Causes of the Chronic Abuse of Narcotic Drugs

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Author: Erich Knaffl-Lenz
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Creation Date: 1952/01/01

GENERAL

Causes of the Chronic Abuse of Narcotic Drugs

Pr. Dr. Erich Knaffl-Lenz

Dr Erich von Knaffl-Lenz, Professor at the University of Vienna, took an active part, as an expert in pharmacological and chemical questions, in the drafting of the 1931 Convention for the Limitation of the Manufacture of Narcotic Drugs Dr. von Knaffl-Lenz in a first article studies causes of the chronic abuse of narcortic drugs, and in a second article gives an account of his experiences as an expert of the League of Nations.

The non-medical use of drugs and chemical compounds which are subject to the provisions of the Opium Convention on account of their detrimental effects on health cannot be combated effectively until the numerous causes of such abuse have been ascertained. It is not simply a medical and administrative problem but rather one of social hygiene, of economics and, not least, of criminology.

Before describing the work of the League of Nations, it will therefore be useful to discuss some of these questions briefly and to state the views which the present writer has formed in the course of many years' work as an expert at the League.

The need for substances which have a pleasurable effect on our sensory organs or have a stimulating or narcotic effect on the central nervous system has been felt by all peoples since early times. Substances of the latter kind also played an important part in religious ceremonies and festivals.

Though themselves devoid of nutritive value, when added to food, they have the property of enhancing its flavour and hence its attractiveness by stimulating the nerves of taste and smell and of substantially increasing its digestibility by stimulating the secretion of saliva and digestive juices. Their action is confined to the sensory organs, and even their chronic use does not result in a morbid craving or in damage to health. But there are some which in addition have a stimulating or narcotic effect on the central nervous system, as is the case, for example, with tobacco, alcoholic and caffein-containing beverages. Though harmless if consumed in moderation, they may be conducive to improper use, resulting in addiction and over-dosage and hence in damage to the nervous system.

The German language describes such drugs or preparations of drugs as "means of enjoyment" ( Genussmittel) as opposed to "means of nourishment" (Nahrungsmittel), since their sole value lies in affording pleasure. There is no equivalent term in either English or French.

A common feature of all these "means of enjoyment" is the fact that they are not simple substances but drugs or preparations of drugs. Their value lies in the combined action of several substances, which are often not present in the original drug, but are formed in the process of roasting or fermentation, in the course of which the substances acting upon the nervous system sustain a substantial loss but no diminution of their pleasure value.

By reason of their complex action, they possess not merely sensory but mental properties. Smell, colour and taste affect our senses pleasantly, thereby furnishing aesthetic pleasures, creating illusions, inducing pleasant moods, suppressing the consciousness of inhibiting influences, and thus providing temporary distraction from the cares of everyday life. Their, mental action can stimulate or facilitate intellectual or creative work. The extent of such action is substantially affected not only by the personality structure but also by the cultural level of the user. It may therefore well be that intellectual workers - scholars, musicians, artists and writers - are precisely those who have a stronger and more varied need for such drugs. Their complex action on an over-refined and sensitive nervous system may be such that they are not felt to be in any way disturbing.

The nicotine content does not play a decisive role in the enjoyment of tobacco. If that were so, solutions of nicotine would be a much less expensive substitute. Decisive factors in its enjoyment are the packing, the form and colour of the cigar, the wrapper, the aroma, the type of pipe, etc. All the senses are engaged in smoking - touch, sight, smell and taste. Feelings of hostility which might be aroused by an unwelcome interruption of work do not materialize, because the occupation of all the senses produces an impression of activity, which is in fact non-existent. Boredom does not arise, mental work is more readily accomplished, disturbing anxiety is relieved, fatigue is banished, and preoccupation with the ego is lessened with a resultant increase in sociability. These psychical effects facilitate the course of negotiations, as we know from the pipe of peace and the good cigar

With neurotics, however, the action of nicotine on the vegetative nervous system is also of importance. For them tobaccos with a low nicotine content do not produce the desired effect. Addiction soon develops, as does a craving for the effect of nicotine, which is difficult to suppress. The pure "means of enjoyment" thus becomes an intoxicant.

