The Harrison Act became effective on 3. March 1915. En-forcement was assigned to the Bureau of Internal Revenue within the Treasury Department.1The revenue agents had had long experience with smuggling, evasion of tax stamps, and so on, by manufacturers and retailers and were thus prepared to regulate physicians and the drug trades. By 30 June 3.916, 3.2.4,000 physicians, 47,000 retail druggists, 37,000 dentists, i,000 veterinarians, and 1,600 manufacturers, importers, and wholesalers had been registered.2 The accumulation of information from records was large, and any systematic attempt to scrutinize the records was impossible. When violations came to the attention of the revenue agents, they moved in. After evidence had been gathered, a federal district attorney took charge of the cases and sought indictments.
The first questions to arise were: Could any actions other than nonregistration and faulty record keeping violate the Harrison Act? If records were carefully kept and the dealer was registered and displayed his tax stamp, what other wrong could he do? Influential members of the pharmaceutical profession, like lawyer-pharmacist James'Beal, replied with assurance that if the simple record requirements were obeyed, the federal government should be fully satisfied. Doctors and medical journals which had supported the Harrison bill believed that the otherwise annoying record keeping would strengthen the medical profession's control of these potent medicaments. Similarly, pharmacists saw HR 6282 as an aid in securing trade that might go elsewhere and a step toward the long-desired allocation to pharmacists of the sole right to dispense medicines.3 But when federal agents tried to prevent addicts from being supplied for their comfort and not for diseases, some former advocates in the profession howled in anguish. Protests to the Treasury and Justice Departments quickly revealed the variety of their motives in supporting the Harrison Act, which ranged from financial advantage to the hope of reducing by 90 percent the use of narcotics in the United States.
ENFORCEMENT OF THE HARRISON ACT
In mid-January of 1915 the Treasury Department promulgated the regulations under which the Harrison Act would be enforced.4 Although a regulation could not legitimately make a new law or add to what Congress had intended in the original act, details of the regulations would affect sensitive professional and trade issues. The first surprise to some physicians was the discovery that "in personal attendance" did not simply mean in the presence of a patient but required the doctor to be away from his usual place of business.5 This regulation therefore required much more record keeping than some physicians had expected, but it had already been accepted by congressional lobbyists of medical and pharmaceutical interests in the summer of 1914.6
The regulations also declared that "a consumer, as such, will not be permitted to register under this law and can only obtain a supply of such drugs through a duly registered physician, dentist or veterinarian.7 Therefore an addict could not register, as he did in Tennessee for example, and receive a regulated supply of habit-forming drugs. The new interpretation left registered professionals' as the only legal source of supply. In turn, registrants were hedged in by record-keeping provisions ( with heavy penalties for error ) so that their prescribing philosophies could be monitored. The possession of narcotics through unregistered channels would be, the Treasury averred, prima facie evidence of violation of the Act; under Section 8 the possessor had the burden of proving that he had legally obtained the drug. As for addicts' possessing drugs to satisfy their cravings, the department would argue that even if the addict had a prescription for a maintenance supply, it only appeared to be a prescription: a valid prescription aimed at cure would be a "normal" dose. These administrative interpretations met with some difficulty in the courts.
One of the first public indications that the goal of federal enforcement was prohibition of narcotics for nonmedical addiction maintenance may have been a rather vague phrase in additional regulations published 9 March 1915. Druggists were warned to examine each narcotic prescription submitted to determine whether the physician's signature was forced "or that the quantity of drug prescribed was unusually large." 8 A likely explanation of this language would be that the bearer might raise the originally prescribed amount. But the department may have also sought to place on druggists some review responsibility over physicians, a burden the retail pharmacists almost invariably declined.
From the first days of the Harrison Act, revenue agents began to arrest physicians and druggists who provided drug supplies to addicts via "prescriptions," but the most common method of en-forcing compliance was through stern warnings. In this regard, a druggist in Helena, Montana, wrote the Attorney General on 18 May 1915 asking for advice. He had technically correct cocaine prescriptions for six users, but "the revenue agents who are neither lawyers nor physicians tell me that these prescriptions are in excessive amounts." Since the physician insisted that the doses were not excessive for the users, the druggist was placed "in an anomalous position." He wanted "a straight-out, clear-cut answer and not a vague one that will still leave us to our own opinions and the resulting friction with different inspectors."
The Attorney General replied that this aspect of the Harrison Act was "a proper matter for the determination of the judiciary," and he could not comply with the druggist's request. His formal and brief reply covered a difference in opinion between the Internal Revenue Bureau and the Justice Department. Many U.S. attorney's actually agreed with the druggists that the law was vague in this matter, although this opinion was not publicly available.9 The Treasury Department, however, believed it could decide the issue posed by the druggist by framing a new regulation, TD 2200, on 11 May. Part of this decision relates directly to narcotic maintenance.
Where a physician, dentist, or veterinarian prescribes any of the aforesaid drugs in a quantity more than is apparently necessary to meet the needs of a patient in the ordinary case, or where it is for the treatment of an addict or habitué to effect a cure, or for a patient suffering from an incurable or chronic disease, such physician, dentist, or veterinarian surgeon should indicate on the prescription the purpose for which the unusual quantity of the drug so prescribed is to be used. In cases of treatment of addicts these prescriptions should show the good faith of the physician in the legitimate practice of his profession by a decreasing dosage or reduction of the quantity prescribed from time to time.10
The Philadelphia Medical World, a practical and economically oriented journal for the general practitioner, was outraged at the Treasury regulations which forbade maintenance. The editors had advocated the Harrison Act, but were apparently unaware of the goals or compromises involved in its passage. The Medical World distinguished between the professional treatment of a habitué, even if indefinite, and the "mere pandering to the desires of dope fiends." 11 Like the Medical Economist in New York, the Philadelphia joumal did not condone the mere selling or catering to dope fiends, but on the other hand it felt that physicians were well within their rights in maintaining addicts until a cure came along.12 The distinction between maintaining and pandering seemed to be in the way in which the narcotic was transmitted to the patient. If the addict merely picked up a prescription and gave over his quarter or half dollar, and if, say, more than twenty addicts did this a day in a physician's office, then he was pandering. But if the number of addicts was small, and if the prescription was given in a less hurried and more professional manner, particularly should there be any attempt to discourage use of narcotics to produce euphoria, the patient was "treated." This distinction appeared to be the primary dividing line between respectability and infamy; the physiological state of the patient and the effect of the drug were irrelevant. Thus the strength of the journals argument for distinguishing the "dope doctor" from the physician who "treated indefinitely" was not apparent outside the profession.
Later the Medical World shifted its attack on the new regulation by conceding that "doctors of the right kind do not dispense narcotics to habitués. Few, if any, of the panderers to the dope fiends are within the medical profession, and those that are should be expelled." Dispensing, however, was the point at which the Commissioner's rulings were now declared "unjust and not warranted by law." 13 Such federal restrictions were unusual in 1915 and seemed threatening to the profession's independence. The country practitioner was especially hard hit by the inconvenience to his own dis-pensing; the city specialist who approved of the Harrison Act was not in a position to see the plight of his less fortunate colleagues.
The Treasury Department's opposition to maintenance was not much of an aid to the Justice Department, which even by the date of TD 2200 (ten weeks after the Harrison Act became law) was having considerable trouble convincing federal district judges that registered physicians did not have the right to prescribe as they wished to anyone they wished. To be valid, the Treasury decision had to arise from the statute, and was subordinate to it. Therefore cases had to be argued on the words of the statute. The Harrison Act made no mention of addicts and, although the wording seemed clear to the reformers, it did not define for indifferent or hostile interpreters "legitimate practice of medicine" and "good faith" in prescribing. The manifest lack of federal power to regulate medical practice as well as the need to unify professional support of the Harrison Act may have required these vague phrases.
The chief problem the Justice Department encountered in the attempt to prohibit maintenance of addiction was that federal courts thought any federal regulation of medical practice unconstitutional. The negative attitude of district judges to the government's interpretation of the Harrison Act was found in numerous jurisdictions ( Montana, Pennsylvania, and Tennessee ) within the first few months of aggressive enforcement against addict-maintaining physicians.14
The Justice Department usually followed a set procedure whenever a professional was arrested. The federal attorney did not charge the physician with malpractice but sought an indictment that would include the physician, the druggist, and the addict. Section 8 of the Harrison Act made possession of narcotics by any unregistered person unlawful unless they were obtained from a physician who prescribed in good faith. The Act also placed the burden of proof upon the defendant. Therefore the physician and the druggist could be charged with conspiracy to place the drugs unlawfully in the possession of the addict by prescribing and dispensing, the prescription not having been made in good faith but only to maintain the addict's habit. Or, an indictment would charge the physician with aiding and abetting the addict to secure drugs which he could not legally possess.15
A conspiracy indictment had the advantage of potentially punishing the sequence of wrongdoers at the retail and consumer level. It rested on the assumption that the maintenance of addiction was illegitimate medical practice and could not be conducted in good faith. Of the many questions that district attorneys directed at the Attorney General and the Treasury Department, none questioned this moral assumption. Rather, the question raised was whether the Harrison Act could sustain violations of this morality as an illegal act. Public complaints against dope doctors also assumed that the maintenance of addiction was a convenient and profitable activity by physicians and druggists without any pretense of cure. Examples of such transactions were numerous and blatant in many communities. The legal attack on maintenance was begun on the first day of March 1915, without any hesitation or doubt among Treasury officials that this was a chief goal of the Harrison Act, an interpretation that proved ill founded when tested in the courts.
The first setback occurred in Pittsburgh, in May, where the dis-trict judge declared that since the Harrison Act did not permit an addict to register, he could hardly be held to possess narcotics illegally. The department quickly obtained a writ of error from the Supreme Court and sought to have the decision reversed. In June a similar decision was rendered by Judge John E. McCall in Memphis, much to the dismay of the United States attorney who was desperately trying to stop flagrant sales of narcotics through "drug stores" which existed primarily to fill narcotic prescriptions.16 In one instance the physician moved his office into the front of the shop and wrote out prescriptions for customers who had them filled on the spot. In ten weeks the store filled over a thousand prescriptions for powdered opium, heroin, and cocaine. United States Attorney Hubert F. Fisher complained to the Justice Department:
Prescriptions which are and have been so promiscuously written by physicians can hardly be called "prescriptions" meant by Congress in passing this Act, still the words are in the Act and a registered physician signs the paper which is relied upon by the druggist.17
The first warrants for arrest in Memphis closed down dealers in drugs which could not be registered under the Harrison Act, but this move, Fisher continued, "had the effect of narrowing the fight down to the sale by the drug stores, upon prescriptions by physicians. .
...Prior to March 1, Memphis had been a bad place for the sale of cocaine, opium and heroin, the lax enforcement of the State anti-narcotic law having brought about the promiscuous bootlegging of prohibited drugs." The Harrison Act improved the situation somewhat but seemed to afford no avenue of attack against drug-supplying doctors and druggists.
