Dr. Terry's narcotic clinic in Jacksonville, Florida, may have been the first one established in the United States by a government agency, but it is likely that some arrangements for collective care of a locality's addicts had been made before that time. Poor addicts were the chief clients for clinics; those who preferred not to publicize their addiction could get their drugs more expensively elsewhere—legally and without much difficulty until about 1919.1 The clinic for addicts was an extension of the program of clinics set up by health departments to treat tuberculosis, mental illness, or syphilis.2 Some narcotic clinics were part of a general health clinic; others were separate and specialized.

When Internal Revenue agents made the rounds of police and health departments in the summer of 1919 urging the establishment of narcotic clinics, about a dozen cities complied. The Connecticut clinics set up in 1918-19 in Hartford, Meriden, Norwalk, Waterbury, New Haven, and Bridgeport, and the clinic in Providence, were started on the recommendation of the district collector of the Internal Revenue Bureau. The New York State clinics, in contrast to the city clinic, were established by the Department of Narcotic Drug Control about September 1919 and generally were operated under political patronage except in a few of the largest upstate cities. In some. instances "clinics" were established in cities with little need except a deserving physician with the proper political connections: Port Jervis, Saratoga, Watertown, Binghamton, Corning, Elmira, Hornell, Middletown, Oneonta, and Utica, as well as Albany, Buffalo, Rochester, and Syracuse. The New England and New York State clinics accounted for almost half of the nation's total. The rest of the Clinics (forty-odd) usually had a history and character unique to each. They were unevenly scattered about the nation: in Louisiana (New Orleans, Shreveport, and Alexandria), Georgia ( Augusta, Atlanta, and Macon), California ( Los Angeles and San Diego), Ohio (Cleveland and Youngstown), Tennessee (Knoxville and Memphis), and one each in Clarksburg, West Virginia, Paducah, Kentucky, and Houston, Texas.3 Clinics were contemplated in St. Louis and San Francisco and some were probably established in other cities, but, if closed before mid-1920, they never reached the attention of the Narcotic Division.4 Major cities which do not seem to have had a clinic system include Boston, Philadelphia, and Chicago.

The known clinics, except in New York, never had very large clienteles. The other clinics in operation in 1920 probably did not have as many as 3,000 clients at one time and perhaps as few as 2,500 6 New York had registered 7,500 addicts before it was closed in early 1920. The average age of clients in all clinics other than New York was about 40 for both sexes and men outnumbered women by two to one. Individual clinics had substantial variations in clients' age and sex ratios.6 But these few clients compared to the earlier estimates of 200,000 to 4,000,000 addicts nationally meant either that the clinics were not a major factor in the maintenance of addiction, or that there were many fewer addicts than estimated. Although the clinics were not a major source of drug supply for the addict, they were nevertheless obstacles to the agents' efforts to indict the major purveyors: physicians, druggists, and peddlers.

THE NEW YORK STATE CONTROVERSY OVER ADDICTION CONTROL

Clinics that had been established through the authority of the State of New York were the result of extensive legislative hearings and public debate. An independently established agency, the Department of Narcotic Drug Control, supervised clinic establishment. Even the New York City clinic became ex officio a part of the New York State system, and the commissioner of health in the city was an agent of the State Commission. But the State Commission aroused opposition from several powerful groups. As the rein of the commission tightened to catch the small number of errant doctors and druggists, irritation rose in both professions at harassment and paper work.7

The commission also found itself immersed in a bitter controversy over the fear of state meddling in the practice of medicine. This affected their activities and reacted against the progressive ideology that infused the AMA leadership until about 1918.8 An issue that mobilized a massive campaign of opposition was health insurance. The fear of government control did not come from private practitioners and private health insurance companies alone, but also from Samuel Gompers and other labor leaders who saw health insurance, paid out of wages, as the federal government's opening wedge to gain control of the union movement.9

The Harrison Act and the crackdown on doctors in 1919 seemed proof to many physicians of their suspicions that the federal government viewed them as culprits whose practice needed to be overseen. They also saw the specter of state medicine gaining total control of their profession.10 Although the medical profession had succeeded in putting out of business about half the medical schools of the country on valid grounds of incompetence ( and thereby lessening the competition), they believed that the government wanted to reduce physicians practically to employees.

Dr. Lambert, of course, supported a strict interpretation of the Harrison Act as sturdily as he approved insurance: he saw these two reforms of American medical practice as improving its quality and distribution. Both were designed to curb simple profiteering and to force the profession into responsible service to the nation. He failed in his lifetime to achieve government-sponsored medical insurance, but his interpretation of the Harrison Act prevailed.

How did opposition to the Harrison Act fail, and attacks on health insurance succeed? Partly because the Harrison Act was directed at a social subgroup viewed as a menace to society and a small fraction of the medical profession which was, in the crucial period of 1919-20, a source of fear and revulsion.11 The medical profession's attack on the Harrison Act was up against a general fear of dope fiends; its opposition to health insurance was in harmony with a more widespread fear of state control.

When the Narcotic Control Commission drew its net tighter and tighter around the wrongdoers by methods which also affected the practice of almost all physicians, fears were expressed by these professionals that the government was harassing citizens and exercising an extravagant and unjust power. In New York State the evolution of the clinics and maintenance policy was in opposition to the reform movement of Brent, Wright, and Lambert, which did not favor "coddling" the addict, and it went particularly against the mood of the time. The dominant public attitude by 1920 was strong and fearful: to maintain an addict was to maintain or create a menacing personality.

The repression of maintenance put state and federal bureaucracies in a difficult spot. The orders for vigorous enforcement and elimination of addiction came from above, but they were faced with the reality of a complex social problem which so far had not responded to medical or legal measures. As pressure increased during 1919, responsible state and federal officials in New York State met to talk following conclusions and recommendations to the Cornmissioner of Internal Revenue. The New York City meeting was one of many across the nation which were prompted in the summer of 1919 by the new Treasury Department regulations. The Internal Revenue officials for Connecticut, Rhode Island, and New York, along with the district attorney for the Southern District of New York, Walter R. Herrick of the New York State Department of Narcotic Drug Control, and two deputy commissioners, met twice in September 1919.12

Maintenance clinics were in full operation, while legal agencies sought indictments against peddlers and addict-maintaining physicians. While national enforcement policy was still flexible, the middle management of narcotic legislation discussed their dilemma.
Peddlers and health professionals posed different but difficult problems. The impact of peddlers on drug control was not to be underestimated. The battle could not be won without modification of enforcement procedures. When "peddlers were practically driven off the streets, the physicians and druggists were doing a thriving trade." But when the law closed in on the physician and druggists, there was usually an immediate revival of the street trade.

They seemed legion; as soon as one was arrested another took his place, attracted by the opportunity to make "large profits by selling adulterated drugs at high prices." At any one time the number of street sellers was large, and the ease of moving from More dangerous and less profitable enterprises to peddling drugs was inviting to the criminally bent. It was easy to convict peddlers, but the sentences imposed were usually light and were not effective deterrents, nor did they frighten peddlers into revealing their sources. Large operators were difficult to detect and were willing to take chances because of their "enormous and easy profits."

Erring health professionals, on the other hand, were easy to detect but difficult to indict or convict. They would claim that prescribing narcotics was professional treatment and could evoke a jury's sympathy by describing the sufferings of the addict deprived of his drug. It was particularly irritating to the enforcement group in New York that doctors and druggists often asserted that addictive drugs must be supplied until "provision of adequate means for cure." This argument, Commissioner Roper was informed, "is apt to have weight with the average juryman, who feels that the government should not undertake to shut off the addict's supply without making provision for his relief."

In response to these problems attorneys, revenue collectors, and state administrators pleaded for an expansion of institutional facilities to care for and treat addicted individuals. Suppliers could not be put out of business because the gains were greater than the legal deterrents. Even some physicians and druggists specialized in addict treatment because it brought in "so much more than their legitimate practice." Therefore, the side of the equation that had to be attacked was the addict's need for narcotics. Yet any steps taken to provide treatment "should be accompanied and followed for some period of time by a vigorous and continuous campaign of law enforcement."

Again and again the state and federal officials called for institutional restraint and effective treatment. The group warned that laws "will fail unless they include sufficient provision for the cure of addicts." And cure could come about only by "supplying and maintaining hospitals or custodial institutions adequate for the accommodation of all persons addicted to the use of drugs." But the experts required for their program something that would not be given: "appropriations of considerable size" for hospital establishment and maintenance. The conference in New York City had succinctly posed the policy issues faced by the newly formed Prohibition Unit and its Narcotic Division. If massive appropriations were not forthcoming from federal, state, and municipal governments for institutional restraint, what inexpensive steps could be taken that would reduce narcotic addiction?

The Supreme Court ruling of March 1919 which forbade nonmedical maintenance had been urged by the federal government in a period when the possibility of curative treatment was widely accepted. But now that nonmaintenance was law, cure was thought to be very unlikely by any method, or possible only through expensive institutions. The France bill, which proposed a nationwide program of addiction treatment facilities through federal assistance, would never receive congressional approval. The states and cities themselves were in a deepening postwar depression causing diminishing tax revenues.

Therefore a traditional enforcement attack against suppliers was launched, which naturally included municipal and state agencies, narcotic clinics, and private health professionals. If all other parts of the national and international program worked as hoped, the restrictions on clinics and health professionals would plug a legal loophole in drug supply. If the grand plan of the federal government failed, enforcement at least would have eliminated "legal" addiction, one part of the fundamental goal of federal narcotic reform.

When the Narcotic Division adopted the view that no addiction maintenance was justified or tolerable except for medical reasons, the New York State Narcotic Drug Commission was an obvious target for attack. The commission had established many maintenance clinics; some functioned efficiently and honorably and some were glaring examples of mercenary political patronage. Defects in the New York clinics would make their closure that much more simple, but all clinics were to be closed regardless of the quality of operation. Closure of the clinics would place the maintenance decision with the private practitioner, an easier target for intimidation or indictment than a state or city health department.

THE NEW YORK CITY HEROIN CLINIC, 1919-1920

In July 1919, while the New York City clinic was rapidly expanding, the Bureau of Internal Revenue urged its agents to cooperate with other local authorities in supplying the emergency needs of addicts whose supplies had been cut off by enforcement of the amended and strictly interpreted Harrison Act. Dr. Royal S. Copeland, Health Commissioner, and Major Porter, head of the federal narcotic agents in New York City, agreed on the danger of addicts to the city. The Commissioner estimated 150,000 to 200,000 addicts there, of whom many were "recently discharged soldiers." Heroin was the favored drug and 70 percent of the heroin users were under age 25.13 Major Porter warned the city that enforcement of the Harrison Act would be strict and without compromise. His determination matched his belief that the drug habit had grown to become the "biggest problem of the nation." 14

As addicts arrived by the hundreds at the Health Department's Worth Street clinic, a counterattack to this usurpation of their prerogatives was launched by the Physicians' Protective Association. The association condemned the decision that physicians must give decreasing doses of narcotics. Dr. Copeland was two years late in handling this problem, spokesmen for the association maintained, and a reputable physician, not a clinic, was the proper source of treatment. Opponents of the clinic argued that only about 10 percent of addicts were criminal and did not want treatment. The rest, estimated by the association to be 212,500, should be treated by private physicians—not the city, county, or state.15 A group in the New York County Medical Society also tried to raise opposition to the Health Department's program but failed to rouse substantial numbers of their associates.16 The association's hostile response to the legal attack on narcotic maintenance had very little effect on the city's Health Department. But the ineffectiveness of the addict-maintaining physicians to reverse enforcement policy was only partially due to their small numbers. One of the strongest arguments against any toleration of addiction was the fear that Prohibition would create even more addicts than the enormous number suspected in early 1919. The Association Opposed to National Prohibition, in one of its last efforts before defeat, published an interview with the New York City Commissioner of Public Charities in which he expressed fear that Prohibition would result in a great increase in drug addiction.17 Others, like the late Dr. Wright, had also used this reasoning to show that liquor prohibition was ill conceived. But when the 18th Amendment had been adopted and upheld by the Supreme Court, the argument served only to make the crackdown on addicts seem more necessary, lest the known millions of tipplers ( far more of them than addicts) would sink even lower to become morphine or heroin or cocaine habitués. In this sense Prohibition, which divided the nation, unified the public in a condemnation of narcotic abuse and maintenance.

