History of Medical Cannabis[size=12]THE first reference to the medical use of cannabis is in a pharmacy book written about 2737 B.C. by the Chinese Emperor, Shen Nung, who recommended it for "female weakness, gout, rheumatism, malaria, beriberi, constipation and absent-mindedness." In China at that time, the hemp plant was also a major source of fiber for the production of rope but there is little indication that its psychotropic properties were of much interest. Its pain-killing powers were well-known to the Chinese physician Hoa-Gho, who mixed the resin with wine. This preparation, which was called ma-yo, was employed as an anesthetic in surgery.
Some years later cannabis extracts were introduced in India, where they have, for more than a thousand years, had medical applications. An Indian girl who worked for me as a laboratory technician tells a story of her experience with the drug: She came from a wealthy family in Bombay, which, when she was a little girl, sent her to the finest physician in the city because, apparently, the parents felt she was too skinny to attract a man. The doctor prescribed a glass of Mang before each meal, which greatly enhanced her appetite. By the time she was 17 she was voluptuous and eminently nubile, though not obese. Surprisingly, she cannot recall any psycbotropic effects, nor was she told by her physician to expect any.
The ancients in other countries seemed to know cannabis as a balm or, perhaps, an antiseptic (though, of course, they knew nothing about bacteria then). In the papyrus of the pharaoh Ramses, for example, washing sore eyes with extracts of the plant was recommended. In a folk remedy of the Middle Ages in Europe the dried leaves were kneaded and applied with butter to burns. Extracts were also used as drops for earaches and for preventing inflammation of ulcers, and there are even claims that women stooping due to a disease of the uterus were able to stand straight again after inhaling smoke from the plant.
Western physicians, however, remained largely ignorant of cannabis until 1839, when a 30-year-old British doctor serving in India, W. B. O'Shaughnessy, wrote a 49-page article in "The Transactions of the Medical Society of Bengal" describing his experiences with the drug. (The fact that we are able to pinpoint historically the introduction of cannabis into European medicine is itself notable, since most drugs seem to be gradually adopted by doctors after originating in folk medicine.) O'Shaughnessy reviewed the literature on the use of cannabis in Indian medicine during the preceding 900 years. A cautious man, he was not satisfied with the drug's well-documented record of safety and proceeded, in a series of animal experiments, to test its effects as well as the limits of the dosage. He found cannabis remarkably safe in animals, a conclusion which has been reaffirmed many times. In fact, despite many escalations of the dose he could not kill any mice, rats or rabbits. Then, Dr. O'Shaughnessy administered the drug to patients suffering from seizures, rheumatism, tetanus and rabies. His findings were that it relieved pain, was an anti-convulsant and acted as a muscle relaxant.
O'SHAUGHNESSY'S work excited the interest of clinicians throughout Europe, and soon there were descriptions of its application to a range of ailments, including menstrual cramps, asthma, childbirth psychosis, quinsy, cough, insomnia, migraine headaches, chorea and withdrawal from opiates. Some idea of this broad usage can be gleaned from 19th-century medical journals. One investigator wrote: "It acts as a soporific or hypnotic, causing sleep; as an anodyne in lulling irritation; as an antispasmodic in checking cough and cramp; as a nervine stimulant in removing languor and anxiety. Also, it raises the pulse and enlivens the spirits, without any drawback or deduction of indirect or incidental convenience; and it conciliates tranquil repose without causing nausea, constipation or other signs of effect or indigestion, without headache or stupor."
Such testimonials from the medical profession were by no means rare. Hobart Hare's "Standard Textbook of Practical Therapeutics" stated: "Cannabis is very valuable for the relief of pain, particularly that depending on nerve disturbances; it produces sleep; it gives great relief in paralysis and tends to quiet tremors; it is used in spasm of the bladder due to cystitis or nervousness; it is used in cough mixtures and does not constipate or depress the system as does morphine."