A similar problem arose in Florida when one pound of granulated opium was prescribed for a person not registered under the Harrison Act. The district judge upheld the constitutionality of the Act but directed a verdict of not guilty to the jury. The judge believed that "there was nothing in the law to limit the quantity that a physician might prescribe," that by the law this was left to the discretion of the physician. The court also held that a doctor was not required to prescribe only such quantity of the drug as might be sufficient for immediate needs of the patient; in other words, if the patient was a habitué, the "physician could prescribe such quantity of the drug as in his opinion was necessary for the use of the patient for several days." 18
By September 1915, Assistant Attorney General William Wallace, Jr., chief strategist for the Harrison Act indictments, conceded to a questioning Denver attorney that "the present condition of the enforcement of the law is not entirely satisfactory." The U.S. attorney for Colorado had grave doubts that a registered physician could be successfully prosecuted for prescribing "narcotic drugs to a patient who is a habitual user thereof without any intent to cure." After analysis of the Act's wording the attorney concluded that "it would seem to us to be a fair construction of the Act that a written prescription by a registered physician absolutely protects the physician from a charge of violating the Act, regardless of the fact that he was prescribing the same to drug fiends without any intention of effecting a cure." Nevertheless, the attorney was under pressure by internal revenue agents to present a number of such cases to the next grand jury.19
A month later the government received bad news from Montana where Judge G. M. Bourquin dismissed cases against consumers who he felt were not permitted to register under the Act and therefore could not be punished for not registering.20 In Kansas City, Kansas, the district judge had taken the presentation of indictments of alleged violators of the Harrison Act as an opportunity to deliver a strong statement in favor of civil freedom and against the encroaching powers of government bureaucracies. Although taking the arguments under advisement, the government attorneys realized that the public statements of the judge, prominently reported in the local press, were not good omens. The Attorney General sent detailed arguments to the local district attorney with the plea to urge these arguments with all your power upon Judge Pollock, as it is important that the government should not suffer a defeat on the question of the constitutionality of the Act." The District Attorney in Baltimore received similar encouragement, although Assistant Attorney General Wallace admitted that the situation "is a difficult one because the United States Judges feel doubt as to the constitutionality of the law, and in most instances seem to be opposed to it." 21
The fight to preserve the Act's constitutionality represents a retreat from aggressive prosecution of addict-maintaining physicians to a defense of the very existence of the Act itself. The instructions sent to district attorneys in late 1915 increasingly emphasized arguments for constitutionality and expressed displeasure with the progress of enforcement against physicians and druggists who were registered and prescribing for addicts. The internal revenue agents' enthusiasm for blocking addict maintenance was suffered patiently by the attorneys, who saw it as a very difficult legal issue.
One of the most instructiye discussions of the physician's right to prescribe for addicts occurred between the U.S. attorney for Nevada and the collector of internal revenue in San Francisco. The collector gave the attorney voluminous evidence of two Reno physicians who had prescribed for addiction maintenance, and commented that the physicians seemed to be in direct conflict with TD 2200. In a detailed analysis of the Harrison Act, sectiorl by section, the attorney stated that although "the conduct of these physicians is most reprehensible, and not in the course of their professional practice" nevertheless,
It is not clear to me that the writing of a prescription, even though there may be lacking good faith on the part of the physician, and it is not issued in the course of his legitimate profesgional practice, is embraced in any of the prohibitory sections of the Act, a violation of which constitutes a criminal offence.
In response, the collector, having received the same advice from the San Francisco district attorney, reluctantly agreed that such cases could not be prosecuted without a change in the statute. The Attorney General's office, reviewing this correspondence, advised as usual to proceed for conspiracy to violate Section 8 or to charge the physician with aiding and abetting the unregistered addict to have the drug in his possession. But the Justice Department recognized that if the Supreme Court ruled against the government's interpretation of Section 8 and affirmed the decision of the district judge in the Pittsburgh Jin Fuey Moy case, these recommended approaches would be invalidated.22
U.S. v. Jin Fuey Moy, /9/6
With opposition from district judges throughout the nation to the Treasury's interpretation of Section 8, and with the Justice Department believing no other approach would be successful against maintenance physicians, the hearing before the Supreme Court on 7 December 1915 assumed considerable importance. The Jin Fuey Moy case, which so affected the early enforcement of the Harrison Act, was an attempt by the government simply to stop a physician from supplying an addict with drugs. Dr. Jin Fuey Moy, of Pittsburgh, had prescribed a dram ( about 1.8 grams or 06 ounce) of morphine sulfate to Willie Martin, an addict. The physician, according to the government, conspired with the addict to place in the addict's possession morphine, not for medical purposes, "but for the purpose of supplying one addicted to the use of opium." Since it was illegal for anyone not registered under the Harrison Act to obtain morphine except by prescription written in good faith, Martin's possession was a violation of Section 8. The government's argument was the one favored by the Justice Department and contained the assumption that maintenance of addiction was not compatible with medical practice in good faith.
The district judge had quashed the indictment on grounds that Martin was not required to register under the Harrison Act since he did not "import, produce, manufacture, deal in, dispense, sell or distribute" the morphine, but merely consumed it. Therefore he could not violate the Harrison Act by merely having morphine in his possession.
The 'Act was understood by the lower court as strictly a revenue act and, if it went beyond revenue or interstate commerce powers, it might violate the provisions of the Constitution of the United States. Unconstitutionality, presumably, would arise by government's attempting to regulate directly the practice of medicine, a power reserved to the states.
In June 1916 the Supreme Court's decision in the Jin Fuey Moy case confirmed the Justice Department's doubts of the legality of directly attacking the maintenance physician. By seven to two the Court rejected the government's arguments for broad police powers under the Harrison Act.23
The Court's majority opinion, written by Justice Oliver Wendell Holmes, Jr., maintained that there was no indication in the wording of the Harrison Act that it was passed in fulfillment of treaty obligations and, even if it were, the details of Section 8 were not required by treaty. When one considers the years of agitation by the executive branch to get a domestic narcotic law to fulfill America's international pledges, the drafting of the law in the State Department and its intimate relation with the American-inspired Hague Convention, one can sympathize with the governmenes and Dr. Wright's anguish at this decision.
If the law was not in aid of a treaty and did not deal with a totally foreign substance, Congress had much less power to legislate in this area than the government claimed. The Court held, "Only words from which there is no escape could warrant the conclusion that Congress meant to strain its powers almost if not quite to the breaking point in order to make the probably very large proportion of citizens who have some preparation of opium in their possession criminal or at least prima facie criminal and subject to serious punishment." Like the lower court, the Supreme Court was critical of the provision in Section 8 which placed on the citizen burden of proof that the narcotic in his possession was obtained within the provisions of the Harrison Act. The Court would not even consider prescribed in good faith" open to a broader interpretation, since the phrase was "so vague that it may have had in mind other persons carrying out a doctor's orders rather than the patient." 24 Justices Mahlon Pitney and Charles Evans Hughes dissented.
In the Treasury's annual reports of 1916, 1917, and 1918 vigorous requests were made to Congress to counteract this emasculating decision, by amending the Harrison Act.25 The commissioner warned in reference to the Jin Fuey Moy case:
This decision makes it practically impossible to control the illicit traffic in narcotic drugs by unregistered persons, as the mere possession of any quantity of the drugs is not evidence of violation, and therefore the government is forced to prove in every case, even where the circumstances indicate sale and dispensing, actual sales by this class of offenders, which it has been found difficult to do.26
According to the Internal Revenue Bureau, a large number of unregistered persons had been convicted under Section 8, now found inapplicable, and although they were quickly released from prison, there was evidently no statutory authority to return their fines. The law must be amended, the Treasury warned, if the nation was to be protected from the drug evil. In addition to making general statutes applicable to the Harrison Act, with regard to seizures, forfeitures, etc., other strengthening seemed necessary—specifically, the imposition of a tax on narcotics by weight and provision for stamped packages. Lack of a stamp would be evidence of illegal possession unless the drug was obtained through legitimate prescription. This would at least make cases against possessors of large amounts of unmarked narcotics easier to prosecute, Substantial revenue would also make the Act more believable as a tax measure since the courts had interpreted the antinarcotic law as a revenue act. Next, registration should be explicitly restricted to those lawfully engaged in dealing under the Act: alteration of records, forging of prescriptions, and lack of record keeping should be punished by suitable penalties.
Finally, Congress should provide some medical agency for treatment, a plea that would be repeated in subsequent annual reports and by many writers on the drug problem, but which would, for a variety of reasons, not be provided by the federal government until 1935, tvventy years after the Harrison Act. In the belief that treatment was essential, the Internal Revenue Bureau would in 1919 support the establishment of clinics for temporary maintenance and seek the cooperation of the Public Health Service to take over federal responsibility for institutional treatment of indigent addicts deprived of drugs.
Although the Revenue Bureau appeared anxious to go after narcotic violators, attention directed at Harrison Act enforcement was modest until a separate Narcotic Division was established in the Prohibition Unit on January 192o. This separation was reasonable, since the federal staff was not large and the primary responsibility of the Alcohol Division was to oversee the largest single source of internal revenue for the United States government. In the fiscal year 1916 the aggregate receipts from internal revenue were $513 million, of which the largest item was from distilled spirits ( $153 million ) and the second, fermented liquor ( $88 million ). Individual income tax accounted for only $68 million. Thus the Alcohol Division was too occupied to police the almost infinite details of the Harrison Act.27
The original and strict interpretation of the Harrison Act, which had been softened by the fin Fuey Moy case of 1916, was reasserted in March 1919 by the Supreme Court in two crucial decisions. By a five to four decision the Court reversed a District Court dismissal of an indictment against Dr. Charles T. Doremus of San Antonio, who on 11 March 1915 had provided five hundred one-sixth grain tablets of morphine to a known addict. The lower court held that the restrictions on Dr. Doremus's practice were irrelevant to the collection of revenue and therefore exceeded the Constitutional powers of the federal government ( U.S. v. Doremus, 246 Fed. Rep. 958, decided 2 January 3.918 ). On appeal, Chief Justice White and Justices McKenna, Van Devanter, and McReynolds agreed with the district judge; Justices Day, Holmes, Brandeis, Pitney, and Clarke constituted the majority. This triumph of the reformers confirmed the constitutionality of the Harrison Act's tax on physicians and concomitant control over the manner in which the drugs could be dispensed, that is, "in the course of . . . professional practice only" and through "prescriptions" ( U.S. v. Doremus, 249 U.S. 86, decided 3 March 1919).
Having affirmed the Act's constitutionality, the Court on the same day decided the other important issue: Could the legitimate practice of medicine include the maintenance of addicts? In this case a re-tail druggist, Goldbaum, and a practicing physician, Webb, had been indicted for conspiracy to violate the Harrison Narcotic Act by providing maintenance supplies of morphine to an addict with no intention to cure but "for the sake of continuing his accustomed use." A similarly divided Court concluded that to call "such anbrder for the use of morphine a physician's prescription would be so plain a perversion of meaning that no discussion of the subject is required" (Webb et al. v. U.S., 249U.S. 96).
THE RED SCARE OF 1919
The change in judicial outlook between 1915 and 1919 with regard to addiction maintenance was not the triumph of a minority but the majority's success in making a minority view intolerable. What had been a respectable viewpoint by 1915, although not the dominant attitude of the public—the value of addict maintenance by physicians or others—by 1919 and 1920 had come to seem a great danger and folly. Advocacy of maintenance was repressed as sternly as socialism. Vigorous protests from a few physicians, congressmen, politicians, and laymen were completely ineffective in modifying legal opposition to supplying drugs for the pleasure or comfort of addicts.
Between the Jin Fuey Moy decision in 191.6 and the vigorous attack on addiction in 1919, profound social changes had occurred in the United States. World War I had been fought, the 18th Amendment had been adopted, and the liberalizing movements of LaFollette, Theodore Roosevelt, and Wilson had declined into a fervent and intolerant nationalism. As a corollary perhaps to the last change came an enormous fear of Bolsheviks and anarchists, which has been termed the Red Scare of 1919-20.
