OPIUM IN THE WEST, 1700-1900

Opium use was extensive before the modern era.1 By the Middle Ages opium was used in standard antidotes such as theriac, mith-radatium, and philonium, which combined an elaborate array of substances with large amounts of opium. In the mid-sixteenth century opium was particularly associated with the Svviss firebrand Paracelsus, and it is likely that his followers began to use the word laudanum for the alcoholic tincture of opium. The laudanum that bemused beQuincey and Coleridge, however, was the recipe of one of the greatest seventeenth-century English physicians, Thomas Sydenham: the opium was dissolved in sherry flavored with cinnamon, cloves, and saffron—an early cocktail. Sydenham considered opium "one of the most valued medicines in the world [which] does more honor to medicine than any remedy whatsoever." 2 The use of such concoctions as laudanum led to medical warnings of the hazards of opium. John Jones in his tract The Mysteries of Opium Revealed ( 1700 ) warned that the "effects of sudden leaving off the uses of opium after a long and lavish use thereof [were] great and even intolerable distresses, anxieties and depressions of spirit, which commonly end in a most miserable death, attended with strange agonies, unless men return to the use of opium; which soon raises them again, and certainly restores them." 3 This rather good description of the withdrawal syndrome included an early statement of a durable belief among physicians that death could easily result from a termination of habitual opium intake.

Jones's warning was only one reason that other eighteenth-century writers cautioned against frequent use of opium. Some physicians considered that opium addiction was dangerous not as a disease but that opium's pain-relieving povvers might simply rnask a disease that required other treatment for cure. To the question of who is susceptible to opium habituation, one also finds a comment by Samuel Crumpe ( 1793 ) suggesting that only in certain persons could opium take hold, depending on their constitution.4 Jones and Crumpe state both sides of a dialogue on opium addiction that is still debated after two centuries: Can anyone become addicted or are only certain persons, psychopaths or biochemical misfits, likely to succumb? A modification of Crumpe's theme was the assertion that Orientals were much more resistant or susceptible to opium than Occidentals.5 In Victorian England the view was expressed in medical periodicals that the lower classes had a worse reaction to the use of opium than middle or upper classes, leading in the former to degeneracy and in the latter to no noticeable behavioral changes. As for the withdrawal syndrome, the eighteenth-century also inaugurated a long tradition of pharmacological manipulation during withdrawal to either replace the opium with another drug or to counteract its effects in order to make vvithdrawal safe.6

Opium preparations were remarkably popular in these centuries in the western world, although one could not be certain of their potency, which depended on the crude opium from which they were prepared. Dr. Pereira's standard British text of therapeutics ( 1854 ), also widely used in America, echoed Sydenham's description of opium as "undoubtedly the most important and valuable remedy in the whole Materia Medica." The effects of opium are "immediate, direct, and obvious; and its operation is not attended with pain or discomfort." Opium could be used for the "relief of maladies of everyday occurrence" with great success. Dr. Pereira recommended opium for almost every ailment for which a physician might be consulted:

to mitigate pain, to allay spasm, to promote sleep, to relieve nervous restlessness, to produce perspiration and to check profuse mucous discharges from the bronchial tubes and gastro-intestinal canal. But experience has proved its value in relieving some diseases in which not one of these indications can be at all times distinctly traced.7

Some of the other remedies available to physicians were bloodletting, large doses of laxatives, mercurials, and other harmful ( and in many cases very uncomfortable ) applications, including various forms of skin irritation or denudation such as blistering. The sweet effect of opium in fevers, inflammatory diseases, delirium tremens, insanity, depression, convulsions, poisoning, hemorrhages, and venereal diseases must thus have appeared in many cases superior to an alternative regimen.

As to the dangers of opium use, medical opinion in Great Britain in the first half of the nineteenth century was divided. Perhaps the recent "opium wars" with China had encouraged moderate statements about the danger of the habit. The poor and destitute in China and Great Britain who took up opium smoking were generally agreed to suffer from it. Pereira (p. 1039 ) considered that continued opium smoking damaged the physical and moral character of the individual, "especially among the lower classes." He warned, in an earlier tradition, that "if the poison be withheld, death terminates the victim's existence." Yet there were respected contrary opinions that many years of opium smoking were not incompatible with longevity, a vigorous physical constitution, and a praiseworthy morality.8 The difficulty of stopping opium smoking was recognized, and the withdrawal syndrome was described fairly accurately. In keeping with the concept of inheritance of acquired characteristics and damage to germ cells by disease or excesses, the offspring of opium smokers were understandably declared by Pereira to be weak, stunted, and decrepit." Widespread use of opium in Great Britain was feared; Pereira believed that addiction was increasing, and import statistics were known to be rising, but no numerical estimate of habitués was offered ( pp. 104o, 1025 ).

In contrast to Pereira's ambivalence, a leading American text, Treatise on Therapeutics ( 1868 ), by Dr. George Wood, professor of the theory and practice of medicine at the University of Pennsylvania and president of the American Philosophical Society, extolled opium uncritically:

A sensation of fullness is felt in the head, soon followed by a universal feeling of delicious ease and comfort, with an elevation and expansion of the whole moral and intellectual nature, which is, I think, the most characteristic of its effects. There is not the same uncontrollable excitement as from alcohol, but an exaltation of our better mental qualities, a warmer glow of benevolence, a disposition to do great things, but nobly and beneficently, a higher devotional spirit, and withal a stronger self-reliance, and consciousness of power. Nor is this consciousness altogether mistaken. For the intellectual and imaginative faculties are raised to the highest point compatible with individual capacity. The poet has never had brighter fancies, or deeper feelings, or greater felicity of expression, nor the philosopher a more penetrating or profounder insight than when under the influence of opium in this stage of its action. It seems to make the individual, for the time, a better and greater man. Sometimes there may be delusion; but it is not so much in relation to the due succession or dependence of thought, as in the elevation of the imagination and the soul above the level of reality. The hallucinations, the wildness, the delirious imaginations of alcoholic intoxication, are, in general, quite wanting. Along with this emotional and intellectual elevation, there is also increased muscular energy; and the capacity to act, and to bear fatigue, is greatly augmented.

After a length of time . . . this exaltation sinks into a corporal and mental calmness, which is scarcely less delicious than the previous excitement, and in a short time ends in sleep.9

A physician reading this description of opium would, in all likelihood, consider the substance to be a most efficacious and therapeutic device, or worth giving to a healthy friend.

Dr. Wood recognized the possibility of becoming a slave to opium, although he considered its effects less dangerous to the individual and society than those of alcohol. Nonetheless, overindulgence in opium, he wrote, could lead to the "lowest stage of degradation" when the user experiences a "total loss of self-respect, and indifference to the opinions of the community; and everything is sacrificed to the insatiable demands of the vice." But the cause of this fall from respectability could be found in the user's weak character. Since opium, unlike alcohol, did not destroy body tissue, the functions might be deranged but, "It is satisfactory to know that this evil habit may be corrected, without great difficulty, if the patient is in earnest." Sudden deprivation of opium, however, might lead to death. "The proper method of correcting the evil is by gradually withdrawing the cause; a diminution of the dose being made every day, so small as to be quite imperceptible in its effects . . . leading to a cure in somewhat more than a year" or even less ( pp. 725-28 ).

By 1868 morphine had become a useful and common medicine. Dr. Wood considered it even more advantageous and safe than opium preparations, which had to be compounded from "parcels of opium [with a] diversity of strength." Generally, morphine was more agreeable to the patient and "less liable to provoke irregularities of mental action, and, with an equal excitant influence on the faculties and feelings, to derange them less frequently, and in less degree." Pain, insomnia, and nervous irritation were the chief indications of morphia.10

One of the greatest advantages of morphia over opium is the ease with which it can be injected by the hypodermic method into the subcutaneous tissue. To Dr. Wood it was remarkable that morphia, when injected, "even though applied at a distance from the seat of the disease, removes the pain quite as effectually as if injected into its immediate vicinity." As a consequence, "There are few affections in which opium is indicated, in which the salts of morphia have not been advantageously given in this way" ( p. 762). Dr. Wood did not include in his description of morphine any warning about its habit-forming properties; perhaps his earlier discussion of opium habituation would apply to morphia also.

The writings of Pereira and Wood indicate that at the midpoint of the last century and well thereafter the danger of opium was balanced by its effective treatment of the symptoms of disease. The authors were skeptical about claims that opium was a serious danger to those classes of society above the lowest, to those who had will power, and even to those who were not Orientals. In fact, Pereira quotes some medical reports that opium users in the Orient were healthier than the average workers (p. 1039 ). Wood's praises for opium read very much like encomia over cocaine in the 1880s.11 If opium was an actual assistance to the strong-willed, those who abused it were denigrated as weak-willed; enslavement to opium was real degradation but not cause for too much worry. Medical proponents of opium did not claim it was harmless, but that it was, like any powerful and effective medicine, capable of being abused.

