17
Opium at the End of the Century
By
the end of the century opium was no longer so central to medical
practice, nor did it occupy its former place in popular culture. The
`opium of the people' had been taken over by the medical profession;
the established division between medical and nonmedical usage was
recognition that the previous widespread diffusion of opium use in
society was declining.
Medical practice itself was changing. New
drugs like chloral, quinine and the bromides were replacing opium as a
timehonoured standby in fever and sleeplessness. The opiate 'composing
draught' at night was replaced by a dose of chloral, as many
prescription books indicate. Some medical men of the `old school'
lamented the change. Dr Samuel Wilks, Consulting Physician to Guy's
Hospital and long an opponent of a headlong change to new and often
untried drugs (he had attacked the unwise use of chloral as early as
1871), commented in 1891 on the general medical `ignorance of the best
properties of opium' and
with some medical men an actual dread of
it, some ill-defined fear of its excessive harmfulness so as to make it
a drug to be avoided by all possible means, and that every substitute
should be thought of in its stead ... For my own part, I have seen more
evil results from the long continued use of chloral and bromides than
from opium.1
A few consultants like Wilks continued to defend the
drug's use, but theirs were isolated voices. W. B. Cheadle, Physician
at St Mary's and Lecturer on Clinical Medicine at the medical school
there, even launched a full-scale attempt at rehabilitation in 1894.
Recommending treatment by opium in a range of illnesses from goitre
through to heart disease, bronchitis, ulcer, whooping cough, colitis,
dysentery, diarrhoea, peritonitis, gall stones and diabetes, he
lamented that in general the use of opium was becoming ,more and more
narrow and routine'.2 But his was a losing cause. As a means of easing
pain or procuring sleep, or as a suppository, or in small doses for
coughs and diarrhoea - these were by then about the limit of its
accepted usefulness. Continuous and systematic treatment with the drug
was by this time rarely seen.
Wilks and Cheadle appear to have been
correct in their assessment of the decline in use, at least as far as
hospital practice went. At King.'s, opium was being used from the 1
870s primarily to deal with pain and sleeplessness and in the treatment
of diabetes. William Osler's classic Principles and Practice of
Medicine (1894) recommended the drug only in a limited number of
conditions. He counselled hypodermic morphine rather than opium in
rheumatism, rabies, tetanus and stomach ailments. Squire's Companion
listed only a reduced number of sixteen opium preparations in its 1899
edition.3 In general practice, opiates seem to have remained reasonably
popular, for not all local doctors would be conversant with the most
up-to-date medical opinion, and patients could continue to have
prescriptions, as their own property, redispensed. In Islington, 15.5
per cent of all prescriptions dispensed in 1885 were still opium-based
.4 The opiates which were used were changing too. Old-established
preparations like laudanum and syrup of white poppies were less
popular; doctors were tending to prescribe more morphine and paregoric,
the camphorated tincture. It would be unwise to conclude that, there
was a considerable decline in the medical use of opium by the end of
the century. At the top _of the profession this was the case, but the
drug, in varied forms, still retained popularity in everyday medical
practice.
Its popularity for self-medication was becoming more
limited. Giving opium to babies remained quite common in working-class
areas until the early decades of the twentieth century. A few drops of
laudanum in a baby's bottle of milk continued to be acceptable. But
mortality ascribed to the administration of such drugs was decreasing.
The under-five death rate was in permanent decline after 1868. Twenty
infants died from the effects of opiates in 1885, only ten in 1898. A
rate of 4.8 per million population for the underfives in 1890 had
dropped to 3.2 by 1900 and 1.8 by 1907 (Table 4, p. 276). The practice
still continued, but opium was less central to working-class child
care. Elderly women still remember young babies being given laudanum on
sugar, and chemists whose experience dates back to the 1900s still
prepared quantities of Godfrey's and `babies' carminatives'.5 But the
chemists' preparations had become an ancillary rather than a central
part of child care. Investigations by the British Medical Association
into patent remedies in the 1900s found that opium had been dropped
from the formulae of those products still on the market. It was
sometimes doubtful if the new recipe was an improvement. Mrs Winslow's
Soothing Syrup had jettisoned morphine in favour of potassium bromide,
alcohol and sugars And this period of declining child mortality from
opium demonstrated conclusively that opium had not been a major cause
of infant mortality. For the general infant mortality rate was, at 163
per 1,000 live births in 1899, at its highest ever.
Opium was less
important, too, for adult use. Old practices, on occasion, still
continued. At the turn of the century in North Kensington, for
instance, an unqualified `horse doctor' also acted as doctor to the
people of the neighbourhood. Opium and red lavender was his usual
remedy for coughs and diarrhoea. His young daughter was sent to the
local chemist to buy the pennyworths of laudanum and opium much as the
children of factory operatives had gone on similar errands fifty years
before .7 But opium was used for a more limited range of complaints.
