NARCOTICS IN NINETEENTH-CENTURY AMERICA
Before 1800, opium was available in America in its crude form as an ingredient of multidrug prescriptions, or in such extracts as laudanum, containing alcohol, or "black drop," containing no alcohol. Valued for its calming and soporific effects, opium was also a specific against symptoms of gastrointestinal illnesses such as chol-era, food poisoning, and parasites. Its relatively mild psychological effect when taken by mouth or as part of a more complex prescription was enhanced by frequent use, and the drug was supplied freely by physicians. In addition, self-dosing with patent medicines and the ministrations of quacks contributed to narcotic intake. The medical profession's need for something that worked in a world of mysterious mortal diseases and infections cannot be overlooked as a major stimulus for the growth of the opium market. A drug that calmed was especially appealing since physicians could at least treat the patient's anxiety.
Technological advances in organic chemistry during the early nineteenth century led to plentiful supplies of potent habit-forming drugs. Alkaloids in crude opium were separated and crystallized to isolate active principles that give opium its physiological and psychic effects. Analysis of the coca leaf occurred in mid-century, and cocaine was finally isolated.1
Opium and Its Derivatives
Morphine grew in popularity as its great power over pain became better appreciated. It was cheap, compact, and had a standard strength—unlike tinctures of other forms of opium extracted from the crude plant. When the hypodermic needle became popular in the middle of the century it permitted direct injection into the body of a powerful, purified substance. Of the many substances injected experimentally, morphine was found to be exceptionally effective as a pain-killer and calming agent, and it came into medical practice after the Civil War. Writers have remarked on the coincidence to explain the apparent frequency of addiction in the United States in the latter half of the century.2 Of course, this line of reasoning does not explain the relatively few addicts proportionally or absolutely in such nations as France, Germany, Great Britain, Russia, and Italy, which also fought wars during the latter half of the nineteenth century and also used morphine as an analgesic.
Whatever the cause, a relatively high level of opium consumption was established in' the United States during the nineteenth century. This appetite for narcotics calls for some examination if only because opiate addiction has been described in the United States as "un-American" and "non-Western." 3
Because opium has not been commercially grown to any great extent in America, the national supply was imported. Before 1915 ( 1909 for smoking opium) no restriction other than a tariff was placed upon importation, and except for opium for smoking, these tariffs were modest. Tariff records reveal the demand for opium and opiates during most of the nineteenth and early twentieth centuries. It is reasonable to assume that smuggling did not severely modify the overall trends of opium importation, because the period of free entry ( 1890-96 ) did not dramatically alter the importation curve. The imported opium was mostly crude, although it did include opium prepared for smoking. The United States exported almost no manufactured opiates before World War I because European drugs undersold them on the world market.4
Crude opium contained an estimated 9 percent morphine content extractable by American pharmaceutical concerns. One of the largest morphine-producing firms in the nineteenth century, Rosengarten and Company of Philadelphia (later merged into what is now Merck, Sharpe and Dohme ), began manufacturing morphine salts in 1832. The first statistics on the importation of opium date from r84o and reveal a continual increase in consumption during the rest of the century. The per capita importation of crude opium reached its peak in 1896. The Civil War, far from initiating opiate use on a large scale in the United States, hardly makes a ripple in its constantly expanding consumption, but addicted Civil War veterans, a group of unknown size, may have spread addiction by recruiting other users. Although there is some reduction in crude opium imports during 1861-65, presumably due to the blockade of the South, the amounts imported within a few years before and after the war are very similar. The rapid rise in crude opium did not begin until the 1870s; then it quickly outstripped the annual increase in population. Morphine did not begin to be imported in great amounts until the late 1870s.5 Another cause of increased consumption was the widespread use of opiates by physicians and manufacturers of patent medicines during a period when there was little fear of their use. The unregulated patent medicine craze in the United States hit its peak in the late nineteenth century—a time when the opiate content in these medicines was probably also at its highest.
The characteristics of opium and its derivatives were ideal for the patent medicine manufacturers. There was no requirement that patent medicines containing opiates be so labeled in interstate commerce until the Pure Food and Drug Act of 1906. Many proprietary medicines that could be bought at any store or by mail order con-tained morphine, cocaine, laudanum, or ( after 1898) heroin. Attempts at state regulation of sales were not successful during the last century.6 Even "cures" for the opium habit frequently contained large amounts of opiates. Hay fever remedies commonly contained cocaine as their active ingredient. Coca-Cola, until 1903, contained cocaine ( and since then caffeine).7 Opiates and cocaine became popular—if unrecognized—items in the everyday life of Americans. The manufacturers were remarkably effective during the nineteenth century in preventing any congressional action to require even the disclosure of dangerous drugs in commercial preparations.8
After 1896, the per capita importation of crude opium gradually began to decline and, jast before prohibitive laws rendered the im-portation statistics valueless, had fallen to the level of the 188os. That level was not low, but consumption did drop as agitation mounted for strict controls. One traditional opium import which did not decline after i9oo was smoking opium, in spite of its holding no special interest for prescribing physicians, patent medicine manufacturers, or wounded Civil War veterans. Smoking opium, solely a pastime, lacked any of the elaborate advertising campaigns which boosted morphine and cocaine preparations; it had had a slow but steady rise in per capita consumption since import statistics began in 1860.6 Suddenly in 1909 smoking opium was excluded from the United States. Weighing heavily against it was its symbolic associa-tion since mid-century with the Chinese, who were actively persecuted, especially on the West Coast. By then they were almost totally excluded from immigrating into the United States.
The prohibition of smoking opium also served notice to other na-tions that America was determined to rid itself of the evils of addiction. In 19o9 the United States convened the first international meet-ing to. consider opium traffic between nations, specifically that traffic into China which was so unwelcome to the Chinese govern-ment. Although motivation for American initiative in the Chinese problem was a mixture of moral leadership, protection of U.S. domestic welfare, and a desire to soften up Chinese resistance to American financial investments, the United States was also led by the nature of the narcotic trade to seek control of international ship-ments of crude narcotics to manufacturing countries and thence to markets. But the United States, on the eve of entering an international conference it had called to help China with its opium problem, discovered it had no national opium restrictions. To save face, it quickly enacted one. American prejudice against the Chinese, and the association of smoking opium with aliens, was in effect an immense aid in securing legislation in the program to help China. Indeed, a prime reason for calling the International Opium Commission was to mollify China's resentment of treatment of Chinese in the United States.
What might explain the pattern of decline of opium importation for consumption in the United States before the Harrison 'Act in 1914? First would be a growing fear of opiates and especially of morphine addiction, which was marked by the quick spread of antimorphine laws in various states in the 1890s.10 That opium addiction was undesirable had long been common opinion in the United States. Oliver Wendell Holmes, Sr., in an address delivered just before the Civil War, blamed its prevalence on the ignorance of physicians. Holmes, then dean of Harvard Medical School, reported that in the western United States "the constant prescription of opiates by certain physicians . . . has rendered the habitual use of that drug in that region very prevalent. . . . A frightful endemic demoralization betrays itself in the frequency with which the hag-gard features and drooping shoulders of the opium drunkards are met with in the street."
As the century progressed and the hypodermic injection of opiates increased their physiological effect, the danger of morphine addic-tion was more widely broadcast. For this reason patent medicine makers resisted attempts to require the listing of ingredients on labels. The knowledge that such substances were in baby soothing syrups and other compounds would hurt sales. Nevertheless growing publicity disclosing the contents of patent medicines, early regulatory laws in the states, and public opinion all worked together as forces to curb this use of opiates and cocaine.
Another possible explanation, although untestable, is that the opiates had nearly saturated the market for such drugs: that is, those who were environmentally or biochemically disposed to opiates had been fairly well located by the marketers and the consumption curve leveled off as the demand was met. Such reasoning could apply also to a product like cigarettes, the use of which grew at a fantastic rate with the beginning of World War I but eventually leveled off in per capita consumption: although they are easily available not everyone desires to smoke them.
The numbers of those overusing opiates must have increased during the nineteenth century as the per capita importation. of crude opium increased from less than 12 grains annually in the 1840s to more than 52 grains in the 1890s." Eventually the medical consensus was that morphine had been overused by the physician, ad-diction was a substantial possibility, and addition of narcotics to patent medicines should be minimized or stopped. There is reason to emphasize the gradual development of this medical opinion since physicians, as well as everyone else, had what now seems a very delayed realization that dangerously addicting substances were distributed with little worry for their effect. Cocaine and heroin were both introduced from excellent laboratories by men with considerable clinical experience who judged them to be relatively harmless, in fact, to be possible cures for morphine and alcohol addiction
By 1900, America had developed a comparatively large addict population, perhaps 250,000, along with a fear of addiction and addicting drugs.13 This fear had certain elements which have been powerful enough to permit the most profoundly punitive methods to be employed in the fight against addicts and suppliers. For at least seventy years purveyors of these drugs for nonmedical uses have been branded "worse than murderers," in that destroying the personality is worse than simply killing the body. What is most human is what is destroyed in the drug habitués, the opponents of narcotics argued.