RECOGNITION OF ADDICTION

Within a few years, warnings about the habit-forming propensities of morphia taken hypodermically began to accumulate in the medical literature. Dr. Clifford Allbutt, one of Great Britain's most eminent clinicians, stated in 1870 that he had not read any warnings against frequent and regular morphia injections; he feared the prevalence of practitioners "of whom the syringe and phial are as constant companions as was the lancet to their fathers." Nine of his patients with neuralgias appeared to have developed a morphia habit, yet he was uncertain whether this was really the case. Allbutt typifies the hesitancy among the best clinicians to assert the addictive properties of morphia:

Injected morphia seemed so different to swallowed morphia, no one had any experience of ill effects from it, and we all had the daily experience of it as a means of peace and comfort, while pain on the other hand was certainly the forerunner of wretchedness and exhaustion. Gradually, however, the conviction began to force itself upon my notice, that injections of morphia, though free from the ordinary evils of opium-eating, might, nevertheless, create the same artificial want and gain credit for assuaging a restlessness and depression of which it was itself the cause. . . . If this be so, we are incurring a grave risk in bidding people to inject whenever they need it, and in telling them that the morphia can have no ill effects upon them so long as it brings with it tranquillity and well being.12

This was not the first warning; a little earlier one had appeared in the German medical literature,13 but Albutt's was among the first in an English periodical, and it was published simultaneously on both sides of the Atlantic.

In Germany, mid-nineteenth-century publications came from two schools of thought, each with its own explanation for the addiction of certain persons. One school held that morphine craving was a psychological hunger related to the personality or constitution of the addict, while the opposition, represented by Eduard Levinstein of Berlin, argued that regular doses of morphine would make anyone an addict since the cause lay in a physiological reaction to opiates.14 Dr. Levinstein was rather pessimistic about the cure of morphine addiction. In 1875 he reported that his own limited follow-up of patients weaned from opiates had a relapse rate of about 75 percent.15 For withdrawal he suggested that in most cases the patients should agree to total seclusion and management by hospital staff, since voluntary outpatient treatment simply would not work. He did not favor gradual reduction, comparing it to cutting off a dog's tail one slice at a time. He recommended abrupt cessation of opiates along with medical management during the two to three days of extreme discomfort. He felt this was preferable to prolonging withdrawal over many weeks and exhausting the patient as well as his funds and confidence.16

Levinstein accurately described the withdrawal syndrome. Since the basis of addiction is the normal human physiological reaction, all classes of people could, and did, succumb. Moreover, he averred, morphine addiction affected an upstanding victim's moral sense and turned him into a hopeless liar, especially with regard to drugs. This meant that addiction could not be controlled in a setting where the patient could in any way get his own drug supply.17 Levinstein, Wood, and Pereira agreed independently that decline of moral character is associated with chronic opiate use in either some or almost all instances.

Addiction had a long way to go before it was widely recognized as an unmitigated evil, a danger to society, and deserving of the most severe penalties, but the belief grew that prolonged use of opiates endangered anyone who indulged and could lead to immoral and criminal actions and social ineffectiveness. Any intellectual or social value in opium, even for the higher classes, was eventually discounted, and the ease of becoming an addict began to be accepted as an extreme hazard.

The notion of a vice-disease easily acquired, progressively damaging, and difficult to cure was a triad familiar to the public: opiate addiction easily fit this category. In the late nineteenth century there were two other common social afflictions, syphilis and alcoholism, that shared these characteristics. Both were largely associated with the lower classes and with gradual deterioration of the mind and body. The public probably came to consider opiate addiction a similar vice.18 As the more direct causes of disease were discovered. in the decades after Allbutt's warning, more sophisticated treatments arose--and the number of illnesses treated by alcohol and opiates diminished.

In the last decades of the nineteenth century bacteriology became the model for the medical profession. The bacteria causing tuberculosis, diphtheria, and cholera were located and studied. None of these diseases could be cured by administration of opiates. As a result, opiates had fewer and fewer specific uses other than subduing pain. Opium's use as a soothe-all, so useful to medicine in past centuries, began to appear unscientific, unprofessional, and an indulgence fraught with danger.

The microscope and the research laboratory led to great discoveries that began to change the practice of medicine and its theoretical foundations. Many old problems were reexamined by enthusiastic investigators. Even the cautious and brilliant bacteriologist Robert Koch announced in 1890 that he had discovered a cure for tuberculosis, and several years passed before it was realized that "tuberculin" was useless in treatment and actually could innoculate an individual with the disease. If Koch's zeal could carry him beyond his evidence, there were many other investigators who also believed that they had come upon the answer to mysterious problems.

Opiate addiction provided, then as now, one of the most baffling problems in medicine, and extensive research was conducted from the 1870s on. The two elements of opiate addiction that led to the most extensive investigation were tolerance and the withdrawal syndrome. In 1883 Marmé claimed to have discovered a breakdown product of morphine, oxydimorphine, which had effects the opposite of morphine. Increasing doses of morphine were required to neutralize its effect, and when morphine was stopped, the breakdown product caused the withdrawal syndrome.19 This explanation attempted to explain both tolerance and withdrawal, but unfortunately oxydimorphine could not be located in the blood of addicts by other investigators, nor could it, prepared in 'vitro, cause any symptoms when injected into an addicted animal.20

Immunological theory provided the basis for Gioffredi's work in 1897 which appeared to demonstrate that an antitoxic substance was produced in the bodies of addicted dogs, which, when injected as a serum into kittens, protected against large doses of morphine.21 Several other investigators also reported the production of an antitoxin to opiates.22 If true, this would have been unusual sirke all other known antitoxins were stimulated by the complex proteins of viruses and bacteria. Later this antibody or antitoxin theory of addiction was espoused vigorously in the United States by Dr. Ernest S. Bishop of New York, a national leader among those physicians and laymen who believed that indefinite maintenance of some addicts was rational and humane.23 Dr. Bishop collided head on with federal enforcement policies after 1919 and lost. One element in his defeat was the disproval of the antibody hypothesis, which led some of his opponents to conclude that there was no organic basis for withdrawal phenomena.

A somewhat similar theory, and one based on another popular medical belief, was the "autotoxin" theory of Dr. George E. Pettey.24 Some laboratory evidence for this theory existed as well as that hypothesizing antibodies, but its immediate plausibility came from the invocation of intestinal autotoxins, a widely accepted cause for a multitude of ailments, and one advocated by Nobel Laureate Ellie Metchnikoff ( 1908 ).25 According to Pettey, opiates stimulated the production of toxins in the intestines, which had the physiological effect associated with withdrawal phenomena. Morphine in increasing doses was necessary to counteract the toxin production; if it was stopped, the toxins would be unchecked. Therefore treatment would consist of purging the body of toxins and any lurking morphine that might remain to stimulate toxin production in the future.26 In 1914, Valenti reported that serum of dogs taken during signs of abstinence and injected into normal d-ogs produced similar abstinence phenomena.27

Other explanations for addiction, often with voluminous laboratory data, included shedding of endothelial cells of endocrine glands leading to blocked secretions ( Sollier 1898); an increased ability of the body to destroy morphine ( Faust 1900); changes in cell protoplasm (Cloetta 1903); degenerative changes in brain cells ( Willcox 1923); and changes in cell membrane permeability ( Fauser and Ottenstein 1924).28

TREATMENT OF ADDICTION

There have been dozens of different theories for the treatment of addicts. A myriad of details as to timing, size of dose, and prognostic signs fill journal pages, but the fundamental treatment categories were few. Patients could be purged to eliminate toxins or morphine; or sedated during withdrawal by innumerable substances—bromides, barbiturates, trional, etc.; or put into a state of confusion or forgetfulness with hyoscine or atropine. A drug similar to the addicting opiate might be substituted, perhaps codeine or, for a while, heroin or even cocaine. An antagonist to some withdrawal symptoms, e.g., sweating or diarrhea, might be prescribed—perhaps one of the atropine-like drugs such as belladonna. Theory might determine how long the treatment was given, for a few days or a few weeks, or whether one element in the treatment was essential and one of the other standard treatments totally contraindicated. All treatment sought to make withdrawal as pleasant as possible, and some writers claimed that it could be quite comfortable. This goal might lead the therapists to employ slow or abrupt withdrawal. Of course at any one time there were some therapists who believed withdrawal was psychological and did not require medicines, and some who believed that withdrawal was life-threatening and therefore recommended indefinite maintenance. But from the mid-nineteenth century until about 1920, physicians continued to tell one another that withdrawal and perhaps a few weeks of aftercare would lead to the cure of addiction in most cases. Levinstein's prediction in 1875 of 75 percent relapse, and a United States Public Health Service study in 1942 that more than 75 percent of the addicts treated at Lexington Narcotic Hospital relapsed, bracket a period of therapeutic enthusiasm in the midst of which American narcotic laws were enacted and the enforcement style established.29

In the first decade of this century there was confidence that an addict was eminently curable. In i9oo, dozens of sanitaria for alcohol and drug habits were scattered across the United States. Naturally, as private operations they catered to those who could pay, middle- and upper-class unfortunates who wanted to be cured or at least dried out for a while. The sanitarium operators wrote extensively on the drug and alcohol evils, proudly spreading their successful treatments. Two physician-proprietors, Dr. C. B. Pearson of Maryland and Dr. T. D. Crothers of Connecticut, took opposing views on how to treat the addict, each condemning the other's mode of operation, and each claiming remarkable effectiveness for his own.

Dr. Crothers, superintendent of Walnut Lodge Hospital in Hartford, maintained in Morphinism and Narcomania ( 1902 ) that the first prerequisite to treatment was "control of the patient" for his will must be subservient to the physician's.30 An opposite view was expressed by Dr. Pearson, who preached an optimism about voluntary reduction of opiates. Among his many patients he said he had had great success, and his description of success where others failed should have been persuasive. All he asked was a sincere willingness to be cured:

A prominent woman took treatment eleven times and failed each time. At last her finances became reduced to a sum just sufficient for her twelfth treatment. On this occasion she was entirely successful and remained free from morphinism until her death several years later. Everyone knows that morphinism does not improve with age, therefore it is evident that this lady could have succeeded at any of her previous attempts had she wished to.31.

