Early local and state narcotic controls in the United States grew out of the danger perceived by those American communities that were directly affected. Pennsylvania, the home of leading morphine manufacturers, enacted an antimorphine law as early as 1860. Two decades later Ohio passed a law against smoking opium, and in 1897, twelve years after the way had been prepared by pharmaceutical research for massive production of the compound, Illinois enacted a law against cocaine.1 Soon thereafter, as the activity of the American Pharmaceutical Association between 1901 and 1903 suggests, efforts within the states to control opiates and cocaine rapidly reached across the nation. Cocaine's euphoric and stimulant qualities, as well as its association with crime and with a feared and repressed minority put it at the top of any list of outlawed substances. These characteristics of cocaine are similar to the description in the mid-1930s of marihuana's effects,

Local laws varied in their severity. Some were so complicated or all-inclusive that it was practically impossible to fulfill their requirements. Others were expressions of concern over narcotics, but with loopholes to protect the sale of patent medicines and other domestic remedies that contained narcotics.2 The sale of drugs and patent medicines across state lines was affected little, if at all, by local measures. A typical law would provide for the sale of narcotized proprietaries without restriction, but would confine provision of pure drugs to pharmacists and physicians, requiring a prescription that would be retained by the pharmacist for inspection for a period of time, perhaps two or three years. Naturally, there were many ways around this modest regulation. A physician might dispense narcotics directly to his patients or to anyone coming to his office. Inspection of pharmacists' prescriptions was notoriously rare; in some drugstores one could simply purchase a. dime or a quarter's worth of cocaine or morphine.

Some laws prohibited refilling of narcotic prescriptions in the attempt to cut off an unlimited supply of narcotics to anyone who had a tattered prescription. These laws generated arguments which became wearyingly familiar as the antinarcotic crusade progressed. On the one hand the wholesale and retail drug trades expressed concern for the poor who would be forced to visit a doctor every time a prescription for morphine or heroin had to be refilled. It was on behalf of unfortunates in the cities and in isolated rural communities that prescription refilling at the patient's request was sought. Complaints that a prescription which could be indefinitely refilled was in effect a dangerous and uncontrollable opportunity to obtain habit-forming drugs was met with avowals that no self-respecting druggist would lower himself to be a mere purveyor of such substances.

Physicians, on the other hand, could accept the wisdom of such prohibitions; they did not plan to overcharge just because the patient had to return for prescription renewal. The effect of prohibiting prescription refills was to create steady customers who came back daily or weekly for brief visits to some physicians to get new prescriptions. A small percentage of physicians devoted themselves to this "specialty." Their encounters with their numerous "patients" were short—some saw hundreds daily—but the fact that there was an encounter at all gave the public the satisfaction of knowing that addicts were "under the care of a physician."

Let's not confuse the nefarious with the respectable, the, maintaining physicians argued, and treat patients with chronic diseases like addiction, dropsy, liver cirrhosis, and constipation as if they were criminals.3

Other physicians, the vast majority even according to advocates of addiction disease, shied away from treating, maintaining, or encouraging addicts. These doctors shared an attitude comma in America: patient habitués were troublesome and untrustworthy. The rare physician who before 1919 publicly favored maintenance of addicts pleaded with his colleagues to cooperate, but the practitioners' interest in doing so, either initially or as antinarcotic legislation gained ground, appeared to be rather small.4

The health professions occupied a prominent position in the anti-narcotic crusade. No one questioned the medical need of opiates in some medical situations, and so initially the profession had a generally free hand. Lawmakers relied on professional ethics to control use of narcotics, but in the day-to-day practice of medicine, legal definitions could not easily distinguish between well-meaning overuse, use in error, and indiscriminate dispensing that led to addiction. Legally, restriction of narcotic transactions to licensed health practitioners was fairly simple, and the thought that this regulatory approach would fail because of the professionals' own culpability was painful to contemplate, for the result would be an enforcement nightmare.

In the Harrison Act an attempt was made to distinguish legitimate from illegitimate prescription of narcotics by physicians. The Treasury and Justice Departments would argue in 1915 that supply of drugs for mere comfort or maintenance of addiction was illegitimate, but this interpretation was not supported by the Supreme Court until 1919. One can conceive the difficulty of framing legal rules for the practice of medicine, and it was this difficulty which earlier legislators believed could be avoided by trusting doctors to police themselves. When fear of narcotics grew, the health professions were high on the list of culprits.

Loopholes in various state narcotic laws also received criticism when alarm over addiction did not decline after legislation had been enacted. The patent-medicine makers, however, had some unusual weapons that protected their commercial well-being. Beyond the usual art of lobbying, proprietary manufacturers had clever contracts with newspapers that provided for cancellation of their large advertising contracts should any state law be enacted restricting the sales, labeling, or claims that the medicine makers chose to employ. This provision generally resulted in silencing the news media with regard to restrictions on patent medicines and revelations of their dangers. But by 1935 the criticism of narcotized proprietaries became so outspoken that the Proprietary Association of America, comprised of the leading manufacturers, favored strict limits on the amount of narcotics in across-the-counter remedies.5

Furthermore, until labeling requirements were mandated by the federal Pure Food and Drug Act ( 1906), not only did manufacturers not list the narcotic or alcohol contents, they often positively denied its presence when it was plentiful in the substance.6 Apparently the remoteness of mail-order houses clouded their special role. By default, then, the health professions had a prominence greater than they deserved.

If the fear of drug abuse had diminished in the new century, the health professions would have had no worry. Fear accelerated, however, in spite of a leveling off in per capita narcotic importation. Record-keeping regulations made it possible for jurisdictions to examine the prescribing and dispensing habits of physicians and druggists. It was discovered, particularly after the Harrison Act made national narcotic record-keeping uniform, that a small percentage of the profession was simply selling narcotics, having received, as it were, a license from the state to do just that. Yet when the doctors were questioned or brought into court, they claimed they were merely practicing medicine and that they had every right to prescribe as they thought wise. Pharmacists were similarly brought under legal scrutiny. The law as applied to the health professions was difficult to enforce but could be made more stringent if the public so demanded. Professionals could be made to conform to law much more effectively than unlicensed peddlers or pushers. One cannot but wonder what would have been the public's response if it knew how many preparations handled by the health professions were completely inert or ineffective.

Reformers attacked the patent medicine problem in several ways. Some labeling requirements were achieved in 1906, and an unexpected loophole in labeling claims was corrected by the Sherley amendment in 1912.7 Pressure mounted in state legislatures tt force disclosure of all active ingredients in patent medicines. Surveys made by the American Pharmaceutical Association in 1915 and 1916 monitored the decline in narcotized patent medicines. In 1915, the first year the Harrison Act was in effect, 92 of the 1,108 pack-aged remedies available in retail stores contained opiates, cannabis, or chloral hydrate. Significantly, none contained cocaine. By 1916, only 61 of 1,o78 remedies had any opiate, cannabis, or chloral hydrate. Of the five with cannabis, three were remedies for corns and two were cough preparations. Of the four with chloral hydrate one was a hair tonic, one an antiseptic lotion, one a toothache remedy, and one an ointment for eczema.8

As the number of narcotic proprietaries diminished, so did the narcotic content in many that remained. Pe-ru-na, a cheerful standby for generations, decreased its alcoholic content ( required, the makers said, simply to retard spoilage ) from 28 percent at the turn ofthe century to 17 percent, and by 1918 to nothing. Similarly, the morphine content of Mrs. Winslow's Soothing Syrup decreased from 0.4 grain in an ounce in 1908 to 0.16 grain in 1911, and then to no morphine by 1915. These changes were apparently undertaken because disclosure of narcotics or alcohol content decreased the popularity of proprietary remedies.9

The great furor over narcotic proprietaries represented the public's awareness of insidious drugging by unscrupulous interests. Relief that this menace was receding under the impact of hard-won federal legislation left the self-regulated health professions in an even more exposed position. They were becoming the last legitimate enterprises that could be legally constrained from endangering society with narcotics.

The peddler had been present from an early day; he was not considered an extremely difficult enforcement problem until the most restrictive legislation and court interpretation cracked down on licensed purveyors of narcotics. Once maximum legislative control was applied to the peddler or pusher, it became evident that narcotics would remain available in the largest American cities. Before the peddlers' durability became evident, though, the legal channels of narcotic traffic would have to be attacked.