The Harrison Act appeared to both Republican and Democratic administrations a sound measure to protect the nation from the ravages of addiction. Its form as a tax measure was a familiar ruse to attain a moral end by constitutional means.
Having already been defined by most Americans as immoral or at least the cause of wasted lives, addiction by 1918 was perceived as a threat to the national war effort. Anything so perceived was likely to be in trouble. Any action interpretable as support for the enemies of the United States was punished severely, and the nation adjusted itself to a high level of intolerance and suspicion.28
The socialist Eugene V. Debs, who opposed the war and draft because he believed the whole matter a capitalist enterprise, was imprisoned for his actions under the Espionage Act of 1918, and his ten-year sentence was confirmed unanimously by the Supreme Court in a decision written by Justice Holmes and rendered a week after the basic antimaintenance decisions of Webb and Doremus.29 Debs's arrest,in 1918 came as the popular fear for national survival began to reach a sustained height. The growth of aggressive nationalism could be exemplified by Theodore Roosevelt's change from a strong liberalism in the campaign of 1912 to an anti-German spirit after 1915.30 A. Mitchell Palmer, a leading Wilsonian, a champion of progressive child labor laws and the League of Nations, led the infamous raids against anarchists and Bolsheviks in 1919 which ignored rights of free speech, assembly, and due process and resulted, to his chagrin, in no evidence to justify his hysterical roundup.31 Such astounding shifts in attitude were partly created by a fear based on explicit revolutionary and anarchic statements from domestic agitators. The Bolshevik success in Russia with a small number of dedicated Communists, and the happy anticipation by American Communists that a similar revolt would occur here, strengthened the fears of Americans already on guard against the dangers of the Kaiser, immigration, and a growing radical labor movement.
This intensely fearful period in American history must be bome in mind in evaluating the suppression at that time of dissent on the issue of narcotic control. Since narcotic use was officially described as leading to antisocial acts and individual degeneracy, the current fear of such conditions helps explain the public's angry opposition to anyone advocating the maintenance of such an eviI.32 As a consequence, the federal government could easily shut down the New York State maintenance clinics which were the product of several years of planning by its legislature. Furthermore, it helps explain the remarkable change of opinion in the Supreme Court to the point that the maintenance of addiction—the pandering to the sensual desires of habitués—was considered so obviously an immoral notion that the majority of the Court thought it not worthy of discussion or justification.33 Indulgence in narcotics tended to weaken the nation and was associated with other un-American influences which would dissolve the bonds of society.
In this spirit the mayor of New York established a Committee on Public Safety in May 1919, to look into two specific problems which he saw as related: the heroin epidemic among youth and the bombings by revolutionaries.34 Since narcotics use even in more peaceful times had evoked the image of a Negro cocainomaniac or a seductive Chinese, it was not that the popular image of the drug user changed but that the minority opinion in favor of maintenance became intolerable. As in so many issues in the period 1918-20, free expression of minority opinion was extinguished and maintainers of "dope fiends" went the way of the IWW.
Three weeks into the rabid year of 1919, the thirty-sixth state ratified the National Prohibition Amendment; one year would elapse before it became effective. Therefore the year 1919, which marked the crystallization of a national antinarcotic policy against maintenance, was also the year of preparation for liquor prohibition. Maintenance of addiction could no more be defended than maintenance of alcoholism. Both classes of indulgence were to be treated not by maintenance but by a remedy appropriate for social cancers: surgical extirpation.
THE SPECIAL NARCOTIC COMMITTEE
OF THE TREASURY DEPARTMENT, 1918-1919
Shortly after submission to the states of the 18th Amendment in December 1917, the federal government began planning revision of the Harrison Act to overcome the Supreme Court's adverse decision in the Jin Fuey Moy case. In March 1918, Commissioner of Internal Revenue Daniel C. Roper proposed to Treasury Secretary William McAdoo a special narcotic committee to study the problem of control and to recommend changes in the law and its administration. Roper alluded to the war, now a year old for the United States, as an especially appropriate background for restraint of drug use. Regulation of national habits for the purpose of creating wartime efficiency was a familiar expedient.35
The Treasury Committee, appointed 25 March 1918 by Secretary McAdoo, was a respectable and fairly representative group which combined bureaucratic expertise, congressional influence, and medical knowledge. Its purpose was to rectify adverse Court decisions so that the government could proceed with greater effectiveness against addiction maintenance. This goal was achieved, although not solely through the committee's influence.
The committee represented the federal government's position on drug control in 1918 and 1919 and provided antimaintainers with a very impressive voice. The chairman, Representative Henry T. Rainey of Illinois, was a powerful Democratic leader who would later become Speaker of the House.36 The three other members were Dr. Reid Hunt, professor of pharmacology in Harvard Medical School and former Chief of the Division of Pharmacology in the U.S. Public Health Service ( 1904-13); B. C. Keith, Deputy Commissioner of the Internal Revenue Bureau, a coordinator of legislative efforts with regard to narcotics; and A. G. DuMez of the Public Health Service, who had become, after Wilbert's death the previous year, the service's chief expert on narcotics. Clerk to the committee was a physician, Dr. B. R. Rhees. A drug industry representative was contemplated but not appointed. Admiral Charles Stokes of New York City, former Naval Surgeon General, who had developed a "cure" for addiction, was kept off the committee although he energetically sought an appointment.37
In August, Representative Rainey introduced a bill prepared by Deputy Commissioner Keith which, although only partially adopted, succeeded in strengthening the Harrison Act through provisions added to the Tax Act of 1918, the second general tax revision to raise funds for the war. Rainey failed in his hope to revoke Section 6 of the Harrison Act, which provided for exemption of a limited amount of narcotic in proprietaries, but he did make recording of sales and manufacture of proprietaries mandatory. Also a tax of one cent per ounce or fraction thereof of narcotics was inserted into the Act in compliance with the Internal Revenue Commissioner's repeated recommendations to make the Harrison Act an unquestioned revenue measure. Thereafter, possession of a package without a tax stamp, unless obtained on a physician's prescription, was prima facie evidence of illegal possession. This would help close one loophole created by the Jin Fuey Moy decision which made any amount of narcotics legally possessible by an unregistered person'. The revision would still permit maintenance, but it would open an avenue of attack against possessors with large amounts of narcotics who made no pretense of having obtained the drugs through prescriptions. Lobbyists pleaded with the House Ways and Means Committee to preserve Section 6. At the time, Rainey complained that the committee members were "being flooded with telegrams by interested druggists throughout the country, anxious to retain the privilege of selling the dope which they now sell under Section 6." Section 6 survived, but Rainey's other amendments passed and came into effect on 24 February 1919.38
Rainey held no hearing on the Harrison amendments, for which he was criticized by the drug industry, but he pleaded that there was too much urgent business for such activity in wartime. He also feared hearings that would enable the pharmaceutical industry to whittle away again at the law's effectiveness.39 Some indiqation of the distance Rainey kept from the day-to-day business of narcotic sales was his discovery several years later that his amendments did not prevent grocery stores and other nonmedical commercial establishments from selling proprietaries with narcotics in them.40 But his lack of firsthand knowledge was no hindrance to his being an effective ally of the Treasury Department.
A preliminary report was issued by the Treasury Committee shortly before Rainey's amendments were introduced in the Congress.41 This official statement had the effect of helping persuade Congress that amendments were quite necessary. In June 1919 the final report, Traffic in Narcotic Drugs, was published, although its contents had been known for months and had been discussed in the newspapers. The report, dated 15 April 1919, was preceded by a partial disclaimer from the Treasury Department to the effect that it could not vouch for the accuracy of the statistics nor could the conclusions be taken as final. But the report was considered as "comprehensive a survey as is possible under the circumstances of the problem from the humanitarian as well as from the administrative viewpoint." Heroin, with its appeal to "boys and girls under 20," and the other fiend-maker cocaine, were singled out for special concern.42
Analysis of a questionnaire survey directed at the 125,000 physicians and 48,000 pharmacists registered under the Harrison Act formed a major element in the report. About 30 percent of the doctors and 40 percent of the druggists replied. The physicians reported 73,000 addicts under treatment and the committee extrapolated this to estimate 238,000 addicts if all physicians had replied. In a similar fashion the druggists were estimated to have filled 18.3 million narcotic prescriptions during the previous twelve months, although the amounts and purposes of the prescriptions were not ascertained.43
The. extrapolation method and the questionable reliability of replies on such a controversial subject make the results suspect. Cooperation from other information sources was even less satisfactory.44 Of some interest, however, was the reply from 79 nonprofit institutions providing treatment for drug addiction. The respondents estimated the average length of treatment to be two years and ten and a half months. About a quarter of the state, district, county, and municipal health officers responded. Most had no information nor any means of gathering any, but those who had, reported a decline in addiction over the previous three years.
The responding doctors were almost evenly divided on the question whether addiction was a disease or a vice. The majority of physicians used "gradual reduction" treatment and a quarter employed "special procedures." At least 192 cities and counties were discovered to have provision for treatment of addicts in almshouses and penal institutions. From private hospitals and sanitaria the replies dropped to almost 5 percent—of the 4,568 superintendents asked for information only 227 could provide any for the committee. From these few the average length of treatment for addiction was recorded as only six to seven weeks at about five dollars per day. Encouragingly, 61 percent of patients in private institutions were described as "permanently cured," and up to 74 percent "benefited to some degree." As a cross section of observers' opinions, the report conveys conflicting notions, simplistic explanations, and general confusion on the nature and treatment of addiction at the time the federal government moved dramatically to end addiction maintenance.
From the extrapolation that physicians had under treatment about a quarter million addicts, and assuming that "only a small portion of the total number of addicts present themselves for treatment," and considering the other estimates given for the addict population, the committee concluded that "the total number of addicts in this country probably exceeds 1,000,000 at the present time"—the most commonly quoted statistic from the report.45 This estimate of addicts became questionable the year of publication. New York City's Health Commissioner had informed the committee that the number of addicts in the city was 103,000. Yet when he established heroin-dispensing clinics in April, liberally providing heroin to children as young as age 15, no more than 8,000 habitués could be located in a year. The committee's estimate of more than a million addicts in the United States thus appeared exaggerated when compared to the data from New York, the accepted center of the nation's addict population. It is difficult to escape the conclusion that the committee's report grossly exaggerated the number of addicts in the United States.
In addition to an extravagant estimate of addicts in 1919, the.committee pictured a bleak future. Prohibition of liquor was singled out as a factor that would tend to increase drug use. Although the committee was unsure whether Prohibition enforcement would result in a general turn to narcotics, the "consensus of opinion of those interested in the subject appears to be to the effect that the number of addicts will increase." 46
In summary, the report declared that opium addiction has a disease aspect. Addiction results from continued use of opiates for ten to thirty days, and the addict thereafter takes his drug to remain as normal as possible. But addicts are weak creatures, lacking in moral sense, and when deprived of their drug may commit crime in order to obtain it. The report offered one comfort; the opium addict was not always lost to all sense of decency and honor and could even be an upstanding person except in the area of addiction, to which he was enslaved, and he could not discontinue without outside assistance. With the new amendments to the Harrison Act and the Supreme Court's ruling in March against maintenance, it was expected that many addicts would become desperate for their drugs. Therefore the committee insisted that provision for medical care be made and that federal and local governments enact legislation to provide it.
