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.