In early and mid-1919 the care of addicts was welcomed, if carefully monitored, by the city's Health Department because it feared it could not cope with more addicts than it already had.18 At the same time, federal officials did not yet want to impose restrictions on state and municipal agencies or threaten their employees with arrest.

The state's Narcotic Control Commission moved to assist the city's health commissioner by announcing that a triplicate system of prescriptions for addicts would be inaugurated—the physician would keep one copy, and the addict would give two to the pharmacist who would retain one and send the other to the State Narcotic Commission.19 The addicts would be registered and by this means each would receive only the amount his physician deemed appropriate.

This system would still permit maintenance, and did exist until September 1920 when the new antimaintenance policy of the Internal Revenue Bureau enforced a regimen of decreasing dosages.

Registration was a problem for the Worth Street clinic. How could one be sure that an addict, out of the hundreds who came every day, did not cheat? Many ingenious solutions were proposed. Staining the hands with silver nitrate was favored for a while, but it was dropped because it imposed a criminal-like stigma on the addict. Finally a registration card was adopted with the addict's photograph, signature, identifying marks, statistics, and dosage chart, which would be signed by only one designated physician or clinic for each addict. But such registration also led well-to-do addicts or more resourceful ones to get their drugs from physicians or peddlers.20

In the first days, the Worth Street clinic was quite accommodating. The limit of morphine or heroin to one person was 15 grails; cocaine could also be obtained on request. There was no way to tell what the usual dose of an addict might be and therefore, within the stated upper limit, his word was accepted. After the first day cocaine was not offered, on the grounds that it was not addictive and no special concern needed to be shown for its users. Most of the addicts were young and favored heroin. By the first of July, after two and a half months of operation, 2,723 addicts had applied to the clinic: 8o percent were under age 30, 57 percent under 25, and 27 percent 19 or younger; 507 females and 385 non-white had received drugs, making both categories small minorities. Leading nationalities were American, Hebrew, German, Polish, Irish, and Russian. About 6o percent had a trade or profession; the rest were unskilled. Seventy-nine percent used heroin; about half had been addicted less than six years; 70 percent attributed their use of the drugs to "bad associates" and only a few to illness or pain.21

By January 1920, 7,464 addicts had been registered, of whom almost 1,600 were females and slightly over 1,000 black. The age profile had gradually shifted to older addicts, so that now only 10 percent were under 19 and 38 percent 24 or under. Two-thirds were under 30 years of age. Over 5,000 had been born in the United States and 60 percent had been addicted for over five years. Fewer than one out of four voluntarily entered the hospital for treatment. Addicts' occupations varied, the most frequent, in order, were drivers, laborers, housewives, household help, and clerks; but there were also actors and actresses, journalists, printers, plumbers, and even one grave digger, shoe cutter, song writer, syrup maker, embalmer, detective, and picture framer. The early rush to register slacked off as the year wore on. Young addicts predominated in the early months when the average daily attendance rose to 800
clients.22

Near the close of the clinic in March 1920, the count had declined to 150 daily and the average age had climbed.23 These changes can be partly explained by the treatment regimen. From the beginning the average heroin or morphine dose was about 10 grains with a maximum of 15. Every other day half a grain was dropped until the addict became uncomfortable (at a dose range of 2 to 8 grains) He was then offered a bed in the Riverside Hospital on North Brother Island, a municipal institution which had been used for tubercular patients. If hospital treatment was refused, the clinic continued the dose reduction until it reached zero and the addict was discharged. If no bed was available when the minimum comfortable dose was reached, that dosage was continued until the client could be hospitalized. The clinic treatment program did not appeal to those who did not wish to be cured, and most youngsters were in that category.

By 1920, official attempts to locate addicts failed to reveal a prevalence anywhere near the previous estimate. State registration of addicts in New York City reached 7,000 in 1920, one-third, the state believed, of all addicts in the five boroughs.24 Still, 21,000 would be only a tenth of the Health Commissioner's dire estimate of April 1919. Dr. Alexander Lambert, commenting on the experience of the city clinic in January 1920, remarked:

It is evident that the number of narcotic addicts has been enormously exaggerated and instead . . . of comprising 1 percent or 2 percent of the population, it is evidently not more than one-quarter of i1percent. The Harrison Law strictly applied in New York has produced but about 6,000 addicts, instead of the l00,000 or 200,000 as was claimed and expected.25

In the same vein one of the chief clinic physicians, Dr. S. Dana Hubbard, criticized predictions of panic and mass unrest. The numbers of addicts estimated in New York City "are mythical and untrue and . . . therefore the fear of a panic of these miserable unfortunates was negative." 26

That many fewer addicts existed than had been feared was good news for health and enforcement agencies, but a second question, to which the New York experience would provide an answer, was the success rate of treatment. For the cure of addicts at Riverside Hospital, gradual reduction was employed with physiological support provided by hyoscine after a thorough "elimination" by purgatives. After coming off the opiates in three to five days, the addict was given four to five weeks of rest, exercise, and good food in fairly pleasant surroundings.27 Although the city's program included rehabilitation and medical treatment in the hospital setting, results were very discouraging; within a few days of discharge, most addicts were back on drugs. The addict craving to get off his drug was rarely seen, the doctors reported: "Over 95 percent of all drug addicts treated at Riverside Hospital, from the beginning of the service until now [1920] have shown by their acts a non-appreciation of the service, and have repeatedly attempted to be discharged before the end of treatment, or have in some way interfered with its prosecution while there." The department's annual report for 1920 recommended that: "such cases as are of a truly pestilential character [be] detained in institutions that can provide custodial care, for that is the most important therapeutic agent necessary in taking them off the drug," and that the treatment service close.28

The Health Department's negative response came after a yetr of providing extensive treatment to addicts along the lines of the best medical opinion—and failing. Just to provide hospital beds required the utmost political effort of the Health Commissioner. The problem of addiction probably lay deeper, and the disillusioned doctors in the Health Department apparently believed that addiction was the result of a depraved personality not amenable to medical therapy.

One of the reasons for the failure of Riverside Hospital was the availability of drugs when the patient was discharged. Legal supplies being offered, the addict could simply visit a physician or register at one of the state clinics to resume his habit. Legal maintenance was therefore not viewed with any kindness by the Health Department. As one member complained, "Treatment of the narcotic drug addict by private physicians prescribing and druggists dispensing, when the individual is going about, is wrong. The giving of a narcotic drug . . . for self-administration should be forbidden. Few doctors use this form of treating addicts and it is believed that those doing so must be either ignorant of proper methods, or do so in bad faith." 29 The solution suggested by the department was to make drugs as difficult as possible for the treated addict to obtain, not to entice him with legal maintenance.

Conclusions drawn from the New York experience influenced the Treasury Department's attitude toward all clinics.30 Perhaps the most important lesson was that not many addicts existed or, if more existed than attended a clinic, they could not be lured there even by heroin at two cents a grain. Therefore the clinic was not needed as an emergency station when supplies were cut off by enforcement. Furthermore, the clinic did uncover the fact that at least 75 percent of addicts did not crave institutional treatment. Those who were taken off the drug and given a month's rest, exercise, and good diet returned to addiction at the rate of nineteen out of every twenty.

The Health Department now realized that the underlying flaw in its treatment of addicts was that drugs could easily be obtained in the streets. Shortly after the clinic closed Dr. Hubbard declared an urgent "necessity for the general and uniform enforcement of the statutes. There will be no panic or falling in the streets, or robbing of stores or crowding physicians' offices by the addicts affected. If they cannot obtain a supply, they will reform, and it is certain that not a fatality will be recorded." Abrupt withdrawal or "cold turkey" was declared "not only possible but practical" as demonstrated by its routine employment in Kings County Hospital. Dr. Hubbard was optimistic about the solution of the addiction problem since the addicts he saw were mostly young, few had any physical reasons for using the drug, and many needed only a "fair chance" to change their ways since they may never have had a square deal. Dr. Hubbard avowed that he was more than pleased with the clinic's efforts.31

Dr. Arthur R. Braunlich, Visiting Physician to the Riverside Hospital, believed that "All addicts will relapse with little or no excuse, or one so flimsy that it sounds absurd." He put the matter in scientific language: Addicts' pathological craving seemed to be "due to the impression made by the former use on the memory cells of the brain [which] becomes more pronounced if the former patient knows he can get the drug or has hopes of getting it. To take away all possibility of getting the drugs is, in my opinion, the only way of getting a cure." Dr. Braunlich concluded "In other words, under certain conditions, a man who has once been a habitué is in danger of relapse, even though he has not had morphine for years." 32

In a report in the JAMA, Dr. Hubbard was more optimistic about cure in institutions and used words that are reminiscent of those used by physicians who had advocated outpatient treatment by the general practitioner. "The process of removing the drug and all physical craving is simple, safe, and can be quickly done—a matter of days only, not weeks, months or years, as some would have us believe." This, of course, ran counter to Dr. Braunlich's more pessimistic view of prolonged episodes of craving, lasting perhaps a lifetime. But Hubbard believed his optimism was justified and that success in treatment depended merely on the elimination of drug availability. This could be accomplished through enforcement of laws and prohibiting any practitioner from maintaining treatment on his independent judgment, or worse, for financial gain.33

This was a curiously cheerful conclusion after the fact that most of those treated in Riverside Hospital had reverted to addiction, even after the best that current medical therapy could offer. Although it was undoubtedly true that without narcotics there, would be no addiction, the belief that cure would result from an active enforcement of the laws was so far unproven in the United States. Indeed, an institution which one would think most likely to support the "medical approach" until the bitter end—a municipal agency with a national reputation for advanced and effective programs for public health—abandoned it with finality in 1920.