THE USPHS AND MARTIN WILBERT

In 1912, when the Hague Convention spurred federal agitation for a national antinarcotic law, the United States Public Health Service looked into state laws regarding poisons and habit-forming drugs. The PHS had little influence within the federal government, but it was occasionally called upon to assist in a modest way centers of power such as the State Department; it was watched by the health professions lest it depart from its traditional role of combating communicable disease, treating merchant seamen, and gathering and disseminating information.10

With impetus gained from the national movement to establish a department of health with cabinet rank, the Public Health Service gradually expanded. From the Marine Hospital Service founded in 1798 it became in 1902 the Marine Hospital and Public Health Service, and in 1912. the Public Health Service. The Hygienic Laboratory, established in the late nineteenth century in New York City to perform some rudimentary scientific procedures, also grew and by 1904 was housed in its own building in Washington. Eventually the Hygienic Laboratory became the National Institutes of Health. Martin I. Wilbert, a pharmacist from Philadelphia, was chosen to be a technical assistant in the new laboratory's Division of Pharmacology, at that time the highest professional role a pharmacist had achieved in the federal service11 Wilbert performed well in the intricate development of the federal antinarcotic laws. Like other outstanding investigators of the PHS, his valuable papers were too often confined to the technical Public Health Reports. What influence Wilbert enjoyed was not due to his rank in the Public Health Service; in Philadelphia his scientific work had established the pharmacy of the German (now Lankenau ) Hospital as a model for the health profession. His devotion to raising the standards of pharmacy led to enormous work with the American Pharmaceutical Association, its local branch, and brought him in contact with the medical profession. An original member of the AMA's Council on Chemistry and Pharmacy (1905), he served on it until his early death in 1917. His obvious disinterest in amassing wealth would have been established by his accepting a post with the PHS, if by nothing else. Wilbert had the reputation of being thorough, fair, and a constructive critic. When the National Drug Trades Conference met in Washington, D.C., in 1913, he was asked to represent the AMA in planning the antinarcotic law. Wilbert was the PHS expert in the fleld.12

In a 1912 compilation of state laws on habit-forming drugs, Wilbert declared,

There are few if any subjects regarding which legislation is in a more chaotic condition than the laws designed to minimize the drug-habit evil. . . . In many of the states anti-narcotic laws are so comprehensive that practically every retail druggist would be subject to fine or imprisonment were an attempt made to enforce the legislation ostensibly in force, while in other states the laws are so burdened with exceptions and provisos as practically to nullify every effort to control the traffic in narcotic drugs.

Wilbert's description of the state laws reflected a common belief that local legislation had failed to halt the progress of habit-forming drugs in the United States. His reports left no question that these drugs represented a social danger and required further action, but he shied away from dramatic exaggeration.13

Wilbert and Hamilton Wright present a striking contrast. Wright fought for narcotic control on a grand scale, fending off devious international conspiracies and offending almost everyone he dealt with. Wilbert, an unassuming man with a rather quavering voice, nicknamed "Weepy Wilbert" by his colleagues and devoted to finding the most rational solution to a difficult problem, refused melodrama and aggressive actions. His long hours with committees exhibited "unlimited patience." 14 Wilbert was trusted; Wright was resented. Almost exact contemporaries, they died within a few months of each other, both relatively young and still in the midst of the narcotic control controversy. This period of state and local statute revision and treatment experimentation ( 1910—20) can be clarified by some examples from various places and by a close examination of the approaches tried in New York State.

LOCAL CONTROL: JACKSONVILLE'S NARCOTIC CLINIC

In Jacksonville, Florida, Dr. Charles E. Terry established a style of addiction control which within ten years became the most controversial in America. Dr. Terry, a dedicated public health officer who took an increasingly prominent role in the debate over narcotic control, became a leading exponent of the medical approach. He worked chiefly within the framework of professional or philan-thropic health organizations such as the American Public Health Association and the Bureau of Social Hygiene. Terry eventually compiled a thousand-page anthology of information on narcotics.15

In 1912, however, Dr. Terry was the City Health Officer of Jacksonville, the largest city in the state, where he practiced an approach to drug addiction that became a debated alternative to various kinds of embargo, national or personal. He established a city drug clinic so that habitués could receive free narcotic prescriptions. His work is a direct forerunner of the methadone maintenance clinics which now exist in many American cities.

Dr. Terry decided upon this innovation after the failure of existing state controls. The Florida law had proven inadequate as revealed by prosecution undertaken by the State Pharmaceutical Asso-ciation which all resulted in nol prosses. Therefore he asked the Jacksonville City Council to enact an ordinance regulating in an unusual way the common drugs of habitués. In order to locate physicians who would "lend their services to the fostering of these habits,",he asked that prescriptions containing more than a normal dose of habit-forming drugs be copied and sent to his office. Druggists would be required to keep their drug prescriptions in ledgers which could be inspected by the health officer. Possession of the drugs, except under conditions of the ordinance, was made a misdemeanor. Most importantly, the ordinance permitted the health officer to provide free prescriptions to habitués if he thought it advisable. The prescriptions were provided to eliminate the excuse by druggists that sale without a prescription was necessary because the user was too poor to go to a physician. The requirement would also "bring the health officer into personal contact with the unfortunate addicted to drug habits." After conferences with the local medical society and city pharmacists, the law was passed by the council in August 1912. After a few early violators were promptly prosecuted and convicted, Dr. Terry felt the law was generally obeyed.16

After a year of operation, Dr. Terry had registered 646 habitual users, a number equal to about percent of Jacksonville's population. Some, he does not say how many, were transient, but he guessed that this number would roughly equal those receiving drugs directly from their physicians and therefore escape the recording of prescriptions required by the ordinance. Although half the inhabitants of Jacksonville were white and half black, the number of white habitués outnumbered the blacks by almost two to one ( 436 to 23o). He surmised that "with us at least, the whites are far more prone to drug addictions than the blacks." Among the habituated blacks, cocaine was favored by about half; among whites, by about a fifth; opiates took up most of the remaining fraction. Of all users, about 4 percent favored heroin, 20 percent laudanum, 25 percent cocaine, and almost 40 percent morphine. Females outnumbered males by about three to two, and tended to prefer opiates to cocaine.

The relatively low rate of drug use among blacks, and the willingness of Dr. Terry and the city government to supply the dreaded cocaine to them, is further evidence of the exaggeration of "cocainomania" in the American press and by federal government officials.

Dr. Terry gained the confidence of about one-third of the users, and although "mendacity is a common attribute of the drug fiend and information so obtained is not reliable," his conversations with addicts led to the conclusion that 55 percent of the habits had been acquired through treatment by physicians, 20 percent from advice of acquaintances, and 20 percent through dissipation. Only 2 percent arose from chronic and incurable disease treated with narcotics. Dr. Terry stated before the American Public Health Association:

Here were 112 men and women become confirmed drug habitués through the judgment of as many physicians who elected to submit their patients to this risk, in order to relieve varying degrees of pain caused by conditions which, for the most part, were in no way permanently benefited by the administration of an opiate, no small number of which were amenable to surgical interference or other well-recognized treatment, and where, in some instances, opiates, by every rule of intelligent practice, were distinctly contraindicated! . . . In many instances these first doses were not given at the bedside to allay severe pain, but handed out to office patients with apparently as little concern as a dose of calomel.

If this kind of righteous indignation could be aroused by an informed colleague, one cannot be surprised that the public believed the physician deserved to have his prescriptions of habit-forming drugs severely restricted. It is reasonable to assume that most of the physicians themselves shared Dr. Terry's harsh view of the dope doctor.

Dr. Terry also chastised the druggists who reaped an extravagant profit from their narcotic sales, and praised the form of New York's cocaine law of 1913 except for its omission of opiates. Any legislation must "take full cognizance of the practicing physician as a factor of prime importance in the formation of drug users and not content itself with restrictions thrown around the druggist." Effective prohibitive legislation "must provide for the free treatment of existing users." The users should be considered public wards for "at least one rational course of treatment." Dr. Terry had confidence only in public institutions after his experience with home treatments, private sanitaria, and private physicians. As a result of experience in his narcotic clinic, and a belief that medical treatment could be efficacious if given in a public institution, he declared that addiction was best left to health departments and not police departments. The police were distracted by many concerns and had only spasmodic interest in addiction "whenever chance or some too flagrant act brings the matter to their attention."

Clients were not feared by the clinic personnel but seemed an alien and pitiful group; Dr. Terry's description of chronic indigent addicts prior to the Harrison Act is of some interest:

The social misery, the inefficiency and communal depletion resulting from this civic malady, may not be properly realized by one who has not seen for himself this pitiful array of wrecks waiting, as in a breadline, for the free dope prescription, wives fearful lest their husbands discover their condition; fathers and mothers hiding, by every artifice a stimulated cunning may devise, their habit from their own children; young men and women asking in a whisper for a fifty-cent prescription for "coke," a vicious circle of carelessness, ignorance and cupidity involving a responsibility that has been shifted from shoulder to shoulder until no one seems willing to admit it, yet intimately associated with the public welfare and health conservation and deserving of the most careful investigation and expert treatment.

In Terry's early work, themes appear which he developed further over the next tvvo decades.

STATE CONTROL: THE TENNESSEE NARCOTIC ACT OF 1913

Tennessee's revised narcotic law came into effect more than a year before the Harrison Act. Its most distinctive feature was the registration of addicts to enable them to have opiate prescriptions refilled "to minimize suffering among this unfortunate class" and to keep "the traffic in the drug from getting into underground and hidden channels." 17

Like Dr. Terry, Tennessee's State Food and Drug Commissioner Lucius P. Brown believed that physicians were the leading culprits in causing addiction.18 He warned that "a very large proportion of the medical profession has either lost sight of the fact that the habitual use of an opiate produces a true disease, or never knew it." The withdrawal symptoms, he said, were a specific disease, possibly fatal if not forestalled by the readministration of opiates. In this conviction he was following information, readily obtained from journals and textbooks, that was the chief argument for the medical approach toward addiction—it was a true disease, not a mere habit conquerable by exertion of the will.