Dr. Pearson condemned physical restraint and believed that cures resulted from slow reduction, good food, and an understanding physician. This of course was sweet music to the ears of most general practitioners as well as to most patients. Less pleasing aspects were explained away by calling concern with the length of treatment a "puerile objection." And with voluntary gradual reduction and friendly treatment Dr. Pearson claimed success: "I look for 75% of permanent cures in straight cases of morphine addiction, who have never taken treatment and who are up and about at work, regardless of the amount used and length of addiction and a lower percentage of cures in the other types, according to circumstances." 32

Perhaps it is harsh to attribute an obvious form of advertising to these or any other entrepreneurs, for if they thought they had a valid message they were entitled to communicate it in the medical and lay literature. Our knowledge that these treatments were worthless, that they made fortunes for their proprietors, and that their "scientific" pronouncements seemed so under the control of their investments, make it tempting to call them charlatans—but all this knowledge is after the fact. Their financial success elicited enmity from their less fortunate colleagues, just as Treasury Department agents who later investigated physicians seemed influenced by evidence of personal gain accruing from clinics or private practice, although there is no necessary connection between financial reward and charlatanism.

Charles B. Towns and His Treatment for Addiction

Of all the cure proclaimers there was an undisputed king, or perhaps emperor, so magnificent were his accomplishments and so influential his lobbying: Mr. Charles B. Towns. He worked at such a high level of national and international efforts to control narcotism that he appeared to many to be above mercenary considerations.

New York City has long held the distinction of harboring the largest number of narcotic addicts in this country. It is natural that sanitaria and specialists in the treatment of addiction and similar ailments would congregate there, but the leading addiction specialist came for unrelated reasons. At the turn of the century Towns arrived from Georgia, casting about for new fields to conquer. He had no interest in addiction or even medicine, although he was destined to dominate much of the addiction controversy for the next twenty years. In Georgia, Towns had risen by his own efforts from farm boy to a supersalesman who had written "more life insurance than any other man south of Mason and Dixon's line up to that time." When he came to New York in he sought a larger arena for his talents as an insurance salesman but found something that excited him even more by its possibilities—the stock market. From 1901 to 1904 he was a partner in a brokerage firm that eventually failed. While discouraged over his first failure, Towns later related that he was approached by a fellow who whispered, "I have got a cure for the drug habit, morphine, opium, heroin, codeine —any of 'em. We can make a lot of money out of it." Towns was skeptical and sought the advice of his personal physician, who said that the claim was ridiculous. With this opinion challenging him, Towns began investigating the cure by putting advertisements in the paper to locate drug fiends who wanted to be helped. Trying the formula out on such persons and restraining them when they wanted to get out of the hotel rooms Towns used for his experiments, he perfected the treatment so as to "eliminate all the suffering." 33

As he gained patients for his treatment, Towns was shunned by , the regular medical profession. But in a few years he was somehow able to interest Dr. Alexander Lambert of Cornell in his methods. Although Towns would still not reveal the secret formula; he was able to convince Lambert that he had an effective treatment for addiction. Eventually Lambert, Theodore Rooseveles close friend and personal physician, introduced Towns to government officials as a "straightforward, honest man—no 'faker,' " who had a most useful treatment for drug addiction. When Towns wanted to find a market for his "cure" in China, Lambert wrote Assistant Secretary of State Robert Bacon, asking him to smooth Towns' way in China so that he could use his treatment there; he reported it had been investigated by the War Department and "really cures morphine and opium addictures." 34

Towns impressed the American delegation to the Shanghai Opium Commission by his apparent success in China when, in 1908, he claimed to have cured about 4,000 opium addicts there by his method. By that time the Americans believed they had ready a historic announcement: "An everyday American fighter" had located an effective treatment for addiction. The delegation wanted Towns to announce to the assembled members of the commission the treatment that he had now decided to give to the world. It bothered the Americans to have the commission declare itself incompetent to evaluate such a message of hope; consequently, the Towns treatment was relegated to the delegation's official report to the Secretary of State. Nevertheless, the unique prominence given the Towns treatment by the delegation was almost an official endorsement. The attitude of the American delegates toward the possibility of a simple cure complemented their repeated declarations at the commission meetings that a world prohibition of habit-forming drugs should be enacted, excepting only obvious medical uses in the alleviation of pain. The Towns treatment answered the problem of what to do with addicts, and so a possible dilemma was avoided by accepting Towns' claims at face value. If a cure indeed existed, the prohibition of narcotics for simple addiction maintenance or pleasure was no more cruel than the requirement for smallpox vaccination: the prohibition of nonmedical narcotic uses could be classified as a routine public health measure.

In transmitting Towns' regimen to the State Department, the delegation called attention to the fact that the "cure" had "already been favorably reported on by Drs. Lambert and Thomas at the instance of the Philippine Government." It was recommended that it be used under the supervision of Mr. Towns as far as practicable and that "he should be given full credit for the treatment." Towns was described as a man who had eschewed pecuniary exploitation, and his treatment, "properly carried out, is the most successful on record for the cure of the victim of the opiate habit in any of its forms." 35

What was this generous gift to the afflicted? The formula follows.

fluid extract of prickly ash bark    1 part
fluid extract of hyoscyamus          2 part
15% tincture of belladonna          2 parts

It was given in ½ cc doses at half-hour intervals to an addict until signs of atropine effect were noted: dilatation of the pupil, slight dryness of the throat, and redness of the skin. But before beginning with the specific, a "complete evacuation of the bowels" must have been accomplished, and half an hour before beginning formula administration, the largest tolerable dose of the addicting substance was given "to bridge the patient over as long a period as possible without having to use the drug again." 36

About 24 hours later, after a second cathartic had worked its effect, another dose of the addicting drug, but this time only one-half or one-third of the previous amount, was given. Allegedly this left the patient as comfortable as the previous maximum dose. Twelve hours later a third cathartic was given, and 6 to 8 hours later this was followed by to 2 ounces of castor oil. Secretary Root was informed that this last cathartic, the third during treatment by the specific, should produce "a stool that consists of green mucous matter." When Dr. Lambert announced the treatment to the medical profession in September 1909, he wrote that "when this stool occurs, or shortly afterward, the patients often will feel suddenly relaxed and comfortable, and their previous discomfort ceases," thereby bringing the entire treatment to an end.37

This outline is drastically condensed from the original elaboration. Not mentioned, for example, is strychnine in small doses, which was necessary to combat the patient's exhaustion after the first day or so. Towns conceded, "In some cases and in those using large amounts of drugs a patient may have some discomfort during the treatment," but this was not much trouble. The patient "does not remain on the average more than five days." 38 One of the cure's detractors later labeled it "diarrhea, delirium and damnation," but it seemed very neat and scientific when presented in 1909 under the auspices of the federal government, Dr. Lambert, and the Journal of the American Medical Association.

Towns rose in the esteem of the medical profession's elite and in the opinion of the political powerwielders who were under pressure to do something about opium addiction in the Philippines, China, and the United States. Towns achieved a national and even an international role. His techniques as a salesman and his imposing personality took him far, and he was eventually accepted as one of the most knowledgeable and altruistic addiction experts in the United States. By 1920 the belief of Towns' physician that the cure was ridiculous began to be widely held also among the profession and the public, but while confidence in him lasted, Mr. Charles B. Towns was an active figure on the American drug stage.

WHAT IS ADDICTION?

The question of whether addiction is a disease became crucial during 1919 and 1920 in the United States and followed the Supreme Court declaration that maintenance of addiction without a cause such as intractable pain was illegal. But if addiction was a bona fide disease, perhaps addicts could be legally maintained after all. Leading physicians, who in the past had sought stringent anti-narcotic laws and had also declared addiction a disease, now averred that it was not a disease at all, at least not an organic disease requiring doses of narcotics. Withdrawal symptoms and signs for which they had once recommended intricate physiological therapies were now said to be "purely functional manifestations and have no physical basis." 39 This conclusion came while the medical profession was split and each side bitterly accused the other of a conspiracy to either foster dope fiends or to jail sick patients. The battle was so intense that disproval in 1920 of the antibody theory, the favored hypothesis of addiction-disease advocates, was taken to mean that addiction and the withdrawal phenomena had no organic basis at all.40

Just as the belief that addiction was a disease drew upon the new studies in immunology in the late nineteenth century, so the decision in 1920 that addiction was functional came when the new psychology—psychoanalysis—could be invoked as an explanation of dysfunction and as a source of effective therapy. Psychoanalysis, an AMA report explained in 1920, had shovvn how the subconscious life had a strong hold on our conscious behavior. If the problems within the subconscious have caused regression, then psychoanalysis might be able to locate the "sore spot" and release the libido for "higher thought and emotional levels." The goal of treatment must be to "teach this otherwise normal drug addict to irradiate and sublimate this libido which he is so wantonly wasting on the fetish of drug addiction." If the addict was not normal, but a social misfit, he should be rehabilitated along the lines of vocational training and probation. Without correction he might become "organized and vocal," and "society may awaken to the fact that he is an IVVW, a bolshevik, or what not." 41

The assertion that the withdrawal syndrome is functional was a position taken by leading figures in national medicine in 1920, apparently to protect the gains made, in their view, toward outlawing addiction. They associated the argument that addiction is a disease with men whose motives they suspected, since leaders like Dr. Lambert had lost faith in medicine's power to cure addiction.42 "Addiction-disease" seemed a handy cover for "dope doctors" who made enormous profits selling prescriptions or habit-forming drugs. Most physicians shied away from addicts as too troublesome, unsavory, and frustrating to warrant any therapeutic attempt; those physicians who would provide addicts with drugs seemed either an uninformed or a mercenary minority.43 Since by 1920 faith in cure had already begun to fade, one had to choose between indefinitely maintaining what was thought to be an enormous number of addicts, over a million by federal estimate, or trying to stop all "non-medical" drug supplies. In this situation the question of whether addiction was a disease was paramount. It was difficult to advocate elimination of addicts and their drugs if addiction was a true disease, a permanent physiological disorder; in that case opiates could no more be withheld than digitalis from the chronic heart patient. It would appear that a desire to stop the dope doctors led prominent and able clinicians into believing that addiction withdrawal was functional and without an organic basis.