The situation is very similar in the case of alcoholic beverages. When consumed in moderation for pleasurable aroma, colour and taste of wine and for their effect of producing mild euphoria and conducing to sociability, they may be regarded as a harmless means of enjoyment. Where, however, they are consumed in the form of more or less diluted pure alcohol for the purpose of producing intoxication, there is a risk of chronic abuse and of serious damage to health; the harmless stimulant becomes the dangerous intoxicant which led to the almost complete extermination of certain populations.

The value of caffein-containing beverages as stimulants is only in small part attributable to the action of the aromatic by-products produced through the roasting or fermentation process; it is almost exclusively due to the stimulating effect of caffein on the brain, as a result of which fatigue is banished, mental concentration and the process of thought facilitated and a mild state of euphoria produced. Alcoholic beverages are capable of producing the same effects but do so by narcotic action, through which disturbing inhibitions and hostility feelings are removed.

But physical capacities are also heightened. The psychomotor stimulation, which is not unwelcome in sport but is disturbing to mental activity, is weakened by the volatile oils contained in tea. Tea is therefore the appropriate stimulant for intellectual workers and coffee for those who engage in sport.

Caffein-containing beverages are unlikely to lead to abuse, since, if taken in large quantities, they have unpleasant subsidiary effects, such as palpitation, sleeplessness, nervousness and digestive disturbances.

While physiological effects may be the same in different races, the psychical effects vary. They are affected by the psychical make-up, by tradition, culture and the degree of development. It is natural that the imaginitive Oriental should find a particular pleasure in the action of hashish, which stimulates his imagination and gives him the illusion of an artificial paradise, that the contemplative Asiatic should prefer the narcotic effect of opium while the active Northerner takes greater pleasure in the stimulating effect of alcohol.

Alcohol was well known to the aboriginal inhabitants of America and Australia before their discovery by white men. It was not, however, used as a "means of enjoyment" but solely in connexion with ceremonies and religious celebrations. It was their conquerors who first introduced them to the abuse of pure alcohol, which proved to be a deadly poison to their peoples.There is thus no substance which is per se a "means of enjoyment" or an intoxicant.

To sum up what the "means of enjoyment" have to offer to the healthy individual, we must conclude that their moderate use is conducive to both physical and mental pleasure, which, depending upon the personality of the user, can have most valuable effects and can add to the beauty of life. There is therefore no ground for restricting their consumption.

But in addition to these relatively harmless means of enjoyment there are drugs, which have therapeutic value by reason of their stimulating or depressing effects on the central nervous system, but which on account of these effects are liable to abuse by normal persons and particularly by neurotics; the chronic use of such drugs may be seriously harmful to health and may become a deadly poison for whole peoples.

Such drugs were used in the earliest times by all peoples in connexion with religious ceremonies, since they were capable of transporting those who used them into a condition of heightened instinctive and emotional as opposed to intellectual activity, in which sub-conscious impulses and wishes are brought to the surface and the conscious ego detached from the external world. The illusion of contact with the supernatural and the ability to foresee the future is thus created.

These drugs differ from "means of enjoyment" in that they are used only for their effect on the brain and that their psychic effects depend essentially on the personality structure of the user. They include in the first place opium, the morphine extracted therefrom and its derivatives, and also cocaine and hashish (marihuana).

The decisions of the International Opium Conference to which these drugs are subject are intended to make their non-medical use impossible, by ensuring that only such quantities are produced as are required for purely medical purposes.

Since the physiological effects of the drugs in question vary, it is not possible to find a common description for them in any language. Opium is a purely narcotic poison, the stimulating effects of which are probably to be attributed to paralysis of the inhibitory centres. Cocaine is a pure stimulant, and hashish or marihuana are first stimulating and then narcotic. Unlike the other two drugs, morphine does not cause any intoxication. Addiction in the strict sense of the word - and then exclusively in persons with a predisposition - is caused only by morphine and its derivatives, and possibly by hashish.

The various descriptions such as "narcotic drugs", stupéfiants, Betäubungsmittel and Rauschgiftor Suchtgiftare therefore inaccurate. Only the description "substances falling under the provisions of the Opium Convention" would be correct.

The effects of many extraneous substances grow steadily weaker when they have remained in the system for a considerable time. In order to achieve the original effect, the doses must be constantly increased. That is particularly true in the case of substances affecting the nervous system, such as the opiates, the soporifics, alcohol and nicotine. The reasons for this are various: the phenomenon may be attributable to speedier destruction or excretion, to conversion into substances that do not produce any effect or to reduced sensitivity of the cells affected. In this connexion the terms habituation or increased tolerance are employed. This is to be regarded as a defensive biologicalreaction.