But the form of medical care remained uncertain after decades of inquiry. Research was needed, the committee concluded: "at the present time there are numerous forms of treatment for drug addiction, none of which appears to have been given a thorough trial by the medical profession as a whole, or to have received the unqualified support of those members of the profession who have had no financial interest in the matter." In this understated manner the committee admitted a quandary: although addiction would probably rise, for all the usual reasons as well as liquor prohibition (which was only half a year away ), there was not even one accepted medical treatment for it. In fact, deprived of their drug the addicts might become violent. This warning was received by a nation in the throes of a panic reaction to Bolshevik bombings directed at institutions and national leaders, violent and widespread labor strikes, IWW agitation, and anarchist plots. Rarely in recent American history could such a declaration by the federal government about an alleged million-member subgroup carry as much threat of danger to the nation.
The legal battle for the control of "nonmedical" narcotic use had already been won by the reformers when the report came out in June, so it became something of an apologia for activities well under way. Once again Treasury agents went into action against maintainers, but without the legal resistance of 1915. Although arrests were made, suspension of drugs to habitués, particularly opiate addicts, was not intended to be abrupt. Treasury officers feared that if there were a million addicts, abrupt drug restriction would lead to crime or to the death of many addicts. Therefore, when dope doctors or druggists were arrested, some attempt was made to provide the addict-clients with a temporary supply of drugs. The carefully planned establishment of clinics for this purpose indicates that the federal government and particularly the Bureau of Internal Revenue did believe there were many addicts and that treatment should be offered. A federal responsibility for the addicts' plight was accepted by the Revenue Bureau, but this was not sufficient to persuade Congress to enact any of the Treasury's proposed remedial legislation.
THE NEW YORK CITY EXPERIMENT
The Treasury Department moved quickly to use its new powers in New York. In April 1919 several New York City physicians and druggists, who had been supplying hundreds of addicts, were arrested. These professionals had been under watch for several months but it was not until the Webb and Doremus decisions that the government thought it could successfully prosecute addiction maintenance. The raids were led on the federal side by Major Daniel Porter, who was slated to head Prohibition enforcement in New York City when the 18th Amendment became effective the coming January.47
The city was prepared for such arrests, if any preparation was necessary, by early 1919. Respected and presumably well-informed authorities had issued increasingly severe warnings of the narcotic situation. In February, Admiral Stokes, former Naval Surgeon General, simply and directly equated alcoholic and narcotic addicts. He confidently expected an increase of drug addiction with the beginning of Prohibition. Moreover, he could not offer much hope of easily curbing addiction. Cure by outpatient methods would not work, Stokes admonished, because cure could be effected only by a change in the habitué's environment.48
A month later, Health Commissioner Royal S. Copeland issued information on drugstore narcotic sales which revealed that a small percentage of the retail outlets ( 33 of about 2,500 stores) had sold in the single month of December 1918 72 ounces of cocaine, 876 ounces of morphine, and 1,690 ounces of heroin ( an ounce of either opiate can supply the daily needs of three addicts for a month if the average daily dose is assumed to be 5 grains ). Along with these statistics he dramatically warned of the effects of addiction on the daily life of the city. Dr. Copeland echoed Admiral Stokes's prediction that Prohibition would increase the number of addicts. Already, he asserted, one of every thirty New Yorkers was addicted (i.e. about 150,000). With the city threatened by such evil, Dr. Copeland confessed he had little sympathy with those who obstructed drug control by talking about the addict's legal privileges—one should pay at least as much attention to the constitutional rights of the victims of the addicts' crimes as to those of the addict. His most out-spoken criticism was reserved for his own profession: physicians who sell prescriptions to addicts "should be boiled in oil." 49
The federal agents who had arrested the physicians and pharmacists coordinated their activities with the city's Health Department so that clinic as well as hospital facilities would be available as soon as the regular ration of drugs was cut off from several hundred patient-addicts. Major Porter led the raid in the evening of Wednesday April 9. Next morning a narcotic supply clinic opened at 145 Worth Street. Addicts who had been patients or customers of the arrested suppliers were told they could get their drugs at the Health Department and for much less than they had been accustomed to pay.50 Of course, plans to set up maintenance clinics had been contemplated under the second Whitney law and the Commissioner of Narcotic Drug Control had signaled his intention of establishing supply stations wherever needed in the state.51 But unlike the state clinics, the city clinic did not permit maintenance for any lengthy periods but sought cure as rapidly as possible, just as the Treasury Department planned for the nation.
On the first morning, 12 addicts arrived at Worth Street for drugs, by the second day 135 had volunteered for hospital treatment. Federal and city officials had minimized the agonies of withdrawal among the addicts and they had ready not only an outpatient clinic generously providing narcotics but also institutional facilities. The hospital beds soon proved inadequate and only after enduring repeated disappointments and rebuffs by communities around possible hospital sites would the Health Department be able to provide sufficient beds. While waiting for a bed the addict was maintained.52
Complete hospital care and rehabilitation would be a public and crucial large-scale test of the assumptions which underlay institutional treatment and outpatient narcotic dispensing stations. If institutional treatment did release addicts from their craving, and if addicts did in fact want freedom from their bondage, then a model addiction treatment program would have been established for the nation. If the assumptions of the Health Department were erroneous, there would be a major setback for the proponents of medical treatment for the elimination of addiction.
THE FRANCE, BILL AND 'THE PUBLIC HEALTH SERVICE
A clinic proposal from the Treasury Department was part of a more elaborate program contemplated by the Bureau of Internal Revenue. It included potentially more extensive and curative aspects in the use of Public Health Service hospitals for treatment of addiction, PHS officers for liaison and consultation with the various states, and matching funds to the states for the care of addicts through institutions, leading to definitive cure.53 The clinics inspired by the Treasury Department were the doorway to institutional cure. In some respects this antinarcotic proposal resembles a recently approved ( 1918 ) venereal disease program of the Public Health Service which provided matching funds and coordination of a national attack on VD.54
The chief proponent of the comprehensive federal plan was Daniel C. Roper, a Democrat from South Carolina, who had ably served as chairman of the party's organization bureau in the second presidential campaign of Woodrow Wilson. He had been Çommissioner of the Intemal Revenue Bureau for over two years when the drug crisis loomed. Roper's determination to strike at narcotics was tempered by sympathy. In his autobiography he writes that the rejection of 8,000 draft-age addicts in New York City prompted a campaign to rid the nation of the dope menace, and he helped institute a campaign against dope. He concluded that "if the always incensed at the doping of race horses, could be aroused into one half the same state of indignation over the destruction of human beings by improper drugs, the problem would be easier of solution." The Special Narcotic Committee may have been part of this drive to inform the public, a motivation which would help explain the com-mittee's exaggeration of the menace in its report. He described his own early experience with the narcotics question during his term as clerk of the House Ways and Means Committee ( 1911-12.) when antinarcotic laws were under discussion, and the more personal impact of the death of the manager of his South Carolina farm from an overdose of narcotics given to him by a local druggist for "nerves." 55
Roper did not believe the tax agency of the government was an appropriate instrument to direct the control of addiction, nor did he believe the Revenue Bureau should have to assume Prohibition enforcement, which Congress had settled on it over his strenuous objections.56 He had sought to strengthen the laws by establishing the Special Committee the previous year, but he did not hesitate to declare that the treatment crisis was federally created. As the reality of rigorous antimaintenance enforcement came closer, he sought aid for the medical emergency from the federal health organization. He warned the Surgeon General in June 1919 that when supplies were shut off, there would be a great outcry.57 Commissioner Roper began to prepare legislation later introduced by Senator France of the Senate Public Health and Quarantine Committee.58 New regulations for the Harrison Act containing recommendations for the temporary supply of addicts were promulgated on 15 July.59 On 31 July Roper wrote the collectors of internal revenue across the nation advising them to work with local authorities to take care of the addicts who would be abruptly taken off their drugs.60 He feared deaths from sudden withdrawal or perhaps violence. In accord with this directive, clinics or other arrangements for drug supply were established in various parts of the nation. Some areas probably handled the problem quietly by permitting certain physicians to prescribe, or registered addicts to receive, maintenance doses. In some localities a formal clinic was established by the municipal government, some-times in a police station, as in New Haven, or in the Health De-partmtnt, as in Cleveland. These clinics were intended to remove addicts from the hands of private physicians who might have been continuing the addiction for their own profit.
The France bill was a substantial proposal which would require both congressional appropriations and the active cooperation of the Public Health Service. The PHS reacted with some reluctance to the commissioner's notion that their hospitals and men should assume responsibility for addicts. The PHS saw addiction as a traditional public health problem, one in which it had a limited role —certainly no responsibility for direct services except to merchant seamen. In its view all health issues must be shared by the states. The PHS even hesitated to give advice to the medical profession with regard to treatment or its possible legal complications; it simply disseminated information. The PHS countered Roper's plea by suggesting the pattern already set up to combat venereal disease.61 Like addiction, VD was a hidden social vice with less than ideal treatment, whose spread alarmed responsible citizens everywhere. Under law, federal matching funds were awarded to localities for the establishment of public clinics. The PHS therefore suggested that funds for addiction treatment be awarded on a matching basis by the federal government, but that clinics and treatment be the responsibility of the states. By following the precedent of the VD program the PHS would not be committed to supply treatment, about which it had serious questions, but would still perform a vital coordinating function.62
The Surgeon General's alternative was accepted by Roper, but legislation authorizing increased federal activity in the health field was opposed by the medical profession as a portent of state medicine. In the AMA the France bill received the support of the liberal element, but this faction's power was rapidly waning, particularly in legislative matters.63 The Sheppard-Towner Act of the same Congress, providing matching funds for maternal and child health passed, but it was never fully successful because of the opposition of national and state medical societies. The France bill faced similar opposition. And in addition to opposition on the grounds of political principle, the number of addicts seemed fewer than predicted, and their possible panic less than anticipated. But other reasons existed for congressional disinterest in new appropriations for any purpose. The Republican-dominated Congress wished to establish a record for budget trimming in preparation for the congressional and presidential elections. Then in 1920 the nation slipped into an economic recession. The France bill, a well-intentioned national program to combat addiction, could hardly have bid for appropriations al a less propitious time, and it never became law. Submitted to committee on 15 August 1919, the bill was slightly amended and recommended for passage on 10 October, but it failed of passage in the Senate.64
The clinics envisioned by the federal government were not to be indefinite maintenance stations but an emergency measure; addicts were to be offered hospital treatment. The PHS, however, did not share the conviction that medical treatment was a necessary step in addiction control. Its narcotic experts were doubtful of specific treatments and cures at least by late 1918, well before Dr. Hubbard questioned medical treatment after his experience with the New York City clinic. A. G. DuMez, a member of the Treasury's Special Committee, in an internal memorandum for the PHS, outlined a program leading to its more active involvement in the narcotic problem. It was proposed, in the ancient tradition of the PHS, that it compile statistics on the numbers of addicts, conduct educational campaigns, and investigate the mechanism of addiction, methods of treatment, etc. For this purpose he recommended a staff composed of a writer and lecturer, a lawyer, a pharmacologist, and two stenographers; he did not recommend direct services to patients.
