whole. The Committee decided, therefore, that the most that could be undertaken in the way of intensive studies would be comprised in a review of the legal uses of these drugs in certain selected areas. Six communities representing as nearly as possible all factors contributing to a varying use of these drugs were selected for these studies.
"It was decided that racial characteristics, occupations, geographic location, disease incidence, and other influences should be considered and that as a basis for selection the ratio of these factors in the aggregate should be typical of the country as a whole. In this connection, attention was paid also to the admixture of urban and rural population in order that the presence or absence of medical, institutional and sanitary equipment might be represented fairly.
"The determination of the amounts of narcotic drugs used in the communties studied depended upon a complete inspection of certain records required to be kept by the federal narcotic act known as the Harrison Narcotic Law. The communities selected and their populations are indicated in the appropriate tables.
"It is not necessary to review all of the provisions relating to record-keeping outlined in the federal law in this country but only such as relate to the end distributors of the proscribed drugs. Physicians, dentists, veterinarians and hospitals are required to register and may secure these drugs only upon duplicate order forms for personal administration or dispensing. One copy of each form is sent to the dealer from whom the supplies are purchased. The other is retained by the registrant. In addition each registrant under this class is required to prepare as of July 1 of each year an inventory of stock on hand. It is possible, therefore, to secure from the records of the inventories and those of purchases upon the required order forms exact information as to the amounts of opium and coca leaves and their preparations used by each registrant during a given twelve-month period. The registration of physicians, dentists, and veterinarians also includes permission to prescribe these drugs upon certain forms. Retail pharmacists under the provisions of the law may register in another class and fill such prescriptions provided that the original prescriptions be kept on file for a period of not less than two years. In addition through their registration they may dispense without a prescription certain exempt preparations described in section six of the law, provided that a record be kept of all such sales. This section defines 'exempt' as follows:

Preparations which do not contain more than two grains of opium or more than one-fourth of a grain of morphine, or more than one-eighth of a grain of heroin, or more than one grain of codein, or any salt or derivative of any of them in one fluid ounce, or, if a solid or semisolid preparation, in one avoirdupois ounce; or liniments, ointments, or other preparations which are prepared for external use only, except liniments, ointments, and other preparations which contain cocaine or any of its salts or alpha or beta eucaine or any of their salts or any synthetic substitute for them.
"From the records above described it is possible to determine the amounts
of these drugs actually delivered to the consumer in any given territory. In
the communities studied it was necessary personally to consult each record
required to be kept by retail distributors of the drug in question—registrants
under the Harrison Narcotic Law.
"The number of registrants of the different classes distributing narcotic drugs to the ultimate consumer in the six communities studied are shown in Table I. "Table I. Registrants Distributing Opium and Coca Leaves.
Class of registrants    Sioux City, Ia.    Mont-    Tacoma,    Gary,    Elmira, N. Y.    El Paso,    Totals otals
gomery,    Wash.    Ind.        Texas   
Ala.                   
Physicians, dentists, veterinarians and other practi-    113 6 55    59 3 24 14    134 15 54    57 4 34 ..    68 7 21 ..    81 8 58 ..    512 43 246 15
tioners                1               
Hospitals                               
Pharmacists                               
Other retailers                               
*    *    *    *    *
"The actual work of the field studies consisted in tabulating in detail all amounts of opium and coca leaves and their derivatives and preparations distributed as follows:
1. By physicians, dentists, veterinarians, institutions, and laboratories.
a. Non-exempt drugs bought for dispensing or administering. Secured from duplicate order forms kept by physicians, etc. Balance on hand at beginning and end of period noted.
b. Exempt drugs administered and dispensed.
2. By druggists.
a. Non-exempt drugs sold on prescriptions.
b. Exempt preparations sold to others than physicians, dentists, veterinarians, institutions, laboratories or other dealers.
3. By other retailers.
a. See b, under 2.
"Conclusions.— . . . It will be noted that the conversions of the alkaloids, salts and other derivatives into terms of opium and coca leaves have been made on two bases. One cf these depends on the molecular relationships involved, the other takes into consideration destruction and other losses in the manufacture of these preparations. The amounts of the crude drugs which are required on the molecular basis are indicated in the column entitled 'Theoretical Basis' and those required in general manufacturing practice are indicated in the column entitled 'Practical Basis.' These two figures are given for purposes of comparison. As far as the alkaloids are concerned, both methods of calculation have been made on the basis of 10% morphin, 0.3% codein and 5% narcotin present in opium and 0.5% cocain present in coca leaves. The amount of codein present in the amount of opium necessary for all other purposes has been subtracted from the total codein needs and the amount of opium necessary to manufacture the balance from morphin as indicated has been added to the total amount of opium. The amount of opium necessary for all other purposes is sufficient to provide for the needs of the less important alkaloids.
"Supplementary Institutional Use.—It was realized that no one community could be typical of the country as a whole in hospital use of narcotic drugs by reason of the unequal distribution of these institutions of different types throughout the country. Therefore the hospital use in the communities studied was disregarded and what may be termed a 'normal' hospital use was obtained by further studies. We queried all hospitals and allied institutions, and the hospital per capita consumption for the country as a whole was determined and applied to the several communities.
"We also queried scientific research institutions such as experimental laboratories both private and commercial. The reports from these laboratories were not satisfactory inasmuch as the percentage of replies was too small for purposes of general application.
"Comments.
"1. Whatever the danger of generalizing from insufficient data, the paucity of numerical facts upon which to base an estimate of the country's needs in these drugs is so great as to render desirable almost any rational effort to secure them. It should be appreciated, however, that studies involving many times the population covered by the Committee's investigation might have elicited additional important facts and might have exposed for review and consideration conditions and factors not included in the six studies with which this preliminary report is concerned.
"A consideration of the findings in the individual communities studied, the difference in per capita consumption of the same preparations and the employment in each of certain preparations not included in the others, all make for the desirability of further investigations of this nature and point to the entrance of inevitable error into the findings observed from any too small group of data.
"2. It should further be borne in mind that the yearly need of opium and coca leaves and their derivatives may quite conceivably vary. Unusual conditions of disease incidence, wars, uprisings and other catastrophes may require without warning large additional supplies.
"3. It should also be noted that theft and wastage affect the amounts of these drugs required and in view of their irreplaceable nature in general and special medical practice these factors should be given due consideration.
"4. The requirements for scientific research are also factors of importance as affecting the amounts of these drugs to be provided.
"5. A further consideration is the effect of the recent prohibition of the manufacture of diacetylmorphin and its salts on the future requirements of opium. In view of this action there will be presumably an increased use of substitutes such as codein and morphin and the manufacture of these substitutes, because of the relatively larger doses employed to obtain the same therapeutic effect, will require a greater importation of opium than was needed for the diacetylmorphin.
"8. Use as employed in this study is necessarily restricted to use under the provisions of existing federal law. Whether that law adequately covers all legitimate needs in connection with the use of these drugs, this report does not presume to determine."
Tables Nos. XIII and XIV show the findings in the communities where studies were made, the per capita for these communities, and the amounts of opium and coca leaves resulting from the application of each per capita to continental United States.

TABLE XIII
TOTAL NARCOTIC USE IN SIX COMMUNITIES
Cities and adja-    Popu-    Physicians        Drug stores        'Hospitalat        Totals   
cent districts    lation *                               
In terms of crude        In terms of crude        In terms of        In terms of crude   
drug        drug        crude drug        drug   
Theoreti-    Practi-    Theoreti-    Practi-    Theo-    Prac-    Theoreti-    Practi-
cal    cal    cal    cal    reti ca!    ti cal    cal    cal
basis    basis    basis    basis    basis    basis    basis    basis
grains    grains    grains    grains    grains    grains    grains    grains
Sioux City, Ia        106,023    81,330    54,132    308,958    337,701    41,444    45,346    431,733    467,180
Montgomery,Ala.    80,853    76,037    76,745    966,109    1.019,447    31,605    34,580    1,073,752    1,130,774
Tacoma, Wash        152,531    51,653    53,229    482,667    517,124    59,624    65,237    593,945    635,592
Gary. Ind        82,566    37,167    43,198    210.313    230,596    32,275    35,313    279,755    309,108
Elmira, N.Y        69,913    150,451    152,491    781.558    806,374    27,328    29,901    959,338    988,768
El Paso, Teaxs        120,191    28,874    29,955    473,066    519,832    46,982    51,405    548,923    601,194
Sioux City, Ia        106,023    2,931.265    2,933,972    1,026,192    1,026,447    349,706    349,759    4,309,164    4,310,179
Montgomery.Ala.    80,853    434,015    434,124    969,931    970,167    266,685    266.725    1,670,632    1,671,017
Tacoma, Wash        152,531    3,199,409    3,199,956    740,855    740,984    503,108    503,184    4,443,372    4,444,125
Gary, Ind        82,566    261,952    262,020    394,949    394,993    272,335    272,376    929.237    929,391
Elmira, N  Y        69,913    1,465,223    1,485,589    116,818    118,831    230,601    230,835    1,812,642    1,813,056
El Paso, Texas        120,191    139,477    139,490    525,719    525,852    396,437    396,498    1,061,835    1,061,841
*Population bawd on interceneal estimates of the U. S. Bureau of the Census.
fFigures in this column were obtained by applying per capita derived from hospital survey.
The dangers inherent in generalizing from local figures become obvious on viewing the per capita arrived at in Du Mez's study of Allegany County, Md., and those resulting from the six studies made by the Committee on Drug Addictions. The lowest figure, that of
Gary, Indiana,-3.39 grains—is but one-fourth the amount of the highest figure obtained-13.72 grains in the Elmira, New York study.