Whereas in the case of mentally healthy people the absorption of opiates alleviates bodily pains, eliminates cramps, and induces tiredness and increased disposition to sleep, and in large doses produces narcosis, there is a type of person who reacts with a hitherto unknown feeling of well-being and happiness called euphoria. The desire for a repetition of this experience soon asserts itself and demands ever-increasing doses. In the end, the individual is unable any longer to withstand this morbid desire unaided. If the desire is not satisfied by a renewed dose of morphine, severe morbid mental and physical symptoms appear and create a compulsion to further misuse of morphine.When this condition, which is described as toxicomania, has established itself, further doses of morphine do not induce euphoria but serve only to prevent the outbreak of abstinence symptoms.

Whereas after the administration of morphine has been discontinued and physical recovery achieved a person not chronically infected with morphine feels no further desire for morphine and reacts with only slight symptoms of abstinence, a morphine addict requires, after dishabituation and physical recovery, continuous mental and physical treatment in an institution in order to be cured of his morbid desire and made fit for work again.

The disposition to addiction may be regarded as a latent disease which does not become manifest until morphine has been administered.

People predisposed to addiction belong to a type of neurotics characterized by a disparity between their abilities and their need for recognition. This disparity is based, not on lack of intelligence, but on reduced powers of concentration and endurance, caused in turn partly by over-excitability and partly by the tendency of the nervous system to become easily and quickly fatigued. Organic sensations and fits of depression are felt much more strongly and cannot be overcome, as in the case of healthy people, by the individual's own resources.

The psychopathic symptoms of a disposition to addiction can often be traced back to early infancy and include lack of appetite, hypersensitivity to noises, smells and pain, susceptibility to mental and physical fatigue, disturbed sleep, inclination to depression andvasomotor disturbances, etc. In the case of adults, predisposition to addiction is largely determined by the type of reaction to such mental disturbances.

The effects of codein and similar morphine derivatives differ from those of morphine in that they lack its analgetic properties, though the other effects differ only quantitatively. In cases of prolonged usage, and where the doses were larger than those required for purely therapeutic purposes, habituation and chronic poisoning were occasionally established, but no addiction. Not until the 1930's were cases of true codein addiction reported in Germany and Poland. These cases displayed symptoms of addiction similar to but weaker than those displayed by morphine addicts. Then reports of such cases came in increasing numbers from Canada and the United States of America. The difficulty of obtaining morphine made morphine addicts try to find a substitute in codein, of which they took large doses (up to 4 grammes) in subcutaneous or intravenous injections. In such large doses, codein also has analgetic properties. This last characteristic would therefore seem to be decisive in causing addiction. It has hitherto been found that all the new synthetic substitute products having the effects of morphine are more or less capable of producing addiction. It would be interesting to determine whether there is any correlation between the strength of the analgetic effects and the intensity of the addiction caused. Experiences with heroin and also with eucodal would seem to indicate that such a correlation exists. According to those experiences, it is the psychopathic constitution and reaction of the individual rather than the chemical composition of the compound which seems to determine whether a compound has any addiction-causing properties or not. If this hypothesis is correct, there would appear to be no prospect of finding a compound with the analgetic properties of morphine and without the tendency to produce addiction in those predisposed thereto.

At the end of the last century a morphine derivative, diacetylmorphine, was discovered, which was called heroin, on account of its heroic effects, these being about three or four times as strong as those of morphine. Since it is also a stimulant and induces euphoria even in small doses, it at first enjoyed great favour in institutions for the treatment of pulmonary diseases. It soon became manifest, however, that not only the therapeutic effects, but also the toxic effects were considerably stronger, that it led much more quickly to addiction, that the addiction it produced was much more difficult to treat because of the severe damage to the circulatory system, and finally that the resultant moral disintegration was also much more extreme than in the case of chronic misuse of morphine. On the basis of this experience, warnings against the use of heroin were issued in Germany at a very early stage. Its use in clinical hospitals practically came to an end, whereas in England and France it is still much used by practitioners. When it was discovered that it could be absorbed through the nostrils like cocaine, it was quickly welcomed in consumer circles on account of its stimulating effects and its ability to eliminate inhibitions and self-control, and it became the most, serious competitor of morphine and cocaine.