In the nineteenth century addicts were identified with foreign groups and internal minorities who were already actively feared and the objects of elaborate and massive social and legal restraints. Two repressed groups which were associated with the use of certain drugs were the Chinese and the Negroes. The Chinese and their custom of opium smoking were closely watched after their entry into the United States about 1870. At first, the Chinese represented only one more group brought in to help build railroads, but, particularly after economic depression made them a labor surplus and a threat to American citizens, many forms of antagonism arose to drive them out or at least to isolate them. Along with this prejudice came a fear of opium smoking as one of the ways in which the Chinese were supposed to undermine American society.14
Cocaine was especially feared in the South by 1900 because of its euphoric and stimulating properties. The South feared that Negro cocaine users might become oblivious of their prescribed bounds and attack white society.15 Morphine did not become so closely associated with an ethnic minority, perhaps because from its inception it was considered a simple substitute for medicinal opium and suitable for all classes. When opiates began to be feared for their addictive properties, morphine was most closely attached to the "lower classes" or the "underworld," but without greater, specificity.16
The crusade for alcohol prohibition which culminated in the adoption of the ifith Amendment started in the South and West early in this century. Intrastate Prohibition weighed most heavily on the poor since, until the Webb-Kenyon Act of 1913, it was quite legal to purchase liquor in bulk from wet states for shipmeneinto dry states. When poor southerners, and particularly Negroes, were alleged to turn to cola drinks laced with cocaine or to cocaine itself for excitement as a result of liquor scarcity, more laws against cocaine quickly followed. Here, however, the South was at a loss for comprehensive legal control since the goal was to prohibit inter-state as well as intrastate shipment. This could be done only with a federal statute which would threaten the states' police and com-merce powers. Consequently, the story of the Harrison Act's passage contains many examples of the South's fear of the Negro as a ground for permitting a deviation from strict interpretation of the Constitution.
Cocaine is a good example of a drug whose dangers became widely accepted although at first it was immensely popular. It was pure, cheap, and widely distributed; its advocates distrusted not only the opinions of their opponents but also their motivation. Cocaine users were so impressed by its euphoric properties that they were unable to evaluate the drug objectively.
Cocaine achieved popularity in the United States as a general tonic, for sinusitis and hay fever, and as a cure for the opium, morphine, and alcohol habits. Learned journals published accounts which just avoided advising unlimited intake of cocaine.17 Medical entrepreneurs such as the neurologist William Hammond, former surgeon general of the army, swore by it and took a wineglass of it with each meal. He was also proud to announce cocaine as the official remedy of the Hay Fever Association, a solid endorsement for anyone (see p. 252, n. 7). Sigmund Freud is perhaps the best-remembered proponent of cocaine as a general tonic and an addiction cure. He wrote several articles in the European medical press on the wonderful substance to which his attention had been drawn by American medical journals.18
In the United States the exhilarating properties of cocaine made it a favorite ingredient of medicine, soda pop, wines, and so on. The Parke Davis Company, an exceptionally enthusiastic producer of cocaine, even sold coca-leaf cigarettes and coca cheroots to accompany their other products, which provided cocaine in a variety of media and routes such as a liqueurlike alcohol mixture called Coca Côrdial, tablets, hypodermic injections, ointments, and sprays.
If cocaine was a spur to violence against whites in the South, as was generally believed by whites, then reaction against its users made sense. The fear of the cocainized black coincided with the peak of lynchings, legal segregation, and voting laws all designed to remove political and social power from him. Fear of cocaine might have contributed to the dread that the black would rise above "his place," as well as reflecting the extent to which cocaine may have released defiance and retribution. So far, evidence does not suggest that cocaine caused a crime wave but rather that anticipation of black rebellion inspired white alarm. Anecdotes often told of super-human strength, cunning, and efficiency resulting from cocaine. One of the most terrifying beliefs about cocaine was that it actually improved pistol marksmanship. Another myth, that cocaine made blacks almost unaffected by mere .32. caliber bullets, is said to have caused southern police departments to switch to .38 caliber revolv-ers. These fantasies characterized white fear, not the reality of cocaine's effects, and gave one more reason for the repression of blacks.19
The claim of widespread use of cocaine by Negroes is called into question by the report in 1914 of 2,100 consecutive Negro admissions to a Georgia asylum over the previous five years. The medical director acknowledged the newspaper reports of "cocainomania" among Negroes but was surprised to discover that only two cocaine users—and these incidental to the admitting diagnosis—were hospitalized between 1909 and 1914. He offered an explanation for cocaine disuse among Negroes—that poverty prevented a drug problem equal to that among whites.20
The most accepted medical use of cocaine was as a surface anesthetic, for example, on the eye to permit surgery on a conscious patient, or as an injection near a nerve to stop conduction of pain stimuli. When sniffed, cocaine crystals shrink mucous membranes and drain sinuses. Along with sinus drainage, the patient gets a "high." Eventually such substitutes or modifications of cocaine were developed as benzocaine and procaine, which do not have such euphoric effects but are still capable of preventing nerve conduction.
Since cocaine was by no means limited to physicians' prescriptions, the "lower classes," particularly in "dry" states, found they could get a jolt which took the place of hard liquor. Bars began putting a pinch of cocaine in a shot of whiskey and cocaine was peddled door to door. By 1900, state laws and municipal ordinances were being rapidly enacted against these activities. But law-abiding middle and upper-class employers also found practical uses for cocaine; it was reportedly distributed to construction and mine workers to keep them going at a high pitch and with little food.21 This value of cocaine had been first discovered by the Spanish in sixteenth-century Peru and was put to work among the native slaves who mined silver. Cocaine thus was economically valuable, but the fear of its overstimulating powers among social subgroups predominated, in the United States, and its provision to laborers waned.
State laws designed to curb the abuse of morphine and cocaine came mostly in the last decade of the nineteenth century. The realization of "abuse" and its seriousness gradually undermined con-fidence in simple regulatory laws and led to a determination that decisive action must be taken. Addiction became a challenge to medical and legal institutions. State and municipal laws generally required cocaine or morphine to be ordered on a physician's prescription, which then had to be retained for perhaps a year for inspection. The laws had one great loophole: the patent medicine manufacturers repeatedly obtained exemptions for certain quantities of narcotics in proprietary medicines. These loopholes permitted the narcotized patent medicines to be sold, but the laws lulled the public into believing that this abuse of narcotics was under control. To some extent these lacunary antinarcotic laws did alert the more wary, and manufacturers began to be cautious. But as curbs on the sale of narcotics for nonmedicinal use, the laws were not effective; they were not well enforced because, among other factors, the states did not have sufficient manpower to maintain surveillance.
Although a state might enact an antinarcotic law and even en-force it, bordering states without such laws often provided drugs for users and sellers. New York State reformers bitterly criticized New Jersey's lax narcotic regulations, which vitiated enforcement of New York's carefully framed legislation.22 Furthermore, although the law-abiding physician had more paper work, unethical physi-cians could circumvent state and local laws and the consequent paper work in various ways. The "dope doctors" could simply pur-chase drugs by mail from another state and then dispense them to their "patients," thereby bypassing laws which relied on prescrip-tions and pharmacies to monitor drug use. Generally, physicians resented the legal advantage of patent medicines which, by means of statutory exemptions, contained narcotic dosages capable of producing addiction. These evasions were in painful contradiction to the intent of legislation and a distinct reminder of the political influence of those profiting from narcotic sales.
Federal control over narcotic use and the prescription practices of the medical profession were thought in Igoo ,to be unconstitutional. Gradually, federal commerce and tax powers were broadened by Supreme Court decisions, notably those upholding a federal tax on colored oleomargarine, federal prohibition against transportation of women across state lines for immoral purposes, the interstate transportation of lottery tickets, and carrying liquor into a state that prohibited liquor imports. But that congressional activity was still circumscribed by the Constitution was reflected in the Supreme Court ruling in Hammer v. Dagenhart (1918) wherein the court declared that congress could not regulate the interstate shipment of goods produced by child labor.23 The ruling clearly indicated that federal police powers under the guise of tax or interstate commerce powers had narrow application.
