The letter by Dr Silkworth that opens the Big Book of Alcoholics Anonymous was written July 27, 1938 under the letterhead of the Charles B Towns Hospital – a medical facility with  a national reputation in alcohol and drug addiction treatment.

In part, it states:

These facts appear to be of extreme medical importance; because of
the extraordinary possibilities of rapid growth inherent in this group
they mark a new epoch in the annals of alcoholism. These men may well
have a remedy for thousands of such situations.
You may rely absolutely on anything they say about themselves.

The July 27, 1938 letter was originally written as a letter of reference for Bill W to aid in fund raising for the Big Book project. The Alcoholic Foundation was legally established as a charitable trust the following month (August 5). The letter also served as a medical endorsement in the foundation’s fund raising efforts and later was included in its entirety in the Big Book introduction “The Doctor’s Opinion.”.

The second narrative by Dr Silkworth was not a letter. It appears in the Big Book based on a suggestion by Dr Esther L Richardson of John Hopkins Hospital. She was sent a prospectus which included two sample book chapters (“There Is A solution” and “Bill’s Story”). A July 18, 1938 letter she wrote to Bill W included a rave review of the two chapters and a recommendation that:

“I think you should get an A No. 1 physician who has a wide knowledge
of the alcoholic’s medical and social problem to write an
introduction.”

The second narrative from Dr Silkworth is that introduction and was written specifically to be included in the Big Book. Part of his introduction states

“There was, therefore, a sense of real satisfaction when I was asked to contribute a few words on a subject which is covered in such masterly detail in these pages.”

The precise date the narrative from Dr Silkworth or “The Doctor’s Opinion” introduction were written is unclear, but it was part of the multilith manuscript distributed for review in January 1939.  December 1938 is a safe guess.

After review of the multilith manuscript, Dr Silkworth was one of the reviewers who suggested easing the tone of the book from “you must” to “we ought.” (see AA Comes of Age pgs 167-168). Bill W wrote “And we must never forget that it was Dr Silkworth who wrote the introduction to the first edition of Alcoholics Anonymous, giving the volume
medical standing.”

As an item of AA trivia “The Doctor’s Opinion” began as page 1 in the 1st edition and was not changed to Roman numerals until the 2nd edition. The basic text ended at page 174 in the 1st edition, not 164 as it does today. Nobody really knows why Bill W renumbered the pages but there is much entertaining speculation on the matter.

Dale Mitchel’s biography of Dr Silkworth is a wonderful read and quite revealing of the magnificent character and commitment of Dr Silkworth. He served as a non-alcoholic trustee on the Alcoholic Foundation Board the two years prior to his death and is reputed to have treated over 40,000 alcoholics in his lifetime at Towns and Knickerbocker Hospitals
in NYC.