Later in the 1920s the belief in the organic reality of withdrawal, even if not understood, was again asserted by many in the medical profession, but it was still linked to psychological disorder. Dr. Lawrence Kolb, Sr. of the United States Public Health Service represents the highest level of medical research in addiction from the 1920s into the 194os. In the 1920s he believed that "normal" persons did not choose to become addicted; therefore the addict by choice was a "psychopath." Addiction was only one aspect of the psychopath's life, which included other criminal activity and social ineptness. Dr. Kolb stated that the joy of a morphine injection would be felt only by the psychopath; a normal person would feel little or nothing. In his opinion the accidental case, whether addicted from patent medicine or a physician's malpractice, had been greatly reduced as a result of the Harrison Act, so that in the 1920s only psychopaths were seeking the pleasure of opiates. In 1925 he summarized some of his research:

Opiates apparently do not produce mental pleasure in stable persons except a slight pleasure brought about in some cases by the reflex from relief of acute pain.

In most unstable persons opiates produce mental pleasure during the early period of addiction. The degree of pleasure seems to depend upon the degree of instability.44

As for the pain and suffering of the withdrawal syndrome, the 1920s silenced the claims for specific treatments and cures of addiction by a series of careful and controlled studies in Philadelphia and New York.45 The work of the Mayor's Committee on Drug Addiction ( New York ) has a finality about it because it was chaired by Dr. Alexander Lambert, one of the most respected clinicians in the nation and an advocate of a specific withdrawal method since 1909. Although Dr. Lambert had, in the hectic year of 1920, apparently abandoned the physiological basis of the withdrawal syndrome, a few years later he was again actively investigating various specific treatments.46 In 1921 the Mayor's Committee, composed of Health Department physicians and other experts, was given financial support by the city and the use of a ward in Bellevue Hospital with a full medical staff. In 1928 and 1929, 318 addicts were studied at Bellevue with physical and psychological tests, and the various treatments suggested for addiction were applied to subgroups of the addicts. Controls were maintained for each test of an addiction treatment. The committee's report was published in 1930. Some of its conclusions were:

That the patients be given as rapid a reduction treatment as the age and physical condition and response to morphine dosage would permit.

Younger addicts in good physical condition could often be given abrupt withdrawal without danger.

A small number of well-adjusted drug addicts should be permitted to continue daily dosage under proper supervision.

There was no evidence to confirm claims of "cure" or a "specific" which would miraculously rid habitués of addiction. Withdrawal of narcotics does not constitute a "cure." 47

The year 1930 may be taken as the close of the era of therapeutic optimism with regard to opiate addiction. It had been increasingly difficult since World War I to rouse enthusiasm for an addiction cure, and within a decade the full weight of clinical medicine was against any such claims. Everything had been tried and everything failed; the relapse rate was appalling. When Congress established narcotic institutions in 1929 the primary reason for federal aid to addiction was not to provide treatment; the Lexington and Fort Worth narcotic "farms" were unmistakably built for the large numbers of jailed addicts who had crowded federal penitentiaries. Yet in the debate over authorization, the warm hope was expressed that through these hospitals effective treatment or a new discovery would begin to wipe out the addiction menace.48

The search for an effective medical cure for addiction has so far failed. The occasional cure that has gained brief professional endorsement and popularity has later proved to be the result of wishful thinking, financial investment, or poorly designed evaluative methods. A not uncommon occurrence in the history of medicine, the powerful desire for a cure has produced a succession of them: eventually the patience and credulity of the medical profession and the public have become resistant to new claims.

A recent review of the opiates concluded that probably no other group of drugs has been so extensively studied with such uncertain results,49 but this dismal information was not available to dampen the enthusiasm of earlier American reformers. Professional and public confidence that addiction could be successfully treated must be recollected in order to understand the history of narcotic control, particularly in the United States, where belief in medicine's ultimate triumph was never stronger than in the early decades of this century.

At present, the reasons for the initial nonmedical use of opium and similar substances is in dispute, the physiological basis for addiction is unknown, and a treatment with even a quarter the effectiveness of penicillin in pneumonia is lacking. The regular user's reaction to sudden deprivation of an opiate is generally well validated. According to a contemporary authority this phenomenon has the following characteristics in morphine addiction and is similar for other opiate-like drugs.

The abstinence syndrome that develops when repeated Injections of morphine are suddenly terminated is quite stereotyped. Although the patient may complain much earlier, frequent yawning, nasal discharge, tears, widening of the pupils, sweating, erection of the hair, and restlessness are usually observed 12, to 16 hours after the last dose. Later, muscular aches and twitches, abdominal cramps, vomiting, diarrhea, hypertension, insomnia, loss of appetite, agitation, profuse sweating and weight loss develop. . . . In addition, spontaneous ejaculations may occur in the male and profuse menstrual bleeding in the female.

The constellation of signs, together with more variable behavior changes, reaches peak intensity on the second or third day after the last dose of morphine, and then subsides rapidly over the next week, but . . . a stable state may not be reached for six months or longer. If, at any time during this abstinence period, a single dose of morphine is administered, all the abstinence phenomena subside dramatically, only to reappear again within 4 to 6 hours at a level comparable to that had morphine not been administered. The untreated morphine abstinence syndrome is rarely fatal except in patients with cardiac disease, active tuberculosis, or other debilitating illness.50

Mild abstinence symptoms can be produced in man by abruptly withdrawing morphine after two weeks' administration four times daily in doses of 15 or 20 milligrams (34 to grain ). A yearning for a sense of well-being, or relief from pain, either of which may have led to the first use of an opiate, diminishes as the same amount of drug is readministered; more drug is required for the same effect. Apparently in many instances of opiate addiction, euphoria cannot be regained and the drug is then taken simply to prevent the onset of the abstinence phenomena. Other effects which decline as the same dose is repeated are depression of respiration, nausea, and vomiting. Pupil constriction and muscle spasms of the kind that cause constipation seem to respond indefinitely to the same dose. Adrenocorticotrophic hormone ( ACTH ) production is suppressed, with the result that the male becomes impotent and the female ceases to menstruate.

The mode of administration seems to affect the ease with which addiction develops and has been claimed to affect the ease of withdrawal from the drug. Smoking opium apparently has a rather mild effect, eating opium a stronger one; taking by mouth the purified principle morphine, or its derivative heroin, produces a more powerful result; the greatest impact results from intradermal, intramuscular or intravenous injection. If this appraisal is correct, the ingestion of crude opium before the nineteenth century would have had milder effects than hypodermic injections of purified opium derivatives. Still, the phenomenon of large numbers of people finding opiates to be irresistible and addictive was described before the last century. There is now little doubt that organic factors are an integral part of the addiction syndrome.

MORE ABOUT MR. TOWNS

After 1920 Towns continued work at the Charles B. Towns Hospital, using apparently the same treatment he had popularized in the first decade of the century. As his standing in the medical world fell, his claims became more and more extravagant and the substances he inveighed against multiplied to include tobacco, coffee, tea, bromides, marihuana, paraldehyde, etc., as well as opiates and alcohol. He recounted his days of fame and acceptance in little books; for example in this passage in a 44-page volume published in 1932,:

We have never had a negative result in any case, free from disability, or from an incurable painful condition which enforced the continued use of an opiate—such as gall stones, cancer, etc.51

In the bright days of the Towns Hospital and its support by leading physicians the cure rate was usually set as high as 75 to 90 percent. This was based on the reasoning that if you never heard from a patient again, he no longer needed your services. Or as a brochure put the issue of successful treatment in 1914 after several thousand patients had taken the five-day course:

A little less than ten percent returned to us for a second treatment, a reasonable presumption being that the ninety percent from whom we have never heard further that left our care had no need to consult with us a second time.52

While the treatment had credibility, even Dr. Lambert did not closely question this logic and in fact employed it himself, but when evidence accumulated that the Towns treatment was ineffective, the weakness of such claims for cure seemed evident to all."53 Elever years after his initial research on the Towns treatment, Dr. Lambert had lost his faith in merely withdrawing the drug. "I tried it," he said, "in about 200 patients at Bellevue . . . and I had looked them up afterwards. I found that about four or five percent really stayed off. 54 Towns, however, still clung to his illusions about the patients who did not return. When his medical friends asked him what percentage of his alcoholics were cured, by 1931 Mr. Towns would reply that he had not the slightest idea:

I tell these doctors that when a patient leaves this hospital, we are through with him. We never communicate with a patient, either directly or indirectly. . . . Our psychology in this particular line, I believe, is sound. You can hardly expect to establish confidence in a drinker by constantly communicating with him, or by having him report regularly to you.55

Prevailing concepts of control of addiction in the United States abandoned the medical approach, which Towns sold as avidly as life insurance or stocks, and he faded from the national scene to become the proprietor of just one more sanitarium in New York City. Towns did not change his medical theories, his treatment, or his style of presentation, but the nation discarded specific treatments and was soured on the fantastic claims from their proponents. At the beginning of his career in combating "habits that handicap," Towns' story reveals the deep belief among many leading Americans that a cure existed for addiction and that Towns had it. The flaws in his statistics were overlooked as both physicians and statesmen persuaded themselves that a simple cure existed for this difficult social problem. Towns' own confidence and his bearing must have been part of his triumph; Dr. Richard C. Cabot of Boston knew him as "one of the most persuasive and dominating personalities in the world." 56 But the chief fâctor of his success was the confidence Americans had in the progress of medicine and its ability to solve by such therapeutic inventions a complex social and personal ailment.