As a result of constitutional uncertainty over legislation enabling federal law to prevail in an area of morals, there was little effort until after igoo to enact a federal law to control the sale and prescription of narcotics. After the passage of the Pure Food and Drug Act ( igo6), some elements of the pharmacy trade supported a regulatory antinarcotic law based on the interstate commerce clause, a movement seconded by Dr. Harvey Wiley of the Agriculture Department."24 Finally, by 1912 when the State Department's campaign for a federal antinarcotic law was making substantial progress, proponents opted for basing it on government's revenue powers. Thus the framing of an antinarcotic law paralleled the widening possibilities open to Congress in the area of policing morals. Even so, the Harrison Act of 1914 had to survive a number of unfavorable or close court decisions until its broad police powers were upheld in 1919. And as late as 1937 the Marihuana Tax Act was carefully kept separate from the Harrison Act in order to dis-courage more court attacks.25 The Drug Abuse Act of 197o scrapped the Harrison Act's foundation on revenue powers and rests on the interstate commerce powers of Congress, returning to the basis proposed more than sixty years before. In the last half century, the interstate commerce clause has been substantially broadened so that its powers can sustain strict regulation of drug use without the need to portray a police function as a revenue measure.26
Lay reformers took a vigorous and uncomplicated stand on narcotics. In general, two problems enflamed them: corporate disregard of public welfare and individual immorality. This dichotomy is artificial but it helps to identify the objects of the reformers' zeal and it made a difference in the kinds of laws proposed. Reformers like Samuel Hopkins Adams, whose "Great American Fraud" series in Collier's in 1935-07 revealed the danger of patent medicines, were of course concerned over the damage done to unsuspecting victims of such medicines. Adams directed his attack against phar-maceutical manufacturers whose expensive and inaccurate advertising promotions sold harmful nostrums to the public. In keeping with his exposés of crooked politicians and corporations, Adams argued that regulatory laws should be aimed at the suppliers.27 For other reformers, though, the addict evoked fears; their agitation resulted in legislation directed more at the user, who might be sent to jail for possession, than at the manufacturer who produced bar-rels of morphine and heroin. The Southerner's fear of the Negro and the Westerner's fear of the Chinese predominated in this ap-proach to the drug problem. The origin of concern thus affected the aim and quality of the laws. Both classes of reformers looked to federal legislation as the most effective weapon, and both tended to measure progress in the reform campaign by the amount of legislation enacted.
The reformers can also be examined from another viewpoint. One group thought in moral abstractions while another was inter-ested in a practical solution. The Right Reverend Charles Brent, who played an important role in the movement for narcotic control, was an abstract reformer who saw the narcotics problem, like any other social problem, to be a question which required first of all a moral approach to the decision.28 Did narcotics have a value other than as a medicine? No: unlike alcohol they had no beverage or caloric value. Should such substances be permitted for casual use? No: there was no justification, since there was the possibility only of danger in narcotics for nonmedicinal uses. Therefore recreational use of narcotics should be prohibited, their traffic curtailed on a world scale, and a scourge eliminated from the earth. To compro-mise, to permit some ( for instance the Chinese) to use narcotics would be inconsistent with morality, and therefore not permissible. Reformers like Brent were charitable but unwilling to compromise.
Other reformers sought a practical and partial solution which edged toward total narcotic restriction but was modified to allow for the cravings of addicts. These compromises often came from political divisions smaller than the federal government. In contrast to Bishop Brent's proposals, the compromise programs were based on the assumption that the supply of and the desire for narcotics could not be eliminated, and therefore any attempt at total prohibition would be a failure.29
Narcotics, however, constituted only a small part of the American reform movement at the turn of the century. In the last decade of the nineteenth century, rising public interest in protecting the environment and health was evident in exposés, public education and reform proposals in Congress for such things as a pure food law, but not until the presidential years of Theodore Roosevelt was this interest translated into substantial national legislation. Roosevelt's advocacy of ecology and conservation followed a popular revulsion against the excessive concentration of wealth and the manner in which it was amassed, and the disregard of general welfare by powerful private interest.
Upton Sinclair's bitterness led to The Jungle, in which the young Socialist portrayed the slaughterhouse owner's utter disregard for employee welfare. Often credited with giving the final push toward enactment of the Meat Inspection Act in 1906, Sinclair soon became disillusioned with his efforts at substantial reform through idealistic principles: the big meat packers benefited from the reforms enacted by Congress since small business firms could not afford the new inspection requirements nor meet the standards of foreign nations which had criticized the purity of American meat exports.
But if some reforms were actually an assistance to institutions reformers hated, other reforms were the nuisance or corrective their advocates desired. An aggressive administrator of the new regula-tions restricting environmental and physiological damage was Dr. Harvey Washington Wiley, who developed the Agriculture Depart-ment's Bureau of Chemistry into an avid detector of unsavory manufacturing practices.30 He was condemned by industry because his criticisms and regulations often appeared to go beyond aft rea-sonable limits. For example, he wanted to prohibit caffeine-contain-ing drinks such as Coca-Cola as well as patent medicines containing narcotics. His particular attention to unlabeled additives resulted in an indictment of the Coca-Cola Company and the holding up of shipments of French wines not labeled to show sulfur dioxide as a preservative. These disputes required the attention of the President, the Supreme Court, or a Cabinet officer. Theodore Roosevelt's sup-port of Wiley waned in 1938 as the criticisms grew, and he felt some personal evaluation was necessary. He called Wiley to the White House to confront industrial spokesmen. All went well until the conversation turned to the President's treasured sugar substitute, saccharin. Wiley at once declared saccharin a threat to health which should be prohibited in foods. Roosevelt angrily reacted: "Anybody who says saccharin is injurious is an idiot. Dr. Rixey gives it to me every dayl" His doubt about Wiley strengthened by this encounter, Roosevelt established the Referee Board of Consulting Scientific Experts. By 1912 Wiley had been forced out of government service because of his aggressive and, some thought, unreasonable antagonism to food and drug impurities and false claims.31
THE HEALTH PROFESSIONS AND NARCOTICS
Medicine and pharmacy were in active stages of professional organ-ization when they became involved with the issue of narcotic con-trol. The status of both pharmacists and physicians was less than desirable, and both suffered from weak licensing laws, meager training requirements, and a surplus of practitioners. Their intense battles for professional advancement and unification had an effect on the progress and final form of antinarcotic legislation.
Although the state of medicine in the nineteenth century was improving, its only tangible progress lay in some ability to contain a few communicable diseases. Yet, if the physician could not effect cure, he could assuage pain and apprehension: opiates were preeminent for these functions and were apparently used with great frequency. Drugs are still overused in this casual, convenient way—penicillin, the sulfas, tetracycline, barbiturates, and so on—they carry a message of effective treatment to the patient, fulfilling his emotional needs even if sometimes risky and superfluous from an ob-jective viewpoint.
The American Medical Association ( founded in 1847), which now appears monolithic and powerful, was a weak institution at the close of the last century. The vast majority of doctors refrained from membership. The AMA's battle for higher standards of train-ing, licensure, and practice was threatening to many within the profession and seemed to the public to be but a covert plea for special preferment by one of several schools of medical practice.32 While one may admit that the AMA reform program improved the political, economic, and social status of the medical profession, the public welfare was also to be improved. The Flexner Report, with its independent and corroborating analysis of the profession's weak-nesses, was accepted by impartial critics.33 Meanwhile, however, the low standards of the nineteenth century predominated and were consistent with the great reliance on such symptomatic relief agents as the opiates.
Although the drive to organize pharmacy was contemporary with the AMA's efforts, it was not so successful. However fragmented medicine might appear, pharmacy was far more fundamentally split into special-interest groups, often divided on questions of legislation, ethics, and professional standards. The druggist operated a competitive retail business to which his prescription service usu-ally contributed only a fraction of his profits. He had some difficulty adhering to the strict professional standards enunciated by the American Pharmaceutical Association (1852)—stressing the ancient science of pharmacy—as the highest priority in his business. He found an ideal relationship with the physician was particularly difficult to attain since the oversupply of doctors led many of them to do their own dispensing. Similarly, pharmaceutical manufactur-ers, importers, exporters, and wholesalers were also engaged in businesses far removed from the archetypal pharmacist dispensing an intricate prescription. The various professional components often felt that their particular interests could not be adequately served by an association in which all elements of pharmacy had an equal voice. Dissatisfaction with the APhA led to many trade associations with specific membership criteria.34
Physicians and pharmacists were vocal and effective in their lobbying efforts. Each saw that in addition to aiding the public welfare, strict narcotic laws could be a distinct advantage for in-stitutional development if great care was exercised in their framing. Knowledge of this rivalry and ambition clarifies legislative history; it also reminds us that in the competition to find a convenient law it was rather easy to lose sight of the victim of drug abuse. The public's fear of addicts and minority-group drug users might supply the powerful motive force for legislation, but the law's final form would await the approval of the institutional interests affected.