TABLE XIV ESTIMATED NEEDS FOR CONTINENTAL UNITED STATES FOR PERIOD COVERED ON BASIS OF PER CAPITA USE IN SIX COMMUNITIES STUDIED
Cities and adjacent districts    Per capita use        Application to Continental United States *   
Theoretical    Practical    Theoretical    Practical
basis    basis    basis    basis
gr.    gr.    lbs.    lbs.
Opium               
Sioux City, Ia.        4.07    4.41    64,342    69,718
Montgomery, Ala.        13.28    13.99    209,944    221,168
Tacoma, Wash        3.89    4.17    61,497    65,923
Gary, Ind        3.39    3.74    53,592    59,125
Elmira, N. Y.        13.72    14.14    216,900    223,540
El Paso, Texas        4.57    5.    72,247    79,045
Coca Leaves               
Sioux City, Ia.        40.64    40.65    642,480    642,638
Montgomery, Ala        20.66    20.67    325,667    325,824
Tacoma, Wash        29.12    29.14    460,360    460,676
Gary, Ind        11.25    11.26    177,852    178,010
Elmira, N. Y.        25.93    25.93    409,929    409,929
El Paso, Texas        8.83    8.83    139,594    139,594
* Population = 110,663,502—Based on intercensal estimate of the U. S. Bureau of the Census.
Such wide variations preclude the possibility of employing the average figure derivable from these studies as representing general conditions. It is quite conceivable that had more communities been studied even greater variations in local use might have been exposed and a very different "average" figure might thus result. Du Mez says in explaining the selection of Allegany County, Md.: " . . . it was thought that Allegany County represents as nearly as possible a normal unit . . . where conditions prevail which can be taken as typical of the country as a whole." The reasons for the selection of the six communities studied by the Committee on Drug Addictions have been stated above but in view of the final figures reached we must conclude that any one or none of the seven localities studied may be typical of the whole country.

As to what factors contributed to these widely different findings we may only speculate as yet. The roles played by such possible influences as disease incidence, population composition, occupation, medical training and custom, sanitary equipment, etc., as well as of other less obvious factors have not been determined and cannot be accounted for. We believe, therefore, that in spite of these studies the selection of a per capita figure susceptible of general application must still be more or less arbitrary and therefore hazardous.
In the use of any per capita figure obtained from studies such as the above of the legal distribution of the drug as a basis for the computation of narcotic requirements, we should take into consideration a factor which affects in varying degree the amount of the drug legally distributed. Such a factor is comprised in the purchase of their supplies of the drug from the illicit peddler by so-called legitimate cases of addiction in order to avoid official record, because their physicians are afraid to prescribe for them, or for other reasons.
In the present use of the term "legitimate user" we refer to those individuals who for any reason are incurable and hence require the continued use of the drug and to those who because of lack of facilities have been unable to find relief.
That such cases of legitimate use exist is known, but their number and the extent to which they affect the above estimated per capita is at present a matter of speculation.
That the findings in the six studies made by the Committee on Drug Addictions were influenced by this factor is very probable. Thus in the two communities giving the highest figures of per capita use—Montgomery, Ala., and Elmira, N. Y.—special arrangements existed for supplying incurable cases of addiction through legal channels, while in the other four localities in which the legal use of opium and its preparations was very much less, no such provision had been made and the assumption is that to a greater degree in these localities such cases secured their supplies from other than legal channels.
Another estimate of narcotic use has been made recently as the result of a questionnaire sent out by Dr. Carleton Simon in June, 1923, to all of the physicians and dentists in New York State. Simon reports as follows: 22