Perhaps it would be worthwhile to consider the cure as a type of medical cure in general. The physiological basis for the treatment was quite reasonable: Opiate withdrawal usually produces sweating, diarrhea, and vomiting. The atropine-like action of the formula was thought pharmacologically to counteract these symptoms, thereby aiding the patient in lasting out the withdrawal. Atropine also had the effect of causing a delirium confusion, a kind of twilight sleep which erased memory of the withdrawal. In an age of belief in various potent intestinal autotoxins and antitoxins, the wisdom of complete evacuation of the intestinal tract before treatment was quite understandable, as was the continued evacuation of the bowels during therapy. Cathartics rid the body of the poisons that might be causing withdrawal symptoms as well as of any opiates lurking in the intestinal tract that might stimulate antitoxins later on. Therefore, what might now seem a bizarre treatment without rationale was in reality a harmful regimen within an accepted set of beliefs.

The way in which the cure was presented by leading medical authorities also conveys a sense of the science as well as the art of medicine. There were endpoints to be looked for—atropine toxicity in the administration of the specific, and the characteristic "green, mucous stool" which meant the treatment was completed. In addition to these guidelines, the treatment was repeatedly characterized as one requiring great care, "for the success of this treatment," Dr.  Lambert admonished, "depends on the conscientious adherence to its many details." 57

Now forgotten, the Towns cure is an example of some of the classic medical "cures" of the past that have combined arcane scientific knowledge, elaborate detail, and professional expertise. Benjamin Rush's purging and phlebotomy to cure yellow fever in the 1790s, and lobotomy in the twentieth century are two more examples. It will suffice to note that the Towns method had so many social and political pressures favoring it that refutation was difficult for a decade after its publication. It seemed to succeed because the alternatives—no effective medical cure for addiction, and the inaccuracy of some medical theories of the time—were unacceptable.

NOTES

1 Glenn Sonnedecker, History of Pharmacy, 3rd ed. (Philadelphia: J. B. Lippincott Co., 1963), pp. z78 if.; D. I. Macht, "The History of Opium and Some of Its Preparations and Alkaloids," I AMA 64 477-81 (1915); P. G. Kritikos and S. N. Papadaki, "The History of the Poppy and Opium," Bull. Narcotics 19 : 17-37 (1966); S. Hamameh, "Pharmacy in Medieval Islam and the History of Drug Addiction," Medical History 16 : 226-37 (1972); A. Hayter, Opium and the Romantic Imagination ( London: Faber and Faber, 1968).

2 H. E. Sigerist, "Laudanum in the Works of Paracelsus," Bull. Hist. Med. 9 530-44 (1941 ).

3 John Jones, The Mysteries of Opium Revealed ( London: Richard Smith, 1700), p. 32.

4 Samuel Crumpe, An Inquiry into the Nature and Properties of Opium ( London: G. G. and J. Robinson, 1793), p. 177.

5 Glenn Sonnedecker, "Emergence of the Concept of Opiate Addiction," J. Mondial Pharmacie, Sept.—Dec. 2962, pp. 286-87; Jones denied any difference in reaction among nationalities (Mysteries, p. 307).

6 Crumpe, Inquiry, p. 177; Jones, Mysteries, p. 306.

7 Jonathan Pereira, The Elements of Materia Medica and Therapeutics, 3rd American ed., edited by Joseph Carson, 2 vols. (Philadelphia: Blanchard and Lea, 1854) 2 : 1039-46 passim.

8 Robert Christison, A Treatise on Poisons, 1st American ed., from the 4th Edinburgh ed. (Philadelphia: Barrington and Haswell, 1845), pp.552 IT.

9 George B. Wood, A Treatise on Therapeutics and Pharmacology or Materia Medica, 3rd ed., 2 vols. (Philadelphia: Lippincott, 1868), 1 : 712-13,1 :725-28.

10 Wood, Treatise, i : 761; also see Christison (Poisons, p. 558), who is inclined to agree that morphine "in medicinal doses does not produce either the disagreeable subsequent or idiosyncratic effects of opium."

11 For example, Freud's "Ober Coca:" see above, ch. 1, n. 18.

12 Clifford Allbutt, "On the Abuse of Hypodermic Injections of Morphia," Practitioner 3 : 327 (1870).

13 B. F. Von Niemayer, A Textbook of Practical Medicine, trans. from 7th German ed. by G. H. Humphreys and C. E. Ackley, 2 vols. (New York: Appleton, 1869), 2 : 291.

14 Eduard Levinstein, Morbid Craving for Morphia, trans. by C. Harrer (London: Smith, Elder, 1878), pp. 6 ff.

15 E. Levinstein, "Die Morphiumsucht," Berliner kiln. Wochschr. 12 : 646— 49 (1875), esp. p. 647. Also see Morbid Craving, p. io9, where Levin-stein comments on the extremely easy relapse- after withdrawal.

16 Levinstein, Morbid Craving, pp. log-18. Levinstein described the morphine abstinence syndrome and stated that it lasted about 48 hours, did not result in death, and improved if morphine were administered; he distinguished it from delirium tremens in chronic alcoholism. Morphine, unlike alcohol, produced no bodily deterioration, according toLevinstein.

17 Ibid. See also William Osler, The Principles and Practice of Medicine (New York: Appleton, 1894), p. loo6: "Persons addicted to morphia are inveterate liars, and no reliance can be placed upon their statements."

18 Although narcotic and alcohol reform movements and research can be distinguished, similar factors caused them to be often considered together. Many of the "cures" or treatments for one were also recommended for the other. The Towns-Lambert treatment was considered efficacious by its proponents for both habits. The chain of cure establishments, e.g. the Keeley, Oppenheimer, and Neal sanitaria scattered across the nation, treated both kinds of patients. Alcohol was often called a "narcotic" and the American Medical Society for the Study of Alcohol and Narcotics was established in the 19th century to pursue research in both. The Journal of Inebriety, edited by Dr. Crothers of a Hartford sanitarium ( which cared for both classes ), published articles mostly on alcohol but did not neglect opium and cocaine habitués. Various reform organizations, the WCTU, the International Reform Bureau, missionary societies, etc., opposed both habits. Richmond P. Hobson moved smoothly from his role as a leading antiliquor spokesman to head of an antinarcotic association in 1923. Distinctions between drugs were not clear to the public, and in the 19th century opiates occasionally were falsely considered to provoke violence whereas cocaine produced passivity (as in Sherlock Holmes ), but the violence of alcohol intoxication was fairly frequently exhibited in all communities. Alcohol was hated as an old, familiar enemy; narcotics continued to have an aura of mystery.

19 W. Marmé, "Untersuchungen zur acuten und chronischen Morphinvergiftung," Deutsch. med. Wochschr. 9 : 197-98 (1883).

20 A. G. DuMez, "Increased Tolerance and Withdrawal Phenomena in Chronic Morphinism," PIMA 72 : ya69 (1919).

21 C. Gioffredi, "L'Immunité artificielle par les alcaloides," Arch. ltd. de Biol. 28 : 402-07 ( 1897); "Récherches ultérieures sur l'immunisation pour la morphine," ibid. 32 : 398-411 ( 1899).

22 See Leo Hirschlaff, "Ein Heilserum zur Bekampfung der Morphiumvergiftung und iihnlicher Intoxicationen," Berliner klin. Wochschr. 34 : 1149-52,1174-77 (1902).