Since extracts of hemp from colonial India were the most abundant source of cannabis in the 19th century, British physicians were responsible for the first explorations of the medicinal uses of the drug. Of course, in those days, before the current era of super-specialization in medicine, individual doctors researched and treated patients with a wide variety of illnesses. Thus. men like Dr. J. Russell Reynolds, a physician to Queen Victoria, devoted 30 years to careful evaluation of cannabis under many conditions. He was particularly impressed with its ability to relieve pain; his observation that the drug was especially effective when an emotional or psychosomatic element aggravated an illness Is of special interest. Perhaps cannabis's tendency to release neurotic inhibitions and bring on euphoria, as well as its mild sedative action, was responsible for its unique ability to ease "nervous" pain. in much the same way today, a mild barbiturate together with aspirin and caffeine --- called Fiorinal --- constitutes a most effective anti-tension-headache cocktail. Thus, Dr. Reynolds especially recommended cannabis for migraine headaches. "Very many victims of the malady," he reported, "have for years kept their sufferings in abeyance by taking hemp at the moment of threatening or onset of the attack."
There are also indications that cannabis can help prevent future attacks. or at least reduce the frequency and severity of the headaches.
In modem medicine two different types of drugs are normally prescribed for these purposes: ergot derivatives such as ergotamine alleviate acute pain, and methysergide (Sansert) --- which is, interestingly, a close relative of L.S.D. and is hallucinogenic itself in bigger doses --- is used to ward off future headaches. Dr. Hare, a professor of medicine at the University of Pennsylvania, concluded that cannabis can fulfill both roles.
ONE medical complaint that can benefit from a drug that relieves "nervous" pain is menstrual cramps, since relatively severe attacks are often emotionally caused. Indeed, cannabis was prescribed extensively for the cramps In the 19th century, and physicians soon discovered that it also relieved excessive menstrual bleeding, or "menorrhagia." Its successes here seem to have been spectacular. For instance, Dr. Robert Batho reported: "It [cannabis] is par excellence the remedy for that condition ... it is so certain in its power of controlling menorrhagia that it is a valuable aid to diagnosis in cases where it is uncertain whether an early abortion may or may not have occurred." How cannabis slows down menstrual hemorrhage is something of a mystery.
Like narcotic pain-relievers such as codeine, cannabis was also used frequently to control coughs. While today this may not seem to be so important, in the 19th century tuberculosis was the leading killer of the young and debilitated people of all ages with incessant, intractable coughing; any medicine that could ease the cough was thus a blessing.
Cannabis was introduced in the West at a time when opiates were prescribed freely and addiction was far more widespread than it is today. As a consequence, it was natural that the drug should be tested as an aid in withdrawing patients from opium, as well as from other addictive substances, such as alcohol and chloral hydrate. For example, Dr. Edward Birch reported in The Lancet: "I am satisfied of its immense value [in withdrawing patients from chloral hydrate or opium] ... the chief point that struck me was the immediate action of the drug in appeasing the appetite for the chloral or opium and restoring the ability to appreciate food."
The potential value of cannabis in helping to withdraw patients from alcohol or opium was rediscovered about 50 years later during an investigation of the marijuana problem in New York City sponsored by Mayor La Guardia in the early nineteen-forties. Doctors Samuel Allentuck and K. Bowman found that by substituting cannabis for heroin, "the withdrawal symptoms were ameliorated or eliminated sooner, the patient was in a better frame of mind, his spirits were elevated, his physical condition was more rapidly rehabilitated, and he expressed the wish to resume his occupation sooner." Other investigators. however, have said recently their experience is that cannabis is not effective as a means of easing off heroin.
One is struck by the suggestion of some researchers that besides easing the craving for an addictive agent, cannabis had a tonic-like action, raising the spirits of the addict and increasing his energy and appetite. In O'Shaughnessy's first report on its uses in medicine, he cited its value in controlling convulsions. (Convulsions resulting from many different causes in those days were lumped together, while today we can distinguish epilepsy from other causes.) There followed reports of cannabis treatment of chorea, resulting from rheumatic fever, in which wild flailing of the arms--- called St. Vitus's dance --- resembled convulsions.
However, its possible value in epilepsy remained buried for many years until routine screening of many substances in animals for anticonvulsant activity revealed an analogue of T.H.C., that is, a chemical similar to it in composition, which seemed to have anticonvulsant properties. At this time, the late nineteen-forties. the attacks of most epileptics could be controlled by diphenylhydantoin (Dilantin) or phenobarbital, which are still the major antiepileptic drugs in medical practice today. To see whether T.H.C. could help epileptics, two researchers --- Doctors J. Davis and H. Ramsey --- chose five institutionalized children whose attacks could not be controlled with phenobarbital, Dilantin or even a combination of the two. Given T.H.C., two of the five became almost completely seizure-free, and the other three did at least as well as they had on their previous drug regimen. The unavailability of cannabis or T.H.C. derivatives in the succeeding decade prevented any further medical investigation of this problem.