THE AMERICAN PHARMACEUTICAL ASSOCIATION
The pharmacists who were eager to proclaim themselves pro-fessionals, as opposed to mere retailers of prepared medicines and sundries, became members of the American Pharmaceutical As-sociation. Retail druggists were divided over patent medicines, some making profits from the preparations, others embarrassed by such trade. Nevertheless, many druggists stocked proprietaries in self-defense. The APhA frowned on narcotic use for other than medical purposes, and the association's leaders fought proprietary medicines, as did the AMA, on both moral and self-interest grounds: they were dangerous, self-medication had inherent risks, and legitimate trade was taken from the pharmacists who prepared their own products.35
In September 1901, the American Pharmaceutical Association convened in St. Louis. The Section on Legislation and Education heard lawyer-pharmacist James H. Beal report that the model state pharmacy law which had been adopted at the previous convention was gaining popularity, and that a number of states had already enacted some of its provisions. Nevertheless, the desire of physicians to register as pharmacists without examinations continued. Beal also spoke of a new issue that merited the dose attention of pharmacists. He called the section's attention to enactment in the previous year by Kansas and Tennessee of restrictions on habit-forming drugs, specifically cocaine and morphine. Beal warned: "If pharmacists do not take up and deal rigorously with these matters, they will be dealt with by the general public, and in a way not likely to be altogether agreeable to the pharmacists." Movements to restrict habit-forming drugs focused also on alcohol, chloral hydrate, other hypnotics, and a few other preparations. In Colorado, morphine and cocaine were tied together in proposed legislation with "malt, vinous, and spirituous liquors," which would be available only on a, physician's prescription. Although the bill was defeated, it showed a trend toward drug and alcohol legislation which the pharmacists quickly realized must be dealt with before it went beyond their ability to influence.36
Atlanta's trouble with cocaine in its "Negro quarters" was brought to the attention of the association by its second vice-president, G. F. Payne. Several drugstores had been catering to the "extensive addiction" among Negroes and, although he doubted that stores were receiving most of their income from it, as was the rumor, he knew a lot of money was exchanging hands. A city ordinance had merely moved the "cocaine joints" out of tovvn, whereas Georgia state restrictions appeared to have closed them completely. He noted that the cocaine was only 25 percent pure, but "the darkies seemed to be very well satisfied with that kind of cocaine." Another speaker spoke of increasingly popular sleeping medicines which also deserved study and restriction, and moved for the formation of a committee to look into the whole problem. An ad hoc committee was approved and directed to "consider the question of acquire-ment of drug habits, and the best methods of legislative regulation of the danger." 37
This committee represented concern by a competent and broadly based organization whose members had an important role in the supply of drugs to the public. All members of the organization were pharmacists and were in a good position to gather facts about the prescription and purchase of morphine and cocaine, the chief offenders at this time. At an early stage in the national movement for narcotic laws the committee had an opportunity to report on atti-tudes toward habit-forming drugs and consider recommendations for their control.
A year later the American Pharmaceutical Association met in Philadelphia to celebrate its fiftieth anniversary. The Section on Education and Legislation was assured by its chairman, E. G. Eberle, that professionalization was still moving apace. Fewer physicians were dispensing, and the enactment of salutary pharmacy laws continued, but some activities needed closer watching. The federal government gave away serum against infectious diseases more liberally than seemed warranted, leading to competition with private enterprise. Also the free medical dispensary, although laud-able in its aims, was "another evil in disguise." A good solution to free-loading was the scheme proposed by the medical and pharmaceuti-cal professions of Pennsylvania to require dispensary patients to be registered, under penalty of a considerable fine, so that only the deserving received free care. As for habit-forming drugs, Eberle hesitated to comment on the upcoming report of the ad hoc committee, but he believed the best law would not be one with many penalties, or one based on fear, but one which simply required the druggist to be of "moral character." 38
The Committee on the Acquirement of the Drug Habit had studied the statistics of narcotic importation over the previous five years (1898—1902). Inspection of imports revealed the startling fact that, although the population had increased by only io percent, im-portation of cocaine had risen 40 percent, opium 500 percent, and morphine 600 percent.39 The committee believed that the increasing use of habit-forming drugs was not the fault of physicians, since those with whom they had contact were generally prescribing less than formerly as the danger of addiction became more widely appreciated.
Questionnaires had been sent to about a thousand physicians and pharmacists in New York, Brooklyn, Philadelphia, Baltimore, and a scattering of towns in Pennsylvania and New Jersey; about 3o percent replied. The questionnaire did not list alcohol among the drugs nor mention cannabis, but it did include preparations such as laudanum and chloral hydrate. On the estimate of five habitués reported per pharmacist, the committee concluded that there were about 200,000 habitués in the United States. This rough value is close to a later estimate for this period by the Public Health Service." Two groups, the committee reported, Negroes and women, easily succumbed to cocaine:
The use of cocaine by unfortunate women generally, and by Negroes in certain parts of the country, is simply appalling. No idea pf this can be had unless personally investigated. The police officers of these questionable districts tell us that the habitués are made madly wild by cocaine, which they have no difficulty. at all in buying, sometimes being peddled around from door to door, but always adulterated with acetanilid.
Several recommendations were offered. Smoking opium should be suppressed by the federal government by banning its importation. Since retail druggists rarely sold smoking opium and physicians were not known to prescribe it, such a recommendation was morally and economically sound. The only group that valued smoking opium, the Chinese, did not intimidate the committee: "If the Chinaman cannot get along without his 'dope', we can get along without him. The great increase in the quantity of this special kind of opium proves one of two things, or both: either our exclusion laws are being violated, or the smoking of opium is largely practiced by others than Chinese." 41 The last two recommendations were less specific: at the state level, uniform laws should be framed by state medical and pharmaceutical associations to protect citizens from habit-forming drugs. Finally, the association should refuse member-ship to traffickers in these drugs.
After a year of further study, and with the assistance of Beal, the committee recommended a model state law. This model of 1933 provides an insight into the status of habit-forming drugs before adoption of any federal controls. First, the proposal for regulation at the state level reflected the belief that the simplest way to control habit-forming drugs within the United States was through the states' police powers. Any intrusion by federal police power would meet resistance from strict constructionists and criticism as an en-forcement task beyond the capacity of the small federal establish-ment. Moreover, the American Pharmaceutical Association's history of successful influence within state legislatures made lobbying on the state level a familiar operation. Therefore a state law would be customary and of assured validity.
Beal had conferred with various experts as to which drugs should be controlled. He included cocaine, opium and its derivatives ( which would include heroin, morphine, and codeine), and chloral hydrate. These drugs should be given only under written order of a licensed practitioner, and prescriptions should not be refilled.
Beal then confronted an issue which is still actively debated: Should physicians be permitted to prescribe for habitués? Trying to take a middle course, he realized on the one hand that if this were permitted, unscrupulous physicians could prey on the victims of addiction and reap a harvest. On the other hand, a significant body of opinion in 1903 held that opium ( and especially morphine) habitués could not be deprived of their drugs without "great danger to their lives." The use of opiates might even be part of the cure or treatment of the disease. Since this was the case, he argued, the goal of the law should be to restrict, rather than to prevent entirely, the sale of narcotics. Beal concluded: "The principal object of the law must be to prevent the creation of drug habits, rather than to reform those who are already enslaved, however desirable the., latter might be, and the draft has accordingly been constructed upon this theory." 42
Prescription of the forbidden drugs to a "habitual user" was outlawed provided "that the provisions . . . shall not be construed to prevent any lawfully authorized practitioner of medicine from prescribing in good faith for the use of any habitual user of narcotic drugs such substances as he may deem necessary for the treatment of such habit." Any prescription written by a licensed practitioner (physician, dentist, or veterinarian) was to be kept by the phar-macist for inspection for a period of two years. As one would expect in the pharmacists' model law, no provision was made for dispensing by physicians.
Preparations containing no more than specified amounts of a narcotic, such as less than grain of morphine in one fluid ounce, were exempt from the law. Recognizing the seemingly invulnerable popularity of narcotized patent medicines and their makers, the restrictions would not apply in any way to "preparations recom-mended in good faith for diarrhea or cholera, properly packaged." This exemption reflects the great prevalence of intestinal ailments at the turn of the century and also touches on a complaint of physicians: too many druggists "recommended" drugs for diseases, and thereby encroached on the doctors' special province.43
Along with the submission of Beal's model law, the Committee on the Acquirement of the Drug Habit presented its second and final report.44 Even more questionnaires had been sent out than previously and the report represented ( with a free admission that it was fragmentary ) conditions and fears from the whole nation. Some of the findings are of interest. For example, of 150 drug habitués reported in Alabama, 8 were heroin addicts. This indicates a fairly rapid spread of heroin into the drug-abuse class since it first became commercially available in 1898.45 Georgia reported that almost every Negro prostitute was addicted to cocaine. Maryland, Georgia, Ohio, and other states gave examples of disreputable physicians and druggists who sold gigantic amounts of cocaine or other drugs. Michigan reported an increase in sales to Negroes. Pennsylvania also reported several heroin addiction cases and a small retail dealer's purchase of ¼-grain morphine tablets in 100,000-tablet lols. Virginia reported an enormous growth in the cocaine habit among Negroes.