In its well-publicized denunciation of the medical approach, the Health Department did not deny the disease concept of narcotism, but the syndrome appeared as an unmysterious disease about which one would like to know more, but merely from a purely scientific point of view. Therapeutically, however, the condition was said to be understood sufficiently so that success in detoxification could be obtained from present methods of treatment: "In the vast majority of instances-99 percent—excellent results may be obtained by simple abrupt withdrawal." No esoteric knowledge, no complicated specific cures were necessary, just stop the drug—and, if one wanted to be more gentle, use hyoscine support. Addicts difficult to cure, perhaps one-fourth of all those addicted for nonmedical reasons, should simply be hospitalized or institutionalized "and held there, until a medical officer considers it safe for [them] to return to society." Although the role of the medical officer approximates that of a warden, it is only fair to recall that this severity toward addicts came from a health department which had made a vigorous and optimistic effort to treat addiction and had been confounded. The doctors then turned to quarantine as the magical tool to correct the deficiencies with which they were intimate. Control of narcotics was a practical police matter. Either drugs should be available for maintenance and therefore to anyone who wanted them, or they should be eliminated to stop addiction "by sufficiently stringent laws strictly and efficiently enforced [since] as long as addicts can obtain cheap supplies of drugs without personal risk, very few will apply for hospital curative treatment."

Hubbard denied that criminal addicts were criminals because of their addiction; the habit was not the cause of immoral character but just another reflection of unsavory environment. Causation of addiction certainly was more complex than a direct relationship with criminality.34 Hubbard's analysis foreshadows a reevaluation of the addict that became more common among psychologically minded physicians in the 1920s, replacing physiological explanations.

Even Dr. Lambert, who had so elaborately confirmed the Towns treatment, now found the primary cause of addiction in the user's personality.35 Such reasoning followed further study of deviance and social disorder. Increasingly, the cause of social or individual disorder as located in psychological dynamics—deep-rooted and long-standing character formation which antedated the appearance of the manifest antisocial behavior. Since by this interpretation basic character would have been formed long before drug abuse, addiction could only be one manifestation of personality and certainly not the cause of deficient character. The influence of psychoanalytic thought, and the rise of social work and psychology, would offer support in the 1920s to the belief that the causes of addiction lay deeper than its manifestations. While investigators evolved their psychological explanations, the Supreme Court, the Treasury Department, and Congress had put into effect methods to eliminate drug availability through traditional methods of law enforcement.

THE NEW ORLEANS CLINIC, 1919-1921

Although the New York State clinics were easily closed by the Narcotic Division, those in Louisiana, where the legislature had similarly authorized addiction maintenance, more effectively held off closure. In the favor of clinics in New Orleans, Shreveport, and Alexandria was their more efficient operation and the lack of blatant political manipulation. Under authority of the Board of Health, the three clinics came into being in the spring of 1919, just after the decisive Supreme Court ruling which led to arrests and fear among addicts and some physicians.

Shreveport maintained the most important of the Louisiana clinics. In the early 1920s the clinic presented the Narcotic Division with one of its most worrisome holdouts to closure, and it was closed only after three full investigations. Its performance is still heatedly debated by opponents and advocates of a national maintenance system. Its dispensary, under the direction of Dr. Willis P. Butler, has been totally damned by the Federal Bureau of Narcotics and warmly praised by, among others, sociologist Alfred Lindesmith.36

Louisiana has another reason for importance—Dr. Butler's nemesis, Dr. Oscar Dowling. Dr. Dowling was the president of the State Board of Health under which the clinics operated. From favoring the clinic plan in 1919 he became one of its most implacable enemies by 1922 and assisted the Narcotic Division in closing not only the three clinics in Louisiana but any others that caught his attention. His influence was not confined to the state since he was a member of the AMA's most powerful governing body, the Board of Trustees, from 1913 to 1925, and its chairman in 1923 and 1924. He served on AMA and American Public Health Association commtttees which studied drug abuse, and in 1921 he chaired the Committee on Drug Addiction of the State and Provincial Health Authorities of North America.

Initially Dr. Dowling favored clinics as a humane service to the community and thought that any defects were not in their goal but in faulty operation.37 Before becoming a staunch opponent of clinics, he discovered that in spite of an apparent friendship with Levi Nutt, the best-run clinic would not satisfy the Narcotic Division. Prohibition Commissioner Kramer also warned him that as president of the Board of Health he might be indictable for authorizing clinics.38 This threat helped transform him into an eager lieutenant who would use his office to help close the resisting New Orleans and Shreveport clinics. About the Alexandria clinic little has been learned, but evidently its closure never presented a problem.

Louisiana clinics had their origin in state legislation of 11 July 1918.39 The State Board of Health employed a consultant, Dr. Charles Rosewater of New Jersey, to survey the narcotic situation. He estimated 18,000 addicts in Louisiana and saw the situation as, very serious.40 Thereupon the legislature acted. Similar to the First Whitney Act in New York State, the law provided for oflicial narcotic prescription blanks for addicts, commitment to institutions either by complaint or voluntarily, and investment of the State Board of Health with power to set up regulations for the prosecution of the law.

In March 1919 there was an appeal by addicts to the State Board of Health for drugs, apparently prompted by the early effects of the Supreme Court decision. In the temporary absence of Dr. Dowling, Dr. M. W. Swords, secretary of the board, began dispensing drugs in New Orleans to a few addicts each day. The number grew in a few weeks to several hundred. Dr. Swords saw this service as a response to the needs of addicts and as a precaution against their purchasing drugs at greater cost from peddlers.41 The State Board of Health asked the attorney general of the state for advice on the legality of selling drugs to addicts, since there was no appropriation to cover the expenses, and was told that it was permissible—in fact, that it was the board's clear duty to do so in order to reduce the likelihood of property and personal damage by addicts.42

Within a few months an old building was fitted out with examining rooms, segregated into three areas for white men, white women, and the non-white; application cards; history forms; etc. Dr. Swords said he tried to reduce the addicts to a minimal maintenance dose and keep them comfortable until institutional care became available. But the State Legislature declined to establish an institution, and New Orleans had available only the house of detention and the jail. Dr. Swords became an ardent advocate of the clinic as the only alternative if no institutional care was possible.

Dr. Dowling began to recommend closing the clinics, especially after the mid-November 1920 visit of Nutt to the city to urge the district attorney to that same goal."43 Yet the rest of the board, Dr. Swords and the new governor, John Parker, were hesitant: first provide an institution, and then we can phase out the clinic, they argued.44 Local narcotic agents responded that the police superintendent had promised a vigorous crackdown on peddlers, as soon as the clinic ( now operating in violation of the Harrison Act) was closed, but not before. The U.S. attorney complained that the clinic greatly hindered prosecution under the Harrison Act since the clinic did openly what private physicians were told they could not do. Therefore the federal agency demanded the clinic cease operalion and it conducted in late 1920 a quick "investigation" to implement this order.45

The board took up the consideration of closing the clinic on 15 February 1921. An intensive investigation by a narcotic agent was planned for the interval until the board meeting. Swords had believed that the previous brief investigation was biased and designed not to ascertain facts but to build a case against the clinic.

W. T. Truxtun, the revenue agent in New Orleans, angered by Swords's attack on the first report, did his best to present a thorough case to the governor: 223 addicts were registered on 2 December 1921. Eighty-one of these had criminal records, including offenses against state and federal drug laws. Some were prostitutes, three had given false names, five were treated by Swords under pseudonyms, and the rest were suspect, although Dr. Swords had stated that the clinic supplied only respectable working residents of New Orleans. Dr. Swords also claimed to have dispensed only morphine, but it was discovered that he had provided one addict with a daily ounce of laudanum. Also he had received from wholesale drug houses 2 ounces of cocaine and 2 drams of heroin. Three drams of cocaine had been consumed and the rest ( 29 drams) was "stored by Swords outside the walls of his institution, in the possession of the state chemist, who it is to be assumed had no knowledge of medicine whatsoever." 46 One dram of heroin had been distributed without record and the other dram was also in possession of the state chemist. A few other faults were found: at one time, although not recently, Dr. Swords had dispensed drugs to six persons with addresses in other states, and in several instances registrants were alleged to have sold their morphine to other addicts not enrolled. It was not denied that 80 percent were employed, as Dr. Swords claimed, but the clinic's hours-9 to 3 on weekdays and 9 to 12 on Saturdays—were said to be inappropriate for workers.

Examination of Truxtun's report reveals that he found only a small percentage of faulty dispensing and his most substantial statistics, the number of registrants with criminal records, was actually irrelevant to whether, if addicted, people with criminal records should receive narcotics until treatment in an institution was available.47 Truxtun's statement to the governor suggests that he was determined to put the clinic and its director in an unfavorable light.

Dr. Swords complained that he had not received from the inspecting government officials "the courtesy and consideration that you would naturally expect of a representative of a government of a free people, particularly when I represent not an individual, but a sovereign state." But Dr. Dowling believed that the agents, particularly Truxtun, were working hard to discover the truth, and his firm views on clinics were also the official position of the American Medical Association, adopted during its convention in New Orleans in April 1920.48

With Governor Parker in the chair, the State Board reconvened in mid-February 1921 to consider the narcotic agents' investigation of the clinic. The board had used the interval to conduct its own investigation. Four of the seven board members united in recommending the establishment of a hospital where addicts could be confined and treated, but continuation of the clinic until then. With a hospital the clinic would operate "as an outpatient service for the purpose of dispensing morphine to incurables, aged and infirm and those cases in waiting, preparatory to being admitted into the hospital for treatment." The committee specifically commended Dr. Swords and Dr. Butler "for their splendid services rendered." The police and federal agents as well as Dr. Dowling did not budge, and the board retreated from its support of the clinics.49 By the end of March the board ordered closed the New Orleans, Alexandria, and Shreveport clinics which provided maintenance narcotics.50 Shreveport's clinic, however, continued to operate for two more years under authority of a city ordinance.

THE SHREVEPORT CLINIC, 1919-1923

Like the New Orleans Clinic, the Shreveport Clinic was high on the list of sites to be investigated by the Narcotic Division in early 1920. The first full-scale investigation of Dr. Butler's clinic was completed on 27 March 1920.51

The investigation viewed the clinic as a means leading to institutional treatment believed to be curative. It was not presented to nor perceived by the agents as a maintenance clinic. The strong support of enforcement and other public officials was impressive, and the agents "were very favorably impressed with the clinic, and also with Dr. Butler, who seems very efficient, and seems to have one idea of curing the addicts by treatment in the hospital."

A second investigation was made on Nutes verbal orders in October 1921. By this time the clinic was becoming conspicuous-almost all municipal and state clinics in the nation were now closed.

Two agents, one of whom was Dr. B. R. Rhees, secretary of the recent Special Narcotic Committee of the Treasury, went to Shreveport. First they visited the drugstores. No prescriptions were found for narcotic addicts, a significant fact to the investigators; the reputable druggists of Shreveport unanimously praised Dr. Butler as "honest and sincere in his efforts to help the City of Shreveport." Then they visited three prominent doctors and again approval was unanimous—they were no longer bothered by drug addicts except an occasional visitor to the city. The physicians warned that "there would be serious objection to the clinic's discontinuance." The agents saw little if any opportunity for morphine to be improperly disposed of. Every grain was accounted for. One hundred-twenty-nine patients had been declared incurable and were receiving maintenance supplies. Each incurable was so certified by three or more physicians.