Summarizing the narcotic problem, DuMez saw the recent years offering more hope than in the past when addiction was considered a mere vice by the public and the vast majority of the medical profession. Now ( 1918), he believed that almost all recent knowledge pointed to the conclusion that the habitual use of opiate drugs leads to a diseased condition which "requires a continued use of the drug or special medical treatment leading to complete withdrawal." 65 But no specific treatment had been established; in fact, considerable doubt had been thrown on the Towns-Lambert method because "these men operate a private sanitorium for the treatment of addicts and have been charged with being influenced by the monetary remuneration received therefrom." In this confidential report to the Surgeon General, DuMez was suggesting a way for the PHS to assume leadership and giving a broad overview of the addiction problem. DuMez also reported that the physician was generally considered the number one cause of addiction in the United States even by the majority of medical writers. The lack of any clearcut and satisfactory treatment was evident from his statement.66
A few months later DuMez undertook to review the "treatment of narcotic drug addiction" for the Surgeon General. In this instance his criticism of the various treatments is more direct. Again he points out that "it is only [since the Harrison Act] that the medical profession has awakened to the fact that addiction to the use of narcotics produces changes in the organism which cannot be controlled by the will power of the individual." After reviewing the standard cures advocated by sanitaria and medical men, he concluded with a pessimistic statement that the claims of some institutions of 80 percent cures have been investigated and found greatly exaggerated. When such treatments have been carried out in state institutions, "only about 10 percent of cures have been reported.
. . . Our present methods of treating drug addiction must be considered failures." 67
Therefore, before the New York City clinic opened and the Supreme Court decision outlawed simple maintenance, a responsible and informed physician was convinced that no satisfactory medical treatment existed for drug addiction. DuMez's report would influence the PHS in conducting national treatment programs in its own or other hospitals. His dismal and well-documented review of addiction treatment would not encourage the Surgeon General to enter an intensive campaign for a medical approach. The PHS concluded that any method that got the addict off drugs, including abrupt withdrawal, would work as well as the celebrated cures, thus moving the antinarcotic program toward reality.
If no cure was more effective than just keeping the addict away from drugs, then the problem really was: How do you keep addicts away from drugs? And this question was not medical, it was an enforcement problem. In the early years of strict enforcement, after 1919, the PHS, with the exercise of commendable objectivity, had excused itself from claiming knowledge of how to cure addicts and drew the conclusion that the nation should rely on legal enforcement to control narcotic supply."68 The Internal Revenue Bureau, on the other hand, frustrated in its attempts to curb addiction through enforcement, looked to medical treatment as the answer.
THE NARCOTIC DIVISION OF THE PROHIBITION UNIT
The center of antinarcotic activity in 1919 remained in the Bureau of Internal Revenue in spite of its efforts to share responsibility with the Public Health Service. Evidently the PHS did not actively seek any of the responsibility the tax collection agency had acquired in 1915, partly because of its role which excluded direct.patient services to civilians and partly because the government's health agency had no faith in medical antinarcotic treatments. The failure of the France bill relieved the PHS from statutory responsibility to treat any addicts other than those among its legal wards. The responsibility of the Treasury Department, however, was increased by the strengthened legal assault on addiction, although Roper continued to protest that addiction was not a police problem.69
In October the Volstead Act, passed over President Wilson's veto, provided the detailed legislation under which the 18th Amendment would be enforced. As a compromise with the wet opposition, enforcement was given over to the Internal Revenue Bureau over Roper's well-publicized protests. Another part of the compromise excused Prohibition agents from civil service requirements. Agents were appointed through political patronage and were generally such poor choices that even in the first flush of enforcement fervor they were described as inadequate and incompetent by federal judges and grand juries. The Prohibition Unit, headed by National Prohibition Administrator John F. Kramer, included the Narcotic Division, headed by a former official of the Alcohol Tax Division, Levi G.Nutt.70 The Narcotic Division headquarters and the field force were under civil service.*
In 1920, the Narcotic Division's chief problem was what to do with the various maintenance clinics operating in the nation. Whatever strategy Nutt established would be more effectively carried into action than in any previous year, for in fiscal year 1920 expenditures for enforcement rose to $515,000 ( almost double that for fiscal year 1919 ) and provided for 170 narcotic agents to work out of district offices.71
As a preliminary to fundamental decisions on national narcotic enforcement, the Revenue Bureau in late 1919 sent questionnaires to leading physicians and scientists in America asking their opinion on the present state of narcotic treatment, the wisdom of ambulatory treatment, and the existence of specific antibodies in the blood of chronic addicts ( a physiological hypothesis for addictive phenomena ). Collectors of internal revenue were also canvassed for their opinions on the best way to enforce the Harrison Act.72 For a period of several months the narcotic unit, with the help of expert opinion, considered its basic enforcement policy.
Most medical opinion opposed the antibody theory because it had not been substantiated by evidence; this strengthened the unit's doubts that addiction was a special disease with unique bodily changes requiring long-term or indefinite maintenance. The negative response also increased suspicion against clinicians such as Dr. Bishop, who were vigorous opponents of the government's anti-maintenance stand. The government's opponents were perceived as a serious hindrance to law enforcement; this was regrettable, for physicians who argued that addiction was a special disease held to a view which until at least World War I had been respectable.
The medical authorities by a large majority pronounced themselves opposed to ambulatory treatment and in favor of institutional confinement; the former was basically faulty and unworkable, the latter was favored because the addict would be held in a state of abstinence and treated medically for his withdrawal symptoms.
Collectors of internal revenue were also critical of ambulatory clinics, but there was division of opinion among them on the wisdom of maintenance clinics. Some thought them quite reasonable and successful, others considered them dens of iniquity. There was in fact less consensus among the agents than among the medical experts against ambulatory clinics.73
The collected evidence pointed to a more strict nonmaintenance policy but, before taking further steps, the Narcotic Division received formal support from the AMA in opposition to the ambulatory regimen. At the annual meeting of the AMA in New Orleans in April 1920, the Committee on Habit-Forming Drugs introduced a resolution opposing ambulatory clinics.74 The resolution was approved by the Council on Health and Public Instruction, and then by the House of Delegates of the AMA."75 The AMA's action, like the response from medical experts to the questionnaire, did represent current medical thought, and we have no evidence that coercion or deception was exercised to get this support.
The Narcotic Division's next step was to investigate the clinics and determine in each case the prevailing conditions and tht results obtained. In sum, there was evidence that no significant number of cures had been obtained and that the clinic approach was subject to a variety of abuses. There were some clinics without discernible abuses and with strong community support, but these also did not cure. Of course, this investigation was conducted with the government's attitude toward maintenance clinics already determined and backed by expert medical opinion.
The Narcotic Division, under the leadership of Levi Nutt, decided in late 1919 or early 1920 to close maintenance clinics and oppose maintenance in every case except among the aged and medically incurable. This was accomplished with ease in some cases, after several years of effort in others, and was grounded on a variety of considerations. ( 1) There was no medically proven specific treatment for narcotic addiction, while there was the assurance by the PHS and other medical authorities that any withdrawal method would result in getting the addict off drugs. (2.) The danger of death in withdrawal cases was exaggerated, and authenticated cases of such deaths were difficult to locate. ( 3) After any method of withdrawal, addicts would usually return to drugs if they were available. ( 4 ) The chief source of drugs was still thought to be a small percentage of physicians who would write out a prescription for anyone. ( 5) The clinics were merely another supply source for those who wished drugs for comfort or pleasure.
Legal restraints on physicians had to be inflexible in order to prevent easy prescribing of drugs by a determined minority; outlawing maintenance was a weapon commensurate with this need. But legal maintenance clinics, if permitted by the federal government, would make indictment of the erring physician very difficult to obtain. How could the federal government arrest ihe dope doctor when he was doing nothing legally distinguishable from the clinic operated bv a local health or police department? And, if maintenance wa's a good public health or police practice, it would be difficult to prevent regular physicians from follovving an accepted therapy. The federal government did not have authority to restrict maintenance to certain physicians or to well-operated clinics—maintenance would have to be allowed nationally or not allowed at all. Discrimination on the basis of "responsible" prescribing placed the federal government in even more constitutional uncertainty than strict anti-maintenance, a policy which rested on a five-to-four Supreme Court decision, since discrimination was in effect the licensing of physicians.
There was little evidence that the maintenance clinics effected cures. Even the clinics that were operated without abuses and by competent medical direction did not claim a large number of cures, but rather "social adjustment" for the addicts. From the inception of the State Department's campaign the government had not sought to stabilize the addict population at one of the large figures commonly quoted, say a million citizens, for the effects of addiction were thought to be moral degeneracy and paralysis of productivity among the addicted. To maintain a million or so addicts was not tolerable to a nation fearful of numerous unassimilable minorities. And there was also the deep fear that to maintain so many addicts —in such widespread and loosely controlled supply sources—would lead to a great increase of addiction among the rest of the nation, particularly the youth. Therefore the government sought to reduce or to eliminate addiction. To do so, the legal and enforcement agencies had fought a long battle since 1915 to outlaw maintenance. This was eventually accomplished in March 1919.
It was reassuring in 1920 to note that addicts were apparently fewer than had been estimated in earlier antinarcotic campaigns. The number seemed much more controllable by police methods than had been previously thought. For these reasons, then, there was little fear that disaster would befall addicts or the nation if legal and illegal drug supplies were suppressed.
Nevertheless, legal provision was still made for rapid withdrawal under a physician's supervision, and hospitals and institutions in many areas were made available for indigents; private sanitaria remained open for paying customers. Since the federal government believed there was no valid medical treatment other than withdrawal, no need existed for distribution of specific remedies or the specialized training of physicians. Enforcement agents had to keep in mind that the supreme goal was to get addicts off their drugs within some reasonable limit. In 1921, thirty days was taken to be reasonable, an adoption by the federal government of a California statute." If the addict could not come off in thirty days, he was indeed in trouble. He could no longer get legal supplies of drugs; possession would now be evidence of guilt. The best way to aid the addicts who had tapered off, or did not have the will power to do so, was to eliminate drug supplies. Naturally a first step would be the end of legal sources of indefinite maintenance—that is; the narcotic clinic and the physician's right to prescribe narcotics as his judgment dictated.77
Abuses of clinics had occurred, sometimes flagrantly, and these served the Narcotic Division as ammunition for public denunciation or quiet intimidation. But the clinics were closed if they maintained addicts and even if no abuses were discoverable.
* In 1930 the Narcotic Division became an independent agency and remained under the Treasury Department when the Prohibition Bureau was transferred to the Justice Department.
1 One of the best studies of the agency for this period is The Bureau of Internal Revenue: Its History, Activities, and Organization, by L. F. Schmeckebier and F. A. Eble, Service Monograph of the Government, Institute for Government Research (Baltimore: Johns Hopkins Press, 1923), esp. pp. 42-43. A history of that part of the Internal Revenue Bureau relating to alcohol and the subdivision established to enforce the 18th Amendment is L. F. Schmeckebier, The Bureau of Prohibition: Its History, Activities, and Organization, Monograph no. 57, Institute for Government Research ( Washington, D.C.: The Brookings institution [Lord Baltimore Press], 1929), esp. pp. 3-4, 136-45.
2 U.S. Treasury Dept., Bureau of Internal Revenue, "Report of the Commissioner for the Fiscal Year Ending June 30, 1915" (GPO, 1915), p. 147. (Hereafter cited as BIR annual report).
3 The Medical World of Philadelphia thought protection of dispensing rights of the physician lay in the Harrison Bill (see "Our Ancient Privilege in Danger," editorial, 31 : 439-42  ). If the Harrison Bill was not passed, the journal feared retail druggists might succeed in the next session of Congress in prohibiting dispensing by physicians. It was, therefore, better to make some compromise (see "The National Antinarcotic Bill," editorial, ibid. 32 : 91-92  ). See JNARD 26 : 1404 (1913), for the pharmacists' view.