The committee did not want to imply, however, that the abuse of drugs was confined to "the fallen and lower classes." Although the lower and criminal classes were the most difficult to cure, had frequent relapses, and stole in order to get their stimulants, the higher classes, even those of intellect and with social prestige, were not strangers to the overuse of habit-forming substances. The com-mittee concluded, in the 1903 Proceedings of the APhA, with an observation which suggested law enforcement as an adjunct to cure, a presentiment of the federal narcotic policy of the 19.2os: "those who think they cannot break the results of the habit are those who are free to obtain the drug by purchase or otherwise" (pp. 467-68,471).
Acquiring the habit was related to many factors in American life, the committee continued. Lawyers and preachers took cocaine in order to be "bright." Even worse, "many of the leading lights of the medical profession . . . become slaves to a vice which they are supposed to combat." Patent medicines contained the drugs to produce quick relief regardless of the illness. Physicians believed they could build up a good practice by demonstrating to their patients the relaxing or pleasurable effect of one hypodermic shot. "Society's whirl demands late hours," the committee averred, be-lieving that the need for immediate sleep led many to overuse sedatives. Headaches the next day could be cured by patent "head-ache powders" and so a vicious cycle started. Availability of drugs at a soda fountain diminished the wariness of the customer. With the use of narcotics increasing, "evil effects from it [will] come to succeeding generations" ( p. 477 ).
Although the report made some serious allegations, there was no attempt to hide the incompleteness of the data or the uncertainty in various classes of response. Replies from prisons and asylums were particularly suspect because no accurate record was kept, although we believe the state should exact it." It was recommended that in any later investigation one person in each locality should carefully gather and evaluate information, since questionnaires had limited value and comprehensiveness ( pp. 467, 473 ). This frank and self-critical analysis became rarer as the debate over narcotics intensified in the next decades. From every trade group, regardless of the profit to be made from habit-forming drugs, the committee received the distinct impression that legislation was needed and expected. Smoking opium, a particularly indefensible vice, should be prohibited. Domestically, stringent state regulation of sellers with fines, imprisonment, and surrender of license would be required to stop the evil. Since illicit sales would naturally accompany drug restriction, the need for severe penalties was obvious (p. 477 ).
The criminal class posed a special problem. The "drug fiend" preying on society seemed unlikely to be cured. Even after a period of apparent respectability, he might begin stealing to obtain the drug. The chairman felt forced to conclude that perhaps certain classes of people, "the demi-monde, known criminals or those whose occupations are shady," should be totally prohibited from the drug. Information from the police that most drug abusers become so "after they had joined the ranks of the underworld, does not lessen the danger to society" ( p. 475 ) . How certain groups were to be kept from narcotics was not explained. Men in the army and navy were rapidly increasing their use of opium, perhaps due to their contact with the natives and Chinese in the Philippines during the insurrection there ( 1899-1902 ). No evidence pointed to the responsibility of service physicians for the spread of the drug habit, but the great increase in men separated from the armed services for addiction during the previous year was evidence to the committee that their companions—civilians and "lewd men and women"—had introduced them to the habit.46
"Unless very stern and speedy action is taken now, the people of the United States will pay dearly for the neglect in the not distant future," warned the committee's chairman. He had little faith in an appeal
to the moral sense of the men who are today supplying retail drugstores with all the drugs they can sell, nor of the class of druggists who supply the "dope fiends." There is but one appeal to such men, and that is through fear—fear of their pocketbooks or fear of jail—and the only way to stop them from continuing their practice is to make the penalty severe enough to be adequate to the danger of their crime. Let it be administered in this spirit. The murderer who destroys a man's body is an angel beside one who destroys that man's soul and mind.47
DISTRICT OF COLUMBIA PHARMACY ACT, 1906
The pharmacists' early formulation of a national policy led to en-dorsement of state laws that would restrict to pharmacists and physicians the supply of habit-forming drugs. A second and slightly revised model law was adopted by the NWDA, NARD, APhA, and the PAA in December 1905, formally extending the drug trades' support of the 1903 APhA model. In May 1906 Congress adopted for the District of Columbia a pharmacy act which druggists, particularly the American Pharmaceutical Association, considered exemplary.48 It followed closely the language of the model state pharmacy law promulgated by Beal in 1900 and included two sections adopting most of the association's model narcotic law of 1903.46
As a general pharmacy law, the Act protected registered phar-macists from those without a license, as well as from the sale of drugs by hawkers and door-to-door peddlers. As usual, physicians were exempt from the law with regard to their own patients, for whom they could compound and dispense medicines.
Changes from the model narcotic statute reflected compromises reached in most attempts to restrict dangerous but popular medications. Minimal amounts of morphine, opium, cocaine, and chloral hydrate exempted in patent or proprietary medicines were doubled over Beal's earlier recommendation. The phrase "derivatives of opium" was omitted throughout the Act, thereby exempting any derivative that might be habit forming, such as heroin. The practice particularly offensive to physicians, "recommendation" of preparations for cholera and diarrhea by pharmacists, was rephrased to read "sold in good faith." Prescriptions for narcotics could be re-newed only on the written order of the physician and were ordered kept three years for examination.
Congress appears to have strengthened provisions against addic-tion maintenance. Beal's model law seems somewhat more liberal in its provision that the physician could prescribe in good faith sub-stances he might feel necessary for treatment of the habit. The District of Columbia law permitted the prescription of habit-forming drugs only when "necessary for the cure" of addiction. The physician must prove that he acted in good faith and believed the drug "necessary for the cure of drug addiction . . . or for the treatment of disease, injury, or deformity, and for no other purpose whatsoever." 50
This law, although applicable only to the District of Columbia, assumed considerable importance later in relation to the question whether Congress had ever considered allowing drugs simply for the comfort of an addict. In the same spirit, Congress had mandated, a year earlier, nonmedical narcotic prohibition for the Philippine Islands.51
A month after passage of the District of Columbia Pharmacy Act, Congress approved the long-debated and controversial Pure Food and Drug Act. Administration of this Act was placed in the Bureau of Chemistry of the Department of Agriculture, headed by Dr. Harvey W. Wiley.
Although Wiley was not chiefly concerned with narcotics—most of his professional life had been devoted to the purity of food—the Act required the listing of narcotics, including cannabis, on the labels of patent medicines shipped in interstate commerce. Within a few years of the inclusion of this simple device, it was estimated that patent medicines containing such drugs dropped in sale by about a third.52 Nevertheless, large sales did continue and pharmacists enlisted Wiley's aid in drafting an amendment to the Pure Food and Drug Act which would eliminate any medicines containing habit-forming drugs from interstate commerce except under the prescription of a physician. In Wiley's opinion, through such an amendment "the whole commerce in so-called patent medicines containing these habit-forming drugs would be practically destroyed." 53 This would be an important trade victory for the retail and compounding pharmacists, for it would increase dispensing by pharmacists, decrease sales in grocery stores, and eliminate sales across state lines by mail-order houses. The amendment would also accomplish a reform which most impartial authorities agreed was desirable for the health of the nation.
Wiley recommended this change in the Pure Food and Drug Act to the State Department at the beginning of 1908, when some federal action was contemplated as a token of American concern about the international narcotic traffic." Assistant Secretary of State Robert Bacon was interested in the Wiley amendment but claimed it came too late for submission to the current session of Congress.55 By summer the situation had changed as far as the State Department was concerned. The department now felt that a simple amend-ment to an existing law would not suffice. A separate federal law was required, opposing in some respect nonmedical opium consumption." The State Department now came into prominence as a leading proponent of narcotic legislation both nationally and internationally. The drug trades receded somewhat from public attention to work more quietly, but just as effectively, in the molding of restrictive legislation. The value of educating pharmaceutical groups as to their best interests in narcotic control was evident in the eventual legislation at the federal level. The drug trades were able to veto a number of schemes to control narcotics which violated, in their view, the legitimate interests and prerogatives of their industry.