"As to the quantity of narcotics used and prescribed by physicians and dentists in the state of New York as an index to the legitimate demands per capita, replies to the questionnaires revealed that in 1922, 7,559, or 51.37 per cent, of the physicians of this state prescribed 1,392 ounces, or 43,296 gm., of morphin, and 30 ounces, or 933 gm., of heroin.
"The basis of 1,392 ounces, or 43,296 gin., of morphin used by 7,559 physicians established an average of 5.727 gm., for each physician, which, when applied to 14,715 physicians in the entire state, gives a total of 2,709 7/10 ounces, or 84,272 gm., of morphin prescribed by the physicians of this state during the year 1922.
"On this basis also, 30 ounces, or 933 gm., of heroin prescribed by 7,559 physicians would give an average of 0.1234 gm. for each physician, which, when applied to 14,715 physicians in the entire state, gives a total of 58 88/100 ounces, or 1,815.83 gm., of heroin prescribed by the physicians of this state during the year 1922."
On the above basis of 5.727 gm. morphin and 0.1234 gm. heroin for each physician, the needs of the 145,966 physicians in the entire country in these two drugs would be 835,947.28 gm. or 29,487 oz. morphin and 18,012.2 gm. or 635.36 oz. heroin. It should be noted that this survey did not cover opium derivatives in any other forms than morphin and heroin. Likewise it did not include the use of opium and its preparations in hospitals and allied institutions and research laboratories, or the amounts used in exempt preparations sold over the counter.
Two more recent estimates of the amount of opium required for medical purposes are of interest as they are the result of different methods from those already considered.
In 1926 in the "Report by the Government of the United States of America" on "The Traffic in Opium and Other Dangerous Drugs for the year ended June 30, 1926," certain figures are given showing the per capita use, in grains of morphin, of morphin and crude opium in continental United States. This report does not include in its morphin per capita figure the amount of codein used in terms of morphin from which codein is made, but limits itself to what it considers the two important drugs—opium and morphin—inasmuch as it states that codein has but slight habit-forming effect. The following quotation is self-explanatory:
‘. . . . During the year 1926 the quantity of morphine sold by manufacturers thereof, less the quantity exported, totaled 102,845 ounces, which is probably a fair indication of the home consumption of this drug in whatever form required for legitimate purposes. In this connection it may be noted that the figure for legitimate morphine consumption during 1925, ascertained in the same manner, was 105,235 ounces. The officially estimated total population of the continental United States on June 30, 1926, was 117,136,000. The total net sale of 102,845 avoirdupois ounces of morphine is equivalent to 44,994,687.5 grains, which, divided by the population as officially estimated, would indicate an average per capita consumption for 1926 of 0.384 grain. Similarly, during 1926, a net quantity of 10,736.5 pounds of opium in medicinal form was sold for domestic use, or an equivalent of 75,155,500 grains. This figure, divided by the figure for the officially estimated population, gives 0.64 grain as the per capita consumption of opium for 1926. Since opium is equivalent in morphine to only about 10 per cent of its weight, it follows that the per capita consumption of opium in terms of morphine is equivalent to 0.064 grain. The two figures added together give a total per capita consumption for 1926 covering opium and morphine combined of 0.448 grain or, with slight approximation, 0.45 grain. It appears unnecessary to consider other products of opium in this connection, such as codeine, dionin, narcotine, as their habit-forming effect is slight as compared with opium and morphine. Moreover, since the legitimate drug market in the United States is practically devoid of heroin, it is unnecessary further to consider that drug in determining the domestic consumption for legitimate purposes. The Government, therefore, urges all concerned to take notice of the foregoing figure and fully observe that the annual legitimate consumption in the United States of the admittedly dangerous and vicious habit-forming drugs producible from the poppy plant is less than the equivalent of one-half grain of morphine per person."
The figure given in the above quotation of 0.45 grain of morphin as representing the per capita use of this drug in continental United States is not comparable with figures which have been published from time to time dealing with the opium per capita consumption of continental United States, or with the opium per capita consumption of other countries, inasmuch as codein is not considered.
In another paragraph this report states that the amount of codein estimated to be used during the same fiscal year is 136,220 ounces. In order to determine the opium per capita consumption involved in these various amounts, we have converted the codein into grains of opium which would have been used in the manufacture of this codein. In the following table are given the figures involved:
Morphin used in terms of opium        449,946,875.0 grains   
Opium used as such        75,155,500.0    "
Codein in terms of opium used for its manufacture        662,180,555.0    "
Total, in grains of opium        1,187,282,930.0    "
This total represents the number of grains of opium used in continental
United States-1,187,282,930. Divided by the official estimated popu-
lation of 117,136,000, we obtain 10.13 + grains as the opium per capita figure for continental United States. This figure is higher by approximately 3 grains than that estimated to be sufficient by the Advisory Committee on Opium and other Dangerous Drugs.
In 1927 the "Report of the Government on the Traffic in Opium and Other Dangerous Drugs" supplies similar information to that given in the report just quoted. Making the necessary calculations, we find that for the fiscal year ending June 30, 1927, the opium per capita figure for continental United States was 9.83 grains.
In considering these figures, it must be borne in mind that they represent with considerable accuracy the amount of drugs "sold by manufacturers," as the report states. However, they do not take into consideration the stocks on hand at the beginning and end of the fiscal years in retail drug stores, hospitals, and in the hands of physicians, dentists, and veterinarians. As has been stated already the actual consumption figure can be determined only from the end distributors, i.e., retail druggists, hospitals, physicians, dentists, and veterinarians.