Whereas to mentally healthy people morphine does not offer any temptation to misuse, even healthy people can be induced to misuse heroin because of its stimulating and sexually exciting effects.

Owing to its small bulk, heroin is more adapted to the illicit traffic than any other narcotic. It is understandable that in many countries diacetylmorphine should have been removed from the pharmacopoeia and its manufacture prohibited.

In Egypt, the misuse of narcotics, chiefly hashish and opium, was customary in certain circles before the First World War. Not until 1917, after large quantities of cocaine had been imported, did the consumption of cocaine among the middle classes assume the proportions of a social plague. The industrious and healthy fellaheen, however, escaped, because among them the conditions requisite for the misuse of narcotic and stimulating poisons did not exist.

When in 1927, however, large quantities of diacetylmorphine and similar morphine esters with comparable effects but not covered by the provisions of the OpiumConvention were smuggled very skilfully into Egypt by an organization engaging in the illicit traffic and were offered to the fellaheen as aphrodisiacs, the young men between 20 and 40 quickly fell into temptation. In the course of a few years, half a million out of a total peasant population of 7 million had already fallen victims to the poison.

The explanation why a healthy, industrious peasant population which had not hitherto been addicted to the misuse of narcotics should have fallen victim to the poison to this extent must be sought in psychological causes. For the poor, hard-working Oriental, sexual satisfaction and, the desire for progeny are almost the only joys in life which can be easily obtained without material sacrifice. It is therefore understandable that he should quickly fall victim to a poison, which, as propaganda asserted, would ensure him the satisfaction of this desire to a heightened degree. The stimulating effect of heroin produces a sensation of potency, while in a young man the narcotic effect restrains the sexual excitement so that the culmination of the orgasm is delayed. The initially stimulating effect soon loses its strength, however, and makes it necessary to increase the dose. The result of this is an intensification of the narcotic effect which in the end leads to impotence. This effect of heroin also makes it understandable why the older men did not succumb to the temptation, for the repressive effect was stronger than they desired.

Those who became addicts were forced to engage in the illicit traffic themselves and to pass on the poisonas a condition of obtaining the quantities they needed themselves. The misuse resulted in impoverishment, severe under-nourishment, reduced capacity for labour, physical and moral degeneration, and sterility among young males. The absorption of heroin in the form of snuff was often replaced by subcutaneous or intravenous injections, and the result of this was blood-poisoning and the transmission of malaria owing to deficient asepsis. Courses of hospital treatment lasting many months involved the State in very heavy expenditure. The addicts were generally glad to be freed of their affliction by hospital treatment. There was a great danger that the peasant-population would in a few decades meet with the same fate as that which overtook certain populations as a result of indulgence in alcohol.

Before the First World War the only country besides Germany to engage in the manufacture of heroin was England. Towards the end of the war, however, production was started also by Switzerland, the United States of America and Japan. In Japan, production increased from 70 kilogrammes in 1917, to 4,900 in 1920, while in 1921 a further 1,100 kilogrammes were imported. Meanwhile, heroin, which could be completely dispensed with for therapeutic purposes, had become one of the most dangerous narcotics, its use being many times more widespread than that of the others. Only the United States of America drew the right conclusion when in 1924 it prohibited the import and manufacture of heroin.

The Zürich chemist, Dr. Hefti Müller, at Basle, and the great Roessler, factory at Mühlhausen took advantage of the fact that other morphine esters like benzoylmorphine or acetylpropionylmorphine, which had the same properties as diacetylmorphine, were not yet covered by the provisions of the Opium Convention. The syndicate mentioned above flooded Egypt with these products. Vienna was chosen as the trading centre, for there the penalties for violating the provisions of the Opium Convention were lowest. When an end was put to the illicit traffic from this source in 1929, two factories in Paris became the chief suppliers of the East and also of the United States of America. The French legislation then in force allowed legally manufactured narcotic products to be exported in unlimited quantities. In 1930, strict laws were enacted which made this impossible in future. The two factories (Sico, managed by Devineau and the Comptoir Central des Alcaloides, owned by Mechelaere), which had worked exclusively for the illicit traffic, had to close down and transferred to the Bosphorus in Turkey, which had not yet acceded to the Opium Convention. A large part of the world was then supplied with narcotics from that source. While world heroin requirements were at that time estimated at 2 tons a year, exports from these two factories, according to information supplied by the Turkish Government, amounted to 4 tons in a single half-year.