Pharmacists in practice at the time remember that most of their regular
customers for the drug were elderly - old women who called in on a
Saturday night, for instance, for a few drops of 'lodlum' to help them
with their coughs and sleeping." Few young people took the drug in any
extensive quantity. That this was the case is borne out by generally
declining levels of mortality and of home consumption of the drug (so
far as this can be measured). Estimates of home consumption indicate
that it rose after the abolition of import duty in 186o, but that the
trend took a downward turn between the mid 1870s and the 1890s (Table
3, p. 275). A permanent decline in overall narcotic death rates began
at the end of this decade, too, and continued in the early years of the
twentieth century. A rate of 6.5 per million living in 1894 had fallen
to 4.9 per million in 1903.'
The deviance of regular opium use was
by no means universally accepted; addicts still found ready acceptance
in their communities and among those pharmacists who sold the drug to
them. `Nobody noticed addiction and everyone had laudanum at home,'10
commented one. The limited nature of the recreational drug sub-culture
at the turn of the century was in itself testimony to a continuing
overall cultural acceptance of drug use. For the sub-culture
encompassed only the use of those drugs which were outside medical
practice - smoking opium and cannabis most obviously. Drug taking for
its participants was subsidiary to their rejection of literary
convention; it was certainly never, at this stage, a way of life in
itself.
Nor, indeed, did every `medical' addict even accept the new
definition of his condition. Injecting addicts who refused to conform
to the model of disease and treatment were a continual source of
official anxiety to those concerned with the Inebriates Acts. The case
of one addict, the son of a leading South Wales physician, was put by
the family solicitor in 1905. This 'drug-ebriate' was refusing
to go
to any sort of retreat. He is not a drunkard ... and he cannot be
certified to be insane ... After the effects of the drug are over he is
mentally well. If he were insane he could of course be taken to an
Asylum ... but not being a drunkard nor insane and refusing voluntarily
to go to any `Home', the problem is what to do with him ...11
But at
an official professional level, opium use was clearly set within a new
paradigm by this time. The ethic of professional control replaced the
general social use of opium of the earlier decades. Restriction under
the legitimizing `expert' control of the. medical and pharmaceutical
professions was by this time central to any consideration of opium use.
The medical moves to establish control of the redispensing of
prescriptions, and in particular those containing morphine
(prescriptions were at this date still the patient's own property and
redispensable at will), which began in the last decades of the century,
underlined the changing balance in the relationship between doctor and
patient.12 The restrictions of the 1908 Pharmacy and Poisons Act which
placed opium and all preparations containing more than 1 per cent
morphine in Part One of the poisons schedule (cocaine was also added to
Part One) demonstrated continuing reliance on pharmaceutical expertise.
More
important than the practical ways in_ which professional control
continued to be extended was the ideological shift which had taken
place. The disease view of addiction with its implicit notions of
constitutional or hereditary predisposition established an
individualistic, privatizing ideology, nominally value-free. Medical
concepts reinforced and reflected existing social structures. A
distinct area of ideological terrain had been won. The alliances which,
on this basis, went on to shape narcotic policy in the twentieth
century were already at this stage present in embryo. They foreshadowed
the collaboration between the medical cal profession and the civil
service, between government and doctors, which was established as the
basis of policy in the 1920s. There were links between the strong
medical contingent in the public health movement, campaigning against
the open avail. ability of opium, and the government statisticians who
provided the data on which much of this case was based. There was the
connection, too, between doctors involved in the operation of the
Inebriates Acts and the civil servants who administered them. Policy in
the twentieth century would be formulated and controlled through the
interaction of these influential elites. The `medical model' of
addiction would be placed at the centre of policy formation. 13
These
medical perceptions of disease and treatment are implicitly criticized
in the analysis of nineteenth-century opium use in England. It is not
simply backward-looking to draw attention to the popular non-medical
use of opium which undoubtedly existed; and indeed, in many respects
popular and medical cultures of opium use intermingled. The parallel
`medical' and `popular' uses of opium indicate that the transmission of
such knowledge was not simply a one-way, top-to-bottom, process. Nor is
a more rigorous approach to the historical roots of medical perceptions
a denial that there was indeed something to worry about. People did die
unnecessarily from accidental overdoses; babies were doped by their
mothers. But the social situation out of which such events arose was as
important.
Nevertheless, the contemporary, implications of the
historical perspective are less obvious than some might wish.