Brown outlined the state's options: either provide opiates to indigent addicts to prevent suffering and perhaps death, or provide "state curative treatment for all indigent addicts, with permanent commitment of those incorrigible to institutions for the feeble-minded." After registering addicts and gathering statistics in Tennessee, the option of cure or commitment proved "to be out of the question . . . because of the enormous number of persons involved." The reasoning is simply stated: if addiction is a disease, the victim can hardly be made to suffer for what he cannot help and, if the state cannot build gigantic sanitaria, the necessary drug must be provided. Issues of degeneracy, criminal behavior possibly induced by drugs, and moral turpitude leading to addiction were ignored by the Commissioner. The physician or druggist was seen as the chief wrongdoer and the state as the inevitable and reluctant caretaker.

In meeting the problem of addiction the state must prevent abuse of prescriptions. Numerous regulations were intended to assure that certified addicts received drugs at only one store and that the amount was recorded. When the permit was renewed an attempt was supposed to be made to lessen the amount of the drug allowed.

In the first twelve months of operation 2,37-0 persons were registered, of whom 86 percent used morphine. Only 1.3 percent used heroin, although it was thought that more heroin addicts remained unregistered, "inasmuch as this drug is used almost altogether for dissipation." Females outnumbered males two to one; the average age of addicts was 49 for both sexes and they had been addicts an average of eleven years. Although a fourth of the Tennessee population was black only a tenth of the addicts registered was black. Commissioner Brown suggested that this might be due to the fact that "the average Negro avoids as far as possible any contact with an official and to the fact that the Negro appears to use relatively less morphine, and more cocaine, than the white man." Cocaine was not included in registration because it was felt that no disease or "toxemia" was produced by it; one could stop cocaine without any dire physiological consequences. Commissioner Brown confidently placed the blame for the addict population: "Other investigations by me, as well as the experience of all other writers on this subject, would appear to indicate that well over 5o percent of existing cases of narcotic addiction are due to the indiscreet administration of drugs by physicians."

The Tennessee experience gives excellent information on heroin addiction. The suspicion that fewer than the actual number of heroin addicts were registered, and that heroin was used simply for dissipation, reflects attitudes toward the age group which used heroin: "youngsters from 15 to 25 years of age." Heroin was described as having "a very pronounced stimulant effect, and for that reason is largely used by boys and young men as a means of dissipation." The association between young men and boys and heroin was to be a repeated phenomenon in the decade 1910-20. Heroin's appeal for the adolescent seems to set it off from opium-smoking, morphine, laudanum, gum opium, etc. The age of heroin users was much lower than the average age of Tennessee's other registered addicts. Brown thought the habit, "as might be expected from the character of its devotees," would be difficult to cure and advised: "The sale of this drug ought to be hedged about with just as rigid and drastic restrictions as are possible to enact into law."

Neither Terry nor Brown was optimistic about cures in private sanitaria or by private physicians. Brown saw institutionalization as an impracticable ideal. For both, in fact, medical treatment did not mean cure, but prevention of suffering. But addiction maintenance would be associated in the public's mind with moral turpitude, the spread of vice and crime, indulgence in.sensual delights, and the destruction of the human soul. In New York State, from 1913 to 1920, the full expression of these conflicting attitudes, as well as the interplay of mercenary and political influences, provides an instructive record.

NEW YORK STATE ANTINARCOTIC LEGISLATION

Accredited as a world authority on narcotics, Charles B. Towns proposed his own antinarcotic law to the New York Legislature in early 1913 and had it introduced by Senator John J. Boylan. Towns's bill had been endorsed by the Kings County Medical Society." From the well established, Towns had little trouble,20 but from the rank and file medical man who was then beginning to organize to better his economic and social status, he evoked hostility and resentment. The general practitioner's distaste for Towns and his antinarcotic bill is apparent in some provisions of his proposal which were too extreme to be approved in 1913.

Some elements were legitimate attempts to require that a prescription include the address and legible name of the prescriber, prohibit fraudulent professional credentials, and monitor transactions between wholesalers and retailers. All prescriptions for habit-forming drugs would be filled in on special forms serially numbered and retained for inspection by the pharmacist. Towns claimed that these measures would overcome the problems of fraud in obtaining narcotics and ignorance of the amounts of narcotics sold to physicians and druggists, and keep the continued supply of narcotics to patients under the control of physicians. Such restrictions could not be faulted except on grounds of excessive paper work for the busy physician and druggist. Towns did not, however, recommend an exemption clause for proprietaries, and this alone would have killed the measure. But perhaps the major opposition among physicians was created by his proposed restrictions on narcotic prescribing. For example, he would limit to three weeks the time a physician could freely dispense narcotics to a patient. Continuation thereafter would require approval from the local health department. This constraint was introduced to prevent the practitioner from indefinitely "treating" .an addicted patient who could not be cured on an ambulatory regimen. Towns suggested that if a patient was addicted he should be offered medical treatment in a sanitarium, say for a week, and, if judged incurable, be furnished drugs cheaply by the local health authority.21

Such an unprecedented legislative restriction on the private physician did not go unnoticed and could not have been more effectively designed to stimulate the fear and enmity of the general practiiioner. Although the direct loss of income might not have been great for most, the transfer of service responsibilities to health departments continued what the GP considered a trend of government competition for the patient's dollar. The cure of addicts would be shunted to sanitaria, probably operated by "hospital doctors," the unpopular elite of the profession.

By this effort to control the medical care of addiction, Towns set himself up as an enemy of the average physician in New York City. He was called a fraud who sought legislation that would injure the unfortunate addict, to Towns's pecuniary advantage,22 attacked as practicing medicine without a license, and accused of hiring physicians on contract, a high-ranking sin among doctors. Towns's comrade, Alexander Lambert, was a strong proponent of health insurance, annual licensing of physicians, and the establishment of a standard fee schedule. Towns's antinarcotic law was opposed more for its threat to traditional freedom of medical practice than for its goal of restricting narcotic use. Thus two forces were set against each other—a growing public demand that physicians be restrained from complete freedom in narcotic dispensing, and the medical profession's fear that the state would dominate the practice of medicine.

At the same session of the New York Legislature that rejected Towns's suggestions, a new cocaine law was enacted through the leadership of Assemblyman Alfred E. Smith.23 So many elaborate restrictions were placed around cocaine that there was little opportunity thereafter for its legal distribution in any significant amount by physicians or patent medicine manufacturers. The passage of the cocaine law reflected the total condemnation of that drug in American society. Opiates remained controlled by older laws with many loopholes.24 A modern law that would keep step with increasing fear of opiates was not enacted until 1914.

Enforcement of the cocaine law had an important effect on the movement to control the availability of narcotics. The courts swelled with offenders who would not fulfill the requirements of the new and intricate law.25 This result might placate public opinion, but a side effect of these arrests was the discovery that cocaine was only one of the delights offered in the "drug orgies" raided by police. Along with cocaine habitués, heroin users were found who were regulated only by the sanitary code of New York City. Heroin and cocaine became linked as drugs of dissipation that were without medical justification.26

The Boylan Act, New York, 1914

Public disclosure of drug abuse stimulated reformers to urge a new antinarcotic law for New York. Financial support for a committee carne from Mrs. William K. Vanderbilt, Sr., who had interested herself in the drug cause, and thus the legal, correctional, and city officials who composed it were termed the Vanderbilt Committee. Although occasionally credited with the subsequent passage of the antiopiate Boylan Act, Mrs. Vanderbilt seems merely to have chosen a popular cause with which to associate her name. Not only was Towns again the major proponent of the bill, which John J. Boylan introduced, but Senator Boylan also described himself as the mouthpiece of Mr. Towns, and he strongly rejected any insinuations that Mrs. Vanderbilt influenced the bill's passage. "At one time," Boylan declared, "I sincerely feared that this 'assistance' from the group which bore Mrs. Vanderbilt's name would kill all effective anti-drug legislation for the session." 27

The Boylan Act incorporated essential compromises which diluted the purity of the previous year's unsuccessful but more comprehensive bill.28 The first compromise was an exemption from the law for proprietaries containing less per ounce than 2 grains of opium, ¼ grain of morphine, ¼ grain of heroin, 1 grain of codeine, or 10 grains of chloral hydrate. Prescriptions were to be completely filled out and could not include any of the controlled drugs unless the physician had first given the patient a physical examination. Also, pharmacists must verify by telephone or other means the authority of any prescription containing more than 4 grains of morphine, 30 grains of opium, 2 grains of heroin, 6 grains of codeine, or 4 drams of chloral hydrate. Narcotic prescriptions could not be refilled. Possession of narcotics without an authorized certificate prepared by the retailer would constitute a misdemeanor. Order blanks furnished by the state health commissioner were required in transactions between retailers and wholesalers. Records had to be kept of the retail transactions of any of the drugs and the record preseived for five years. Hypodermic syringes could be obtained only on prescription. The license of a registered professional could be revoked if he was addicted to the use of any habit-forming drug or convicted of any violation of the Boylan Act.