4 Internal Revenue Regulations no. 35, "Law and Regulations Relating to the Production, Importation, Manufacture, Compounding, Sale, Dispensing, or Giving Away of Opium or Coca Leaves, Their Salts, Derivatives, or Preparations," Commissioner of Internal Revenue, 15 Jan. 1915 (GPO, 1915).
5 Ibid., article 10, p. 13.
6 Eugene C. Brokmeyer to HW, 24 Oct. 1914 (WP, entry 36).
7 In articles of Internal Revenue Regulations no. 35 (1915), no provision is made for registration of consumers, and in Treasury Decision of 9 March 1915 ( TD 2172 ) consumers, "as such," are forbidden to register under the Harrison Act.
8 U.S. Treasury Decision 2172,9 March 1915.
9 C. McFarland to the Attorney General, 18 May 1915 (JDR); Wm. Wallace, Jr., Asst. Attorney General, to C McF, 27 May 1915 ( JDR); WW Jr. to U.S. Attorney H. F. Fisher, Memphis, Tenn., 16 June 1915 (JDR): "The Act is undoubtedly a difficult one to construe and effectively enforce, but it is one of great importance to the public." And see exchanges with other U.S. attorneys discussing cases in various district courts, below (JDR).
The Justice Department felt that cure was an easy matter particulary if the addict was held in custody for a substantial period. Their evidence for this optimistic belief came from Federal Penitentiary annual reports: "Our success in the treatment of the narcotic cases is very encouraging • . . all cured. This was accomplished without undue suffering on the part of the unfortunate individual" ("Annual Report," U.S. Penitentiary, Leavenworth, Kans., 1913, p. 42). "I am pleased to again report success in the treatment of our narcotic cases. My experience this year with these cases has strengthened my opinion, as expressed in the last annual report that this class of prisoners should have a sentence sufficiently long to enable them to become fully restored physically and mentally, particularly, to have restored their will power, which, in my opinion cannot be accomplished with less than a ten-year sentence." ("Annual Report," U.S. Penitentiary, Leavenworth, Kans., 1914, p. 50).
10 One medical journal called the decision a "cruel injustice" without ground or authority, N.Y. Med. J. 103 : 1036 (1916).
11 "Penalties Imposed by the Harrison Antinarcotic Law," editorial, 33 : 459 (1915). Also, "If any doctor is found guilty of using his professional rights and position to foster the continuance or increase of addiction to narcotic drugs, he should be stopped with a firm hand and punished. Such a man should be driven from the profession in disgrace" (Med. World 33 : 416  ).
12 C. F. J. Laase, "The Practitioner of Medicine and the Narcotic Addict," Med.'Economist 6 : 37-41 (1918), esp. p. 38.
13 "The Harrison Law and the Commissioner's Rulings," editorial, 33 : 203 (1915). Also see editorial, Boston Med. Surg. I. 174 434 (1916) which favored the Harrison Act and opposed physicians who prescribed narcotics for maintenance.
14 Montana: U.S. v. Woods, 224 Fed. Rep. 278 (3 July 1915); Pennsylvania: U.S. v. Jin Fuey Moy, 225 Fed. Rep. 1003 ( 13 May 1915); Tennessee: U.S. v. Friedman, 224 Fed. Rep. 276 (1 June 1915).
15 The conspiracy charge would be based on ch. 1, sect. 6, "Seditious Conspiracy," of U.S. Statutes at Large, vol. 35, part 1, ch. 321 (4 March 1909), Revision of the Criminal Code. Charges of aiding and abetting would be based on sect. 332 of ch. 321. For examples of advice to U.S. attorneys to take these two courses, see WW Jr. to U.S. Attorney R. E. Byrd, Roanoke, Va., io June 1915; to H. F. Fisher, Memphis, Tenn., 16 June 1916 ( JDR). The philosophy Wallace advised U.S. attorneys to pursue was that "doctors and druggists should not be prosecuted where there is room to believe that they are acting in good faith, and that only those doctors and druggists should be prosecuted whose actions clearly show that they are merely pandering for gain to the desires of drug addicts." Lack of good faith would require evidence of "continuous acts upon the part of the doctor and druggist, showing utter disregard of the needs of the patient, the amount of the drug prescribed or dispensed, and the frequency of its prescription and dispensing," WW Jr, to Perry B. Miller, U.S. Attorney, Louisville, Ky., 18 January 1916 ( JDR).
16 See above, ch. 6, n. 14.
17 H. F. Fisher to Attorney General, 13 May 1915 ( JDR).
18 For further discussion of prosecution problems, see H. S. Phillips, U.S. Attorney, Southern District of Florida, to L. L. Froneberger, Deputy Collector of Internal Revenue, Jacksonville, Fla., 15 July 1915 ( JDR).
19 WW Jr. to H. B. Tedrow, U.S. Attorney, Denver, Colo., 15 Sept. 1915 ( JDR ); HBT to Attorney General, 9 Sept. 1915 ( JDR).
20 See above, ch. 6, n. 14.
21 F. Robertson, U.S. Attorney, Kansas City, Kans., to Attorney General, 2 Oct. 1915 ( JDR ). WW Jr., to F. Robertson, ii Oct. 1915 ( JDR).; this letter contains a good summary of the government's reasoning in defense of the Harrison Act's antimaintenance powers. WW Jr. to S. K. Dennis, U.S. Attorney, Baltimore, 7 Oct. 1915 ( JDR).
22 J. J. Scott, Collector of Internal Revenue, San Francisco, Calif., to W. B. Woodburn, U.S. Attorney, Carson City, Nev., 15 Nov. 1915 ( JDR). WBW to JJS, 16 Dec. 1915 ( JDR ). JJS to WBW, 23 Dec. 1915 ( JDR ); the correspondence was sent to the Attorney General by Woodburn on 31 Dec. WW Jr. to WBW, 7 Jan. 1916 ( JDR).
23 U.S. v. Jin Fuey Moy, 241 U.S. 394, decided 5 June 1916. Justice Holmes delivered the majority opinion; no dissenting opinion was filed by the minority. In one medical journal's opinion the decision was regrettable: "the Act now seems so leaky that it will hold nothing unless Congress does some recasting" ( N.Y. Med. 1. 104 : 905-06  ). See also J. H. W. Rhein, "Some Phases of the Drug Habit Problem, Especially in Relation to the Harrison Act," Penna. Med. J. 20 : 97-101 (2916): Dr. Rhein condemned outpatient reduction of drugs as a mere device to evade the law and recommended stricter laws since after the Jin Fuey Moy decision the federal laws were inadequate.
24 The Court's doubts on opium production were well founded, since opium has been produced in the United States, although not with great commercial success. The majority opinion did not claim that none of the Harrison Act was in fulfillment of international obligations, only that the particular revenue specified in Section 8 was not required by the Opium Convention, and that, in addition, nowhere in the Act was there any reference to the Convention (241 U.S. 401-402). For an example of the various documents leading up to the Harrison Act which specified that the Act would be in fulfillment of treaty obligations, see "Registration of Producers and Importers of Opium, etc.," House Rept. 23, 24 June 1913, 63rd Cong., 1st Sess. (GPO, 1913).
25 BIR annual report, for year ending June 30, 1916, pp. 24-25. Even before the Jin Fuey Moy decision in 1916, the Commissioner recommended changes in the Harrison Act to facilitate "restricting or entirely eradicating the use of narcotics for other than medicinal purposes, which prior to [the Harrison Act] had become an evil of the gravest menance." He recommended inclusion of chloral hydrate and cannabis, tax on drugs by weight, repeal of the Act's Section 6 regarding exemptions for proprietaries, record-keeping requirements for all narcotic drugs handled, and provision of treatment by the Public Health Service, or another appropriate agency, for indigent addicts deprived of their drugs by effect of the Harrison Act (BIR annual report for year ending June 30, 1915, pp.
26 After the Jin Fuey Moy decision in mid-1916, the request for amendment became even more insistent, for the decision was said to have severely crippled the federal government's campaign against illicit narcotic use by unregistered persons (which would include addicts and peddlers). See BIR annual report for year ending June 30, 1916, pp. 24-25. This plea is repeated in the BIR annual reports for 1917 and 1918 and set the basis for appointment of the Treasury Special Committee. See BIR annual report 1916, p. 24. The Justice Department doubted that the Harrison Act could be given strengthened police powers by congressional amendment because the Act seemed at the borderline of constitutionality in its present weakened interpretation. See W. C. Fitts, Asst. Attorney General to Senator William Calder, 2 Nov. 1917 ( JDR).
27 Reorganization, vast new tax-collecting responsibilities brought on by the threat and then the reality of war, gave the Internal Revenue Bureau inadequate personnel and little time for enforcing the Act. See Schmeckebier and Eble, Bureau of Internal Revenue, pp. 44, 47, 52. This inevitable neeect of the Harrison Act was seen as one reason to give the whole task to the Public Health Service in JAPhA 7 : 572 (1918). BIR annual report for year ending 30 June 1916, p. 45. The standard study of the period is Robert K. Murray's Red Scare: A Study of National Hysteria, 1919-1920 (Minneapolis: Univ. of Minnesota Press, 1955). My account is also dependent on the chapter "Red Scare" in William E. Leuchtenburg, The Perils of Prosperity, 1924-1932 (Univ. of Chicago Press, 1958), pp. 66-83.
28 A direct connection between the efficiency needed for the war effort and the inefficiency caused by narcotic use was made by the Treasury Department. Warning of narcotic use as a threat to the war effort appeared in the Commissioner of Internal Revenue's annual report for 1917 (BIR annual report for year ending 30 June 1917, p. 16; see also Daniel Roper, Fifty Years of Public Life [Durham, N.C.: Duke Univ. Press, 1941], pp. 185-90). Rep. Rainey's fear of addiction's toll on draftees and youth in general has been mentioned. A popular expression of this fear is found in "Narcotics and the War," by Janette Marks (North American 206 : 879-84 (Dec. 1917). It was associated with the effect of opiate treatment of war injuries on the rate of addiction in the postwar period. Recognition that narcotics caused inefficiency could not be overlooked in light of the vigorous action of Congress in prohibiting the sale of liquor to members of the armed forces in May 1917, a month after the declaration of war. Also see Andrew Sinclair, Prohibition: The Era of Excess (Boston: Little, Brown, 1962), pp. 117-18; National Commission on Law Observance and Enforcement, "Report on the Enforcement of the Prohibition Laws of the United States," 7 Jan. 1931 (GPO, 1931), pp. 4-7. The manufacture of distilled spirits was forbidden by the Food Control Act in 1917 and the withholding of supplies from brewers was made an option of the President. The Agricultural Appropriation Act of 1918 prohibited the manufacture of liquor in the United States after 30 June 1919 if a state of war still existed, and it banned the use of foods stuffs for making liquor. On 16 Sept. 1918 the President ordered that food no longer be used in the making of beer.
29 Debs V. U.S., 249 U.S. 211 ( decided lo March 1919); a week earlier the Court had similarly upheld the conviction of an antidraft pamphleteer (Schenck v. U.S., 249 U.S. 47 [3 March 1919] ).
30 Leuchtenburg, Perils, pp. 120-39.
31 Murray, Red Scare, pp. 196 ff.
32 For another example of a mental health authority who before the war had described heroin and addiction without alarm see Pearce Bailey, "Applicability of the Findings of the Neuropsychiatric Examinations in the Army to Civil Problems," Mental Hygiene 4 : 301-11 ( April 1920), p. 303. In describing addicts and diseased personalities Bailey warns, "It is in them that mental contagion which leads up to hysterical mass movements, spreads with the greatest rapidity, and in their minds sedition finds an easier route than realism. . . . Suggestible, they easily become the tools of designing propagandists in spreading seditious doctrines, or in the commission of acts in defiance of law and order" (p. 308). Brailey had been the army's chief neuropsychiatrist.