1 Opium Problem. Message from the President of the United States transmitting . . . a report of the International Opium Commission . . . Senate Doe. No. 377, 61st Congress. 2nd Session.

2 Ex. Doc. No. 79. House of Representatives 50th Congress. 1st Session.

3 Importation and Use of Opium. Hearing before the Committee on Ways and Means of the House of Representatives, 61st Cong., 2nd Sess. May 31, 1910. $200 per pound.

4 For text see Appendix V. °For text see Appendix VII z For text see Appendix VIII.

5 "In a prosecution against a physician for violating Harrison narcotic law by dispensing narcotics to habitual users of the drugs, the exclusion of a letter from the Commissioner of Internal Revenue in response to a query by defendant physician as to dispensing of narcotics held proper. (Thompson v. United States, 258 Fed. 196).

6 Indictment which charged that defendant, a practicing physician, did feloniously, etc., sell, exchange, barter, and give away a specified quantity of morphine sulphate to a person named, not pursuant to an order on a form issued by the Commissioner of Internal Revenue by issuing and dispensing a prescription to such person, not a patient of the physician, which morphine was dispensed and distributed by the physician, not in the course of his professional practice only, was sufficient. (Jin Fuey Moy v. United States, 254 U. S. 189.)

7 (a) The acts of the principal become the acts of the accessory or aider, and he may be charged as having done the act himself, and be indicted and punished accordingly, under Penal Code, section 332, making the accessory a principal. (DiPreta v. United States, 270 Fed. 73.)
"(b) A person dealing in drugs is required to ascertain at his peril whether that which he sells comes within the statute, so that an indictment for violation of that section need not allege that defendant knew the character of drug sold. (United States v. Balint, 66 L. Ed. 352, 42 S. C. R. 301.)
"(c) Nothwithstanding Harrison Narcotic Act, section 2, exception (b), except-ing sales of the prohibited drugs on the written prescription of a registered physician, a sale by a druggist, who knows that the prescription was issued to gratify the holder's appetite and not to cure disease or alleviate suffering, violates the law, and the physician issuing the prescription, knowing it is to be filled by a druggist having such knowledge, aids and abets the violation.
"Knowledge by a druggist that a prescription under the Harrison narcotic law was issued to gratify the holder's appetite, and not to cure disease or alleviate suffering, is essential to guilt, and negligent failure to inquire will not take the place of knowledge.
"On a trial for aiding and abetting violation of the Harrison narcotic law, exceptions to the charge on the ground that there was no evidence of the facts hypothesized by the court in its instruction respecting knowledge, and knowledge was immaterial when the sale was made on the prescription of a registered physician, did not raise the point, presented no appeal, that the charge authorized conviction, though the druggist had not actual knowledge if he negligently failed to make inquiry. (Doremus v. United States, 262 Fed. 849.)
" "(a) Expert testimony as to proper method of treating addicts admissible. (Reeves v. United States, 263 Fed. 690.)
"(b) In a prosecution under Harrison Narcotic Act, section 2, against a physician who sold large quantities of narcotics to habitual users of the drug, medical testimony as to recognized methods among physicians for treating persons addicted to the use of narcotic drugs was admissible for the purpose of showing that the accused physician did not come within the exception as to physicians dispensing drugs in the course of their practice, for, while the act is in the guise of a revenue measure it was intended to accomplish a moral purpose. (Thompson v. United States, 258 Fed. 196.)