After Egypt had been flooded with narcotic products from these factories, the Government repeatedly intervened and succeeded in securing the closure of the factories and Turkey's accession to the Opium Convention.

This put an end to the illegal manufacture of narcotics in Europe. Russell Pasha, who was at that time Chief of Police, performed the inestimable service not only of freeing his own country, Egypt, from the narcotics plague, but also of making the illegal manufacture of narcotics in Europe impossible, a success which had been denied to the League of Nations for ten years.

The first serious extension of chronic morphinism was observed in Germany during the Franco-German War of 1870-71. The subcutaneous injections of morphine, which had first been used in England in the middle of the previous century, were used in the military hospitals for the first time on a large scale. Not only were they used in military hospitals to relieve severe physical pain, however, but they were also used at home particularly by neurotics as a soporific, and to eliminate the mental disturbances which had been caused by the war and which the individual could not overcome out of his own resources. In this way a large number of those predisposed to addition became acquainted with the sensation of euphoria produced by morphine, an effect which formerly, when the method employed was that of administering comparatively small doses internally, as opposed to the rapid absorption of comparatively large quantities subcutaneously, was seldom produced.

Starting from Germany, the misuse of morphine spread first to France and then to England. In the United States of America also a. connexion can be traced between chronic morphinism and the Civil War. The dispensing of morphine was often left to the subordinate medical staff. Since most cases of addiction arose in connexion with therapeutic treatment with morphine, morphinism was then not unjustly called a "medical disease".

It is understandable that the first victims of morphinism should have been those to whom morphine was easily accessible, that is to say, doctors and members of the healing professions, nurses, midwives, chemists and their wives. In other professions those who contracted the addiction were almost exclusively people who had experienced the sensation of euphoria while undergoing a prolonged course of treatment with morphine.

Morphinism in Germany scarcely increased after the 1880's because there was a general reluctance to use opiates and the medical prescriptions were much more strictly observed. It must also be assumed that the number of neurotics contracting the addiction was not increasing.

After the First World War the number of addicts again increased sharply because the prescriptions forthe use of morphine in the military hospitals were not strictly enough observed. Thus, a large proportion of neurotics became acquainted with the sensation of euphoria produced by morphine and contracted addiction. After the end of the war morphine from plundered army stores was also easy to obtain.

That the increase was chiefly among people originally predisposed to addiction is apparent from statistics compiled at that time (Dansauer and Rieth). Of the morphine addicts who had been injured in the war 81.6 per cent had relapsed into addiction after one year, 93.9 per cent after three years and 96.7 per cent after five years. The way in which the dishabituation course was conducted made no difference to this result. On the other hand the specialist psychotherapeutic treatment following withdrawal had a great effect on the duration of the period of resistance to relapse.

The new German Narcotics Act enabled the number of chronic morphine addicts in Germany to be determined, for all prescriptions for opiates in excess of the maximum dose had to be retained in the chemists' shops. This extremely valuable material relating to the first half of 1928 has been used in a very interesting study by K. Pohlisch.

Chronic morphine addicts were considered to be those who daily and continuously consumed at least 0.1 grammes of morphine or a corresponding quantity of some morphine derivative. Pohlisch made the unexpected discovery that the number of morphine addicts was not more than 3,500-4,000, that is to say 0.56 per 10,000 of the population. To allow for possible mistakes, this figure may be raised to 0.7, and to 1.0 if the calculation is restricted to persons over 20. The incidence of addiction is not significantly related to injury during the war, for the relation between the figures for men and women (1:0.76) does not markedly differ from the normal.

The geographical distribution reveals the unfavourable influence of life in large towns on the nervous system, the figure for Berlin being 1.91; Hamburg, 1.26 and Munich, 1.13; for small towns like Bautzen, Lüneburg, Chemnitz and Neckarkreis, on the other hand, it is only 0.2. The observations at clinical hospitals show that the incidence of other psychopathic diseases is similar.

A surprisingly large number of cases are to be found among doctors. The proportion is 109 per 10,000, with only a slight difference between large towns and country municipalities. Since it cannot be supposed that the disposition to psychopathic disorders is greater among doctors than among other intellectual workers, the explanation must be that owing to the ease with which they can obtain morphine and their constant use of it, those predisposed to addiction cannot resist the temptation. The highest percentage is to be found among doctors for mental and nervous disorders, the proportion being 229 per 10,000, The explanation, must be that more neurotics devote themselves to this special study than to other branches of the profession. It is clear, however, that the accurate knowledge of the misuse of morphine which such specialist doctors must be presumed to possess is seldom able to prevent them from satisfying their morbid desire to use it.