The Act permitted commitment of individuals regularly using habit-forming drugs to "a state, county, or city hospital or institutions licensed under the State Lunacy Commission." In order to preserve order in such institutions, there was provision for the transfer of recalcitrant addicts to institutions for disorderly vagrants, although they would be separated from other inmates.29

The Boylan Act may appear to have been a victory for Towns, but from his point of view there was at least one large defect. An action for commitment could be brought only against regular drug users who were not "under the direction and consent of a duly licensed physician." 30 Therefore the Act permitted the maintenance of addicts but restricted it to physicians. Nothing prohibited the physician from prescribing as large an amount of a habit-forming drug as he wished, although the prescription could not be refilled. In this respect the Boylan Act had created a potentially sizable number of patients who were bound to physicians by their need to obtain nonrenewable prescriptions and by the fear that without a personal physician they were liable to institutional commitment.

Between the enactment of the Boylan law on 14 April and its effective date on July 1914, warnings were given by Towns to the "innocent" drug addicts—those who were not criminals and who might not even know they were addicted but were only aware that they had to keep taking certain medicines or proprietaries. He was quoted in the New York Times 31 as declaring that these new strictures would make it impossible for the involuntary fiends to secure more drugs from their physicians; but he was optimistic of,results, if enough preparation were made for the influx of addicts to hospitals, since "it takes only five or six days to cure a drug fiend in a hospital." Such statements, in the face of the law which did in fact permit ambulatory maintenance, understandably confirmed the suspicions of doctors who had long been wary of Towns's sincerity and supposed lack of self-interest. But at least in this instance he did not blame the licensed professional for the drug habit, for he averred the principal cause of addiction was prior cigarette smoking, found in every case of the six thousand he had studied, long before the victim began to take drugs.

The Times asserted editorially on July 1914 that drugs for habitual use were now outlawed. Education of the public about the provisions of the Boylan Act was apparently inadequate as reformers' dreams became reality. Hospitals were pressed to provide beds for users who volunteered for cure or were committed. Seventy-five beds were made available at Bellevue, fifty on Blackwell's Island, and some facilities were provided at the City Farin on Staten Island.32 The City Inebriate Farm near Warwick in Orange County seemed a good place to set up a more permanent facility, but appropriations were difficult to obtain.

Urgency for treatment grew partly from the increasing number of drug-related arrests in New York. In 1914 there were 1,950 arrests for violation of drug laws in the city; 947 were convicted. In 1913 there had been only 511 arrests.33 The increased arrests heightened concern; agitation for even stricter drug laws led in 1915 to amendments to the Boylan Act. Sales of drugs to minors so angered the legislature that such sales were upgraded to felonies. Record-keeping regulations for pharmacists were also tightened. 34 With the somewhat strengthened Boylan law and the federal Harrison Act coming into effect in March 1915, even more illicit drug transactions were uncovered. Although physicians could prescribe for addicts, it was said by such informed persons as Justice Cornelius Collins of the Court of Special Sessions that many physicians had stopped prescribing because they were uncertain about the law's provisions. The disinclination of doctors to maintain addicts, Justice Collins stated, was crowding court calendars to capacity with drug cases, and was causing more commitments for treatrnent and a wide-spread belief that the underworld was moving into the drug market to fill the vacuum left by the physicians.35

Once again the effect of police enforcement, particularly after the Harrison Act, was marked. Lieutenant Scherb, head of New York City's sixteen-man "dope squad," described the results:

The poor victims who have been getting their dope from peddlers on the street are having a pretty rough time. From every report I get there is panic among them. Many of them are doubled up in pain at this very minute and others are running to the police and hospitals to get relief. Those who have been getting their drugs from dope doctors and fake-cure places are not so hard hit, because these traffickers have not been touched by the laws, but the poorer people, the men and women we call the "bums," who have always bought from street peddlers, are really up against it. The suffering among them is terrible.36

The cost of heroin on the streets rose from $6.50 an ounce to about $100 an ounce, according to the police. Hospitals took in those needing drugs and attempted cures by reduction.37 But physicians at The Tombs prison reported in December 1914 that they doubted any quick cure, saying that it might take two months to get some users off drugs and that if they were then not isolated from drugs for at least a year, the outlook for cure was dim.38 The problem of addiction became in 1914 and 1915 increasingly prominent and menacing to the public. Paradoxically, alarm was created by the enforcement of antinarcotic laws, which brought many users into court and caused the drug problem to appear greater than before enforcement. From Scherb's comment it is clear that the dope doctors and the fake-cure places were seen as islands of evil resistance in an otherwise fairly successful antidrug campaign. Public fear of dope peddlers grew with the increase in arrests. The medical profession, by obtaining a legal monopoly of the treatment and maintenance of addiction, also found itself a target for public animosity as other legal sources of supply were restrained.

The medical profession's response to their exposed position, like that of the pharmacists, was divided. Most doctors were not interested in having anything to do with addicts. They shared the prevailing view that addiction led to moral degeneracy and crime. The doctor who used minute amounts of morphine in his practice yearly was not concerned about the severity of narcotic restrictions. Charles Towns repeatedly got medical society support for his measures, which, if adopted as first drafted in 1913, would largely have excused private medical practitioners from the care of chronic addicts.39

But there were some physicians who rejected the attitude that addicts should be shunned. Without doubt some disagreed because there was a good income to be made from them. Others saw no harm in maintenance if it would enable a fairly normal life for a doubtfully curable individual. The New York Medical Journal denied in May 3.915 that addiction was a vice, describing it as a "compromise or an adjustment to the conditions of life." 40 For some citizens, drugs were necessary to keep up with the American pace. Narcotic addictions would be the negative but perhaps unavoidable aspect of "the American way of life."

One source of organized resistance to the prohibition of addiction maintenance came from a physicians' group in New York City. These physicians opposed such a step as an element in a wider and more serious threat to the medical profession, which included health clinics, school nurses, fixed fee schedules, salaried and contract doctors, exclusiveness in granting hospital privileges, and an influx of other "foreign" ideas of social planning which would enslave and pauperize them. Recognition of this attitude places the narcotic debate in the context of larger professional and social issues.

In 1911, two groups of physicians in New York, the Yorkville Medical Society and the Medical Alliance, "began a systematic agitation for the protection and promotion of the economic interest of the medical profession." In the next two years more groups formed, and the need to coordinate their activities led to the formation in June 1913 of the Associated Physicians' Economic League, a federation of the Medical Alliance with the Brooklyn Physicians' Economic League, the Bronx Physicians' League, the Downtown Physicians' Protective League, and the Physicians' Protective League of New York. That same year the federation began publication of a periodical, the Medical Economist, which was either a propaganda sheet or a fearless defender of the GP, depending on one's viewpoint.41 The periodical never gave Charles B. Towns or Alexander Lambert. respite from criticism. It often declared the incompetence of the medical societies and urged its readers to fight for their views at Albany and City Hall. One of its proudest accomplishments, frequently cited as proof of the federation's effectiveness, was the exemption from ticketing and towing of physicians' cars while they were double-parked. Such practical accomplishments were its metier; it left science to the more effete medical societies.

The Associated Physicians' Economic League of New York spent much of its energy in the battle for antinarcotic laws favoring the general practitioner, but the fight to keep him as the primary agent of society responsible for the care and treatment of addicts was only part of a larger movement. The issues were economic betterment and the control of medical practice in ways acceptable to the GP. The specific faults denounced by the federation were contract practices ( with social lodges, etc.), under which physicians were employed to treat a specific number of patients, each of whom paid the same modest premium. This contract physician violated the principle of payment for the amount or skill of work done: whether he worked two or twenty-four hours a day, he got the same salary. He also took patients away from fee-for-service physicians. The hospital dispensary which treated the poor at no cost was also a danger because of the ease with which the undeserving were believed to obtain enrollment. The league wanted only those demonstrably indigent to be treated; abusers of the system should be prosecuted. Unauthorized practice of medicine, by a prescribing pharmacist or by mail-order physicians, was similarly anathema, for which redress was sought in the legislature.

But even some regular private-practice physicians evoked the average practitioner's ire. Specialists maintained a stranglehold on the hospitals and on appointments to the hospital staff. The league complained that appointments were reserved for the influential. Even appointment as an intern seemed to be based on the applicant's race, religion, ancestry, and station, which had to be acceptable to the hospital directors. The system worked to the advantage of the few. The paying patients were bled by the consultant surgeon or specialist and hospital alike. In any event, the general practitioner was left out in the cold.42 Through concentration on such evils, in a few years the league claimed a membership of several thousand, a sizable proportion of the practicing physicians in greater New York.43

Dr. Lester D. Volk rose in this movement to lead numerous forays against the federal government's efforts ( successful after 1919) to separate the addict from the private physician. Earlier he had worked with greater success to mold the state antinarcotic laws in favor of the average practitioner. His remarkable career spanned the economic movement. In 1906, at the age of tvventy-two, he had received his M.D. degree from the Long Island Medical School, but he soon became interested in law and politics. He was admitted to the bar and helped inaugurate the Medical Economist, of which he later became editor. His early interest in Theodore Roosevelt's Progressive Party and its radical social notions evolved into vigorous representation of the downtrodden GP. After a term as a Bull Moose assemblyman he declined renomination, switched from medicine to law, and established his second professional practice. After service as a medical officer in World War I, he enthusiastically and successfully championed veterans' bonuses and was soon elegted as a Republican from Kings County to the House of Representatives. He served in Congress from igzo to 1923, bitterly attacking Pro-hibition and the Harrison Act, particularly the regulations pro-mulgated by the Treasury Department which prohibited maintenance or reduction supplies of narcotics to addicts. His public career ended after he had served as an assistant state attorney general from 1943 to 1958.44