Historically in this century, the alternatives to medical concepts in
the area of narcotic use have been penal ones. This alone has been
sufficient to secure continuing adherence to a more humanitarian means
of control. Yet, as the nineteenth century shows, even this approach
has always had its limits. There was even then a more overtly
repressive response for addicts outside the middle class. Limitation of
sale or admission to the workhouse were the working-class addicts'
equivalent of the medical categories of disease and treatment. Medical
and penal approaches are not as mutually exclusive as they are often
posited to be.
But to argue on this basis, as some critics of the
medical perspective have done, for a return to liberal individualism,
man as `a responsible agent, subject to temptations which he may resist
or to,_ which he may yield', is to miss the complexities of the
historical situation. 14 Those who argue that, because controlled and
moderate opium use has been possible without any form of restriction,
it should be so again are misjudging the issue. Open sale and avail-__,
ability of opium did not lead to the rapidly escalating levels of use
one might expect; and the problems attributable to it had their wider
context. But the re-creation of such a situation is another matter. For
if the present societal reaction to, and reality of, narcotic use is
very much the outcome of its nineteenth-century and early
twentieth-century past, it is also in another sense a victim of it. As
Griffith Edwards also points out in Chapter 18, the nineteenth century
cannot be taken out of context as a simple model for the present.
This
is not to argue that the changing attitudes towards opium in
nineteenth-century society have no relevance at all. The medical
response to opium which was established was almost inevitable given the
type of social and structural changes at work in society at that time;
the re-classification of poverty, homosexuality and other conditions
along similar lines is indicative of that. But the history of opium and
other narcotics in nineteenth-century society does provide a vantage
point from which the assumptions of both the `penal' and the `medical'
models (so far as these can be separately identified) can be analysed.
Above all it demonstrates that the concepts, the reactions, the
structures of control which are now taken for granted are not fixed and
immutable. The division between `medical' and 'non-medical' use, the
categorization of what is `legitimate' or `illegitimate' drug use,
addiction as a sickness, or even as an exclusive condition, are not
timeless concepts, but historically specific and laden with implicit
assumptions. Contemporary attitudes towards narcotics are not simply an
arbitrary figment of man's unreason for which history provides some
whiggishly relevant insights. They are the product of a social
structure and the social tensions of that time. Michael Ignatieff has
commented in a recent study of the establishment of the prison in the
early nineteenth century that no proper discussion of reform or change
can take place as long as the participants still use concepts _and_
perceptions which arise out of a past which they ostensibly deny."
Discussions of the historical relevance of opium and its contemporary
implications have suffered from much the same deficiency. But through
an awareness of the dynamics of the `problem' of opium use, of the
social roots of medical ideas, of the developing links between medicine
and the state, can come a questioning of our present-day
assumptions and contemporary pretensions to control.
References
1. S. Wilks, `On the vicissitudes of opium', British Medical journal, I (1891) pp. 1218-19.
2. W. B. Cheadle, `A lecture on the clinical use of opium', Clinical Journal, 4 (1894), PP. 345-51.
3.
W. Osler, op. cit., pp. 33, 58, 98, 124, etc.; and P. Squire, Companion
to the Latest Edition of the British Pharmacopoeia (London, J. and A.
Churchill, 1899), pp. 448-9.
4. Islington prescription book, op. cit.
5.
Most of the pharmacists I have spoken to, or corresponded with,
remember this to a limited extent; e.g. interviews with Mr Ive, 1978,
Mr Hollows and the late Mr Lloyd Thomas.
6. British Medical Association (1912), p. 147.
7. Interview with Mrs Cooper, Kilburn, 1978.
8. G. H. Rimmington, personal communication, 1975.
9.
Home consumption of opium is difficult to assess after the abolition of
import duty on opium in 186o. Home consumption figures prior to 186o
had not been directly associated with the variation in imports and
exports (Table 2, p. 274). Subtracting exports from import figures
gives a poor estimate of home consumption; it corresponded only very
generally with actual home consumption data prior to 186o. After that
date, estimated consumption is the only figure available, but it can
only be used to indicate a very general trend, which is demonstrated in
Figure 3 (P. 35). For further discussion of this point, see V. Berridge
and N. Rawson, op. cit.
10. Miss I. Robertson, personal communication, 1975.
11. Home Office papers, H.O. 45, 10454 1905, `Case of a drug addict not covered by the Inebriates Acts'.
12.
W. Gadd, `The ownership of medical prescriptions', Lancet, 2 (1910), p.
1030 ; `Prescriptions of opium and morphine', British Medical Journal,
2 (1904) P. 78.
13. V. Berridge, `The making of the Rolleston
Report, 1908-1926', Journal of Drug Issues, 10 (1980), pp. 7-28,
surveys this further stage in the evolution of policy.
14. T. Szasz, op. cit., p. 170.
15. M. Ignatieff, A Just Measure of Pain, op. Cit., p. 220.