The effects of the German Narcotics Act of 1932 have shown that the medical use of narcotics in Germany can be considerably decreased without detriment to the patients by means of strict prescriptions for the use of opiates and supervision of production and trade.

Whereas in the first quarter of 1930 medical requirements amounted to 188 kilogrammes of opium, 318 kilogrammes of morphine, 11 kilogrammes of heroin and 120 kilogrammes of cocaine, requirements in the same period of 1932 fell to 90 kilogrammes of opium, 188 kilogrammes of morphine, 1 kilogramme of heroin and 20 kilogrammes of cocaine. The number of morphine addicts also has a decisive effect on total consumption. The 4,000 morphine addicts required almost half as much morphine as the remaining population if 64 millions. Inquiries at the Vienna Federal Sickness Insurance Fund led to similar results: twenty-six chronic morphine addicts needed 40 per cent of the total requirements for 480,000 insured persons.

Opium was known to the ancient Greeks and used exclusively for its curative properties, but neither as a means of enjoyment nor as an intoxicant. The need for such substances was satisfied by alcohol and in many districts also by hashish. Only after Mahomet had forbidden indulgence in alcoholic beverages were they replaced by opium, which was eaten. Its use must have been quite general, for the Moslems introduced the custom into all countries they entered during their military campaigns. In this way, it also came to Persia and India, where large areas were devoted to the cultivation of the opium poppy. Misuse of opium, however, never assumed the proportions which it assumed in China.

Opium was soon reputed to be a panacea, for at that time there were no pain-relieving sleeping aids or substances to relieve coughing. Mothers who had to go away to work during the day used it as a drug to make their unwatched children sleep, and to this the high infant mortality rate may be ascribed. Opium was a substitute not only for all the medicaments now at our disposal but also in many cases for medical treatment.

It was also the indulgence of middle age, when the desire for quiet contentment and comfortable indolence developed. The purpose was not the creation of a sensation or of an experience of euphoria, but the induction of a comfortable mood of contentment and the removal of slight physical or mental discomfort after the day's work, effects which in the case of the white race are achieved by the use of alcoholic or caffein-containing beverages and by tobacco. Occa-sionally it was also used as a tonic when hard physical or mental labour had to be done.

After the institution of the State monopoly, with the consequent increase in price, opium was abandoned by the masses in favour of the considerably cheaper Indian hemp, or it was replaced by alcoholic beverages mixed with chloral hydrate.

Chronic drug addicts, similar to those with whom we are familiar today, were also to be found in large towns, among the workers as well as among the upper classes.

In India also, opium and hashish were always constantly used at religious ceremonies and family celebrations, and their use was even compulsory hence the large consumption in religious districts such as Benares for example.

Whereas in Europe chronic morphinism was confined almost exclusively to people who were mentally, unbalanced, in China the misuse of opiates at times spread like an epidemic to a large proportion of a mentally sound and exceptionally hard-working population.

In China, as in Persia and India, the use of opium was customary as early as the thirteenth century. It was, however, entirely suppressed, although it had already become very widespread. Not until the eighteenth century, when tobacco impregnated with opium extracts was smoked and the subsequent prohibition of tobacco led to the production of a smokable opium, did this vice assume the proportions of an epidemic which, in spite of the severest penalties, proved to be almost ineradicable.

Smoking opium was not only a means of enjoyment, when used in moderation, did hardly, more harm than our alcoholic and caffein-containing beverages or tobacco-smoking, but also a means of intoxication for the great masses of a people living under the worst possible social conditions. The social causes responsible for the spreading of the vice were therefore similar to those which at one time operated in the case of alcoholism among the working classes. Poor housing conditions, inadequate pay, lack of provision for unemployment and sickness, and also the impossibility of putting leisure to pleasant use after exhausting work and thus finding diversion and recreation, drove many to the saloon, where the money which was hardly sufficient to pay for the necessities of life was spent on drink and led to physical and moral degeneration. Since alcoholism was mostly attributable to exogenous rather than endogenous causes, it could be fought by removing those causes: by relieving the housing shortage, by improving living conditions, by instituting unemployment and sickness insurance, by providing amusement for leisure time through sport, the cinema and the radio and by raising the cultural level.