Various officials were also interviewed. Federal District Judge Jack again affirmed his high opinion of the clinic, which now had been operating for over two years. He warned that he Would vigorously oppose any steps taken toward a discontinuance of the clinic, because from his own knowledge it had lessened crime in the city. The city judge was even more outspoken than the federal judge in his praise of Dr. Butler. He particularly favored care of the incurable addict which enabled him to work and not be a charge on the city. Both the chief of police and sheriff said that crime, such as petty thievery which might be resorted to to pay for illicit drugs, had lessened since the inauguration of the clinic. The U.S. marshal was of the same opinion.

The agents discovered a political environment which they found unique among communities with clinics: "There is absolute cooperation between Dr. Butler, the Police Department, the City officials, and the Federal officials." They recommended that the clinic not be discontinued since it was "operating under the full sanction of officials charged with the preservation of peace and order in the City of Shreveport and the Parish of Caddo." 52

Shreveport's survival attracted national attention. Dr. Charles Terry, now Executive Director of the Bureau of Hygiene, sought a large number of statistics from Dr. Butler and grew to admire the operation and success of Butler's clinic 53 For American Medicine Butler wrote a detailed description of the clinic, which was published in March 192.2.54 Now other cities began to ask if they also could set up such clinics. Shreveport became an obvious irritant an threatened to cause a revival of clinics throughout the nation—yet no fault in the clinic operation could be located. Two full investigations had found only praise for Dr. Butler among all the officials of the area, local and federal, and even the agents had been won over.

Dr. Butler began to infuriate some of the narcotic officials. The narcotic agent in charge of the Kansas City Division claimed he "made probably five or six visits to Shreveport, Louisiana, and stayed something like a day or two each time with no other business except to see if any point of approach could be gotten from which to ferret out and disclose the true working conditions and sentiments connected and controlling in the operation of the Shreveport Clinic." Finally the chief narcotic agent in the division decided that there was an explanation for the existence of this terrible situation: Dr. Butler was not only the head of the clinic but also "of an organization oi propaganda in support of the clinic, and covertly in opposition to the Harrison Narcotic Law." 55

The clinic's demise began in late August 1922, when an agent, H. H. Wouters, happened to be in Shreveport allegedly on business having no connection with the clinic whatsoever. He reported that a group of four citizens approached him and asked his aid in shutting off illicit supplies of narcotics sold by a peddler. They told Wouters that none of the local authorities could be trusted and that the illicit dealer was believed paying "full tribute to one of Dr. Butler's so-called inspectors." The next morning, when Wouters consulted with the district attorney, he was instructed to conduct any narcotic investigation with the aid of the sheriff, Dr. Butler, and his inspectors. As a dutiful agent, Wouters saw only one course: "I did as requested, with the result that no case was made against the apparent illicit dealer." A "reputable businessman" from whom the agent stated he got a lot of his information, told Wouters that he was being "double-crossed by the gang" and that Wouters's undercover buyer would be kicked off the peddler's veranda that night when he tried to make a purchase. And so he was. That was enough to arouse Wouters' suspicion of Dr. Butler and his distrust of the "authorities." Even more strange events occurred. The night of his first day in Shreveport, "as my custom when going into a strange city, I circulated around in the rough section during the evening." The next morning, when visiting Dr. Butler's clinic, he saw "a half dozen prostitutes that had solicited me the previous night, in line, getting their daily allowance." He told the doctor he did not think much of that nor of his clinic.56 On his part, Dr. Butler found the agent "as vile and vulgar a man as I ever had to converse with." 57

The immediate cause of the formal investigation, although prompted by Wouters's August visit, was made on the verbal order of Nutt, who had received an anonymous letter from someone purporting to be a clinic registrant. Under the date of 10 September 1922, the letter, signed "Use your own judgment," informed Nutt that Dr. Butler coached the registrants whenever an agent came to town because "he knows we get more than we need and we sell what we have to spare." Nutt was concerned about this letter and asked Wouters to make an investigation at his earliest opportunity.58 The agents in September interviewed about 50 of the 129 registrants and convinced themselves that the clinic was just a fraud," while being careful not to reveal their animosity toward the clinic to such supporters as Judge Jack or the U.S. attorney.

The true reason for the clinic's existence, they decided, was to maintain a large payroll of clinic employees. If the addicts were really cured, or given morphine for only genuine illnesses, Butler would be out of business and his payroll ended because the addicts maintained the clinic. The agents based this conclusion not only on their acute suspicion of Dr. Butler but also on their interviews with about 40 percent of the registrants. How these registrants were chosen is not indicated, but the agents found in them easy proof of the need for closing the clinic, if only the local officials would lose their confidence in Dr. Butler. The interviews reveal the issues deemed pertinent by the agents, their reasoning, and their characterization of long-term addicts. A few of them, excerpted from the agents' report, follow.

E. W.-39 years old, occupation sign worker, not working. Came to Shreveport 3 years ago from Joplin, Missouri. On clinic ever since he came to Shreveport. . . . Had been receiving, ii grains daily from Dr. Butler ever since coming to Shreveport. Said he would take much less if it cost more. "To our minds, Wilson is a drug addict, pure and simple."

Mrs. M.—had lived at another address for 6 months than the one listed by Dr. Butler. Came from Indiana 3 years ago, got 10 grains daily after starting at 8. Weighed 186 pounds when she came to Shreveport and lost 50 lbs. "Looks good and healthy but claims she feels bad if she doesn't get her daily allowance of morphine . . . a typical drug addict [with] no visible means of support."

Mrs. S.-37 years old, 8 years an addict, received io grains daily, had no visible means of support. Appeared to the agents as "a good healthy plain everyday drug addict."

J. R.-54 years old, morphinist for 20 years, " a physical wreck" receiving lo grains daily. Although "appearing in very poor condition" the agents were "naturally unable to tell if he was affected with any ailment" but warned against his use as a witness in any prosecution due to his "physical appearance." He told the agents that two inspectors from Washington a couple of years ago said "there were very few people receiving narcotics on the clinic that were entitled to same, but that he was one of them."

B. J.—Prostitute, 32 years old, addict for 12 years and on clinic rolls for two. "Admits that on several occasions she has been off the drug, but not since she has been going to Dr. Butler; receives 12 grains daily." Although claiming a little of many diseases, she did not strike the agents as ill, but in reality "the picture of health; strongly built, and to our minds is a simple vicious addict." The agents were "solicited by her when we entered the premises."

W. M.—"a well-known bootlegger in liquor and narcotics" who had been driven out of Oil City by "a Public Committee" (the Ku Klux Klan). He had his daily dose of morphine picked up by his son against the time he should return. But the wife and son could not locate the drug for the agents when asked for it.

M. P.-52 years old, storekeeper, "a respectable man" who had been receiving 6 grains daily from the clinic for the past year. He would like to stop taking the drug and could do so "providing it is hard to get same." Claims a lot of healthy people got morphine from Dr. Butler who did not need it.

F. V.-30-year-old woman, "old opium smoker" who had switched to morphine. Came to Shreveport in 1920 ( the year the Houston Clinic closed) "to satisfy her addiction for the drug." Claimed to have given money for hospital treatment to Dr. Butler which he would not furnish, although she would like such treatment. She had purchased drugs from outside sources, particularly from Jew R," who, it was claimed, paid $50 a week protection money to one of Dr. Butler's "narcotic inspectors."

S. W. H.-39 years old, claimed to have been off morphine several times for as long as 2 weeks at a time "when he was unable to obtain it."

Investigations continued, and the case built against Dr. Butler depended on information given by persons whose veracity or motives were not closely examined. The collection of accusations could have come from a small group that profited from peddling and saw the clinic as competition, or from a group which simply disliked the clinic or Dr. Butler for political reasons. The grounds ori which antagonistic information was credited seem to have no internal consistency.

In conveying Wouters's report to the Prohibition Commissioner, the narcotic agent in charge of the Kansas City Division warned of the danger of the Commissioner should he ever meet Dr. Butler in person. Dr. Butler, he said, was a deliberate violator of the law and the most subtle medical opponent of the Harrison Narcotic Act in that part of the country. If Dr. Butler should visit Washington he should "be given to understand that the law must be adhered to by the high as well as the low in the social strata." Wouters had written earlier (29 September) to Assistant Prohibition Commissioner Blanchard in fear that Butler might come to the Capitol, that he was "One of the greatest soft soapers that I have met for many years and I am afraid, to use another slang expression, that you may be carried away by his smooth ways. . . . He must not be given the slightest encouragement at Washington." Wouters asked that his letter be circulated to Nutt so he could be prepared if Butler should come to see him.

Study of Wouters's report in Washington led to agreement that "the District Judge and the U.S. Attorney evidently feel kindly disposed toward this clinic, on account of .propaganda." 60 The Narcotic Field Force decided to send a "diplomatic" representative to the federal officials before contemplating prosecution. For this task the narcotic agent in charge of the Richmond, Virginia, Division, G. W. Cunningham, was dispatched to confer with the judge and attorney. But even before Cunningham could get to Louisiana to meet with federal officials, Nutt had visited New Orleans and had spoken with Dr. Dowling on 4 December. Apparently Nutt had asked Dr. Dowling to write and put pressure on Butler for various reports on the supply of narcotics for the clinic, to remind him that the State Board had ordered the clinic closed, and to ask for the specific authority under which the clinic operated.61 Dr. Butler replied on the ifith, explaining that he was not representing the State Board in any narcotic matter and that the hospital operated on the basis of a city ordinance which he enclosed. He stated that the district judge and U.S. attorney had given him verbal support and had expressed the belief that he was not violating any federal law.

On 30 January 1923, a conference was held, attended by Dr. Butler, the U.S. attorney, and three revenue agents, at which time it was mutually agreed to close the clinic on io February, leaving time for the "legitimate" clients to get their drugs elsewhere. The conference was not what Dr. Butler had expected. Two days later he wrote to Edward Wilson of the Atlanta Georgian:

No records were gone over, no patients, officials, or doctors were called and nothing was gone into except the closing of the dispensary. I have felt all along, and still do, that I am right, but rather than enter an endless controversy without reasonable hope of what I consider right to prevail I agreed to discontinue the so-called clinic.

All was very harmonious, and I must say the Inspectors appeared to be very nice gentlemen, far different from Mr. Wouters. I was told that I am not in any way accused of wrong-doing or bad faith, but that the work that I am doing here caused trouble because other places contended that if Shreveport be allowed to have a "clinic," they should also be allowed such a privilege.

Mr. Cunningham read a part of Wouters's report in the conference. The addict's word was accepted by Wouters as truthful without corroboration, and without an investigation of facts that records, histories, and examination findings would reveal. For instance, several cases who have resided here for years were classed as not belonging here. Cases almost dead were called curable, so they report.62

Butler tried to transfer clinic addicts to private doctors or to give them institutional treatment, which was still permitted under state and federal law. For some he believed incurable he continued to write prescriptions on his own authority. 66 In June 1923 the Shreveport Journal investigated the city's drug traffic and claimed that morphine and cocaine were being freely sold, whereas before the closing of the clinic the traffic was practically unknown."64 No clinic has had more controversial history or has provoked such irreconcilable attitudes as Shreveport's. Fortunately, much of the record has been preserved in the government's and Dr. Butler's files, so that a balanced reconstruction is now possible.