23 Ernest Simons Bishop ( 1876-1927) became one of the best known and most zealous American advocates of the antidote-antitoxin hypothesis of opiate addiction. He received his M.D. from Cornell in 1908, interned and was a resident at Bellevue until 1912. He became particularly attracted to the medical treatment of addiction as resident physician in charge of the alcoholic and prison wards at Bellevue. In his first paper on the subject he praised the methods of his teacher, Dr. Lambert ("Morphinism and Its Treatment," JAMA 58 : 1499-1504 [1912]). The following year he announced his adherence to the antitoxin-antidote hypothesis and argued that this explanation removed the "stigma of mental and moral taint" from addiction. He claimed that the addict was wrongly "held by all of us in despite and disgust, and regarded as so depraved that their rescue is impossible and they unworthy of its attempt." Dr. Bishop now made no mention of the Lambert method and seemed under the influence of the hypothesis popularized by Dr. George Pettey, that morphine in the body stimulates antitoxin formation (see below, ch. 4, n. 24), although he does not mention Pettey's work in "Narcotic Addiction—A Systemic Disease Condition," 'AMA 6o : 431-34 (1913). In the ensuing years Dr. Bishop increasingly emphasized that addiction was not the "popular and generally accepted" result of weakness of ywillpower leading to degeneration of the physical, mental, and moral being lost in "degrading thralldom," but that the addict was a sick man. The antidotal toxic substance manufactured by the body to protect it from the chronic opiate use could "be measured with mathematical exactness" and the addict could be adjusted to a precise amount of morphine so that he would appear and feel a well man. He credits Pettey with having independently come to this conclusion in "An Analysis of Narcotit Drug Addiction," N.Y. Med. J. loi 399-403 (1915). Dr. Bishop now became more confident and enthusiastic, claiming in 1915, that "without restraint, without specific remedies, without special methods, without routine medication, simply on the basis of an understanding of disease fundamentals and the application of rational therapeutics" he could treat the narcotic drug addict in the majority of cases purely on the basis of what he knew of his disease, and could restore him to health and competence. He opposed any restraint on the prescribing of opiates and denounced gradual reduction in most cases as "harmful, barbarous and futile" ("Some Fundamental Considerations of the Problem of Drug Addiction," Amer. Med. ai 807-16 [1915] ).
Dr. Bishop decried the ignorance of the average physician in the treatment of addiction, which he attributed to lack of experience and training, and he favored the establishment of a legal and cheap supply of drugs for addicts until cure was available ("The Narcotic Addict, the Physician and the Law," Med. Economist 4 : 121-28 1916
Bishop's various articles, published between 1912 and 1919, were the basis of his book, The Narcotic Drug Problem (New York: Macmillan, 1920), which appeared just as the New York City clinic was beginning to shatter the enthusiasm of the Health Department, and the Narcotic Division of the Prohibition Unit was deciding to close all clinics and prevent almost all maintenance. Even more coincidental was the indictment of Dr. Bishop in January 1920 for violation of the Harrison Act; he had still not been brought to trial in late 1922. The Treasury Department was accused of attempting to silence his strong stand against the current interpretation of the Harrison Act ( see "Resolution Relative to Dr. Ernest S. Bishop," American Medical Editor's Association, 53rd Annual Meeting, in Amer. Med. 28 : 720-21 [1922] ). The antimaintenance interpretations of the Harrison Act made Dr. Bishop's activities futile, but in his peak years, 1912 to 1922, he was an opponent of specific cures and any laws that would restrict addicts from receiving medically supervised maintenance. He and Dr. Pettey were the chief experts arrayed against Dr. Lambert and the Narcotic Division. His claim to be the first proponent of the "antitoxin" hypothesis irritated other authorities (see J. McIver and G. E. Price, "Drug Addiction," JAMA 66 : 478 [1916] ) as well as the fact, probably, that he announced his "expert" status the year he finished his residency.

24 Dr. George E. Pettey, The Narcotic Drug Diseases and Allied Ailments (Philadelphia: Davis, 1913), pp. 12-27. Dr. Pettey, prior to Dr. Bishop, proposed that addiction disease can be explained through formation of an antitoxin in reaction to the harmful effects of morphine. This hypothesis would make complete elimination of all morphine from the body the chief goal Of treatment and make less important such "morphine-antagonists" as the belladonna group which figured so largely in the Towns-Lambert treatment. His major work, Narcotic Drug Diseases and Allied Ailments, was often quoted until the mid-192os, and he was a featured speaker at New York Medical Society meetings and before the Whitney Committee. For a later modification of Pettey's method, employing "catharsis of the blood stream" by means of intravenous infesions of isotonic saline, see C. S. Bluemel, "A New Treatment for the Morphine Habit," JAMA 72 : 552-56 {1919]).

25 Metchnikoff (1845-1916) received the Nobel Prize in 1908. One of his most influential suggestions concerned the morbid effect of "intestinal autointoxication," which was applied to almost any disease—in this instance, addiction. The weight of his views and their reasonableness made autointoxication popular among physicians and the lay public; his belief that changing the intestinal flora could counteract the intestinal "poisons" and prolong life led to the fad for yogurt which still continues, although Metchnikoff's theoretical inspiration is forgotten.

26 Pettey, Narcotic Drug Diseases, pp. 58 ff.

27 A. Valenti, "Experimentelle Untersuchungen über den chronischen Morphinismus," Arch. exper. Path. Pharrnakol. 75 : 437-62 (1914); this re-
search was among the most disputed in the debate over the "disease" of addiction. It was cited by Rep. Lester Volk, M.D., in his attack against opiate restriction to ordinary addicts (Appendix to Cong. Rec., House, 62, pt. 13 : 13,340-13,345, 13 Jan. 1922, 67th Cong., and Sess.). It was first accepted by DuMez (JAMA 72 [1919] ) and then attacked by the AMA Narcotic Committee of 192o ("Report of the Committee on the Narcotic Drug Situation in the United States," JAMA 74 : 1326 [192o] ).
Eventually, Valenti's work was disproved to everyone's satisfaction (ch. 4, n. 40 below ), but in 1918-22 each side of the disease controversy rested much of its credibility on this one line of research.

28 P. Sollier, "La Démorphinisation. Mécanisme Physiologique. Conséquences au point de vue thérapeutique," Presse Méd., 23 April 1898, vol. 1, no. 34, pp. 201-02, and 6 July 1898, vol. 2, no. 56, pp. 9–so. See abstract in Journal of Inebriety 20 : 436-40 ( 1898 ); E. S. Faust, "liber die Ursachen der GewOhnung an Morphin," Arch. ex per. Path. Pharma. kol. 44 : 217-38 (1900); M. Cloetta, "Ober das Verhalten des Morphins im Organismus und die Ursachen der Angewiihnung an dasselbe," Arch. exper. Path. Pharmakol. 50 : 453-80 (1903). W. H. Willcox, "Norman Kerr Memorial Lecture on Drug Addiction," Brit. Med. J., s Dec. 1923, pp. 1013-18; A. Fauser and B. Ottenstein, "Chemisches und PhysikalischChemisches zum Problem der `Suchten' und `Entziehungserscheinungen; insbesonders des Morphinismus und Cocainismus," Ztsch. Neyrol. Psychiat. 88 : 128-33 ( 1924 ).

29 Levinstein ( see above, ch. 4, n. 14). Reported cure rates vary widely, but usually settle down to a rather low rate. If cure means abstinence, the rate is very low, perhaps io%, but if cure means ability to return to a job then perhaps 30% could be considered cured, even if they did occasionally relapse. In many ways the argument over cure is similar to that in the treatment of neuroses and psychoses—"adjustment" to life often being the criterion employed, not attainment of perfect health.
In the era of therapeutic optimism, say 1905 to 1915, cure rates were estimated as high as 90% or 99%; but both before and after the decade, when the answer to "How many can be cured?" was less politically and emotionally charged, 25% was a rough approximation for treatment programs. Methadone maintenance, of course, is an "adjustment" cure, for the patient is not drug-free, and the goal is return to the community, optimally with a job. Hope for a cure is usually associated With a naïve belief that addiction is something like a cold or appendicitis and not like more frustrating chronic ailments. In each period, respected journals and scientists have swung with social attitudes and either entertained the possibility of a high cure rate or looked skeptically on such claims. Alexander Lambert is one of the highly respected clinicians who lived through pre-World War I optimism, and his publications trace his own raised and then dashed expectation for simple cures.
Some of the many papers written after the period of optimism based their studies on hospitalized patients, often those cared for in the Public Health Service Hospitals at Lexington and Fort Worth. Two papers that illustrate the epoch preceding the new forms of treatment popularized in the 196os are: M. J. Pescor, "Prognosis in Drug Addiction" (Amer. 1. Psychiat. 97 : 1419-33 [1941] ), which suggests that about 30% of addicts treated at Lexington were abstinent about three years after release, mostly according to the patients' own reports; and R. G. Knight and C. T. Prout, "A Study of Results in Hospital Treatment of Drug Addictions" (Amer. J. Psychiat. zo8 : 303-08 [1951] ), based on information collected on the 75 consecutive admissions to New York Hospital, Westchester Division, between 1930 and 1950, in which barbiturates and other drugs were used as well as morphine and heroin: "36% seems to have been benefited," of which about half were abstinent "following hospitalization for one to fourteen years." In 1962 more than go% of the addicts treated at Lexington who returned to New York became readdicted within six months according to G. H. Hunt and M. E. Odoroff, "Follow-up Study of Narcotic Drug Addicts after Hospitalization," Pub. Health Reports 77 : 41-54 (1962). A study of addicts released in Kentucky suggested that if the criterion of successful treatment were revised to include "some period of complete abstinence during the follow-up period," 76% of male addicts would be considered aided by treatment (J. A. O'Donnel, "A Follow-up of Narcotic Addicts: Mortality, Relapse and Abstinence," Amer. J. Orthopsychiatry 34 : 948-54 [1964D. For a recent survey of treatment success which concludes that "none of the presently available approaches to treatment of drug abuse can be expected to be successful with more than a small percentage of the drug-abusing population, and all approaches combined will have an undoubtedly limited effect," see R. M. Glasscote, J. Jaffe, J. N. Sussex, J. Ball, and L. Brill, The Treatment of Drug Abuse: Programs, Problems and Prospects ( Washington, D.C.: Joint Information Service of the American Psychiatric Association and the National Association for Mental Health, 1972).
30 T. D. Crothers, Morphinism and Narconumias from Other Drugs (Philadelphia: Saunders, 1902), p. 150; see also T. D. Crothers, "Drug Addictions and Their Treatment," Med. Record go : 238-41 (i916). Thomas Davidson Crothers ( 1842-1918) received the M.D. degree from Albany Medical College in 1865 and in 1881 organized the Walnut Lodge nospital in Hartford, Conn., for the treatment of alcohol and opiate inebriates. He edited the Journal of Inebriety from 1876 to 1918. He was also a professor in the Boston College of Physicians and Surgeons and its dean in 1908. This medical school is described by Abraham Flexner after a visit in 1909 as a private institution which depended on tuition fees for its existence. The entrance requirements were called "vague," the facilities- "wretched," clinical resources "dubious," and the dispensary "miserable" ( A. Flexner, Medical Education in the United States and Canada [New York: Carnegie Foundation for the Advancement of Teaching, Bulletin no. 4, 19 io), p. 242).