Social causes, however, do not provide an adequate explanation of the enormous extent and stubborn persistence of this vice in China. Chinese were often willing to settle abroad only on condition that opium-smoking was allowed them. They then formed centres of infection in the countries concerned.

It must be presumed that the physiological effects of opium smoking produce psychological effects different from those of a morphine injection.

Numerous experiments, including some by the present author, have shown that not more than 10 per cent of the morphine contained in chandu passes unchanged into the smoke. How much of this is absorbed by the pleura is not known, nor is anything known about the effects of the gases released in combustion. At all events, only small quantities of morphine are immediately absorbed in smoking, whereas when subcutaneous and, particularly, intravenous injections, are employed, comparatively large quantities pass into the system and simultaneously paralyse the sensitive and less sensitive centres in the cerebrum.

The small quantities of morphine which enter the blood stream as a result of smoking will, however, gradually paralyse the brain centres in the order of their sensitivity. It is extremely probable that, in the case of a highly imaginative race which thinks and writes in images, the wishes and longings that are unfulfilled in life become a living experience in dream-like visions when sensation of the outside world is excluded.

The course and consequences of the opium-smoking experience are largely affected not only by the number of pipes (thirty to forty in the case of chronic smokers), but also by personality structure, temperament and degree of culture, and not least by mood, mental employment before smoking, environment and the kind of effect which is anticipated. The sober efforts of a laboratory worker to observe and register the effects critically will therefore lead to experiences different from those of a coolie in an opium den.

The coolie has a pleasurable feeling of anticipation at the thought of the enjoyment which await him, even during the elaborate preparation of ,the opium pipe. After the very first pipe, weariness, hunger and thirst disappear and give way to a feeling of well-being. The train of thought is accelerated as in dreams, perception of the outside world grows fainter and fainter, the active ego is shut out so that imagination can exercise unrestricted sway set free from all the trammels of body and mind. Longings and desires are changed into imaginings which are experienced as reality and create an artificial paradise. Lastly, there sets in a deep, dreamless sleep, from which the smoker awakes in great discomfort, with a feeling of general enervation, with aching head and stomach, and often nausea, symptoms which can be removed by renewed smoking. The chronic smoking of large quantities quickly leads to a decline in capacity to work, and to physical breakdown caused by under-nourishment anddisturbed digestion. The hapless victim must devote the greater part of his wages to procuring opium, for which he sacrifices everything else. When that stage is reached, he can find relief from his sufferings only in opium.

Although Europe and Japan were the chief producers of the opiates needed to satisfy medical requirements and the demands of the illicit traffic, misuse of opium in those countries never reached the same proportions as in the United States of America.

As has already been said, chronic morphinism on an epidemic scale first made its appearance in Europe after the Franco-German War of 1870-71 as a result of morphine injections. Among the civilian population too, morphine was used not only for the relief of acute pain, but also as a soporific and to alleviate neurotic complaints.

At the beginning of the century, the eating and smoking of opium were customary among certain classes, and particularly at seaports in England and also in Paris, though the vice did not spread further into the country. The sources of infection were mainly Chinese, sailors and people who had contracted the vice during their stay in the colonies.

Apart from the short period during which an attempt was made to cure morphinism by means of cocaine, cases of addiction to cocaine appeared before the First World War only in Bohemian circles in Paris and at a number, of seaports. Not until the last year of the War did the drug find favour among those engaged in the fighting. At the end of the First World War, addiction to cocaine spread like an epidemic in most countries, then slowly decreased, and in 1924-25 practically disappeared. The misuse of this drug was chiefly confined to socially uprooted ex-servicemen, unemployed persons, Bohemians and prostitutes. By means of the drug they assuaged their thirst for sensation, fought against their feelings of inferiority and found a substitute for the alcohol which was so difficult to obtain. The cocaine came from plundered army stores and was available in abundance. With the return of normal conditions, the amount of addiction to cocaine became insignificant.

In the United States, the misuse of cocaine was already very widespread by 1898. In many states special laws against misuse were enacted as early as 1902. The discovery that cocaine can also be snuffed led to a sharp increase in imports. After 1905 most other narcotic drugs were displaced by heroin.