Volk's appeal to the medical profession was modeled on the labor union movement:

Membership in our leagues will mean to the physician what membership in his organization means to the working man and when we have once realized that we are not far removed from the level of the working man in our daily acts and duties, then we will lose the false sense of high position we so dearly love to assume towards the laity, but which we fail to maintain among ourselves. . . . Think organization, speak organization, and shout organization till by repetition it becomes a by-word.45

With regard to the narcotic problem, the league's first substantial success was to defeat, in cooperation with other medical societies, the proposal in the 1916 legislature known as the Boylan bill, which was more commonly referred to by the league as the Towns-Hearst bill because of its strong support from Towns and the Hearst papers (the New York American and Journal). This bill would have reclaimed some of the ideas advocated by Towns in 1913: three weeks was set as the usual limit for outpatient provision of an addict with narcotics, and an elaborate registration system for addicts was required; incurables would be furnished drugs by departments of health.46

The bill passed the Senate, but was not called up in the closing hours of the session by the Speaker of the Assembly. In order to settle the narcotics muddle which was becoming an annual donnybrook, the legislature authorized a joint committee of investigation composed of three assemblymen and two senators.47 In time, the league's view of the narcotics problem would exert great influence over this committee. The investigation would mark the beginning of a decline in the influence of Towns and a temporary defeat in New York for those who wished to forbid maintenance of chronic addicts.

The Whitney committee began taking testimony in December 1916 in New York. As the various treatments for addiction were presented it became obvious that the medical profession had no consensus on how treatment should proceed or which treatment was most efficacious.48 But maintenance was also deplored by such distinguished witnesses as the Commissioner of Health of the City of New York, Dr. Haven Emerson, who questioned the social and medical "propriety" of narcotics furnished to addicts by the Health Department.49 Even under the amended Boylan Act, which per-mitted the maintenance of addiction under a physician's super-vision, the Health Department did not encourage such treatment.50 Justice Cornelius Collins testified to an increase in drug use in spite of recent laws, while other witnesses estimated the number of addicts in New York City alone to be about 200,000.51

The committee welcomed Dr. Ernest Bishop, who had worked with addicts at Bellevue and was especially interested in their medical treatment. Unlike Dr. Emerson, Dr. Bishop found nothing wrong with furnishing drugs to addicts of long standing. He had for several years strongly advocated the medical as opposed to the enforcement approach to addiction. His publications gave the impression that the practitioner could usually treat the opiate slave, not by a routine specific regimen of drugs but by the kind of individualized traditional treatment which the private doctor accorded his other patients. As the influence of Towns and his claims for a specific treatment seemed to imperil maintenance of addiction by the private physician, Dr. Bishop became more outspoken in his denial that a specific cure existed. He pointed out the inadequacy of institutions if all addicts presumed to exist were made to undergo isolated treatment. He asserted that addicts most probably were upright citizens who wished to be cured but had been discouraged by worthless treatments. He saw only one course: "the rational handling and care of existing conditions at the hands of reputable general practitioners of medicine." 52

Opposition to maintenance came from equally concerned and sympathetic individuals who believed that the outpatient treatment failed because patients were not isolated from drugs or because of the ineffective ministration of charlatans. All sides agreed that institutions existed which were of value only to the proprietors. Justice Collins, a middle-of-the-road critic of Bishop's view, speaking in early 1919, tried to fend off suggestions that there was no effective treatment.

Although it may be said that while conditions make absolutely necessary a reliance, in the main, upon treatment by the general practitioner, that conclusion does not militate against institutional treatment, when and where available. There is, undoubtedly, an appealing necessity at this time for the establishment of hospitals or parts of hospitals devoted to the cure of drug addictioh with facilities for after care, and a step in this direction will be a veritable godsend.53

The investigators' Preliminary Report to the Legislature in February 1917 used the approach, and in several instances almost the wording, of the report on addiction which had been adopted by the physicians' league.54 Some of the chief positions taken by the Preliminary Report included:

1. "The problem of narcotic drug addiction has passed all bounds of reasonable comprehension in the state of New York anti in the United States [and has become] the greatest evil with which the Commonwealth has to contend at the present time."

2. "Lack of understanding and appreciation of the disease of narcotic addiction and its treatment by a large majority of the medical profession has fostered conditions which make it impossible to determine a rational procedure for treating and curing the addicted by the state at this time."

3. "The constant use of narcotics produces a condition in the human body that physicians of medical authority now recognize as a definite disease, which diseased condition absolutely requires a continued administration of narcotics to keep the body in normal function unless proper treatment and cure is provided."
State and Local Narcotic Control    113

4. "Those afflicted with this disease express every desire to secure humane and competent treatment and cure and . . . drug addic-tion is not confined to the criminal or defective class of humanity."

5. "State investigation of . . . cures and institutions is recommended."

6. "Your committee believes it to be one of the first duties of the state, in dealing with this grave situation, to establish a supply of narcotic drugs, to which the confirmed addict shall have access, under proper state regulation, pending the establishment of rational and recognized scientific treatment for his disease."

7. "Proper and humane treatment and cure should be provided for the addict by the state and necessary legislation enacted to prevent the spread of narcotic addiction."

8. Evidence presented to the committee indicated that legal distribution had declined while public consumption had greatly increased; the committee concluded that the addict must be getting his drugs illegally and that this had occurred because pharmacists and physicians "either through misunderstanding of the law or the true nature of the addict's disease, have refused to prescribe or dis-pense narcotic drugs to the sufferer."

9. more thorough system of recording transactions in narcotics should be developed and a register of addicts compiled, under proper safeguard for confidentiality.

10. Provisions for commitment should be broadened to include ti commitment of said addicts to the care of a reputable physician • • • provided that the person so committed shall have on hand sufficient funds to defray the expense of such treatinent."

Widespread rejection of the medical approach was ascribed to predominant attitudes: the majority of physicians and of the public were joined in their distaste for addicts. But the Whitney Committee was able to demonstrate to the legislature that, regardless of the emotional attitude, some compromise had to be struck between addicts' cravings and the availability of the drugs.

On the whole, the medical societies and the league approved of the law which grew out of the investigation.55 The first Whitney law was signed by the governor on 9 May 1917. It superseded the Boylan law and specifically stated that physicians could treat addicts for their comfort, a circumstance permitted under the Boylan law but apparently considered insufficiently practiced. The relevant section reads in part:

It shall be lawful . . . for any duly licensed physician after a physical examination, personally conducted, to administer to, or prescribe for any person, whom such examination discloses is addicted to the use of any habit-forming drugs . . . in reasonable quantities dependent on the condition of such person and his progress toward recovery, provided that such physician acts in good faith, solely for the purpose of relieving physical stress or of effecting a cure of such habituates.56

The medical societies opposed registration of addicts and the requirement that a list of such patients be furnished each month to the State Board of Health.57 But another provision may have assuaged some of their pain. Section 249 provided that an addict might be paroled by a magistrate to a physician rather than an institution if it "satisfactorily appears to such magistrate that such addict is able to defray the expense of competent medical treatment." 58

One further major change ( Section 2.49) relaxed the legal restraints on providing drugs to the addicted: local boards of health were permitted to furnish without charge prescriptions for drugs "to provide for necessities of such person, pending treatment."

Justice Collins believed this first Whitney law caused 50 percent reduction in the number of court cases for illegal possession and it checked underworld exploitation. Explicit provision for medical treatment by the local physician aided the situation, he believed, and he credited the "honorable practitioner of medicine [with] splendid service to the community." Yet a new problem developed, demonstrating a sort of hydraulic model of drug traffic. Once the underworld was partially blocked, the physician—at least unprincipled physicians—began to dispense narcotics with no regard for minimal doses or no attempt to cure but "to reap dishonorable profit, which in some instances is quite large." 59 Also, there was no scheme to prevent an addict from being treated by several physicians at the same time and thereby garnering a large supply of drugs for sale or personal use. Although preferable to an underworld supply, the promiscuous distribution by physicians called for some control."60 This seemed to be immediately necessary because additional hearings of the Whitney Committee, in the winter of 1917-18, indicated growth of the habit. Estimates of addiction rates up to 5 percent of New York City's population were offered to the committee.61

A new fear arrived with American entry into World War I in April 1917. Concern grew that servicemen would become addicted by pushers, at the instigation of disloyal elements or spies at home or through use of morphine and heroin on the battlefield. Therefore, as severe as the problem might seem on the home front, when the soldiers returned. conditions would be even worse.62 What could be done? A disreputable minority of physicians took advantage of the legal encouragement for maintenance, but shutting off the prescriptions of the medical profession would lead again to underworld traffic. The new menace, heroin, increasingly afflicted youth in eastern cities so that the average age of the heroin addict in court was 22, with a very large number between ages 17 and 22.63 The result of this deteriorating situation was another major legal revision, the Second Whitney Act, in May 1918. The new law established the independent State Commission of Narcotic Drug Control, with authority to issue and modify regulations as it seemed desirable.64 An elaborate system of prescription forms was planned to get a firm hold on the number of addicts in the state and some gauge of their addiction.