8 "An order issued by practicing and registered physician for morphine to an habitual user thereof, the order not being issued by him in the course of professional treatment in the attempted cure of the habit, but being issued for the purpose of providing the user with morphine sufficient to keep him comfortable by maintaining his customary use, is not a physician's prescription within exception (b) of section 2 of the Harrison Narcotic Act. (Webb and Goldbaum v. United States, 249 U. S. 96.)

9 ""(a) In prosecution of physicians for having violated and conspired to violate the Harrison Narcotic Act, the trial court in his general charge properly submitted an issue as to the good faith of defendants in issuing their prescriptions to supposed patients, since the defendants could only protect themselves if the prescriptions were issued legitimately in their practice. (Melanson v. United States, 266 Fed. 783.)
"(b) In a prosecution for violation of Harrison Narcotic Act, section 2, by selling narcotic drugs, not in pursuance of written orders on the prescribed forms, evidence that defendant, although a physician registered under the act, did not dispense the drugs in good faith in the course of his professional practice, which would bring him within exeception (a) of the statute, but sold the same to gratify the appetite of the purchasers, was competent and relevant, and such issue was properly submitted to the jury. (Oakshette v. United States, 260 Fed. 830.)

10 "(a) A careful review of the decisions as they exist at the present time makes clear the fact that when a physician is charged with unlawfully selling or prescribing drugs under the Harrison Act, the case turns largely upon his good faith in prescribing drugs to his regular patients for maladies requiring the administration of the drug or whether he prescribed for persons seeking his professional aid merely to procure the drug. In the latter case the physician might, perhaps, in a single instance afford temporary relief for one whose condition demanded immediate treatment. To go further than this would enable every doctor to do just what the defendant did here—furnish drugs to addicts or afford opportunity to them to procure all the narcotics. they desired—as unrestrained they would go from one physician to another, and thus quickly destroy the whole purpose of the act in question. (Louis D. Barbot v. United States, 273 Fed. 919.)

11 "(b) The purpose of antinarcotic act is to confine the distribution of narcotics to the regular and lawful course of professional practice, and not every order therefor written by a duly registered physician in the form of a prescription is necessarily a prescription within the exception. If the offense is a statutory one, and intent or knowledge is not made an element of it, the indictment need not charge such intent or knowledge. An indictment charging that defendant, a duly registered physician, by means of three prescriptions sold to one whom he knew to be a drug addict, at one time heroin, morphine, and cocaine equivalent to more than 3,000 ordinary doses, without directions or restrictions as to the use thereof by the addict, shows the sale was not within the exception to antinarcotic act. (United States v. Behrman, 66 L. Ed. 345; 42 S. C. R. 303.)
"(c) A physician held chargeable with the offense of selling opium in violation of Harrison Act, section 2, where for a consideration he issued an order or prescription for opium not in the regular course of his practice, but to an addict, for a prohibited use, although the prescription was filled by a dealer who acted in good faith and without knowledge that it was wrongfully used. (United States v. Emil H. Keidans, 270 Fed. 585.)

12 A physician who writes prescriptions for unusual quantities of drugs or a dealer who fills such a prescription is guilty of an offense unless the prescription indicates the necessity for such an unusual quantity. (United States v. Curtis, 229 Fed. 288.)

13 "' For text see Appendix VIII.

14 "C. 0. Linder vs. The United States of America. On Writ of certiorari to the U. S. Circuit Court of Appeals for the Ninth Circuit. Supreme Court of the U. S. No. 183. October Term, 1924. (April 13, 1925.)

15 See Appendix IV for text of Act.

16 The Narcotic Drugs Import and Export Act and the Regulations thereunder—May, 1923.

17 "Lambert, Alexander—The Amount of Opiates Used in the Legitimate Practice of Medicine. J. A. M. A. May 20, 1922. Vol. 78. No. 20.

18 "DuMez, A. G.—Per Capita Medicinal Requirements of Narcotics. Data Secured in a Narcotic Survey of Allegany County, Maryland. Public Health Reports. Vol. 39. No. 37. September 12, 1924.

19 Committee on Drug Addictions, New York. Preliminary Report on Studies of the Use of Narcotics under the Provisions of Federal Law in Six Communities in the United States of America for the Period July 1, 1923, to June 30, 1924. New York. November, 1924.

20 "Simon, C.—Survey of the Narcotic Problem. J. A. M. A. March 1, 1924. Vol. 82. No. 9. pp. 675-679.