The major use in the 19th century was as a pain-killer or mild sedative-tranquilizer and, since in those days opium had been the most widely used drug for these purposes, most medical reports on cannabis concentrated on comparing the virtues and drawbacks of these two drugs. One of the most obvious assets of cannabis, apparently quite clear to 19th-century physicians--- but not yet clear to the United States Narcotics Bureau-was that prolonged use never led to addiction, nor did it result in tolerance to the drug's effects. This was commented on again and again in 19th-century medical journals, was confirmed in the investigations of Mayor La Guardia's committee and has been confirmed repeatedly in studies over the last three years using both crude cannabis as well as pure T.H.C.
In addition, cannabis products are far less toxic than the opiates. The latter drugs, including morphine and heroin, kill by depressing the respiratory centers in the brain, and do so in amounts only a few times greater than therapeutic doses. By contrast, cannabis may well be one of the least toxic drugs known.
What about effects on the vegetative functions of the body? Opiates slow down the churnings of the intestines and routinely produce constipation. Since opiate alkaloids retard the secretions of the liver and the pancreas, they slow down digestion. Opiates retard the flow of bile by constricting the bile ducts, so that the pressure inside them builds up --- sometimes causing severe colic pain; another unpleasant side effect is their tendency to cause nausea and vomiting. Cannabis produces none of these effects.
In one important way opiates are better than cannabis: they are stronger pain-killers. For the excruciating colicky pain produced by a kidney stone or the crushing chest pain of an acute heart attack, morphine is a blessing. For these situations, cannabis is a weakling.
Still, we have seen that the drug could be valuable in treating a number of conditions. Why has it been so neglected in recent years? Legal restrictions are at fault to a large extent, but they cannot be the sole reason. Well before the Marijuana Tax Act of 1937, in the late 19th and early 20th centuries, cannabis as a general medicine was already on the decline.
There had always been problems in prescribing the drug. For one thing, it is insoluble in water and so cannot be injected intravenously for rapid effect. When taken by mouth, moreover, it does not begin to go into action for one to two hours --- longer than for many other drugs.
Even more troublesome was the difficulty during the 19th century of obtaining standard batches of cannabis. Different batches can vary tremendously in their potency, probably because the amount of resin in plants depends on ripeness, humidity, soil characteristics, temperature and time of year. In the early days of cannabis in European medicine, the drug be came highly controversial on this account. On the one hand, highly reputed physicians were praising it as a, "miracle drug." But at the same time others could not duplicate the therapeutic successes of their colleagues and concluded, like Dr. J. Oliver, that cannabis "is hardly worthy of a place an our list of remedial agents."
It is possible that the "therapeutic failures" simply reflected weak preparations. This variability was well known even to O'Shaughnessy, who observed considerable deterioration of the drug's potency while transporting it from India to England.
Then, too, some of -the therapeutic successes of cannabis could possibly have been "placebo" responses suggested by the physician. This is especially the case with headaches, menstrual cramps and emotional ailments, which are particularly responsive to suggestion.
Dr. Reynolds, an astute clinician, also pinpointed another difficulty: the variability of individual responses to the same dose of cannabis. "Individuals differ widely," he said, "in their relations to many medicines and articles of diet, especially those of vegetable origin-such as tea, coffee, ipecac, digitalis . . . and cannabis." Anyone who has attended a pot party can vouch for this piece of wisdom.
One more possible drawback might be that patients treated for medical conditions with cannabis might get high and become potheads. Yet, it is striking that so many of the early medical reports on cannabis fail to mention the plants intoxicating properties. Rarely, if ever, is there any indication that patients --- thousands must have consumed cannabis in Europe in the 19th century --- were "stoned," changed their attitudes about work, love, their fellow men or patriotism. It is unlikely that the plants grown 50 to 80 years ago differed in chemical composition from those growing today. More likely, the difference is a matter of mental set or expectation on the part of the patient. When people see their doctor they want to be treated for a specific malady, and do not anticipate being "turned on" or "tuned in." And recent investigations have suggested that the mental effects of cannabis are quite dependent on the expectation of the subject.