The Final Report of the Whitney Committee, submitted to the legislature on March 1918, reiterated the major contentions of the Prelimirtary Report. The report also concluded that the drugs of addiction, including heroin and cocaine, were useful and should not be totally banned. A central state authority should establish policy for the control of addiction in cooperation with federal authorities; and, "as soon as the financial condition of the state will perrnit," the state should provide an institution for treatment of addiction and its scientific study.65

Somewhat surprisingly the medical economic leagues favored a powerful commissioner of narcotics who would oversee and direct the treatment of addiction.66 Perhaps its early support rested on the hope that Republican Senator Whitney, a man whose views the league accepted, would be appointed commissioner. But Frank Richardson was named by Governor Whitman, although Senator Whitney did become First Deputy Commissioner with responsibility for the New York City area. Then, upon the election of Democrat Alfred E. Smith as governor, Walter C. Herrick, a former state senator, became commissioner and Senator Whitney was replaced by Sarah Graham-Mulhall, an energetic reformer. To the resentment of some physicians, neither Richardson nor Herrick seemed to favor the private practitioner as an addiction therapist but sought to establish clinics throughout the state which would draw the addicted away from the GP into the purview of the state.67 In these clinics addicts would receive their drugs, in some even be encouraged to take treatment in an institution. The clinics, scattered across the state, were in many cases patronage awarded to a physician of the right party—a franchise on addict prescriptions in his town. Some doctors made the venture quite profitable, others were uninterested in the job. But Herrick, by this kind of administration, opened the commission to charges of political spoilage and removed the addict from those vocal private practitioners who wished to treat addicts themselves. His increasingly elaborate restrictions and paper work further increased the anger of the professionals as well as the drug-takers.

The Department of Narcotic Drug Control became operative on 1 February 1919, taking over the work of the Bureau of Habit-Forming Drugs from the State Department of Health. The department was composed of a commissioner, three deputy commisssioners, a chief clerk, and five clericals. With this staff the department faced the 20,000 physicians, druggists, dentists, veterinarians, manufacturers, and wholesalers who would communicate via piles of order blanks, registrations, etc. Soon plans were made to establish narcotic clinics in cities and communities in the state where those suffering from the disease of drug addiction could receive treatment.

The plan of the first commissioner, Frank Richardson, was clear, and one which his successor Herrick also followed: physicians and druggists who took unfair advantage of these unfortunates were to be identified from the records, and when the narcotic clinics were established, but not before, the department would "feel justified in revoking the authority of the physicians and druggists to treat and dispense narcotic drugs to those addicted."

After the department had been functioning for a year, Herrick estimated that there were about 39,000 addicts in the state, of whom 13,000 were registered through the physicians by whom they were treated." This total is substantially less than such figures as 200,000 which the Whitney Committee had accepted as reasonable. Herrick emphasized the involuntary cravings of an addict, contrasting him to the drunkard who "can, if he will, make a sudden determination and quit the habit forever." 69

VVhen the reports began to pour in, it became apparent that some physicians and druggists were buying gigantic amounts of narcotics or prescribing large amounts which appeared to be commercial transactions rather than the careful and regulated dosage the law implied by treatment "in good faith." The effect of such practice was detrimental to the program as a whole. Individuals opposed to the idea of maintenance held up these professionals as criminals and an example of what happens if thousands of variously trained physicians were allowed to do whatever their judgment indicated. The person who favored maintenance was troubled by the knowledge that these leaks in the system made restriction of narcotics to the chronically addicted very unlikely, and it was suspected that the leaks were also being used to create new addicts.

Among druggists, only a minority would deal with such prescriptions since "most of the reputable drugstores find the trade with addicts very disagreeable and fill only a few such prescriptions or none at all." Among those who did deal with prescriptions, many violations were discovered. Part of the basement of one New York drugstore was kneedeep in copies of used official prescription forms; 6,000 were filled in the month of November 1919 alone. In some drugstores only narcotics were available. It was said, the commissioner reported, that one of these druggists had made $75,000 in one year from this trade. Three stores in New York reported that during the month of November 1919 they had filled 6,148, 3,111, and 1,975 prescriptions, respectively; "ordinary drugstores" filled perhaps 50 each during the same month.

But it was among the physicians that the commission found its biggest headaches. Understaffed ( there was only one inspector for New York City, at an annual salary of $1,320 ) the commissioner was constantly hampered in his investigation and regulation of the more than 10,000 physicians registered with the department. Those who were unscrupulous seemed as inventive as the addicts in their evasion of the law's intent. Physicians generally did not want to send in the names of patients who were addicts, for a variety of understandable reasons. Therefore they took advantage of exceptions in the 1918 Second Whitney Act, which permitted prescription on "unofficial" and unreported prescription blanks, to prescribe for large amounts of narcotics as if treating a "surgical case or a disease other than drug addiction." Herrick reported with irony:

The peculiar thing about these unofficial prescription blanks is the fact that some doctors prescribe narcotic drugs as if they were really remedies or cures for diseases instead of being the means by which extreme suffering and pain can be deadened. An innumerable number of patients so treated were receiving no medicines other than these drugs. [Second Annual Report, p. 25.]

Of course, discovery of this state of affairs was dependent on investigation of the drugstores' and doctors' files by what inspectors were avallable—"a very difficult problem of administration." The reaction to this misuse of "unofficial prescription blanks" was the inevitable tightening and rephrasing of regulations so that the loophole was eliminated. Therefore the commissioner ordered in late 1920 the end of unofficial prescriptions and required all narcotics to be prescribed on official forms, copies of which had to be sent to the department within 24 hours of dispensing.70 It had been estimated that 5,000 addicts were receiving their drugs unar the unofficial system, some from more than one doctor and filling their prescriptions at more than one drugstore. But closing this gap only brought more anger from the private physicians who, one can assume, knew well what they were doing when they kept an addict's name from registration.

Although physicians such as Dr. Bishop and Dr. Volk advocated outpatient treatment of addicts on a maintenance or gradual reduction regimen, the Commissioner of Narcotic Control did not interpret the physician's task in so indefinite a manner. He constantly sought reports of cures from private physicians. These were so rare that the reduction method seemed only a feeble excuse for providing a permanent supply. Even the honest doctor could not prevent the addict from also being treated by another doctor, and when the reduced dose became uncomfortable, the addict would either insist and receive a higher one or go elsewhere permanently. One physician achieved some kind of record by giving out in one day 835 official prescriptions.

The number of such doctors and druggists the department had under careful observation was fairly small ( e.g. thirteen physicians and twenty-two drugstores in New York City in 1919) but the number of their "patients" was large.

Having adopted the view that the ambulatory method did not cure and legalization of maintenance made effective control of drugs difficult for the state, Commissioner Herrick in April 1920 declared that institutional treatment should be preferred and whenever possible addicts should be sent to one for withdrawal of the drug. After about two weeks, the addict should then be sent some-where else for rehabilitation, learning a trade or whatever, but not back to the conditions that encouraged drug addiction in the first place. In this regard, the existence of legal ambulatory treatment was particularly discouraging, because whenever the craving for drugs returned to the recently institutionalized addict he merely had to go to a physician or peddler and get back on the habit. Herrick recognized the need for aftercare and general rehabilitation, not just withdrawal of the drug. But his proposal was remarkably optimistic considering the discouraging results by 1920 from institutional care. Also, the provision for such care in New York State was meager, "embarrassing . . . the Department when it found reason to disapprove of a doctor's method of treatment and evecially so in its attempts to get the addicts to turn over a new leaf." Herrick was caught in a now familiar dilemma—if maintenance was provided, abuse of distribution occurred and accurate control of the drugs was extremely difficult, cure a rarity; on the other hand, refusing maintenance and mandating institutional treatment was predicated on the false belief that institutions cure addiction, as well as patently increasing the number of illegal channels. It is interesting that as late as 1920 Herrick could make such a strong plea for institutional care; he explained away the failure of drug withdrawal by lack of good follow-up.

The department's staff was small and unpopular. In addition to the one inspector for New York City there was a stenographer and a file clerk. Deputy Commissioner for New York City, Sarah Graham-Mulhall, was forced to move from one address to another because of the feeling against addicts. She finally set up an office in her own home from which she was protected from dislodgment.71

The commission asked for more financial aid from the state in order to build a larger staff and to be more effective, but Commissioner Herrick was soon to discover that an opposite course would be taken and the commission along with all the state narcotic laws would simply be abolished. This resulted from a head-on collision between state and federal approaches toward narcotic control. Federal control had been strengthened by an amendment to the Harrison Act in February 1919, and in the following month a very strict ruling by the Supreme Court essentially outlawed the maintenance of addiction and even the reduction method and ambulatory treatment.

NOTES

1 Laws of Pennsylvania of the Session of 186o, Act no. 374, Title I, Section 70, "Selling Poisons," p. 401; Ohio Laws: 1885-1887, vol. 82, p. 49, passed 6 Feb. 1885. The Illinois law against cocaine was approved 11 June 1897 (Laws of Illinois [18971, p. 138). It allowed cocaine sale only on a physician's or dentist's prescription and refilling was prohibited.

