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the morphine a day, one after each meal and one before bedtime, are the best intervals for its administration. He urges a very gradual diminution of the daily dose, as more rapid diminution would defeat its object by causing hardship and compelling the increase of dosage. If the patient has been taking very large doses, it is not very difficult to reduce the enormous amounts, but it must be gradual down to 1 grain a day, and from 1 grain down to nothing must be very gradual, even to as little as 100 of a grain, or less, four times a day. This small amount seems absurd, but as a matter of fact, if water is substituted instead of this small amount, the patient will show symptoms. But long before the dosage has ceased, the patient is convalescent, the appetite has returned and nutrition is improving. With this method of reduction, as Pearson urges, the patient is being treated mentally and physically; his morale is encouraged, he has not suffered, and he is gaining in health every day.

Institutional treatment of a patient should not be considered complete until his nutrition has improved, and he has had hydrotherapy, massage, and finally out-door exercise, and then, if there is a diseased condition that has caused him to become an addict, this condition should be properly treated. If he cannot be cured, and no treatment other than a narcotic gives him comfort, he certainly will relapse.

All these patients need iron, and they may need organic extract treatment. Sometimes they develop a very great appetite, and the amount of food that they take should be regulated. All alcohol should be withheld from these morphine addicts, and they should be cured of a tobacco habit, as each one of these habits stimulates other habits, and the better they are cured of all habits, the less likely are they to return to the morphine habit.

COCAINE ADDICTION

The use of cocaine is becoming less and less frequent as laws against obtaining it have been longer in force than those against morphine. Often these addicts have the morphine or heroin habit combined with the cocaine habit; but the cocaine habit is more deplorable than the morphine habit, as the demoralization and the systemic injuries that cocaine causes are greater

than those caused by morphine. No patient can take cocaine for any great length of time without being seriously injured.

The treatment for removal of the addiction is by control, purging, nutrition, nerve sedatives, and cardiac stimulants, the exact method being governed by the condition of the patient.

REGULATED TREATMENT OF DRUG ADDICTS

Theoretically with the long continued action of the Harrison Narcotic Law, drug addicts should become less and less frequent. Until this sad condition is eradicated, each community should appoint a medical member of its health department to have charge of all addicts of his locality. This physician should be furnished with an institution where these sufferers can be properly treated, and no one but this medical appointee or his assistant should be authorized to write prescriptions for, or give morphine, heroin or cocaine to an addict. If the addict has an incurable disease he may be treated regularly by his own physician, but, if he is an addict without an incurable serious disease, there can be no excuse for not placing him where he can be cured of his habit. There is no other good way of treating this kind of a patient; office treatment is not justifiable. To promote cures and for necessary statistics every case of drug addiction should be confidentially reported to the Board of Health or to some other properly constituted authority. Records of such cases should be protected as strictly confidential and the patient should be given a number, and on reports and in correspondence he should be known by his number. If he enters the special hospital, he should be known to the attendants by number.

The necessity for Public Health officials to more seriously consider the drug addiction question will be shown by a few statistics.

Dr. S. Dana Hubbard' shows the magnitude of the traffic in narcotic drugs by quoting the following figures: "The average yearly consumption of opium for the period from 1910-1915 was 491,043 pounds, which at the price of $40 a pound would make a total value of $18,841,720. The average consumption of coca leaves for the same period was 1,048,250 pounds. At the 1 Journal A. M. A., May 22, 1920, p. 1439.

present price of $1 a pound this would represent approximately $20,000,000."

He says that it has been estimated that "about 90 per cent. of the opium and cocaine imported is used for other than medicinal purposes; and 80 per cent. of the addicts visiting the New York Department of Health Clinic are young men and women just out of their teens."

Hubbard thinks that no less than half of the addicts can be brought back to useful lives, and he states that "bad associates and evil environments are the chief causes in producing addiction among youthful habitués in New York". The record for that city is probably not different from that of other cities. This opinion is shown to be correct by the Riverside Hospital (North Brothers Island, N. Y.) Statistics furnished by T. F. Joyce,' the physician in charge. He finds that the overwhelming majority of these patients come from the under world, and largely began to use the drug through association with habitués. Predisposing causes of the drug habit he finds to be "late hours, dance halls, and unwholesome cabarets," especially if the individual is a little subnormal mentally. Joyce describes the treatment at this hospital as follows: As soon as the individual is admitted, his clothing and belongings are removed, and he is given a new outfit, even including hospital shoes. He is then taken to a preparatory ward where, after a period of six days, the dose of the narcotic is brought down to the lowest amount that will prevent the signs of drug privation, which is from 2 to 3 grains in twenty-four hours, even if the addict has been consuming as much as 20 to 60 grains of morphine or heroin a day. "Four-fifths of 2,300 patients treated at the Riverside Hospital were addicted to heroin, while about one-fifth was addicted to morphine or other form of opium." About 12.5 per cent. of the heroin addicts also used cocaine.