33 In 1916 ( U.S. v. 1in Fuey Moy), Justice Holmes doubted that Congress wanted to make criminals out of citizens who had opium in their posession. But by 1919 Holmes subscribed to the opinion of Justice Day which held for the majority in Webb v. U.S. that to maintain an addict by medical prescription "would be so clear a perversion of meaning.[of the word prescription] that no discussion of the subject is required" (249 U.S. 9g-100). The mood of the Court shifts from a concern for citizens' rights against the government's encroachment to a belief that prescription of drugs to an addict could be prevented by federal law.
34 Mayor John F. Hylan to Health Commissioner Royal S. Copeland, 3 May 1919 ( papers of Mayor Hylan, box 442, file "Health Department, 19194," N.Y. Municipal Archives), An exconvict had been arrested with narcotics and explosives in his possession. Coming during the tumult aroused nationally by the discovery of the May 1st bomb packages mailed to prominent antiradical Americans, the arrest made possible the combination of two current fears affecting New Yorkers. Also see N.Y . Times, 27 May and 30 May 1919. No other evidence linking bombs and narcotics appears to have been uncovered.
35 Daniel C. Roper to William G. McAdoo, 5 March 1918 (PHSR). Roper emphasized the need for action in the war emergency. Later that year another internal government memorandum within the Public Health Service gave the same reason for action, since "any work aiming at the reduction of the large number of drug addicts in this country is intimately connected with the official prosecution of the war" (Carl Voegtlin, Professor of Pharmacology, Hygienic Laboratory, to the Surgeon General PHS, Aug. 1918, PHSR).
36 Rep. Henry T. Rainey ( 186o-1934 ) served in Congress from 1903 to 1921 and from 1923 to his death. He succeeded John Garner as Speaker of the House in March 1933. Rainey interested himself in narcotics issues and, until his absence of one term, was a leader in most antinarcotic legislation. When he returned, he continued to serve on committees reviewing narcotic issues but the leadership had passed to Republican Stephen Porter of Pennsylvania.
37 Dr. Rhees later served with the Narcotic Division of the Prohibition Unit as an agent. Charles F. Stokes ( 1863-1931 ) received his M.D. from Columbia in 1884 and was Surgeon General of the Navy from 1910 to 1914. He retired in 1917 with the rank of rear admiral. Stokes found his own cure for narcotics addiction, which differed from the Towns-Lambert treatment and the antitoxin theories of Bishop and Pettey, basing his regimen on attempting to reestablish a balance between the sympathetic and parasympathetic nervous systems. See C. P. Stokes, "Pathology and Treatment of Drug Addiction" Med. Rec. 91 : 969 ( 1917 ). He sought appointment to various other government committees. His was an influential voice warning of impending catastrophe in the growing fear of addicts in New York State in 1919 ( N.Y. Times, 17 Feb. 1919).
38 Rainey introduced HR 12,787 on 20 August 1918 with the goal of repairing damage done to the act by the Jin Fuey Moy decision of 1916 and also repealing Section 6 ( Rainey to Surgeon General, PHS, 23 Aug. 1918, PHSR ). Rainey's amendments were contained in sections loo6-09 of the Revenue Act of 1918, approved 24 Feb. 1919 (Public Law no. 254, 65th Cong. ).
39 Exportation of Opium, hearings before a Subcommittee of the Committee on Ways and Means on HR 14,500, House, 66th Cong., 3rd Sess., 8, 11 Dec. 1920 and 3, 4 January 1921 ( GPO, 1921). See pp. 47-48 for exchange between W. L. Crounse, general representative of the National Wholesale Druggists Association, and Rep. Rainey on this question.
40 Amendments to the Harrison Narcotic Act, hearings before a Subcommittee of the Committee on Ways and Means, House, 69th Cong., ist Sess. 21, 22, 26 May 1926 ( GPO, 1926), see pp. 23-24. See also Exportation of Opium, Hearings ( 1921 ), pp. 16, 43-44.
41 U.S. Treasury, Preliminary Report of the Special Committee of Investigation, August 1918 ( GPO, 1918).
42 Special Committee of Investigation, Appointed March 25, 1918, by the Secretary of the Treasury: Traffic in Narcotic Drugs (GPO, 1919), pp. 3, 23-26, 29.
43 Ibid., pp. 9-19.
44 Chiefs of Police of every American city of over 5,000 population were circularized, but only 32% returned any information. Leading causes of addiction were listed as prescriptions, association with other addicts, and liquor prohibition. Penal institutions—county, state, and federal—returned 3.9% of the questionnaires with information. From superintendents of state, county, and municipal almshouses, state hospitals, insane asylums, and county municipal hospitals ( a total of 5,ioi ), only about 6% reported "any information of value" (Traffic in Narcotic Drugs, pp. 14-19).
330 Notes to Pages 138-41
45 Traffic in Narcotic Drugs, pp. 19-22. Apparently one million was a compromise between the PHS's estimate of 750,000 and the Revenue Service's estimate of 1.5 million. See A. G. DuMez, "Some Facts Concerning Drug Addiction," memorandum prepared for the PHS and marked "Not for Publication in Present Form," 9 Dec. 1918 ( PHSR).
46 Traffic in Narcotic Drugs, p. 22. That Prohibition would create more narcotic users was an old and enduring belief. Prohibitionists looked for contrary evidence, wets warned of a dire avalanche of addicts, and the federal and local governments took the possibility seriously. The New York City Health Department declared that the vigorous drive on addicts in that city in 1919 was prompted by just this fear of the effects of Prohibition ( Department of Health of the City of New York, Annual Report,
1919, p. 193).
47 N.Y. Times, io April 1919. In September 1919 Porter was described in Justice Department documents as Supervising Internal Revenue Agent.
48 N.Y . Times, 17 Feb. 1919.
49 Copeland is quoted in the Times of 23 March 1919, where the figures for drugstore sales are also given. An estimate of how many addicts the heroin or morphine would supply can be computed by multiplying the number of grains in an ounce (437.5) by the approximate number of ounces of heroin and morphine ( roughly 2,500) and then dividing by the average number of grains used by an addict monthly. The daily average in 1919 is often given as io grains, in which case the number of addicts supplied for a month by drugstore sales, if all went to addicts for simpre maintenance, would be about 3,300. If one assumes a conservative daily average intake of 5 grains, the figure would be doubled.
50 As early as January 1919, Justice Collins had written that the City Health Department was ready to open clinics in New York if necessary (C. F. Collins, "The Drug Evil and the Drug Laws," Monthly Bull. Dept. Health N.Y. City 9 : 1-24 , p. 13). In a Times interview of 31%March 1919, mention was made by Copeland that clinics were planned. The clinics' development is closely followed in the Times after io April 1919. Copeland's original optimism was recalled by the president of Chicago's Board of Education, J. D. Robertson, who also had predicted failure ( Limiting Production of Habit-forming Drugs and Raw Materials from Which They are Made, House Committee on Foreign Affairs, Hearings on HIR 430 and HIR 453, 67th Cong., 4th Sess., 13-16 Feb. 1923, rev. print., p. 107). For a more detailed account of the opening see Weekly Bull. Dept. Health N.Y . City, 19 April 1919, pp. 121-22.
51 New York State Narcotic Control Commission ( NYSNCC ), First Annual Report, io April 1919, Legislative Doc. no. 83 (Albany: J. B. Lyon, 2929), pp. 3-4.
52 Seven physicians worked all day to handle the addicts who came through at a rate of ioo an hour. Dr. Copeland warned the city that violence might break out if a supply were not kept flowing to the addicts. N.Y. Times, 11-13 April 1919. The determination to provide hospital and curative treatment for addicts is well documented in the many defeats suffered by the Health Department before it finally secured adequate bed space. A large portable hospital offered by the Rockefeller Foundation was first briefly accepted and then rejected by the city, apparently on suspicion that strings were attached. It was feared that the Foundation, in the words of Corrections Commissioner Bird Coler, sought a "grip on the habits of men" and that it was pro-Prohibition (N.Y. Times, ig July 1919). Secretary of the Navy Josephus Daniels gave the city permission to use the large Pelham Bay Naval Training Station for institutional treatment, but the community objected (ibid., 29 July 1919). Then the city turned to the tuberculosis center on Staten Island, Sea View Hospital, but the community again objected and threatened to picket the ferry and demonstrate if addicts were sent to the Island. Finally, Riverside Hospital on North Brother Island was selected and, since the city owned the island, the hospital, and access, agreement was obtained. In late August, Riverside Hospital became the major treatment facility for addicts transferred from the clinic for institutional care (ibid., 6-26 Aug. 1919).
53 Perhaps prompted by A. G. DuMez's work on the Treasury's Special Committee, the PHS began to consider in late 1918 and early 1919 how to become involved in the fight against addiction while preserving its traditional role as a catalyst only. In a memorandum prepared by the Hygienic Laboratory on 9 May 1919, it was considered proper for the service to warn against "ambulatory treatment" since an addict would not voluntarily withdraw himself, but "any statement as to the treatment of drug addiction, especially morphinism, must be made with caution at the present time as our knowledge of this phase of this subject is very indefinite." While gingerly approaching the proper boundaries of activity, the PHS was about to be solidly pushed toward direct patient care by the Commissioner of Internal Revenue. Commissioner Roper, in a memorandum of 15 July to the Secretary, with a copy to the Surgeon General, suggested that the PHS temporarily take care of all indigent addicts, apparently on a maintenance program, until expansion of the service's hospital facilities enabled admission for institutional treatment and "permanent cure" (PHSR ). Mention of such possible activity by the PHS was written into the July 31st letter to revenue officials which was made public (U.S. Treasury Dept., Bureau of Internal Revenue, Enforcement of the Harrison Narcotic Law, "M-MiM 2212 to Collectors of Internal Revenue, Revenue Agents, and Others Concerned," 31 July 1919 [GPO, 1919] ). The revenue officials were advised to confer with local authorities and U.S. attorneys in order to establish at the earliest date "public clinics" where relief in conformity with the law might be given. Roper did not believe addiction treatment was a proper matter for the government's tax-collecting agency to oversee (Roper to Surgeon General, 19 June 1919, PHSR ). See also L. F. Schmeckebier, The Public Health Service: Its History, Activities, and Organization, Institute for Government Research (Baltimore: Johns Hopkins Press, 1923), pp. 47-52.
54 Surgeon General Blue found in the VD clinics a model for PHS response to demands for action. The clinics would reduce patients to a minimum comfortable dose and then "act as feeders to the institutions where real cure can be carried out." Blue's apparent optimism for a real cure was actually only a belief that detoxification could be carried out in an institution because even before the New York City clinic had completed four months' operation, Blue believed that such cures would not secure permanent results until complete national and international control of drug output was secured (Blue to Roper, 28 July 1919, PHSR). The clinics in New York, New Orleans, and Memphis were given as examples of the kind of clinic desired.
55 Roper, Fifty Years of Public Service, p. 185. For actual figures of draft rejects in New York see above (ch. 5, n. 63). For a contemporary criticism of Roper's figures, see Pearce Bailey, "The Drug Habit in the United States," New Republic, 16 March 1921, pp. 67-69.