In recent decades, the misuse of marihuana (Indian hemp) became more and more widespread. As with the consumption of alcohol, its effects - the induction of ecstatic sensations of joy and paroxysms of laughter, a feeling of happiness, psychomotor excitement, the acceleration of the mental processes, the elimination of self-control, an enhanced consciousness of self, and an urge to sociability - offer a temptation not only to neurotics but also to mentally sound persons and are an important cause of the further growth of this abuse.

Taken in conjunction with the large consumption of soporifics, the great demand for narcotic drugs cannot be a mere consequence of over-production and over supply by the illicit traffic and must obviously have a deeper cause.

An attempt has been made to describe in outline some of the main causes of the use and misuse of drugs which affect the peripheral or central nervous systems. Some of them, such as spices, caffein-containing beverages and tobacco, are to be regarded as ordinary means of enjoyment, which can help to make life pleasanter and are scarcely likely to be misused, while others, though when used in moderation they may also be regarded as means of enjoyment, if taken in excess become poisons dangerous to the race, as in the case of alcohol among the aborigines of America and Australia, opium among the Mongolian race, the coca leaf in Peru and hashish among the populations of Asia and Africa.

The question whether a drug is to be regarded as a narcotic poison or a harmless means of enjoyment will depend on the effect which its consumption is intended to produce and on whether this effect causes a morbid desire for a repetition of the experience and hence leads to chronic misuse and addiction, as is the case with neurotics. The amount of drug addiction which there is in a country will depend on the number of neurotics among the population and on how many of these neurotics have experienced the sensation of euphoria produced by the drug, whether in consequence of therapeutic treatment with opiates or through yielding to enticement, for which over-production and the illicit traffic are to be held primarily accountable. The main cause seems to be a phenomenon of civilization caused by the enervating life of large towns and insufficient regeneration through the admixture of healthy peasant blood. The incidence of drug addiction is therefore incomparably greater in towns than in the country areas. If would be interesting to determine whether there is any relation between the distribution of the population in the large towns and the incidence of neurosis. Over-production alone cannot be the decisive factor: it comes into play only when there is a demand for illegal use. Occasional misuse leads to chronic poisoning and addiction only when there is a predisposition thereto. The enormous over-indulgence in alcoholic beverages among German university students, for example, resulted in chronic alcoholism only among those who drank such beverages to satisfy a need for intoxication or who reacted pathologically to them, while the great majority, as soon as they entered professional life, indulged in alcohol only moderately or even not at all. The case was quite similar with the epidemic of cocaine addiction which spread in most countries after the First World War, and the causes of which were exogenous, namely, the tragic post-war conditions. After order was restored, the abuse quickly disappeared or was confined to the psychopathically inclined, among whom it was then for the most part replaced by addiction to heroin.

Different conditions prevail in Africa and Asia, where a decisive part is played by tradition, poverty and bad living conditions.

If the only counter measures employed were prohibition and strict supervision of the narcotic drugs traffic, unaccompanied by an improvement in the standard of living, the result would merely be the substitution of still more dangerous drugs, as was the case, for example, in China, where smoking opium was replaced by morphine and heroin imported by the ton from abroad.

It can therefore be assumed that in Europe and the United States of America the misuse of narcotic drugs is confined almost exclusively to people whose nervous system has sustained injury, and that the normal human being has at his disposal a sufficiency of harmless means of making life more beautiful and more worth living by material, spiritual or aesthetic pleasures.

In the case of the oriental peoples, on the other hand, the addicts are for the most part normal human beings who seek in the intoxicating effects of narcotics a temporary liberation from the troubles of their everyday life.

BIBLIOGRAPHY

Bonhoefer, Allgemeine Zschr. fiir Psychiatrie, vol. 83, 1926, p. 228.

Pohlisch, Die Verbreitung d. chron. Opiatmissbrauches in Deutschland. Verlag. S. Karger, Berlin, 1931.

Linz, D. M. Wschrft. 1932, no. 29.

Dansauer u. Rieth, "Uber Morphinismus der Kriegsbeschadigten, Arbeit und Gesundheit, no. 18, 1931, Verlag Reimer Hobbing, Berlin S W 61.

W. Chodzko, Un premier cas de Codeinomanie en Pologne, Paris, Office international d'hygiene publique. vol. XXVII, 1935, no. 12.

Bureau Central d'informations des narcotiques, Rapport Annuel, Gouvernement egyptien, 1930, 1931, 1932.