Willis P. Butler, a graduate of Vanderbilt Medical School in 1911, was thirty-five when the clinic opened in mid-1919.65 Three years of clinic operation proved to be an early and anomalous incident in his long career in forensic and clinical pathology. Like Dr. Copeland, he interested himself in politics, but on a smaller scale, and was elected Parish Coroner and Physician for twelve four-year terms. He served as president of the Caddo Parish Medical Society, on the governing council of the American Public Health Association, and he is a founder of the American Society of Clinical Pathologists and the American College of Pathology. He savived the Narcotic Division's personal attacks and continued to receive professional and popular support in his various activities. The end of the clinic experience must have been unpleasant for him, but strong local support and his political and organizational ability as well as his high level of medical training make the clinic's closure one of the nation's most interesting power struggles over narcotic control.

As late as 1955, thirty-two years after its closure, the federal narcotics agency was still condemning Dr. Butler's clinic for permitting "75 percent of the drug addicts in Texas [to make] their headquarters there," and detailing many serious allegations against the Louisiana operation. Dr. Charles E. Terry, however, who had spent seven years as the executive of the Committee on Drug Addiction of the Bureau of Hygiene collecting information on the problem of addiction, wrote Dr. Butler in 1928:

In looking back over the work that has been done here and there throughout the country, I know of no single piece that can compare with yours as a constructive experiment in the practical handling of cases. The only criticism that I would make is that you did this work probably about twenty years ahead of the time when it could be appreciated, and I have little doubt but that in the next ten or fifteen years your plan will be in widespread operation in this country. If it is not, it will simply mean that rational education of both official and lay groups has been slower than I hope it will be.66

Alfred Lindesmith, in comparing the Federal Bureau of Narcotics' account with that in Terry and Pellen's The Opium Problem ( 1928 ) concludes in 1965, "There is hardly a single general statement about the clinic in the Bureau's account which can be accepted as accurate and which does not require serious qualification.""67 The Shreveport clinic remains the rallying point for those who believe a clinic system should have been established across the nation after 1919.

Three other clinics are representative of the several types that existed in 1920. The Atlanta clinic had a long history dating with interruptions back to the first days of the Harrison Act in 1915. In New Haven, a clinic created by the Police Department with the approval of the Internal Revenue Bureau functioned with local satisfaction but was closed by the Narcotic Field Force, although it had no discernible defect. Albany typifies some New York State clinics, operating with profit and significant political patronage, giving ant cocaine as well as opiates, and therefore easy to condemn and to close.

THE ATLANTA CLINIC, 1915-1923

Establishment of the Atlanta clinic in 1915 is evidence that the Harrison Act had an effect on the customary sources of addictive drugs. The Treasury Agents' aggressive attack on addiction maintenance by physicians probably led Atlanta, as well as Jacksonville, Florida, and other cities to make some special provision for the indigent and "incurable" addict. At least since 1919 the "City Physician's Office Service to Drug Addicts" had operated out of the Department of Health, housed in the Atlanta City Hall.

The Narcotic Division's head, Levi Nutt, visited Atlanta on 23 March 1921 and informed the local revenue agents that the maintenance clinic there was illegal.88 Special Agent Erwin C. Ruth then arrived to investigate the clinic." This investigation, in the pattern of many others, described the origin, conduct, and reputation of the clinic, provided a list of addicts, some medical information on each, narcotic dosage, age, etc. The Atlanta clinic provided narcotic prescriptions for about 200 addicts. These would usually be filled at one of the two drugstores which did a fairly substantial business in the drugs, the first selling in the twelve months prior to the inspection 1,004 ounces of morphine and 17 pounds of opium. The average addict's daily dose varied between 5 and io grains of morphine. The two physicians who were employed full time for the medical needs of Atlanta's indigent divided between them the addict clients and wrote free prescriptions. Nonresidents of Atlanta were not regularly served but transients might be given an emergency supply to help them on their way. There were few-instances when any substantial reduction in dosage occurred.

Ruth's report in mid-April recommended that morphine be dispensed in strict conformance with the Harrison Act, that is, for those medically incurable but not for the maintenance of simple addiction. As a result of Ruth's investigation, the Atlan4 clinic dropped half its registrants and retained ninety-five who were described, at least by the city physicians, as incurable for medical reasons or of such long-standing addiction that they must be continued on the rolls. In January 1922 Nutt met in Washington with the chief Atlanta narcotic agent and reemphasized the need to halt the Atlanta maintenance program. Within a few days, T. E. Middlebrook had launched the second investigation of the clinic, with particular attention to the "incurables."

The recommendations of the second investigation were more severe. Middlebrook requested that city physicians be informed that any privileges previously given by narcotic officers were withdrawn and that the physicians be put on notice that prescriptions from then on would be scrutinized with great care. In cases of narcotic law violation, prosecution would be recommended. "I believe," the Atlanta narcotic agent wrote, "that if we stop the city physicians from prescribing that other physicians will be afraid to take [addicts as patients] and in that manner will stop the traffic in dope that is now going on in Atlanta.70

In late 1923 Dr. Lawrence Kolb, Sr., in the early years of a lifetime spent in the study of addiction, visited Atlanta at the request of Nutt to examine those few habitués still receiving drugs at the clinic. His task was to determine who might be cured and who should be left on the rolls. In November he interviewed and examined several dozen patients and prepared reports on them." His trip to Atlanta is significant for the fact that it occurred at the request of the Narcotic Division. The report enabled local narcotic officers to take more clients out of the clinic, but little confidence was placed in his judgment that some addicts merited clinic treatment who were not already on the clinic rolls.

By 1925 the Atlanta clinic had faded away. It had succumbed to repeated investigations and threats to the physicians, although no indictments are known to have been sought or obtained. Whether its demise affected the level of drug use in the area is not known.

THE NEW HAVEN CLINIC, 1918-1920

By 1916 a private physician in New Haven had been designated by an internal revenue agent to write prescriptions for addicts at fifty cents each. This practice gradually accumulated complaints. The cost for a prescription seemed rather high, and purchase of the drugs ,at pharmacies designated by the physician was additional.72 Police Chief Philip T. Smith alleged that drug peddling thrived in spite of the system and that addicts turned to thievery and prostitution to obtain money for drugs. Chief Smith did not oppose the idea of maintenance, but he favored less mercenary methods by the prescribers and dispensers. On 17 August 1918 a new system was inaugurated: addicts were directed to City Hall where they were registered and given drugs at modest prices under the care of police surgeons and pharmacists who were paid by the Police Department.73

The prescription fee was dropped to twenty-five cents and the morphine dispensed to the addicts at four cents a grain. Even at these lower charges a daily profit was made of $15 to $20. The profit went into a fund used to send addicts to respectable institutions for treatment. To register, an addict must reside and work in New Haven and be approved by the Chief; 68 addicts attended daily in August 1918 and this grew gradually to 91 when the clinic was investigated by Revenue Agents H. S. Forrer and O. W. Lewis.74

The New Haven Register reported the addicts' plight before the clinic was established: they would come to the private physician's home for regular prescriptions and "It was getting so the children and residents of the neighborhood recognized them as they wended their way to the doctor's office and pointed them out and subjected the unfortunates to unnecessary embarrassment." 75 It would appear that addicts in New Haven were more menaced than menacing.

The Police Department clinic operated from August 1918 until September 1920. Police Chief Smith saw advantages to a clinic: he traced addicts who failed to report and could thus locate perpetrators of thefts and burglary. Several drug peddlers were apprehended by tips given by clinic registrants. No scandal seems to have been associated with the clinic, doctors, pharmacists, or mode of operation, and, in fact, it received high commendation from Agents Forrer and Lewis in 1920. Its only fault lay in that it violated the Harrison Act by providing addiction maintenance.76

The clinic was closed in September 1920 along with other Connecticut clinics after the operators were threatened with indictment in letters prepared by the Prohibition Commissioner, but not without some remonstrance from Chief Smith, which Agent Ruth, who checked to be sure the clinics were closed, believed was actually an admission of the clinic's failure.

The clinic at New Haven was closed September 13th and the Chief of Police arranged to have the addicts attending thee clinic sent to a private house with a physician in charge. Only two addicts applied for treatment at said house. The Chief of Police stated that most of the clinic addicts are yet in the city and are purchasing their drugs from peddlers. The Chief also stated that the "dope peddlers" doubled their prices on "dope" just as soon as the clinic was closed, admitting that there were peddlers in the city during the time the clinic was in operation. Drug stores are not filling narcotic prescriptions for drug addicts.77

THE ALBANY CLINIC, 1919-1920

The Albany clinic illustrates some of the less desirable features of clinics operated under the authority of the New York State Narcotic Control Commission. It was one of the first established by the commission (i8 April 1919), a week after the New York City clinic had opened. It operated about a year and a half, until September 1920, and had, in June 1920,120 addicts in attendance."78

The clinic had its origin in a meeting in early April 1919 of Deputy Commissioner Whitney, Albany's mayor, the city's health officer, and a local physician. They agreed that the physician would conduct the clinic and be compensated fifty cents for each narcotic prescription. According to investigators Forrer and Lewis, who spent about a week looking into the clinic in June 1920, when Commissioner Herrick replaced Commissioner Whitney, the first physician appointed, who had sought to reduce maintenance dosages, was replaced for political reasons by two other local physicians. After this change in July 1919 no further records or receipts from the sale of prescriptions were kept. The clinic met from noon until two o'clock six days a week for several months until it was instructed by the commissioner's office to meet only on Mondays, Wednesdays, Fridays, and Saturdays. The case histories and records were confusing to the inspectors and they finally concluded that a conspiracy existed among the clinic doctors, the Narcotic Drug Commission, and a local drugstore which filled all the prescriptions. The evidence for this was suggestive. Other drugstore owners claimed that an addict would be cut off the clinic list if he did not take his prescription to this one shop. Other facts indicating a conspiracy around the clinic's operation included the chief clinic doctor's private practice; he prescribed for well-to-do addicts although he denied at first that he treated any addict outside the clinic. One of his private patients was thought by the police to be a peddler who had once been arrested on this charge. The doctor is reported as defending the patient's maintenance on grounds that he "has the appearance of suffering from tubercurosis" although records showed that no sputum examination or other scientific test had been made to establish the diagnosis.

The drugstore made up addicts' drugs in advance and sold them at the clinic for eight cents a grain or fraction thereof, two or three cents per grain above the price of other drugstores. The estimated annual income to this shop after deductions for costs was slightly over $17,000. In 1920, Levi Nutt, the head of the Narcotic Division, had an annual salary of $5,000 and an average agent earned less than half that. A feature that was rare among American clinics was the sale in Albany of cocaine to the addicts. In May 1920, 113 of the 120 addicts received prescriptions for 2 grains of cocaine along with prescriptions for morphine which averaged 7½ grains. At the rate of fifty cents for each of the prescriptions, the addicts paid a dollar at each clinic visit. At four visits a week this income was about $450 each week or about $23,000 annually.