2 Martin I. Wilbert and Murray Galt Motter, Digest of Laws and Regulations in Force in the United States Relating to the Possession, Use, Sale, and Manufacture of Poisons and Habit-forming Drugs, Public Health Bulletin no. 56, Nov. 1912 ( GPO, 1912).

3 The belief in two classes of addicts, one bad and one either good or morally neutral, is a common conclusion of writers on narcotic use. Dr. George Wood (i868) describes the benevolent effects of opium on the healthy, but its baneful effects on the weak-willed. In this century in the U.S., the "underworld" user of narcotics was to be dealt with severely, but the "average" addicted person was to be pitied. Similarly in the Treasury Committee Report of 1919 the two classes of addicts were distinguished (Special Committee of Investigation Appointed March 25 1918, by the Secretary of the Treasury: Traffic in Narcotic Drugs, GPO,1919).

4 When addiction maintenance became specifically legalized in New York State (July 1917 ) the Medical Economist began a series of articles enumerating reasons for a physician to use opiates, partly as an inducement to the mass of physicians to assume some of the supply to addicts which had previously been borne by peddlers and other sources. "Opium —The Obligation of the Physician to Use It" appeared monthly from July through December 1917. The journal's attitude is characterized by a statement appearing in the August installment (5 : 143): "the law has deliberately said that [the physician] alone can use it and thus'this wonderful medicine is wholly in our hands for use in the healing and mediating art of medicine." Most physicians, to judge from the tone of the series, were not inclined to treat addicts, even if such care was legal.

5 J. H. Young, The Toadstool Millionaires ( Princeton Univ. Press, 1961 ), PP. 211-14, 237.

6 L. F. Kebler, Habit-forming Agents: Their Indiscriminate Sale awl Use, a Menace to the Public Welfare, Agriculture Dept., Farmer's Bulletin no. 393, April 1910 ( GPO, 1910 ), pp. 15-18.

7 This amendment declared a label or package misbranded if any "statement, design, or device regarding the curative or therapeutic effect of such article or any of the ingredients or substances contained therein . . . is false and fraudulent." The amendment was approved 23 Aug. 1912 (ch. 352, 37 Stat. L., 416). See J. H. Young, Medical Messiahs ( Princeton Univ. Press, 10i), pp. 49-51.

8 "Report of the Commission on Proprietary Medicines, American Pharmaceutical Association," JAPhA 5 : 1376-81 ( 1916 ).

9 J. P. Street, "The Patent Medicine Situation," Amer. J. Publ. Health 7 : 1037-42 (1917) •

10 For the role of the Public Health Service in the federal government see A. H. Dupree, Science in the Federal Government (Cambridge: Harvard Univ. Press, 1957), pp. 262

11 My interview with Dr. Robert Fischelis, Washington, D.C., 28 July 1970.

12 J. K. Thum, "Martin I. Wilbert," Amer. J. Pharmacy 89 : 49-61 ( 1917).

13 Wilbert and Motter, Digest of Laws.

14 Thum, "Martin I. Wilbert," p. 51.

15 Charles E. Terry and Mildred Pellens, The Opium Problem (New York: Bureau of Social Hygiene, 1928; reprint ed., Montclair, N.J.: Patterson Smith, 1970). Terry ( 1878-1945) received his M.D. degree from the University of Maryland in 1903 and later became the first full-time health officer of Jacksonville ( 1910-17). After serving as medical editor of Delineator magazine, he became executive secretary of the Committee on Drug Addictions formed in 1921, funded by the Bureau of Social Hygiene, a private research organization supported by such philanthropists as Paul M. Warburg and John D. Rockefeller, Jr. He prepared The Opium Problem with the aid of Mildred Pellens, whom he later married. When his position on the bureau terminated, he served at the Harlem Valley Hospital in New York until his death. Terry was closely associated with the American Public Health Association, and many of his articles appeared in the Journal of the APHA between 1912 and 1923. For further details see Edward R. Smith, "Seven Years of Pioneering in Preventive Medicine," J. Florida Med. Assoc. 53 : 725-28 ( 1966 ). I am indebted to Dr. Smith of the Florida State Department of Health and Welfare for providing information on Dr. Terry's life.

16 Charles E. Terry, "Drug Addictions, A Public Health Problem," MPH 4 28-37 (1914), p. 28. Subsequent information and quotations are from the same source.

17 Pliblic Acts of Tennessee, 2923, ch. 11, pp. 403-07, approved 25 Sept. 1913, effective i Jan. 1914.

18 Lucius P. Brown, "Enforcement of the Tennessee Anti-narcotic Law," MPH 5 : 323-33 ( 1915). Subsequent information and quotations are from the same source.

19 Edward Marshall, "Drug Evil Now the Target of Fierce Attack," N.Y. Times, 9 Feb. 1913. See above, Chapter 4, for a full description of medical support for Towns.

20 His hospital acquired "medical consultants" like Alexander Lambert and Samuel W. Lambert who at the time was dean of the College of Physicians and Surgeons ( Columbia ); Smith Ely Jelliffe was founder of the Psychoanalytic Review and co-author ( with William Alanson White) of the leading American text of psychiatry; the other consultants to the Towns hospital were Drs. George Montague Swift and James Watt Fleming.

21 Edward Marshall, "Drug Evil," N.Y. Times, 9 Feb. 1913.

22 Innumerable jibes and attacks directed at Towns appeared in the Medical Economist, e.g. "Townes [sic] on the Law and Medicine on Townes" (2 : 327-35 [19141). Yet to medical specialists he seemed reputable as evidenced by his staff of consultants, and also respected by laymen such as Henry Ford, who chose to send addicted and alcoholic workers to the Towns Hospital for treatment ( N.Y. Times, 8 July 1915).

23 Laws of New York, 1913, ch. 470, pp. 984-91; approved 9 May 1913.

24 Earlier restrictions in the public health laws forbidding refilling of prescriptions and sale of dangerous drugs without prescription were admitted to be commonly violated and rarely enforced (Amer. Drug. Pharmaceut. Rec. 52 :255 [1908) ).

25 See e.g. N.Y. Times, 1 Nov. 1915, which reports 700 violations after enactment of the Boylan law. Also see C. F. Collins, "The Drug Evil and the Drug Law," Monthly Bull. Dept. Health N.Y . City 9 : 1-24 (1919), esp. p. 4.

26 N.Y. Times, 22 Jan., 31 Jan. 1914. Also see Collins, "Drug Evil," p. 4.

27 The Vanderbilt Committee was composed of numerous officials and authorities already active in the narcotic problem, e.g. Katherine Bernent Davis, New York City Commissioner of Corrections, and later executive secretary of the Bureau of Social Hygiene; Justice Cornelius Collins, chief magistrate of New York City, and so on. In 1916 the various officials and committees concerned with narcotic control in New York City were consolidated into one group ( Collins, "Drug Evil," pp. 4-6). The bill the Vanderbilt Committee favored was introduced by Senator J. J. Frawley in March 1914, and the Towns measure was again introduced by Senator Boylan. A modified form of the Boylan bill was later endorsed by the Vanderbilt Committee, and the Boylan Act was signed by the governor on 14 April 1914. A long article by Marshall on Towns's efforts was again carried in the N.Y. Times on 22 February 1914, The Times on 17 April erroneously ascribed the Boylan bill to the Vanderbilt Committee's efforts, which prompted Boylan's outburst. See Letters to the Editor, N.Y. Times, zo April 1914.

28 Laws of New York, 1914, ch. 363, pp. 1120-24.

29 Ibid., sect. 249a, pp. 1123-24.

30 J. A. Cutter, in the Medical Economist, commented that the general press omitted mention of this feature of the Boylan law ("Medical Economics of the Boylan Law," 2 : 296 11914) ).

31 N.Y. Times, 21 June 1914; also see N.Y. Times, i July 1914.

32 N.Y. Times, 8 July 1914.

33 N.Y. Times, 15 July 1914; also 6 Jan. 1915. See also Collins, "Drug Evil," pp. 4-5.

34 Amendments to the Boylan Act, Laws of New York, 1915, ch. 37, pp. 1017-22; became law on 17 April 1915 to take effect immediately.

35 Collins, "Drug Evil," p. 5.

36 N.Y. Times, 15 April 1915.

37 Ibid.; similarly, Philadelphia provided hospital beds ( C. B. Farr, "Narcotic Habitués and Their Treatment," /AMA 64 : 1270-71 [1915)); as did Chicago ( C. E. Sceleth, "What We Believe to Be Facts Concerning Drug Addicts," Ill. Med. J. 46 : 70-72 [1924]).

38 F. A. McGuire and P. M. Lichtenstein, "The Drug Habit," Med. Record 8o : 185-91 ( 1916 ); the authors treated in The Tombs 12,000 addicts in 12 years and reported no deaths from withdrawal of opiates. They concluded that no physician should be allowed to treat a patient outside a sanitarium or hospital, that heroin addicts tended to be young, white Americans, and that opiate addicts tended to steal to maintain their habit and were not given to violence.

39 Leaders of the AMA and the New York medical groups shared society's disapproval of the medical profession for "creating addicts," and some were prepared to support very stringent steps to limit the freedom of addicts.