1 Research and clinical papers on narcotics were many in the igth century, but few current articles attempt to trace the evolution of medical opinion on these drugs. I am greatly indebted to Glenn Sonnedecker's "Emergence of the Concept of Opiate Addiction," J. Mondial Pharmacie, Sept.- Dec. 1962, pp. 275-9o; Jan.-Mar. 1963, pp. 27-34. Another article of relevance is D. I. Macht, "The History of Opium and Some of Its Preparations and Alkaloids," JAMA 64 477-81 (1915). Macht describes some of the history and composition, usually including opium, of the immemorial antidotes diascordium, mitradatium, theriaca, and philonium. The Opium Problem, by Charles E. Terry and Mildred Pellens ( New York: Bureau of Social Hygiene, 1928; reprint ed., Montclair, N.J.: Patterson Smith, 1970), is a very useful anthology of articles published up to the mid-192os.
2 Norman Howard-Jones, "A Critical Study of the Origins and Early Development of Hypodermic Medication," J. Hist. Med. 2 201-49 (1947). Growth of addiction in the U.S. is commonly attributed to morphine injections or other opiates to lessen the pain of Civil War battle wounds; direct attribution is more common in the 20th century and after World War I. Earlier studies equally emphasized the emotional stress engendered by conflict. The lack of statistics on the number of Civil War veterans who became addicts in the service suggests that the war was a convenient event to blame for late 19th-century addiction. According to a recent study, morphine was usually dusted or rubbed into wounds and only sometimes injected ( Stewart Brooks, Civil War Medicine [Springfield, Ill.: Thomas, 1966], pp. 65,88). An extensive report on rising opium consumption in the U.S. published only seven years after the war makes no mention of the recent conflict as the cause of addiction, but rather places its beginnings in the rising teetotalism of the 184os and 185os ( F„ E. Oliver, "The Use and Abuse of Opium," Third Report of the Massachusetts Board of Health, 1872, pp. 162-77). So far no thorough study of morphine use in the Civil War has been located.
3 Excessive opiate use in the igth century was not considered "un-American" but "peculiarly American" ( Harvey Washington Wiley, "An Opium Bonfire," Good Housekeeping, August 1912, p. 252). An anonymous writer in 1861 bemoaned, "in no country in the world is quackery carried on to so enormous extent as it is in the United States" ("Quackery and the Quacked," Nat. Quart. Rev. 2 : 354  ). George Beard, a leading neurologist and psychiatrist of the latter half of the century, associated narcotic use with the frailty of advanced civilization and predicted a great increase in the 20th century ( American Nervousness: Its Causes and Consequences [New York: Putnam, 11381], p. 64). This interpretation was common until World War I when "perfidious foreign nations" were usually held responsible for American drug taking.
4 Some opium was grown in the U.S. during the 19th century and perhaps later (Terry and Pellens, The Opium Problem, p. 7). During the blockade the Confederacy attempted to grow opium to replenish its supplies but found smuggling to be more certain ( Norman H. Frank, Pharmaceutical Conditions and Drug Supply in the Confederacy [Madison, Wis.: Institute of the History of Pharmacy, 1955]; Memoranda on the Manufacture of and Traffic in Morphine in the U S in Continuation of Senate Doc. 377, 6ist Cong., znd Sess., 31 Oct. 1911, prepared for the Secretary of State by Hamilton Wright; for cocaine exports see p. 12; for morphine, p. 14).
5 Statistics on opium and morphine importation until the Harrison Act (in effect after 1 March 1915) are among the best available for estimating the use of narcotics in the United States. The drugs were importable without restriction and at modest or even at times, free duty. Imports do not reveal what segment of the population might have been addicted or how many, but they do reveal a remarkable increase in the domestic demand for narcotics which began to rise at least in the 184os and continued until the 189os, when average domestic consumption of crude opium leveled off to about a half-million pounds each year, and that of morphine and its salts to about 20,000 ounces annually. A convenient source of these figures for 1850-1926 is Terry and Pellen's The Opium Problem (pp. 50-51 ) where the important distinction is made between total imports and that portion of imports "entered for consumption." Hamilton Wright provided statistics which extend the record back to 1840 (ibid., "Report," Appendix IV, pp. 81-83).
6 M. I. Wilbert, "Sale and Use of Cocaine and Narcotics," Publ. Health Rep. 29 : 3180-83 ( 1914 ); Registration of Producers and Importers of
Opium, etc., Committee on Ways and Means, H. Rept. no. 23, 63rd Cong., znd Sess., 24 June 1913, p. 3.
7 L. F. Kebler, Habit Forming Agents: Their Indiscriminate Sale and Use, a Menace to the Public Welfare, Agriculture Dept., Farmer's Bulletin no. 393 (April 1910), pp. 8-12, 15-18. William Hammond, "Dr. Hammond's Remarks on Coca," Trans. Med. Soc. Virginia, 1887, pp. 213-26, esp. p. 226 for hay fever. Oscar E. Anderson, The Health of a Nation: Harvey W. Wiley and the Fight for Pure Food (Chicago: Univ. of Chicago Press, 1958), p. 315.
8 To protect their formulas they did not patent their products; only the names were legally protected by trademarks. But by 1905 the Proprietary Association of America had endorsed a law to exempt small amounts of narcotics, similar to Section 6 of the future Harrison Act. The PAA was fighting for its life against disclosure laws affecting all proprietaries and was burdened by the bad name some products were giving the industry. Manufacturers whose medicines continued to contain excessive narcotics (e.g. Dr. Tucker's Asthma Specific, which contained cocaine) were not permitted to join the PAA. See J. H. Young, The Toadstool Millionaires (Princeton Univ. Press, 1961), pp. 237 ff., and idem, The Medical Messiahs ( Piinceton Univ. Press, 1967), p. 34; typed transcript of proceedings of 31st Annual Meeting of the PAA, 20-22 May 1913, Washington, D.C., pp. 14-15; editorial, Amer. Druggist Pharmaceut. Rec. 57 : 126 ( 292o ). The model law prepared in 1905 by representatives of the PAA, NARD, NWDA, and the APhA is found in "Sale of Narcotics and Proprietary Medicines Containing Alcohol," Am. J. Pharm. 78 : 145— 48 (1906).
9 See above (eh. 1, n. 5.), for source of statistics. Wright's "Report" describes manipulation of duty in an attempt to reduce the importation of smoking opium in the late 29th century (Hamilton Wright, "Report on the International Opium Commission and on the Opium Problem as Seen within the United States and Its Possessions," contained in Opium Problem: Message from the President of the United States, Sen. Doc. no. 377, 62st Cong., 2nd Sess., 21 Feb. 292o).
10 See, e.g., General Laws of Texas, 2905, ch. 35, sect. 2.
11 "Address before the Massachusetts Medical Society, 30 May 186o," in The Works of Oliver Wendell Holmes (Boston: Houghton Mifflin, 1892), 9 : 200-01.
12 See F. X. Dercum, "Relative Infrequency of the Drug Habit among the Middle and Upper Classes," Penn. Med. J. 20 : 362-64,1'1.22 ( 1917 )• Some physicians did begin to sense the danger: in 1900 Dr. John Witherspoon, who was to become AMA president in 1923, delivered his "Oration on Medicine, A Protest against Some of the Evils in the Profession of Medicine" (lAMA 34 : 1592  ):
Ah Brothers! we, the representatives of the grandest and noblest profe-ision in the world . . . must . . . warn and save our people from the clutches of this hydra-headed monster which stalks abroad throughout the civilized world, wrecking lives and happy homes, filling our jails and lunatic asylums, and taking from these unfortunates, the precious promises of eternal life. . . .
The morphine habit is growing at an alarming rate, and we can not shift the responsibility, but must acknowledge that we are culpable in too often giving this seductive siren until the will-power is gone.
See also T. D. Crothers, "New Phase of Criminal Morphinomania," J. Inebriety 21 : 41-51 ( 1899 )•
13 The number of narcotic addicts in the U.S. is a very difficult figure to arrive at. One problem is in the definition of an addict, for there are at least two major categories among those who use narcotics in a regular fashion, the hard-core addict who requires daily opiates to hold off abstinence symptoms, and occasional users who can stop without any significant symptoms. There is another category of "addict," composed of individuals who are not taking enough opiates to create the possibility of an abstinence syndrome but who believe they are. These individuals are dependent on addict life style or even simple needle injections, although physiologically they could not be classified as addicts.