The police spoke against the clinic on grounds that it cured no one and attracted addicts "from all parts of the country" who turned to crime to pay for their drugs. Furthermore, a number of the addicts were prostitutes with criminal records. But the Police Department's complaints are not fully substantiated by clinic statistics. Data for 3 June 1920 furnished to the inspectors by the clinic physicians revealed no addresses for cities farther away than Troy or Schenectady, and about half the addicts had attended the clinic since its opening, making the claim that it attracted addicts from around the country to be, if true, less threatening than it might seem, even without consideration of the small numbers involved. Altogether 47 nonresidents of Albany attended the clinic and of these all but one were from addresses within 15 miles. Thirteen attending had chronic diseases which might justify maintenance morphine. Men and women were evenly divided; a quarter of the women and a tenth of the men were nonwhite. The average age of the women was 30, of the men 34, the range 21 to 58. The daily dosage of morphine for women varied from 5 to 9% grains and for the men from 5 to io grains, the average dose for the whole clinic 8 grains.

Almost all the New York State clinics were good profit makers. The suspicion that politics played a major role was borne ou by the repeated discovery that one had to be a political partisan in order to get a clinic franchise. The large profits from conducting a clinic ostensibly for the cure or curbing of drug use made the whole system a farce to the revenue agents. A showdown took place on the morning of 1 September 1920, in Commissioner Herrick's office. Present were Deputy Commissioners Riordan and Graham-Mulhall, Supervising Federal Prohibition Agent Simonton, and District Collector of Internal Revenue Frank J. Fitzpatrick. Herrick was told that the clinics in New York and in several other states had been investigated, and the reports were then considered at a conference held in Washington. As a result, all the clinics were to be closed except possibly Buffalo's.

The commissioner was willing to correct defects in the operation of the clinics, but not to close them. He believed that such clinics should operate until institutional treatment was available. But to this argument the agents replied that the present clinics were making almost no use whatever of the institutional treatment that was available. Moreover, there was no reason to hope for more facilities, since "it was extremely doubtful whether the State or Federal legislatures would provide the necessary funds for narcotic institutions—certainly not for a year or more, and probably not for many years." This regrettable reality determined as much as any other factor the decision to close narcotic clinics. Evidently by late 1920, federal agents were willing to admit the probable failure of the national program proposed by the France bill and were frank about the impossibility of relying on institutional treatment to end addiction. Then Simonton sternly informed the Commissioner that the Prohibition Unit had "adopted a definite policy in the matter." If he would not cooperate, the Treasury was prepared to take legal action. "I then," Simonton wrote, "exhibited to him, for the first time, one of the letters signed by Commissioner [of Prohibition] Kramer ( the contents of which you are, of course, aware), and informed him that I had been instructed to deliver these letters personally in the event he refused cooperation." 79 The letters, dated 25 August 1920, were addressed to the various clinic physicians and informed them that they were in violation of the Harrison Act and should desist from treating immediately or face prosecution. This final tlireat was effective, for it was supported by the recent Supreme Court decision which clearly prohibited maintenance. The clinics were closed, and early the following year the New York State Commission itself was abolished by the legislature.80

Thus ended the many efforts by the New York State Legislature to devise a- satisfactory drug control law. For six years after 1921 the state had no narcotic legislation, the problem being left up to city ordinances and federal statutes. A separate and distinct approach to addiction met head-on the reformers' plans for nonmaintenance and lost. No effective opposition to the federal stand against maintenance had been mounted by New York State, nor had Washington officials shown any hesitation in closing the clinics, although the clinics had state legislative sanction and were operated by a state agency.

The attack on the drug supply now became the chief goal of the Treasury Department in 1920. Imports and exports would be controlled by federal legislation and international treaties. Strict law enforcement would curb availability in the United States except for legitimate medical uses. Addicts could be treated in institutions and withdrawn from drugs; they could then return to their communities where they would not relapse, because of the danger of arrest and the high price or absence of narcotics. In this view, the narcotic clinic was a disruptive institution: it sanctioned the indefinite maintenance of addiction when the goal of the Narcotic Field Force was its elimination. The clinic not only made indictment of other suppliers of narcotics more difficult or impossible, it openly sustained what the public desired to eliminate. It was not thought that closure of the clinics themselves would miraculously solve any problem, of course. It in fact was anticipated that many long-standing addicts would seek out other supplies when the public source was shut off. For clinic closure to have its full effect, the rest of the control program would have to be successful.

The decision to move against municipal and state narcotic clinics seems to have been taken after deliberation in the winter of 1919-20. Implementation was not to be hasty or crude.81 The Prohibition Unit's legal counsel cautioned against any attempt to close clinics by means of criminal proceedings unless prior wholehearted support had been obtained from local district attorneys and public officials, since grand jury indictments against municipal and state authorities would be difficult.

Perhaps, the division hoped, a simple indictment without prosecution would effect closure among the recalcitrant.82 But no clinic closure ever required indictment. Persuasion or threat was all that was necessary. In New York, not only clinics but the entire .State Narcotic Control Commission was quickly put out of business since its primary task had been to monitor addiction maintenance by private physicians and clinics. In 1921 the act establishing the commission was repealed and no new narcotic laws were enacted by the state legislature until 1927.83

The clinics were closed, but other parts of the federal program—keeping drugs out of America and gaining international control of narcotic traffic—would not be an outstanding success. Yet in 1919– 25, the time of the anticlinic campaign, there were obvious loopholes in the laws which could be plugged, permitting further time to pass before these amended laws proved to be illusory. As long as some legal manipulation remained possible, the solution to the narcotics problem could always be seen just a step away. The psychological value of these legislative tinkerings was similar to the many modifications of the Towns-Lambert and other "cures." Many years had passed before the specific cures were seen to be worthless. For the progress of the human spirit, or at least the maintenance of the reforming spirit, the value of unproved treatments and legislative improvisations can be considered a powerful tonic.

NOTES

1 Between the Jin Fuey Moy decision of June 1916 and the antimaintenance decisions of the Supreme Court in March 1919, there was little the federal government could do to prevent maintenance of simple addiction by physicians if all the tax regulations were followed. Pressure could be applied verbally, what Rep. Rainey admiringly called "simply bluffing the thing through" (Exportation of Opium, Hearings before a Subcommittee of the Committee on Ways and Means on HR 14,500, House, 67th Cong., 3rd. Sess., 8 and 11 Dec. 1920 and 3 and 4 Jan. 1921 [GPO, 1921], p. 47), but unless state laws opposed simple maintenance, as in Massachusetts, physicians were left to their own judgment. The Massachusetts law forbidding indefinite maintenance came into effect 1 January 1915 and was approved on 22 June 1914, before passage of the Harrison Act. The Massachusetts law ( ch. 694, sect. 2, of Acts of 1914) made it unlawful for any physician or dentist to provide opiates or cannabis to any habitual user. In a test of a physician's intent or judgment, the Massachusetts Supreme Court upheld a lower court's decision against a physician for providing drugs to fifteen persons known to him to be habitual users (Commonwealth v. Noble, 230 Mass. 83). This is an antimaintenance statute in a state which had a problem of narcotic addiction and sought to curb addiction by means very similar to the Supreme Court's decisions in U.S. v. Behrman, 258 U.S. .28o (27 March 1922). Three years after Massachusetts, Pennsylvania outlawed addiction maintenance (Laws of Pennsylvania, Act no. 282, sect. 8, approved 11 July 1917). In contrast, New York permitted maintenance under state law.

2 Between 1910 and 192c there was rapid development in the U.S. of the concept of a health district with a health center providing care and education. For a discussion, see George Rosen, A History of Public Health (New York: M.D. Publications, 1958), pp. 470-78.

3 Correspondence and records of the various narcotic clinics were collected by the Narcotic Division of the Prohibition Unit and are now in possession of the Bureau of Narcotics and Dangerous Drugs. Each file contains investigations of the clinics or descriptions of its activity and closure. With the permission of the bureau I examined these records in 1971. Unless noted otherwise, records quoted in this chapter are from this collection.

4 A clinic was under consideration in San Francisco in 1919 and the suggestion received the approval of the PHS (Surgeon General Rupert Blue to W. C. Hassler, 3 Sept. 1919, PHSR). In St. Louis a "free narcotic clinic" was planned under the Board of Health (Revenue Agent in Charge, St. Louis, to Commissioner of Internal Revenue, 8 Sept. 'gig, in U.S. Treasury Dept., Bureau of Internal Revenue, "Digest of Correspondence from Collectors, Revenue Agents and District Attorneys Relative to the Narcotic Situation in the Various States," n.d., RPU). The revenue agents registered addicts in Kansas City, Mo., and physicians were allowed to prescribe for them. The mayor of Kansas City disapproved a public clinic, so physicians were permitted under approval of the Board of Health to prescribe for addicts (E. C. Ruth, Internal Revenue Agent in Charge, St. Louis, to Commissioner of Internal Revenue, 4 Dec. 1919).

5 The number of clinics known to the Narcotic Division was about 40. Registrants at the clinics totaled 2,485 according to a compilation of 44 clinics dated 30 April 1921. In the 26 clinics of which detailed investigations had been made, only 10.5% of the registrants were considered to have a disease other than addiction (O. G. Forrer, Assistant Director, Narcotic Field Force, to L. G. Nutt, Director, 30 April 1921). This compilation does not include the experimental New York City clinic. Forty-four is the usual number of clinics estimated, although it is likely that a close study of local methods of dealing with addicts in 1910-25 would reveal more.

6 Atlanta had an older clinic population in comparison to Albany and New Haven. Atlanta's age range was from 20 10 87; males averaged 43 and females 46. In New Haven the average ages were 33 and 32 respectively; in San Diego the average age of both sexes was 27. The Albany clinic was evenly divided between males and females; Providence had three times as many females as males ( 74 and 27), while New Haven's ratio was,almost reversed ( 66 males and 26 females). Generally more males than females attended the clinics; in the 26 clinics closely examined in 1921, there were 966 males and 591 females.

7 The medical profession was evincing a sharpened interest in regard to state controls. Dr. James F. Rooney, chairman of the State Medical Society's Legislative Committee, declared in May 1921: "Regulations as to the use of narcotic drugs and alcohol are merely the beginning of an attempt to completely control therapeutic methods." Dr. Rooney was elected president of the State Medical Society the following month. ("Report of the Committee on Legislation," N.Y . State Med. J. 21 : 209-13 [1921] ). Pharmacists' opposition to regulation of narcotic dispensing within New York State is described in "No Time to Adopt a 'Model' Law" (Amer. Druggist Pharmaceut. Rec. 66 391-94 (1922).

8 Alexander Lambert is representative of AMA reformers. As chairman of the Judicial Council of the AMA in 1916 which had submitted to the House of Delegates a favorable report on health insurance, Lambert favored some kind of health reform similar to that adopted in Germany and Great Britain. He was also active in the American Association for Labor Legislation, which promoted health insurance in various states, and the improvement of workmen's compensation laws which had slowly gained acceptance during the years before World War I. In New York Lambert favored a fixed-fee schedule for physicians as a corollary to workmen's compensation. Lambert proposed to bring delivery of medical services in the U.S. into alignment with other Western industrial nations as the proper solution to the great need of the poor and the middle class. He was elected president of the New York State Medical Society in 19i8 and of the American Medical Association in 1919.

9 Rosen, History of Public Health, p. 455.

10 An editorial in the Medical Record of New York associated Prohibition, compulsory reporting of venereal disease, antivivisectionism, and the Harrison Act in a complaint about "The Growing Enslavement of the Profession of Medicine" (99 : 18 [19211).