31 C. B. Pearson, "The Treatment of Morphinism," Med. Times 42 245— 46 (1914). Pearson, like Bishop, wrote on behalf of the addict's personal worth, as in "A Plea for Greater Consideration for the Opium Addict" (Med. Record 83 : 342-43 [1913]), reacting against the more general depreciation of the addict among physicians as well as laymen.

32 Pearson, "Treatment of Morphinism," p. 246. Pearson's optimism was matched by C. J. Douglas, superintendent of the Douglas Sanitarium in Dorchester, Mass., who claimed in 1908 that he had yet to meet with his first failure. Douglas put his patients to sleep during withdrawal ("Narcotic Method of Treating Morphinism," Med. Record 74 404-05 [1908] ).

33 Biographical sketches of Towns are found in two articles: Samuel Merwin, "Fighting the Deadly Habits: The Story of Charles B. Towns," American Magazine, Oct. 1912, pp. 708-17; and Peter Clark MacFarland, "The 'White Hope' of Drug Victims: An Everyday American Fighter," Collier's, 29 Nov. 1913, pp. 16-17. My description of Towns's life and progress up to the Shanghai Commission is largely taken from these articles, which were based upon interviews with Towns; there is no evidence that he was displeased with their adulatory tone or the outline of his life. In the years of his greatest credibility, 1908-20, magazines that featured articles by him included Survey, the highly respected journal of social welfare, The Literary Digest, The Century Magazine, American Review of Reviews, and The Medical Review of Reviews. At the height of his career he published Habits That Handicap: The Menace of Opium, Alcohol, and Tobacco, and the Remedy ( New York: Century, 1915), with a preface by Dr. Richard C. Cabot of Harvard, one of America's most eminent physicians and social reformers, who described Towns as knowing "more about the alleviation and cure of drug addictions than any doctor that I have ever seen" ( p. viii) and an appendix by Dr. Alexander Lambert, "The Relation of Alcohol to Disease." The mind reels at the thought of how magnificently Towns could have 'Promoted an effective cure.
Towns was so prominent an authority on addiction that some newspapers and nonmedical periodicals occasionally referred to him as "Dr." Towns, an understandable error, and as recently as 1972 he appeared as "Dr. Towne" in Norman Zinberg and J. A. Robertson, Drugs and the Public ( New York: Simon and Schuster, 1972), p. 59, and in E. M. Brecher, Licit and Illicit Drugs ( Boston: Little Brown, 1972), pp. 46 passim. Towns's nonexistent doctorate seems to date from an earlier claim that he was one of the first "physicians" to recognize the addictive "triad" of compulsive need for an opiate, tolerance, and withdrawal signs upon abrupt withdrawal. See Marie Nyswander, The Drug Addict as a Patient (New York: Grune, 1956), pp. 1-13. In a recent study by Rufus King, The Drug Hang-up: America's Fifty Year Folly ( New York: W. W. Norton, 1972, p. 24), Towns shifts occupations and becomes a New York State Senator.

34 9 Jan. 1908 ( WP, entry 51).

35 See above, ch. 2, n. 4; I have not been able to identify Dr. Thomas. Perhaps he was Dr. Henry M. Thomas, at that time clinical professor of nervous diseases at Johns Hopkins. Towns later claimed that Dr. Victor Heiser, Commissioner of Health in the Philippines, said that he had treated 700 cases of addiction "with highly satisfactory results" (Charles B. Towns to Dr. Hamilton Wright, 13 June 1911 ( WP, entry 36). Dr. Heiser recalled that Towns had an effective treatment of alcoholism at his hospital ( My interview with Dr. Victor Heiser, in New York City, 25 March 1970).

36 Acting Secretary of State to Delegates of the United States to the International Opium Conference, 18 Oct. igii (WP, entry 38).

37 Alexander Lambert, "Obliteration of the Craving for Narcotics," JAMA 53 : 985-89 ( 1909), esp. p. 986. The Towns-Lambert method was criticized by Pettey (Narcotic Drug Diseases, pp. 401-24) for, among other defects, being too brief, approaching the disease as a "vice," and using too drastic medication. Another criticism of the shortness of the treatment came from C. C. Wholey, a Pittsburgh psychiatrist, who also found it of little value in alcoholism and found that the "typical stool" was not a useful sign ("Dangers and Inconsistencies in Some Notable Short-Time Treatments for Drug Addictions," JAMA 64 : 390-92 [1915] ). Lambert's association with the Towns Hospital, even if he did not personally profit from the highly successful operation, was another source of attack, for example from the Medical Economist of New York, and from other physicians who felt economically threatened by the lay-operated hospital.
Shortly after his initial article, Lambert's recommendations were evaluated in an unsigned review article (JAMA 54 : 794-95 [1910]) which generally praised the treatment but cast some doubt on the high percentage of cures claimed, suggesting that probably little more than half remained cured. Yet Lambert's approach was the dominant "respectable" specific treatment among physicians for about a decade. In 1913 he again described his treatment ("The Treatment of Narcotic Addiction," JAMA 6o. : 1933-36 [1913] ) with about the same enthusiasm. Sir William Osler, the most eminent physician in the English-speaking world, chase Lambert to write the chapter "Alcohol, Opium, Morphinism, Cocaine" in the 1914 edition of Modern Medicine, edited by William Osler and T. McCrae, 2nd rev. ed., 2 vols. ( Philadelphia: Lea and Febiger, 1914), 2 : 396-499. Lambert was even more confident in this text than in the /AMA. He claimed that "this [Towns] treatment in my hands in some 800 patients has proved so successful that 8o per cent have remained well" (P. 445). In the pre-Harrison Act description, Lambert calls attention to the "perfect egotism" of morphinism, which is "often given to explosions of intense rage" making the addict destructive and dangerous (p. 439 )•
Lambert's conversion to psychological factors as the determinant in addiction was reflected in January 1920 in Modern Medicine, a new journal devoted to industrial and social medicine, of which he was one of the editors. Later, of course, he was attracted to Narcosan, and by the time of his death at the age of 78 in 1939, he may have been disillusioned about narcotic treatments.

38 Alexander Lambert, "Obliteration of the Craving for Narcotics," 'AMA 53: 985 (1909).

39 E. J. Pellini, "Report of the Special Committee on Public Health of the Greater City of New York to the House of Delegates of the New York State Medical Society," N.Y. State J. Med. zo : 117 (1920).

40 By 1919 the crucial difference of opinion among medical authorities was whether there existed in the body a chemical produced in response to the presence of morphine and directly related to "addiction disease." Advocating a substance in the blood were Drs. E. S. Bishop, L. D. Volk, C. F. J. Laase, and the occasional visitor from Memphis, Dr. Pettey; opposed were Drs. Lambert, Hubbard, and A. C. Prentice. By at least the fall of 1919, Dr. E. J. Pellini, Assistant City Chemist, was conducting experiments at Bellevue Hospital to locate the toxin in the blood claimed by Gioffredi, or the protective substance claimed by Valenti. Pellini was supported by Dr. Lambert; his papers, which sought to disprove either contention, had an unusual co-author, Arthur D. Greenfield, a New York attorney who had made a special study of addiction and the laws affecting it.
Dr. Pellini's research, which still stands fifty years later, was a major victory for the antimaintenance forces. At last it was possible to discredit the antibody doctors as unscientific, the very charge they had made against the antimaintainers. The Internal Revenue Bureau looked upon the antibody theorists as their special enemies. In a report on the New York situation made to the Assistant Commissioner of Internal Revenue, Thomas Cooper described his meeting with Dr. Pellini and his search for "the elusive antibody" expressing disbelief in such a theory (T. A. Cooper to H. M. Gaylord, 22 Oct. 1919, RPU). He also prepared a memorandum of a conversation with Major D. L. Porter, Revenue Agent in Charge, who told of difficulties being given the law enforcers by promoters of the antibody theory. Major Porter said that Dr. Bishop was under suspicion and that Dr. C. F. J. Laase, "his chief lieutepant in self-advertising propaganda," was under indictment for writing 13,000 prescriptions for addicts. Although his fellow "conspirators" pleaded guilty, Dr. Laase was acquitted after trial in federal district court July 1920 and died, apparently of a heart attack, the following month (N.Y. Times, 22 Aug. 1920). "These physicians," Cooper commented, "assume the attitude of being above and beyond the law" ( Thomas A. Cooper, "Visit to New York City in Connection with the Narcotic Situatibn in That City," 21 Oct. 1919, RPU).
The Bureau of Internal Revenue sent a questionnaire on the antibody theory to leading clinicians and scientists in the U.S. apparently in the second half of 1919; 3 replies endorsed the theory, 27 rejected it, and 12 were noncommittal. The chief reason for rejecting the theory was that the experiments of Valenti and Gioffredi were not reproducible and that since morphine was not a protein, it could not stimulate antibody formation (Digest of Replies: Antibody Questionnaire, RPU; the exact date of the replies cannot be determined, but from internal evidence the digest seems to have been prepared in 1919 or very early 1920. For further details see below, ch. 6, n. 72).
When Dr. Pellini and colleagues believed they had proof of the nonexistence of antibodies, they concluded that there was no organic basis for the abstinence syndrome, that abstinence had a "functional" or "psychological" cause (see above, ch. 4, n. 3g). Their opponents, such as Rep. Volk, ignored the evidence and expressed confidence in Valenti and Gioffredi. That is, both sides appear to have decided to fight the battle of addiction's possible organic basis on the question of antibodies, and the Pellini advocates seemed to assume that if there were no antibodies, there was no organic basis for addiction. The intransigence in both camps led to the ferocity and hostility which now motivated much of the debate.
Pellini's refutation of Gioffredi is found in E. J. Pellini and A. D. Greenfield, "Narcotic Drug Addiction: I. The Formation of Protective Substances against Morphine," Arch. Internal Med. 26 : 279-92 (1920), his refutation of Valenti's research in "II. The Presence of Toxic Substances in the Serum in Morphine Addiction," ibid. 33 : 547-65 ( 1924 ). When A. G. DuMez of the PHS appeared to accept Valenti's contentions in a review article of 1919 (JAMA 72 [19191), he was criticized by the AMA Narcotic Committee which elicited a degree of retraction from him. DuMez replied to the committee's request for clarification ( letter dated 17 March 1920, JAMA 74 : 1326 [1920]), that Valenti's research "has not been conclusively proven." For later research in the 1920S which also questioned the existence of a detectable substance in the bodies of addicts caused by the use of opiates, see below, ch. 4, rm. 45, 47.