Given these qualifications, most authors who have closely studied the question of the addict-population in the past (Wilbert, Terry, Pellens, Kolb, DuMez, Lindesmith) tend to agree that there was a peak in addiction around 1900 and that in the teens of this century this number began to decrease and reached a relatively small number (about loo,o00) in the 1920s. The peak might be 200,000 to 400,000 in i9oo. A peak of drug use in 1919 reported by New York City and Federal officials which estimated the total in the U.S. at about one million seems highly unlikely. It seems reasonable to maintain that the decline in opiate use after 19oo probably continued. What actually increased was the fear directed at addiction by officials and the public. By 1930 only the most irresponsible spokesmen argued that addiction had not reached a low figure and was represented chiefly in the largest urban centers. In general, exaggerated figures of the number of narcotics addicts have reflected public concern rather than actual numbers. Nevertheless, the number in the U.S. seems to have exceeded in the 20th century the per capita rate in other Western nations and without question was so perceived by the federal government until the 192os, when the admission became an embarrassment.
14 E. C. Sandmeyer, The Anti-Chinese Movement in California (Urbana: Univ. of Illinois Press, 1939). Sandmeyer points out the similarity of complaints made against the Irish, who had preceded the Chinese as the lowest-paid workers in California ( pp. 38-39). Anti-Chinese feeling was not confined to the West Coast; see e.g. John W. Foster, "The Chinese Boycott" (Atlantic Monthly, January 1906, pp. 118-27), for extralegal methods directed at Chinese, particularly in Boston; and Jacob Rfis, How the Other Half Lives (New York: C. Scribner's Sons, 1890) for his prejudicial remarks about New York's Chinatown.
15 The association of cocaine with the southern Negro became a cliché a decade or more before the Harrison Act. See W. Scheppegrell, "The Abuse and Dangers of Cocaine," Med. News 73 : 417-22 (1898), 'esp. p. 421. In June 1900 the JAMA (34 : 1637 ) editorially reported that "the Negroes in some parts of the South are reported as being addicted to a new form of vice—that of 'cocaine sniffing' or the 'coke habit.' In February 1901 the JAMA (36 : 330) called attention again to this new vice. See also in the New York Tribune, 21 June 1903, an extended statement by Col. J. W. Watson of Georgia on how cocaine sniffing "threatens to depopulate the Southern States of their colored population." Atlanta seemed particularly affected, and legal action was urged against the sale "of a soda fountain drink manufactured in Atlanta and known as Coca-Cola." The Colonel was satisfied that "many of the horrible crimes committed in the Southern States by the colored people can be traced directly to the cocaine habit," and that the habit was also present among young whites. Examination of the Atlanta Constitution ( 27 Dec. 1914 ) also reveals a frequently claimed association between cocaine use and the Negro; by 1914 the Atlanta police chief was blaming "70% of the crimes" on drug use. There is no indication in the Constitution of effective enforcement of drug laws; rather, narcotics appear to explain conveniently crime waves and other problems. In the District of Columbia the police chief considered cocaine the greatest menace of any drug. There it was peddled from door to door (Report of the President's Homes Commission, S. Doc. no. 644, 6oth Cong., 2nd Sess., 8 Jan. 1909 (GPO, 1909), pp. 254-55.
Philadelphia had a cocaine scare in 1910 which resulted in the arrest of several pharmacists, physicians, and policemen for sales to citizens, including school children. The leader of a drive against cocaine, Dr. Christopher Koch, of the State Pharmacy Board, testified before Congress on behalf of federal antinarcotic laws and drew attention to the dangers of the cocaine-crazed southern Negro. In 1914 Dr. Koch was quoted as asserting, "Most of the attacks upon white women of the South are the direct result of a cocaine-crazed Negro brain" (Literary Digest, 28 March 1914, p. 687). Dr. E. H. Williams portrayed in the N.Y. Times ( 8 Feb. 1914 ) a lurid and fearful picture of "the Negro cocaine fiends" who terrorized the South. Dr. Williams published a similar study, but with more statistics, in the Medical Record (85 : 247-49 , "The Drug Habit Menace in the South"). There Dr. Williams attempted to answer a study from the Georgia State Asylum (see ch. 1, n. 20 below) which reported almost no Negro cocaine takers admitted in the years 19o9-.14. In his Opiate Addiction: Its Handling and Treatment (New York: Macmillan, 1922), Dr. Williams attributed popular agitation for antinarcotic laws to spectacular crimes, especially in the South. Also in 1914 Dr. Harvey Wiley referred to "old colored men" hiding cocaine under their pushcart wares and spreading the drugs throughout America's cities (H. W. Wiley and A. L. Pierce, "The Cocaine Crime," Good•Housekeeping, March 1914, pp. 393-98), Thus the problem of cocaine proceeded from an association with Negroes in about 19oo, when a massive repression and disenfranchisement were under way in the South, to a ,convenient explanation for crime waves, and eventually Northerners used it as an argument against Southern fear of infringement of states' rights. For example, Wright wrote the editor of the Louisville Courier-Journal that "a strong editorial from you on the abuse of cocaine in the South would do a great deal of good [but] do not quote me or the Department of State" (16 April 1910, WP, entry 36). In each instance there were ulterior motives to magnify the problem of cocaine among Negroes, and it was to almost no one's personal interest to minimize or portray it objectively. As a result, by 1910 it was not difficult to get legislation almost totally prohibiting the drug.
16 Perhaps it is impossible to describe accurately the distribution of morphine addiction or nonmedical use in the 19th century among the various social groups. It is reasonable, however, to assume that morphine's introduction as a replacement for opium meant a wide distribution among the middle class, which enjoyed professional medical care. But as fear of morphine grew, and the need for symptomatic relief declined, the middle class may have used morphine less often. ( See F. X. Dercum, "Relative Infrequency of Drug Habit . . . ," Penna. Med. J. 20 : 362-64 .)
17 G. Archie Stockwell, "Erythoxylon Coca," Boston Med. Surg. J. 96 : 402 ( 1877 ).
18 Freud's first and most comprehensive study, "Uber Coca," was abstracted in the St. Louis Med. Surg. J. 47 502-05 (1884), the year of its publication in Vienna. Freud believed cocaine could cure morphinism and alcoholism through a ten-day course of hypodermic injections without recourse to an institution. The second paper, "Beitrag zur Kenntniss der Cocawirkung" 1885), continued the optimistic tone which was much muted in his last paper, "Bemerkungen iiber Cocainsucht und Cocainfurcht" ( 1887), a response to an attack on cocaine therapy by Erlenmeyer. The three papers are translated in S. A. Edminster et al., trans., The Cocaine Papers ( Vienna: Dunquin Press, 1963). Two substantial and illuminating studies of Freud's interest in cocaine are Siegfried Bernfeld, "Freud's Studies on Cocaine, 1884-1887, Yearbook of Psychoanalysis 10 : 9-38 ( 1954-55); and Hortense Koller Becker, "Carl Koller and Cocaine," Psychoan. Quart. 32 : 309-73 (1963). Karl Koller, Freud's
colleague, received from Freud the whimsical nickname Coca Koller.
19 N.Y. Times, 8 Feb. 1914; Med. Record 85; 247-49 (1914).
20 E. M. Green, "Psychoses Among Negroes: A Comparative Study," J. Nero. Ment. Dis. 41 : 697-708 ( 1914). Dr. E. H. Williams's reply that the cocainized Negroes were in jails and not insane asylums is found in the Medical Record (85 : 247-49  ), and also in Everybody's Magazine ( August 1914, pp. 276-77). Williams in these writings does not seem so much anti-Negro as anti-Prohibition and uses the stories of cocainized Negroes to show what might happen if alcohol were not available.
21 Hamilton Wright, "Report International Opium," Opium Problem: Message, p. 49.
22 M. 1. Wilbert, "Sale and Use of Cocaine," Publ. Health Rep. 29, 3180-83 ( 1914 ) .
23 247 U.S. 251 ( 1918). For discussions of the complicated byways of the federal police powers involved in such attempts at federal regulation see B. F. Wright, The Growth of American Constitutional Law (New York: Holt, Rinehart and Winston, 1942).
24 According to a memorandum by Dr. Reid Hunt of the Public Health Service, Wiley and the drug trades—the retail interests especially ( represented by the National Association of Retail Druggists)—cooperated to perfect an antinarcotic law based on the interstate commerce powers of the Constitution after it became apparent that pure food advocates feared any tampering with the Pure Food and Drug Act through amendment (PHSR, 2 Nov. 1908).
25 See statement of C. M. Hester, Assistant General Counsel of the Treasury Department, in Taxation of Marihuana, Hearings before the Committee on Ways and Means of the House of Representatives on HR 6385, 27-30 April and 4 May 1937, 75th Cong., 1st Sess. ( GPO, 1937), pp. 7-13. Fear of a new attack on the Harrison Act's constitutionality led the treasury to model the Marihuana Tax Act after the National Firearms Act in which tax was levied on the transfer of certain firearms.