11 See Pearce Bailey, "The Drug Habit in the United States," New Republic,16 March 1921, pp. 67-69; see also "Report of the Committee on the Narcotic Drug Situation in the United States," JAMA 74 : 1324-28 (1920).

12 Francis O. Caffey, U.S. Attorney, New York City, to Commigsioner of Internal Revenue, 27 Sept. 1919. The letter describes meetings held 6 and 17 Sept. 1919 ( JDR). This confidential communication estimated the number of addicts in New York City as "at least four or five thousand."

13 N.Y. Times, io April 1919. The fear that perhaps half a million addicts would be created by the war is found in Medico-Legal Journal 35 : 17-20 (1918), p. 20. Charles Towns had predicted that gassing of soldierswould lead to opiate use and then addiction on a wide scale ("The War and the Dope Habit," Literary Digest, 9 June 1917, pp. 1776-77). The later belief that many of New York City's addicts were returned veterans, for which no evidence has so far been located, was only to confirm a fear of several years' standing.

14 Porter quoted in N.Y. Times, 11 April 1919; he gave as an illustration one physician providing "treatment" to 271 addicts in two hours.

15 John P. Davin, who had ably represented the Medical Economic League in Albany in defending the prescribing rights of the private practitioner now, on behalf of the Physicians' Protective Association, attacked the arrests of physicians by the federal government and establishment of a public clinic by Dr. Copeland (N.Y. Times, 13 April 1919). Dr. Davin was an active member of the Federation of Medical Economic Leagues and was an associate editor of the Medical Economist. His attacks were balanced by the early release of parts of the Treasury's Special Committee Report, Traffic in Narcotic Drugs, which, as reported that day in the N.Y. Times, claimed that 1.5 million addicts were abroad, that the addictive drugs, particularly heroin, were "German products," and that a strict campaign against addiction was now to begin.

16 See N.Y. Times, 14 June 1919. At the special meeting called to consider the narcotic situation in New York City, the physician protestors, led by Davin, were defeated, as we see from the minutes of the County Medical Society. Davin's nemesis, Dr. E. Eliot Harris, as Chairman of the Public Health Committee, offered the following resolution.

Resolved that the Medical Society of the County of New York expresses the wish to co-operate with the State Narcotic Drug Commissioner, Hon. Walter R. Herrick, in every legitimate and constructive way to eliminate narcotic drug addiction and to help cure the addict.

Dr. John P. Davin offered a substitute resolution, which was declared to be out of order.

On appeal from this decision from the Chair was sustained (54-41).

On motion the resolution of the Public Health Committee was adopted ( Archives of the Medical Society of the County of New York, New York City).

At about the same time, the president of the AMA condemned the position advocated by Dr. Davin:

There is a condition in the United States which involves seriously the interests, and even the reputation, of the medical profession: that is, the complicated situation arising out of the narcotic drug laws . . . .
The situation has become such that several states have passed their own narcotic laws to supplement the federal law endeavoring to control a problem which was fast becoming desperate. These laws are making it more and more burdensome for physicians using the narcotics legitimately, but that is a mere annoyance. The responsibility on the medical profession is becoming greater and greater to see to it that some action should be taken against a few renegade and depraved members of the profession who, joining with the criminal class, make it possible to continue the evil and illicit drug trade.
[That portion of addicts who are] real degenerates and criminals are extremely difficult to deal with, and practically cannot be kept from their drug as long as it is possible, through inadequate legal control, to continue the illicit drug trade ( Alexander Lambert, "Address of the President Elect," 'AMA 72 : 1767-68, 1919).

Dr. Davin quickly offered a rebuttal to Lambert and other leaders of the profession and at the same time announced the formation of the American Federation of Physicians, whose goal was the abolition of the New York State Narcotic Control Commission (J. P. Davin, "For repeal of the Narcotic Drug Law" [letter to the editor], Med. Rec. 96 : 161-62, 1919).

As another example of influential physicians applauding the government's actions, see editorial with resolutions of commendation in the New York Medical Journal, 14 Feb. 192o, pp. 292-93.

17 Bird S. Coler, quoted in the N.Y. Times, 13 April 1919. Prohibitionists were unable to locate evidence for this prediction after the start of national Prohibition; see Literary Digest, 16 April 1921, pp. 19-20.

18 Pleas were made because the arrest of "mere dope doctors" scared other doctors who were maintaining some addicts. The line between the two types of practice was somewhat subjective. Dr. Copeland reassured "reputable" doctors that they could continue to treat addicts ( N.Y. Times, 17 and 21 April 1919), and the New York Medical Journal editorially assured physicians that only the most blatant examples of profiteering and selling of drugs by physicians were receiving police attention (22 Feb. 192o).

19 Regulations reprinted in the Weekly Bull. Dept. of Health N.Y. City, 12 April 1919, pp. 115-17. According to Dr. Copeland (N.Y. Times, 16 July 1919), within a few months an estimated io,000 addicts were using the triplicate system. This figure appears to have included 5,000 treated at the city's clinic and 1,200 registered with the State Commission of Narcotic Drug Control's,office on Prince Street.

20 N.Y. Times, 12 and 13 April 1919. R. S. Copeland to Thomas Cooper, Treasury Department, Bureau of Internal Revenue, 16 Oct. 1919, gives details of treatment and hospital operation at that time. Copeland was at this time faulting the availability of drugs on the outside as the reason for lack of substantial success.

21 These statistics are from the summary of clinic operations urto i Jan. 1920; see S. D. Hubbard, "New York City Narcotic Clinic and Differing Points of View on Narcotic Addiction," Monthly Bull. Dept. of Health N.Y. City so : 33-47 (1920), pp. 45-47. Information on the number of clinic applicants between 10 April and 1 July 1919 is reprinted in Alexander Lambert, "The Underlying Causes of the Narcotic Habit," Modern Med. 2 : 5-9 (1920). Early statistics reveal 725 registrants between ages 15 and 19 out of 2,723 total "narcotic applicants." Further information can be found in the department's Annual Report for 1919, p. 194. The several compilations are not totally consistent but in the main agree. The Department of Health was searched without success in the summer of 1971 for the original of these statistics and any other clinic information that might have been retained in its files and archives.

22 Hubbard, "Narcotic Clinic," pp. 46-47, 40.

23 The clinic closed 6 March 1920 (N.Y. Times, 7 March 1920) but the Riverside Hospital continued to receive addicts for institutional treatment under the auspices of the Health Department. (See Weekly Bull. Dept. Health N.Y. City, 16 Oct. 1920, p. 332.)

24 Registrations were approximately 13,000 in the entire state by April 1920; this was thought to be one-third of the total.

25 Lambert, "Underlying Causes," p. 8.

26 Hubbard, "Narcotic Clinic," p. 34. Some of the credence given Hubbard's conclusions can be measured from the fact that versions of his article were reprinted within a few months by the American Medical Association ("Some Fallacies Regarding Narcotic Drug Addiction," /AMA 74 1439-41 [1920] ) and the Public Health Service ("Municipal Narcotic Dispensaries," Public Health Reports 35 : 771-73, 26 March 1920).

27 The regimen followed in the hospital and its results are described in Weekly Bull. Dept. Health N.Y. City, 27 Sept. 1919, pp. 305-06; A. R. Braunlich, "Treatment of Drug Addiction at Riverside Hospital," Monthly Bull. Dept. Health N.Y. City, Feb. 1920, pp. 47-49; T. F. Joyce, "The Treatment of Drug Addictions," Weekly Bull. Dept. Health N.Y. City, 9 Oct. 1920, pp. 322-24.

28 Department of Health, City of New York, Annual Report, 1920, p. 257.
For another hostile reaction to addicts who failed to be cured, see T. F. Joyce ("Denarcotizing the Addict," Monthly Bull. Dept. Health N.Y. City, June 1921, pp. 132-36), "I still insist that if there is any more destructive, more troublesome, more nerve wracking, more ungrateful class of patients . . . we have not as yet met them" (p. 136).

29 Braunlich, "Treatment of Drug Addictions," p. 49.

30 For the Narcotic Division of the Revenue Service, the failure of the New York clinic was due to the availability of illicit supplies on the streets. The clinic experience made apparent the prior necessity to secure the control of illicit narcotics. This was also Copeland's conclusion (Copeland to Cooper, 16 Oct. 1919), and the deduction drawn by the Revenue Service's inspector Thomas Cooper: "If it were not possible for the addict to secure the drug clandestinely, the New York plan ought to be absolutely and completely successful" ( Memorandum for the Bureau of Internal Revenue, 21 Oct. 1919). The New York clinic became the proof that clinics could not work. Simple maintenance clinics were not even considered legitimate because they did not attempt to cure.

31 Hubbard, "New York City Narcotic Clinic," pp. 42-44. Similarly, the experience at The Tombs had suggested that withdrawal was quite safe, if painful ( see above, ch. 5).

32 Braunlich, "Treatment of Drug Addictions," p. 49.

33 Hubbard, "Some Fallacies," pp. 1440-41. Joyce stated ("Denarcotizing the Addict"), "If our legal brothers would cooperate with us, by enacting drastic laws, they would deter the habitual repeater as well as the distributor, and we might get better results" (p. 135).

34 Itubbard, "New York City Narcotic Clinic," pp. 42, 43; also "Some Fallacies," PP. 1440-41.

35 Lambert, "Underlying Causes," p. 5.

36 One comment on the Shreveport clinic by the (later) Federal Bureau of Narcotics captures its attitude toward that clinic and clinics in general: "It was estimated that 75 per cent of the drug addicts in Texas made their headquarters at Shreveport following the operation of that clinic" (Federal Bureau of Narcotics, Narcotic Clinics in the United States [GPO, 19551, p. 12). Prof. Lindesmith, on the other hand, wrote in 1965: "It is the general impression today that the [clinic] in Shreveport, Louisiana, was one of the most efficiently operated" ( The Addict and the Law [New York: Vintage Books, 1965], p. 149).

37 Oscar Dowling (1866-1931) was born in Alabama and received his M.D. from Vanderbilt in 1888. He specialized in eye, ear, nose and throat diseases. In 1906 he was appointed to the Louisiana State Board of Health and served as its president for many years. In the teens of this century he took an active role in fighting patent medicines, alcohol, and narcotics. As late as i May 1920 Dr. Dowling was trying to get approval from Levi Nutt for a clinic operation that maintained addicts but permitted administration of the drug only in the clinic. Nutt, in a memo to the Legal Division of the Prohibition Unit, opposed any concessions on clinic operations. "In view of the proposed plan to abolish clinics throughout the country," he wrote, "I doubt the advisability of committing ourselves . . . at this time." In spite of the New York City experience, Dr. Dowling thought dispensing was not without merit until states could provide institutional curative treatment ( Oscar Dowling, President, Louisiana State Board of Health, to L. G. Nutt, Director, Narcotic Division, Prohibition Unit, 1 and 5 May 1920; L. G. Nutt to Legal Division, Prohibition Unit, 6 May 1920).