56 Roper, Fifty Years, pp. 186, 189-93.
57 Roper to Blue, 19 June 1919 (PHSR ).
58 Senator Joseph I. France, Maryland, a physician, introduced S 2785 on 15 Aug. 1919 ( 66th Cong., 1st Sess.). In the House, Rep. Rainey introduced an identical bill, HR ii, 778.
59 Roper to Secretary of Treasury, 15 July 1919 (PHSR).
6o U.S. Treasury Dept., Internal Revenue Regulation no. 35 (GPO, 1919).
61 Blue to Roper, 28 July 1919 (PHSR).
62 One more example of the PHS reacting to the Revenue Bureau's attempt to deeply involve the medical branch of the Treasury in tge narcotic problem was Roper's suggestion that the PHS agree to add provisions for more laboratory facilities in order to search for an effective treatment of addiction. The commissioner had become convinced that some treatment which counteracted or neutralized habit-forming drugs was necessary for an ultimate solution (Roper to Blue, 5 Sept. 1919, PHSR). The Surgeon General agreed (Blue to Roper, 16 Sept. 1919, PHSR).
63 "Report of the Committee on the Narcotic Drug Situation in the United States," approved by the House of Delegates, April 1920, New Orleans Convention, in Digest of Official Actions, 1846-1958 (Chicago: American Medical Association, 1959), p. 502. The full report is reprinted in JAMA 74 : 1324-28 (1920). The members of the committee were identified in 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. 887), as E. Eliot Harris, New York, chairman; Arthur T. McCormack, Kentucky; Paul Waterman, Connecticut; and Alexander Lambert, ex officio (as president of the AMA 1918-19). Among other recommendations were condemnation of ambulatory treatment of drug addiction, and endorsement of total prohibition of heroin.
64 Care and Treatment of Drug Addicts, Committee on Public Health and Quarantine, Senate Report no. 232, 66th Cong., 1st Sess., 10 Oct. 1919 (GPO, 1919). Printed in the report was a letter from Secretary of the Treasury Carter Glass describing the need for the France bill because of "a critically serious situation growing out of the enforcement of amendments to the Harrison Narcotic Act" (Glass to France, 3 Sept. 1919). Among others involved in trying to develop the most effective and palatable bill was Arthur D. Greenfield, the New York attorney who had gained the respect of the PHS by his attitude toward law enforcement and interpretation of the Harrison Act, opposition to addict maintenance, and lack of any ax to grind or cure to promote. The France bill was not the first federal attempt to care for indigent addicts. Senator Jacob Gallinger had introduced a bill to provide treatment in the District of Columbia for habitués as early as April 1908 ("President's Home Commission," Senate Doc. no. 644, 6oth Cong., 2nd Sess., 8 Jan 1909, p. 258). The France bill allotted $13 million in matching funds for the first year and $2 million for the second year of a national antinarcotic program. Each state would match the federal contribution to establish programs of care, prevention, and treatment of drug addicts. The Secretary of the Treasury would approve all state programs. The states would be permitted to use PHS facilities, and navy and army facilities not then needed could be borrowed by the PHS in furtherance of addiction control. Ten percent of the federal funds might be spent to "collect and spread information in regard to the care and treatment of drug addicts and for administration." The Treasury Department, containing both the PHS and the Bureau of Internal Revenue, considered these legislative recommendations the necessary sequel to providing temporary narcotic supply clinics. Definitive treatment was needed in institutions and the clinics would act as feeders to the institutions. (Quotations from S 2785 as amended by the Committee on Public Health and Quarantine, i Oct. 1919 are from a copy in the files of the
65 A. G. DuMez, "Some Facts Concerning Drug Addiction," memorandum dated 9 Dec. 1918, sent to the Surgeon General from the Hygienic Laboratory, 16 Dec. 1918 (PHSR ). DuMez's description is very similar to Dr. Bishop's concept of addiction disease and illustrates that what would in a year or so be taken as evidence of duplicity or dangerous ignorance was then respectable and seemingly scientific. DuMez also demonstrated his beliefs in a review article (JAMA 72 : 1069 [1919) ) in which he credited Valenti's experiments. Bishop and DuMez were in error as to the indisputable evidence for a detectable antitoxin or antibody. Soon the error became medical heresy which endangered the careers of physicians who did not recant; Bishop is an example. By 1921, even the Surgeon General thought the phrase "physiological balance" was so "controversial" that he did not wish it to be mentioned publically. Cummings to Dowling, 12 Feb. 1921 (PHSR).
66 DuMez, "Some Facts."
67 A. G. DuMez, "Treatment of Drug Addiction," memorandum to the Surgeon General, 28 Feb. 1919 (PHSR).
68 A. G. DuMez to the Surgeon General, 14 June 1921, where it is claimed that the greatest hope for keeping addicts off drugs "lies in a more rigid and thorough enforcement of the present anti-narcotic law." Similarly, Dr. Pearce Bailey, former chief neuropsychiatrist for the army during World War I, complained that "one of the difficulties in the way of meeting the situation has been that drug addiction has too long been considered a medical problem. . . . The problem is not one to be handled by the Boards of Health or by special commissions, but by the Internal Revenue Department, which should check up all sales, by the municipal police, and by the local and federal courts" ("The Drug Habit in the United States," New Republic, 16 March 1921, pp. 67-69). Early in 1919, the PHS and the Bureau of Internal Revenue agreed that the government had a moral obligation to provide cure if cure were made compulsory (e.g. Greenfield to Blue, 31 May 1919,.PHSR, and Roper to Secretary of the Treasury, 15 July 1919, PHSR), but as the impossibility of providing any reasonable chance of cure with current regimens became apparent, the PHS backed away from claiming a major role for medical treatment in the curbing of addiction in the United States,
69 An attempt at this time by the PHS to contribute to the federal effort against narcotics was the near-establishment of a national advisory committee "to formulate such suggestions as will tend to make clear to physicians the exact nature and extent of their right to prescribe narcotic drugs, and to advise with respect to such legislation and such administrative procedure as may be called for by existing conditions" (Blue to Dr. Thomas Blair, Director of the Bureau of Drug Control, Pennsylvania Department of Health, 5 Nov. 1919, PHSR).' The committee ',vas first suggested by Arthur Greenfield to Blue as a response to physicians' confusion over what they could prescribe for and what not. Greenfield believed that an inquiry started under the aegis of the PHS would focus unsettled thinking and speed a "consensus of the best medical opinion" (Greenfield to Blue, 14 Aug. 1919, PHSR). The proposal received Blue's support and the enthusiastic support of the Bureau of Internal Revenue. Roper hoped that the committee would clarify standards of rkactice (Roper to Blue, 3 Sept. 1919, PHSR).
Among those appointed were Dr. Pellini, Dr. Thomas Blair of Pennsylvania, A. C. Webber of Boston, Mrs. Hamilton Wright, and Greenfield himself as chairman; all had taken strong stands against a concept of addiction disease which would lead to maintenance in many instances. The committee was disapproved by Secretary of the Treasury David Houston, who felt it would violate a statute agains expenditures incurred by a committee or commission of inquiry except for expenses specifically authorized. The Secretary's veto came even after invitations had been extended by the Surgeon General (Dr. Homer Cumming) and after approval by the assistant secretary in charge of the PHS and the Bureau of Internal Revenue. These subordinates to the Secretary even approved the committee, with the understanding that no expenditures would be incurred after the members had agreed to serve at their own expense (Asst. Surgeon General Schereschewsky to Greenfield, 23 July 1920, PHSR). Perhaps the powerful influence of Rep. Rainey had intervened to stop this new committee, which Secretary Houston claimed violated the spirit of the statute, for Rainey, in an exchange with Dr. Terry in January 1921, denied any need for an investigation beyond what the Treasury Committee had established in June 1919 (Exportation of Opium, Hearings before a Subcommittee of the Committee on Ways and Means on
HR 14,500, House, 66th Cong., rd Sess., 8-11 Dec. 1920, and 3-4 Jan. 1921 [GPO, 1921], pp. 106-07). Secretary Houston reasoned that the answers sought by the investigation could be supplied by federal agencies responsible.
70 Nutt (1866-1938) was a practicing pharmacist in Ohio when he entered the Bureau of Internal Revenue in 1901. See below, ch. 8 for further details.
71 Schmeckebier, Bureau of Prohibition, pp. 309-10.
72 U.S. Treasury Dept., Bureau of Internal Revenue, "Digest of Responses to Questionnaire Submitted by the Bureau of Internal Revenue to Hospitals and Prominent Physicians Relative to the Methods of Treatment for Narcotic Drug Addicts," with a handwritten note on the cover "completed to December 5-19," (RPU). The opinions favored rapid or gradual withdrawal, hyoscine during withdrawal, institutional restraint, and custodial care for 90 to i8o days or longer. Selected responses from the collectors, dated between 30 July and 15 September 1919, seem in large part replies to M-Mim 2212 of 31 July 1919 ( see ch. 6, n. 53 above), and are collected in a typewritten document "Digest of Correspondence from Collectors, Revenue Agents and District Attorneys Relative to the Narcotic Situation in the Various States" (U.S. Treasury, Bureau of Internal Revenue, n.d., RPU). Cooper's trip to points between Washington and Boston in October 1919 might similarly be considered a gathering of information about the effectiveness of the various clinics stimulated by Commissioner Roper's letter of 31 July. Cooper's memorandum was submitted to the Bureau 22 Oct. 1919 (RPU).
73 See above, ch. 6, n. 72.
74 Dr. J. C. Perry, Acting Surgeon General to Dr. Oscar Dowling, President, limisiana State Board of Health, 29 Nov. 1920 (PHSR). The resolution was apparently submitted by Dr. George McCoy, Director of the Hygienic Laboratory. The full resolution, including condemnation of the use of heroin, had also been approved by the New York State Medical Society on 22 March and was based, according to Dr. Eliot Harris, its sponsor, on the evidence gained from the New York City clinic that addicts must be under "absolute control" when being taken off drugs.
75 For reference see above, ch. 6, n. 62; E. Eliot Harris to Commissioner of Internal Revenue, j May 1920 ( RPU). A note to Prohibition Commissioner John F. Kramer from Narcotic Division Head Levi G. Nutt (5 May 1920, RPU) called his attention to the Harris letter and commented, "Time has arrived when action should be taken leading to the closing of these places." Nutt, however, was already taking steps to close the clinics.
76 U.S. Treasury Dept., Bureau of Internal Revenue, "Amending M-Mim 2212 dated 31 July 1919, and Outlining Treatment of Narcotic Drug Addiction Permissible under the Harrison Narcotic Law," Pro-Mimeograph, pro., no. 217, 19 Oct. 1921 (GPO, 1921). The 36-clay limit prompted Rep. Volk to call for a congressional investigation of the narcotic situation and to describe the new rulings as the efforts of an "organized conspiracy" to drive the narcotic addict into established sanitaria (Med. Record lox : 109 (1922] ). As medical support for the 30-day limit, the ruling cited a resolution passed by the Council on Health and Public Instruction of the AMA on 11 Nov. 1920. Since several members of this committee were New York City enemies of Volk's views, he found the connection further proof of the conspiracy.
77 Specified exceptions to withdrawal: "Those suffering from senility, or the infirmities attendant upon old age, who are confirmed addicts of years standing, and who, in the opinion of a reputable physician in charge, require a minimum amount of narcotics to sustain life" ("Amending M-Mim 2212" Section 3a). Doubtful cases could be investigated by the bureau on request and special instructions issued (p. 4). It is unlikely that any young heroin addict would be granted an exception, but the rule was not without some flexibility.