40 This editorial also criticized the Boylan and Harrison Acts for not making provision for long-term addicts. The N.Y. Times picked up this idea in a sympathetic editorial on 18 May 1915.

41 0. Rotter, "Causes, History, and Achievements of the Medical Economic Movement in N.Y.," Med. Economist i : 4-11 (1913); "New Police Regulations for Doctors' Autos," editorial, ibid. 6 : 41 (i918); L. D. Volk, "The Existing Economic Evils of the Medical Profession," ibid. 2 : 276-82 ( 1914). By 1914, the League had changed its name to The Federation of Medical Economic Leagues.

42 A. Goldman, "An Appeal to the Few from the Many," ibid. / : 6o-64 (1913); Goldman claimed that those on top "with their prestige and power . . . could exert tremendous influence for our economic progress. Through their connections with various institutions, they could bring about reforms in a gradual and orderly way. But right here is where they fear to be identified with our movement. They leave our ranks and align themselves with opposing forces."

43 Membership estimates for the Federation of Medical Economic Leagues are based on statements made in the Medical Economist (1 : 11, 2 : 138,
4 : 221): in August 1913, 1,000; the following year, 350 in Kings County and a total of "several thousand in Manhattan, Bronx and Kings"; and in 1916, 3,000. The number of physicians in New York State rose from 14,117 to 15,877 from 1910 to 1920 ( James G. Burrow, AMA, Voice of American Medicine [Baltimore: Johns Hopkins Press, 1963], p. 403), and the number in New York City was about 7,000 in 1911 (Medical Directory of New York, New Jersey and Connecticut, Medical Society of the State of New York, 1911, vol. 13, p. 15 ).

44 Lesjer David Volk ( 1884-1962). See obit., N.Y. Times, 1 May 1962; also Biographical Directory of American Congressmen, 1774-1961, p. 1756.

45 L. D. Volk, "Organization of the Medical Profession," Med. Economist3 : 202-04 (1915).

46 The New York City Health Department, however, opposed addiction maintenance, and the regular medical societies as well as the Federation of Medical Economic Leagues opposed such severe restrictions on the private physician. The various forces now committed to the narcotic fight—the Hearst papers, Towns, various medical groups including private practitioners and public health officials, the drug trades, and rising public concern—led in 1916 to an impasse in the legislature. Dr. John P. Davin led the fight against the Towns-Hearst bill for the Medical Economic League and became a familiar medicopolitical figure in New York State by opposing any encroachments by the state on the private practitioner. After the bill was defeated, Volk wrote a glowing report of the success of the league in fighting on behalf of the humble practitioner ("The Defeat of the Boylan Bill," Med. Economist 4 : 100-03 [1916] ).

47 Authorized by a concurrent resolution of the Senate and Assembly in April 1916, appointed in September. The preliminary report appeared in February 1917. Members of the committee were George H. Whitney, chairman, George R. Brennan, R. M. Prangen, John J. Boylan, and Maurice Bloch. The committee gave considerable prominence to Dr. Bishop's theories in the preliminary report and could be said to have accepted his view of addiction disease, which included the need for maintenance in many instances ( "Preliminary Report of Joint Legislative Committee Appointed to Investigate and Examine the Laws in Relation to the Distribution and Sale of So-called Habit-forming Narcotic Drugs," N.Y. State Legislature, Senate Doc. no. 31,17 Feb. 1917, Albany).

48 N.Y. Times, 14 Dec. 1916.

49 Dr. Emerson (1874-1957) was one of the leading public health educators and administrators in the nation. He was Health Commissioner of New York City from 1915 to 1917 and later professor of public health administration at Columbia ( 1922-40 ). In 1922 he headed a committee of the Council on Public Health and Instruction of the AMA which sought to write a model state antinarcotic law with the support of the NDTC and other health professions. The model law prepared in March 1922 closely followed contemporary strict interpretations of the Harrison Act ( see Terry and Pellens, Opium Problem, pp. 893-96, 904-05). For provisions prohibiting addiction maintenance and some of the drug trades' opposition to "excessive" legal restrictions on the health professions, see "An Unsatisfactory 'Model' Law," Druggists Circular 66 : 423-24 ( 1922 ).

50 Although authorized to maintain addicts "pending treatment" after 1 July 1917 (Laws of New York, 1917, ch. 431, sect. 249a), the City Health Department did not do so and preferred to send the addict directly to a hospital for detoxification. See "Drug addicts: A Public Health Problem," Weekly Bull. Dept. Health City of N.Y. 6 : 305-07 (29 Sept. 1917). Later regulations emphasizing "temporary" maintenance before treatment were issued by State Health Commissioner Herman Biggs ( see ibid., pp. 394-95).

51 N.Y. Times, 5 Dec. 1916.

52 Bishop's views were fairly closely followed in the preliminary report ( see above, ch. 5, n. 47); also see N.Y. Times editorial of ii Dec. 1916.

53 Quoted by Collins, "Drug Evil," pp. 12-13.

54 Med. Economist 4 : log-10 ( 1916 ). The league took pride in its influence on the committee. See ibid. 5 : 72-73 ( 1917 ), where excerpts from the two reports are compared in parallel columns.

55 Ibid. See also ibid. 6 : 445 ( 1918 ), where approval seems dependent on Senator Whitney's becoming head of the proposed State Narcotic Control Commission.

56 Laws of New York, 1917, ch. 431, 9 May 1917 ( effective 1 July 1917).

57 Laws of New York, 1917, ch. 431, sect. 248; "Report, Special Meeting of Medical Society of the County of New York, 23 June 1919," N.Y. Med. J. no : 130-31 ( 1919 ) .

58 Laws of New York, 1917, ch. 431, sect. 249a.

59 Collins, "Drug Evil," pp. 8-9.

60 "Report of Committee on the Drug Evil," Jan. 1918, in Collins, "Drug Evil," p. 9.

61 "Final Report of the joint Committee Appointed to Investigate the Laws in Relation to the Distribution and Sale of Narcotic Drugs," New York State Legislature, Senate Doc. no. 35, I March 1918, p. 3.

62 Concern over addiction among returned servicemen was commonly expressed. Towns feared 500,000 addicts would return from the war. German spies and machinations to spread addiction appeared in several articles in the N.Y. Times: "Narcotic Inquiry in Camps" ( 28 May 1918); "Germans Sold Drugs to Debauch Soldiers" ( 2o Aug. 1918 ); and on 13 September 1918 the Preliminary Report of the Secretary of the Treasury Committee on Narcotics is quoted as evidence that thousands of draftees were being rejected in New York because of preexisting addiction, and that perhaps 200,000 addicts between ages 21 and 31 lived in New York. A stricter federal law was demanded. An unusual and now amusing account of German ingenuity was described in a Times editorial of 18 December 1918. The Times cautioned that the story was "probably a mere invention" but described how the Kaiser's scientists planned to addict the world by secretly inserting addictive drugs into tubes of exported toothpaste. The drugged toothpaste allegedly had been test-marketed among African natives.
Actually, of 2,510,791 men examined at local draft boards, 1,488 addicts were discovered, of whom 54 were permitted to enter the service. Addicts were found to come predominantly from large urban centers, New York City in particular ( 1,022 urban, 466 rural). Of the urban group, 383 came from New York State ( A. G. Love and C. B. Davenport, Defects Found in Drafted Men, War Dept. [GPO, 1920], pp. 359— 60,,esp. p. 766). One factor that might have alarmed the federal government was that more addicts than alcoholics were discovered among the examined men; only 853 cases of alcoholism were diagnosed among the men between the ages of 21 and 31 ( pp. 359-60).

63 Collins, "Drug Evil," p. 7, quoting his "Report to the State Association of Magistrates" of Feb. 1915.

64 A separate commission was established rather than giving the task to the State's Health Department, which was weary and discouraged after its responsibility for narcotic control under the First Whitney Act; see N.Y. Times of 8 May 1919; also "Statement of Deputy Commissioner Matthias Nicoll, Jr." (Proceedings of Conference of State and Provincial Health Authorities 37 : 116 [1922]): "These are primarily police matters and I speak from experience of one year during which the State Health Department was given legislative control of narcotic drugs in warning you to make every effort to prevent such a prerogative being forced upon you by legislative action. You will accomplish little or nothing and what you do accomplish will be at the expense of strictly public health work." In 1923 Dr. Nicoll succeeded Dr. Herman M. Biggs as State Commissioner of Health.

65 "Final Report," New York State Legislature, Senate Doc. no. 35, 1 March 1918.

66 See above, ch. 5, n. 54.

67 New York State Narcotic Control Commission, hereafter cited as NYSNCC, First Annual Report, io April 1919 ( Albany, N.Y.: J. B. Lyon and Co., 1920), pp. 3-4; NYSNCC, Second Annual Report, 15 April 1920 (Albany, N.Y.: J. B. Lyon and Co., 1920), p. 4.

68 NYSNCC, Secônd Annual Report, p. 8.

69 NYSNCC, Second Annual Report, p. 21.

70 Weekly Bull. Dept. Health N.Y. City ro : 17-18 (15 Jan. 1921).

71 NYSNCC, Second Annual Report, pp. 39-40; N.Y. Times, 14 Nov. 1920.