38 Evidence for Dr. Dowling's fear of indictment is found in a memorandum of his visit to the Narcotics Division in December 1920 prepared by R. C. Valentine of the General Counsel's office. Valentine described Dowling as "afraid that he himself may be arrested under the Federal law . . . and states he is anxious to follow instructions of the Federal Government. He evidently wants us to stand by our guns. We have no choice in the matter in view of the action taken in the New York State Clinics, but I explained the reason for our allowing an extension of the New Orleans' clinic closing date was based upon a necessity of securing, as far as practicable, the cooperation of State governments in enforcement of narcotic laws" ( "Note for Case New Orleans File," 11 December 1920, signed "RCV," [RPU]).

39 State of Louisiana Public Act no. 252, approved 11 July 1918, promulgated 3 Aug. 1918.

40 "News Report," JAPhA 7 : 572 (1918). The survey was also noted in a memo summarizing the New Orleans clinic's history, "Report of Dr. M. W. Swords, in Charge of Narcotic Clinic, Louisiana State Board of Health, to the Honorable Mr. J. O. Bender, Internal Revenue Agent, United States Government, New Orleans, Louisiana, District" (ii June 1919). Dr. Rosewater is apparently the same Dr. Charles Rosenwasser who practiced in New Jersey and testified before the New York .State Whitney Committee in 1917.

41 The clinic in New Orleans opened on 6 Feb. 1919 and is discussed in the memo to Agent Bender, and in an article by Swords, "Drug Addiction and Its Relation to Public Health," New Orleans Med. Surg. J. (1921), p. 272.

42 The exchange with the state's attorney general and his opinion (see minutes of the Louisiana State Board of Health, meeting of 20-21 Feb. 1919), are quoted in the memo by Swords.

43 "Memorandum on the Narcotic Situation in New Orleans and the Status of Clinics Nationally" was prepared by Dr. Oscar Dowling and sent to Nutt under cover of a letter dated 12 Feb. 1921; Nutt to Arthur D. Greenfield, New York, 23 Nov. 1920.

44 New Orleans Times-Picayune, 27 Nov. 1920.

45 Dowling to members of the Louisiana State Board of Health, 26 Oct. 1920; John F. Kramer, Prohibition Commissioner, to Dowling, 8 Nov. 1920; W. T. Truxtun, Internal Revenue Agent, to David A. Gates, Supervising Federal Prohibition Agent, Little Rock, Ark., 12 Oct. 1920.

46 Truxtun's second report was sent to Governor J. M. Parker on 6 February 1921. Truxtun spent considerable time locating any registrants with a criminal record or using a false name since he felt these discoveries would discredit the clinic. The government's attitude toward the clinic was affected by a confidential letter to Nutt from Dr. William Edler, a physician who had been assigned to the anti-VD program of the state by the federal government. After 18 months in New Orleans, Dr. Edler described the clinic as "a social menace exceeded by nothing—and that is saying a great deal for a city like New Orleans." Dr. Edler admitted he had never been in the clinic, but he observed that it attracted undesirables and "merely dispensed morphine at a profit" (Edler to Nutt, 1 Dec. 192o).

47 Evidence that Truxtun was indeed slanting information to make Dr. Swords and the dispensary appear irresponsible and venal comes from another agent's report ( dated 21 Jan. 1921). It was not to a state official but to the Narcotic Division on the matter of Swords's heroin, cocaine, and laudanum purchases. The agent looked into the sales of drugs to the clinic by two wholesalers in New Orleans and discovered that purchases had indeed been made; the heroin and cocaine were purchased on 5 February 1919, at the very beginning of the clinic's operation. Dr. Swords explained that he had at first believed that these two drugs were required by addicts, the same early belief held by the New York City clinic in April 1919. He decided later that heroin and cocaine use was a vice but that morphine was satisfactory for maintenance. He then sent the two drugs to the state chemist for safekeeping, with whom they remained. The dispensing of laudanum to a woman was found to be approved in writing, both by Dr. Dowling and another New Orleans physician, Dr. J. Barth, although the report to the governor in the following month made the dispensing seem an irresponsible and personal violation by Dr. Swords ( John M. Tully, Agent, to Truxtun, 21 Jan. 1921).

48 Swords to Truxtun, 4 Dec. 1920; Dowling to Nutt, 17 Jan. 1921.

49 Dowling to USPHS Surgeon General, 15 and 17 Feb. 1921 (PHSR) Henry Mooney, U.S. Attorney, New Orleans, to Nutt, 17 Feb. 1921.

50 At the time of the February meeting the clinic was also investigated by a designee of the Surgeon General—R. M. Grimm, an officer in the Hygienic Laboratory. Grimm did not report to the Public Health Service the black situation that the narcotic agent described; nevertheless he indicated the concurrent opinion of the PHS that a clinic was not a sufficient solution, "a feeble attempt to treat a social condition which is generally recognized to be far-reaching in its effects" (R. M. Grimm to Surgeon General, USPHS, 25 March 1921 (PHSR ).

51 W. S. Drautzburg and Ralph H. Oyler to Nutt, 27 March 1920.

52 B. R. Rhees and O. A. H. de la Gardie to Nutt, 23 Oct. 1921.

53 Dr. Terry began to request information from Dr. Butler at least as early as December 1922 and considered Butler's reports of great significance ( Terry to Butler, 27 Dec. 1922, BuP).

54 W. P. Butler, "How One American City Is Meeting the Public Health Problems of Narcotic Drug Addiction," Amer. Med. 28 : 154-62 (1922).

55 J. B. Greeson, Kansas City, Mo., to Federal Prohibition Commissioner, 6 Oct. 1922.

56 H. H. Wouters, Special Narcotic Agent, to Nutt, 6 Oct. 1922; Wouters to W. S. Blanchard, Acting Prohibition Commissioner, 29 Sept. 1922.

57 Butler to Edward Wilson, Atlanta Georgian, 2 Feb. 1923 (BuP).

58 Anonymous to Colonel Lee (sic) G. Nutt, 10 Sept. 1922; Nutt to William Blanchard, 19 Sept. 1922. Wouters also saw Nutt in Chicago and discussed the Shreveport clinic and was ordered to investigate it (Wouters to Blanchard, 28 Sept. 1922).

59 Wouters's Report to Nutt, 6 Oct. 1922.

60 Handwritten note dated "s1/2" attached to Wouter's report to Valentine, Legal Division, initialed "AYS"

61 Dowling to Nutt, 15 Dec. 1922.

62 2 Feb. 1923 (BuP).

63 Butler to Terry, 15 Feb. 1923 (BuP).

64 Shreveport Journal, 7 and 9 June 1923.

65 As early as 1915 a U.S. Senator from Louisiana and the local representative requested a hospital for the treatment of addicts in Shreveport (Acting Surgeon General Glennan to Senator Joseph E. Ramsdell, 19 May 1915; Rep. J. T. Watkins, 4th Louisiana District, to Surgeon General, USPHS, 11 May 1915, PHSR). When the Harrison Act began to cut off sources of drug supply for addicts, Dr. Dowling suggested that a clinic be established in the Shreveport area "to protect them from the 'Peddler and to control illegal traffic" (Dowling to Dr. Frank H. Walke, Parish Health Officer, Shreveport, 12 March 1919 [Copy in Bull]).

66 Charles E. Terry, Executive, Committee on Drug Addictions, Bureau of Social Hygiene, to Butler, 7 Nov. 1928 (BuP).

67 Lindesmith, Addict and the Law, p. 16o.

68 Senator Duncan U. Fletcher asked for an explanation of the closing of the Jacksonville clinic in a letter to Nutt of 2 May 1921. He was assured that this was not directed at Florida—that all clinics were being closed.

69 Erwin C. Ruth, Special Narcotic Agent, to L. G. Nutt, 19 April 1921 (the copied report in the file is dated March, but from the covering letter and the report itself, April must have been the month in which it was prepared). Ruth was later arrested and dropped from the service, charged with blackmailing addicts and shaking down druggists and doctors. Sidney Howard, "The Inside Story of Dope in this Country," Hearst's International, Feb. 1923, p. 142.

70 T. E. Middlebrooks, Narcotic Agent in Charge, Atlanta, to L. G. Nutt, 17 Feb. 1922.

71 T. E. Middlebrooks to W. S. Blanchard, Acting Head, Narcotic Division, 30 Nov. 1923.

72 New Haven Register, 17 Aug. 1918. A similar arrangement whereby one physician was authorized to provide prescriptions for the city's addicts was followed in Memphis; the number totaled about 350 daily ("Drug Addicts in the South," Survey, 26 April 1919, pp. 147-48).

73 New Haven Register, 17 Aug. 1918.

74 Memorandum on the New Haven Clinic by Agents H. S. Forrer and O. W. Lewis to Prohibition Commissioner, 17 June 1920.

75 Register, 17 Aug. 1918.

76 Forrer and Lewis report, 17 June 192o.

77 E. C. Ruth, Special Narcotic Agent to L. G. Nutt, 6 Oct. 192o.

78 Report on the Albany Clinic by H. S. Forrer and O. W. Lewis to Nutt, marked confidential, dated 25 June 1920.

79 V. Simonton, Head, Narcotic Unit, Federal Prohibition Office, New York, to L. G. Nutt, 1 Sept. 1920.

80 See Charles E. Terry and Mildred Pellens, The Opium Problem ( New York: Bureau of Social Hygiene, 1928; reprint ed., Montclair, N.J.: Patterson Smith, 1970), p. 843. The legislature passed several narcotic bills as well as one abolishing the Department of Narcotic Drug Control and presented the contradictory bills to Governor Nathan L. Miller. The governor vetoed all but the bill of abolishment. He explained that physicians could not agree on how to treat addiction and until this question was resolved, it was best to defer state laws designed to complement federal statutes. See Public Papers of Governor Miller, "Memoranda on Legislative Bills Approved," section entitled "To Repeal Article 22 of the Public Health Law and Abolishing [the] Department of Narcotic Drug Control," 13 March 1921 ( Albany: J. R. Lyon, 1924), p. 178. New York City responded by passage of an antinarcotic section to the Sanitary Code on 25 July 1921 which reinstated some state controls.

81 Some clinics were brought into being by Commissioner Roper's letter to agents, 31 July 1919 (U.S. Treasury Dept., Bureau of Internal Revenue, Enforcement of the Harrison Narcotic Law, 2212 to Collectors of Internal Revenue, Revenue Agents, and Others Concerned," 31 July 1919, GPO, 1919), as a temporary method of handling the anticipated influx of addicts deprived of their drugs. Less than a year later the Prohibition Unit's legal division prepared a memorandum for Nutt: "The Proposed Plan to Abolish Clinics Throughout the Country" ( 6 May 1920). Between these two dates the decision to close the clinics was made. Probably the decision was made some time after Cooper's glowing reports of the clinics were submitted to the bureau ( 22 October 1919) and before Nutt's trip across the nation ( March 1920) to evaluate for himself, always negatively, any clinic practicing maintenance.

82 J. E. Conway to R. C. Valentine, Head, Legal Division, Narcotic Field Force, Prohibition Unit, 5 May 1920: "The mere bringing of an indictment might have beneficial results, even if it is later decided, upon an understanding being reached with the offending officials, that prosecution could not be maintained."

83 Terry and Pellens, Opium Problem, p. 843.