The treatment was catharsis, but not drastic purging, with capsules containing calomel, ipecac, rhubarb, atropine, and strychnine. The patients were also given saline colonic irrigations. Scopolamine hydrobromide is the hypnotic used 1 New York Medical Journal, Aug. 14, 1920, p. 220.

at this institution, and while this drug is being pushed they do not give food, but give large quantities of alkaline waters.

After the drug of addiction has been completely withdrawn and the patient is practically through with his scopolamine period, which is in about a week or ten days, he is sent to a convalescent ward for physical reconstruction. Later, after light exercises, the patients are assigned to some work, under the name of "occupational therapy.

TOBACCO HABIT

The cigar consumption in the United States has shown some decrease in the last three or four years, from over eight billion in 1917 to over seven billion in 1919. The cigarette consumption has increased from 8 billion 500 million in 1910 to 46 billion in 1919. The use of chewing and smoking tobacco in the same time has also increased enormously, more than 400 million pounds. For the fiscal year of 1919 the revenue of the Government from the tax on tobacco was 206 million dollars.

According to Professor Henry W. Farnam1 the amount spent on tobacco by the people of the United States in the fiscal year of 1917 was probably not less than $1,200,000,000. For comparison of figures, Professor Farnam notes that "the value of all metals mined in the United States in 1915 was $992,816,000., while the coal, both hard and soft, mined in 1915 amounted to $686,691,000, while the cost of building operations in fifty-one largest cities of the United States in 1916 was $780,183,000.; the total cost of education including the common schools, universities, etc., in 1916 was $914,804,000.; and the expenditure on highways in 1916 was $290,000,000.; the toal receipts from passenger service on railroads, including parlor cars, in 1916 was $652,027,000.”

Farnam notes that Great Britian consumed, the year before the war, 2.09 pounds of tobacco per capita to our consumption of 5.57 per capita. Therefore, if we should be satisfied with the amount of tobacco with which Great Britian is satisfied per capita, we would reduce our tobacco bill by $720,000,000. In other words, if we used no more tobacco than Great Britian 1 The Investment Weekly, March 23, 1918, p. 18.

used, we could have duplicated in two years nearly all the buildings built in the fifty-one largest cities of the United States, or we could have added 80 per cent, to our expenditure on education, to say nothing of the loss of efficiency by very many of our working men of all ages through the excessive use of tobacco. Professor Farnam also notes that if we had used the amount that we paid for tobacco more than Great Britian, we could have given some education to a large part of the 5,500,000 illiterates shown to be in this country in 1918. To put it another way, Professor Farnam some years ago estimated that the amount paid by tobacco users in this country was annually about three times the entire cost of the Panama Canal.

The fire cost in the United States from careless smokers is simply tremendous, and the ones most careless with lighted matches and lighted tobacco are the cigarette smokers.

The fine sense of courtesy and thoughtfulness for others seems frequently to be lost by even the best of men who smoke excessively, and such defects are particularly noticeable in the cigarette smoker. If not prohibited, the latter will invade every apartment and compartment, public or private, with his cigarette and its fumes, generally purely thoughtless and not meaning to be discourteous.

The loss of efficiency in mental and manual work is very great in those who over-smoke, and the loss of mental efficiency by young growing boys who smoke cigarettes has long been demonstrated, and is a positive fact. It has also been demonstrated that a large number of delinquent boys and boys who reach the courts through misbehavior are largely cigarette smokers. Also many cigarette fiends become later "dope" fiends, and young men who were wont to take too much alcohol were also frequently very hard smokers, mostly of cigarettes. In other words, the use of tobacco in young boys and the over-use in young men is conducive to bad morals in all lines, and the greatest disturbance to mental efficiency seems to occur in those who use cigarettes.

In all training for athletics tobacco is withheld from the participants by the trainers. In spite of this fact, our soldiers in

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