26 For recent comment on the interstate commerce powers and the resting of national restrictive drug laws on these powers, see M. P. Rosenthal, "Proposals for Dangerous Drag Legislation," in Appendix B of Narcotics and Drug Abuse, Presidential Commission on Law Enforcement and the Administration of Justice ( GPO, 1967), pp. 8o-134, esp. p. 129 and n. 484.
27 Reprinted in book form by the AMA particularly for the reception rooms of physicians. Similar exposés of proprietary medicines made by the AMA appeared in three volumes, Nostrums and Quackery, in 1911, 1921, and 1936, the last entitled Nostrums and Quackery and Pseudo Medicine. Adams attacked such well-known proprietaries as Pe-ru-na which contained more than 25% alcohol, and Hostetter's Stomach Bitters which contained more than 40%; and those containing unlabeled narcotics, acetanalid, and other dangerous substances. He also attacked miracle workers who used such devices as magnetic belts to cure disease. He said they took in a quarter-billion dollars in annual sales, owing to their mass advertising, which he therefore sought to eliminate or regulate.
28 C. H. Brent to James F Smith, Commissioner of Education, Manila, 6 July 1903 ( BP, container 6).
29 Beal's model law and the New York State Whitney Acts (1917 and 1918) avoided prohibition but attempted to prevent new addicts and did permit maintenance of confirmed habitUes.
30 The standard biography of Wiley is Anderson's The Health of a Nation.
31 Ibid., pp. 210, 243 ff. Dr. Presley M. Rixey (1852-1928), Surgeon Gen-oral of the Navy, was the President's official physician. Wiley resigned his post in 1912 after bitter and continual disputes with his superiors in the Department of Agriculture.
32 The history of the pharmaceutical profession and drug trades in America is outlined in Kremer's and Urdang's History of Pharmacy, 3rd edition, revised by Glenn Sonnedecker (Philadelphia: Lippincott, 1963), pp. 1347296. For the history of medicine in America see R. Shryock, The Development of Modern Medicine (Philadelphia: Univ. of Pa. Press, 1947); M. Fishbein, A History of the American Medical Association, 1847-1947 (Philadelphia; Saunders, 1947); R. Stevens, American Medicine and the Public Interest ( New Haven: Yale University Press, 1971). J. M. Burrow, AMA: Voice of American Medicine (Baltimore: Johns Hopkins Press, 1963), describes the weakness of the AMA before World War! (see pp. 27 if. and his ch. 3, pp. 5 ff.).
33 The Flexner Report recommended closure of substandard medical schools in the United States and pointed to Johns Hopkins as the model for a modern medical school. (A. Flexner, Medical Education in the United States and Canada, Carnegie Foundation for the Advancement of Teaching, Bull. no. 4, New York, 1910.)
34 On the founding of the APhA see Glenn Sonnedecker, History of Pharmacy, 3rd ed. (Philadelphia: J. B. Lippincott Co., 1963), pp. 181 ff. Some of the important national drug trade organizations and their dates of founding are; Proprietary Association of America (PAA), 1881, composed of manufacturers of "patent medicines," and over-the-counter proprietaries; National Wholesale Druggists Association (NWDA), 1876, and National Association of Retail Druggists (NARD), 1898, for owners of pharmacies; American Pharmaceutical Manufacturers Association, 1908. The National Association of Manufacturers of Medicinal Products (1912), makers of prescription drugs, merged in 1958 with the PMA. See Sonnedecker, History of Pharmacy, pp. 188 if.
35 The APhA's 1856 constitution listed one of the association's goals: "To as much as possible restrict the dispensing and sale of medicines to regularly educated druggists and apothecaries" (Sonnedecker, History of Pharmacy, p. 185). Although hampered in its attack on proprietaries, because they were profitable for retail druggists, the association was condemning proprietaries at the turn of the century and cooperating with the AMA's Council on Pharmacy and Chemistry, founded in 1905, to expose proprietary frauds and dangers.
36 J. H. Beal, "Report on Pharmacy Legislation," Proc. APhA 49 : 460-64 ( 1901 ), esp. pp. 460-61.
37 "Minutes of the Section on Education and Legislation," ibid., pp. 464-66. At about this time a bill was introduced into the Senate prohibiting opium imports except for medicinal purposes (Chemist and Druggist
6o : 224  )•
38 E. G. Eberle, "Chairman's Address, Minutes of the Section on Education and Legislation," Proc. APhA 50 : 550-61 (1902), esp. p. 559.
39 "Report of Committee on Acquirement of the Drug Habit," Prôc. APhA 50 : 567-73 ( 1902), esp. p. 569. Although the committee may have chosen the previous five-year statistics without propagandizing intent, the year of comparison, 1898, had had the lowest import of crude opium since 1865. The reason for the small importation was the imposition of the higher Dingley tariff that year and the importation of the largest amount ever recorded in 1897 in anticipation of the rise. Therefore the report that opium importations had risen 600% in five years was grossly misleading. Actually if 1898 and 1897 figures are averaged, the importation of opium had reached a plateau. George Beard had noted the increase in annual importations of opium as early as 1880 (American Nervousness, p. 308; see n. 3 above).
40 "Committee on Acquirement of the Drug Habit," Proc. APhA 50 : 570 ( 19o2 ). In 1924 Lawrence Kolb, Sr., and A. G. DuMez estimated a maximum of 240,000 addicts of cocaine and opiates in the United States, in "The Prevalence and Trend of Drug Addiction in the United States and Factors Influencing It," Pub. Health Rep. 39 : 1179-1204 ( May 1924).
41 Proc. APhA 5o : 570,572-73 (1902).
42 J. H. Beal, "An Anti-Narcotic Law," Proc. APhA 51 : 478-82, 485-86 ( 1903 ).
43 "Draft of an Anti-Narcotic Law," Proc. APhA 51 : 486 (1903). This model law was substantially adopted by a conference in igo5 of the NARD, NWDA, PAA, and APhA and became the basis of the District of Columbia Pharmacy Act's provisions with regard to narcotics in 1906; it persisted as the exemption section of the Harrison Act. One of the purposes of the model act was to permit proprietaries to include some narcotics, but not the extremes that had aroused public furor.
Notes to Pages 19-24 287
44 "Report of Committee on the Acquirement of Drug Habits," Proc. APhA 51 : 466-77 ( 1903).
45 For the discovery and spread of heroin see "History of Heroin," Bull. Narcotics 5 : 3-16 ( April—June 1953 ); W. Z. Guggenheim, "Heroin: History and Pharmacology," Internat. J. Addiction 2 : 328-30 (Fall 1967).
46 Proc. APhA 51 : 475 ( 1903 ). The army's Surgeon General reported that admissions to hospitals for "narcotic poisoning" were first noted in 19oo as 6o; in 1901, io8; in 1902, 63; and in 1903, 194. In 1904 the annual report drops narcotic classification. The army declined between 1900 and 1904 from loo,000 to 6o,000. Discharges for narcotic poisoning from 1900 to 1903 were, for each fiscal year, 7, 7, io, and 22, respectively. These data are from Report of the Surgeon-General of the Army to the Secretary of War, fiscal years ending 30 June, War Department (GPO, 1898-1904).
47 Proc. APhA 51 477 (1903).
48 See ch. 1, n. 8 above.
49 District of Columbia Pharmacy Act, approved 7 May 1906, Public Law No. 148.
50 Ibid., sections 11, 12.
51 Philippine Tariff Revision Act, 3 March 1905, 33 Stat. L. 944: Sect. ii, Class III( b ).
52 Hamilton Wright, "Report International Opium," Opium Problem: Message, p. 19. HWW to C. H. Brent, 22 Aug. 1908: "Almost unanimous bpinion that there has been a decrease from 25% to 50% in the sales of patent medicines containing opiates since the Pure Food Law went into effect." Similarly, J. P. Street, "The Patent Medicine Situation," Amer. J. Publ. Health 7 : 1037-42 ( 1917 )•
53 HWW to Robert Bacon, 2 Jan. 1908, BCR. In this letter Wiley remonstrates that it would be unwise to put medical practitioners under the Bureau of Internal Revenue, the alternative to an interstate law based on the commerce powers, because of inconvenience and the uncertainty, if not impossibility, of constitutional regulation of the practice of medicine.
54 The need to put the American house in order by enactment of some federal statute regulating the importation of opium, especially smoking opium, was raised as early as 13 August 1907 by William Phillips, the Second Secretary of the Peking Legation in a memorandum to the State Department, "The Importation of Opium into the United States." A copy of Phillips's memorandum was sent to Wiley by Bacon as evidence for the need of some law (RB to HWW, zo Dec. 1907, BCR).
55 RB to HWW, 4 Nov. 1908, BCR.
56 RB to HWW, 2 Oct. 1908, BCR.