41 With the demise of specific treatments and immunological mechanisms, the AMA Narcotic Committee report of 8 May 1920 ("Report of the Committee on the Narcotic Drug Situation in the United States," JAMA 74 : 1326 [1920) ) sought answers in social science, psychotherapy, vocational rehabilitation, aptitude tests, "careful follow-up," a wise probation system, and in particular the "new psychology"—psychoailalysis. In advice which echoes the style of Shaw's Sir Ralph Bloomfield Bonington's admonition to "stimulate the phagocytes!", the AMA committee advocated a program to "irradiate and sublimate" the libido. Interestingly, the medical background of The Doctor's Dilemma (1913) is almost identical with that of the antibody craze in the treatment of addiction in the U.S. The great discovery in Shaw's play is an amazing vaccine which cured tuberculosis according to immunological theories of MetChnikoff, who, in addition to postulating the dire effects of intestinal autointoxication, described the phagocytosis of bacteria by white corpuscles.

42 Cf. Pellini, N.Y. State J. Med. zo : 119 (1920). Lambert recalled in 1920 how some years earlier he had checked on zoo cases he had treated about i9o9 and found to his regret that only 4% or 5% had remained abstinent. This revealed to him the essential place of aftercare in addiction treatment.

43 The disinterest of physicians in treating addicts does not seem to be explained by the threat of enforcement agencies in the period before 1919 or 1915. Although police and narcotic agents did use threats and Intimidation as well as arrest, particularly after 1919, lack of knowledge or interest, or the unwillingness of most general physicians to treat addicts, was a source of comment well before the legal repression of addiction maintenance. Even a few addicts could disrupt a respectable physician's waiting room, particularly if they were lower class. The effect of an addict's abstinence syndrome on other waiting-room patients, lack of effective treatment reflecting on the physician's competence, and perhaps primarily, the typical physician's attitude toward the addict as a moral reprobate, which Dr. Bishop himself so eloquently described in 1912 (see above, ch. 4, n. 23), made the physician hesitate to treat addicts. Therefore when enforcement agents began to try to stop the activities of addiction maintainers, they acted with the support of many in the medical profession.

44 L. Kolb, "Pleasure and Deterioration from Narcotic Addiction," Mental Hygiene 9 : 699-724 ( 1925), esp. p. 723. Dr. Lawrence Kolb, Sr. (1881-1972), enterefi the Public Health Service in 1909 and retired in 1944, as an assistant surgeon general. He served as head of the Mental Hygiene Division (now the National Institute of Mental Health). His career in the PHS bridges the era from Martin I. Wilbert and A. G. DuMez to that of contemporary medical experts. In the 19205 Dr. Kolb supported strict interpretation of the Harrison Act and believed that restraint had a very marked effect on reducing the number of addicts in the nation. In 1935 he became the first medical director of the Lexington Narcotic Farm. There he grew increasingly doubtful of the efficacy of jailing addicts and enforcing treatment. He has been critical of the former Federal Bureau of Narcotics and Commissioner Harry J. Anslinger for inculcating a fearsome picture of opiate addiction. In 1956 Kolb supported an experimental maintenance plan proposed by the New York Academy of Medicine and strongly opposed in 1951 and 1955 severe federal laws against opiate, marihuana, and cocaine use.

45 Research in Philadelphia was subsidized by funds from the Committee on Drug Addictions of which Dr. Terry was the executive secretary. The Philadelphia Committee for the Clinical Study of Opium Addiction was organized in 1925, conducted most of its research in Philadelphia General Hospital, and published its results in the Archives of Internal Medicine in 1929 and 1930. The papers were collected with an introduction and summary and published as Opium Addiction (1930) by the AMA. Internist in Charge was Dr. Arthur B. Light; Dr. E. G. Torrance and pthers were associates. The major topics included physical condition of the opiate addict, presence of any characteristic substance in the blood during morphine administration and after abrupt withdrawal, effect of scopolamine on addiction, and the excretion of morphine.

46 Alexander Lambert and F. Tilney, "The Treatment of Narcotic Addiction by Narcosan," Med. J. Record 124 : 764 (1926). By 1928, New York City was spending $25,000 to $50,000 annually on Narcosan treatment (R. C. Patterson, New York City Commissioner of Correction, to Rep. Stephen Porter, 15 May 1928, printed in Establishment of Two Federal Narcotic Farms, Hearings before the House Judiciary Committee on HR 12, 781 and HR 13, 645, 26-28 April 1928, 70th Cong., 1st Sess., rev. print., 1928, p. 132). The next year Lambert declared Narcosan to have "no merit" as a result of more careful clinical studies (JAMA 92 : 147 [19291).

47 "Report of the Mayor's Committee on Drug Addiction," Amer. J. Psychiat. .to : 433-538 (1930), esp. pp. 534-35. That current addiction theories and treatments based on them are inadequate is also concluded in L. Kolb and C. K. Himmelsbach, "Clinical Studies of Drug Addiction: III. A Critical Review of the Withdrawal Treatments with a Method of Evaluating Abstinence Syndromes," Suppl. 128 to Public Health Reports (GPO, 1938)•

48 Statement of Rep. Stephen G. Porter, Establishment of Two Federal Narcotic Farms, hearings, p. 19; Rep. John J. Cochran, Cong. Rec., House, 69 : 9413, 21 May 1928,7oth Cong., 1st Sess. (GPO, 1928).

49 Recent standard descriptions of the effects of narcotics and summary of research findings include: J. Jaffe, "Narcotic Analgesics" and "Drug Addiction and Drug Abuse," in L. Goodman and A. Gilman, eds., The Pharmacological Basis of Therapeutics, 4th ed. ( New York: Macmillan, 1970), pp. 237-313; and A. Wikler, "Opioid Addiction," in A. M. Freedman and H. I. Kaplan, eds., Comprehensive Textbook of Psychiatry (Baltimore: Williams and Wilkins, 1967), pp. 989-1003.

50 A. Wikler, "Opioid Addiction," pp. 996 if., slightly rephrased.

51 Charles B. Towns, Drugs and Alcohol Sickness ( New York: M. M. Barbour, 1932), pp. 15-16.

52 Charles B. Towns, The Physician's Guide for the Treatment of the Drug Habit and Alcoholism ( n.p., n.d. ), p. 7. This pamphlet of 8 pages appears to have been published about 1914, for the Medical Economist begins quoting from it then. It reveals that the charge in advance for a 5-day treatment varied from $200 to $350, depending on accommodations in the more expensive main building; in the Annex, "for patients of moderate means" willing to share a room with one or two other patients, the charge was $75.

53 Alexander Lambert, "The Treatment of Narcotic Addiction," JAMA 6o : 1933-36 ( 1913).

54 See ch. 4, n. 42.

55 Towns, Physicians' Guide, pp. 6-7; Charles B. Towns, Reclaiming the Drinker (New York: Barnes, 1931), pp. 75-76.

56 Richard C. Cabot, "The Towns-Lambert Treatment for Morphinism and Alcoholism," Boston Med. Surg. J. 164 : 676-77 ( 1911 ), p. 676. Cabot was a consultant to a Brookline sanitarium, founded in November 191o, which used the Towns method. Dr. Cabot was as distinguished as Lambert and is credited with having inaugurated social work in American hospitals and pioneering psychiatric social work training. His contributions to social work, his medical services, and teaching of physicians were of the highest quality. His adoption of the Towns method can hardly be attributed to mercenary motives or ignorance. See his entry in Dictionary of American Biography, vol. 22, Suppl. 2 ( New York: Scribner's, 1958).

57 Alexander Lambert, "Obliteration of the Craving for Narcotics," PIMA : 989 ( 1909).