Opium in Medical Practice

The `orthodox' medical use of opium was of relatively minor importance at this time. Doctors and pharmacists, until mid-century at least, lacked the organizational structures and professional standing even to begin to define opium use as solely a medical matter. It is easy, reading the expanding numbers of medical journals produced in this period (the Lancet, beginning in 1823, being among the first and most notable), to forget that they catered for a body of men very different from the later unified profession which exerted social, intellectual and political influence. `Properly educated practitioners' were mostly lacking before mid-century. The extraordinary diversity of medical practice in the early nineteenth century, the social `marginality' of local medical practitioners, with medical practice often still very much a trading occupation of indeterminate status, made it impossible at this stage for doctors to establish any form of unitary control over a coherent body of knowledge and practice.1
Opium's uses within medicine were nevertheless legion. The opium preparations on sale and stocked by chemists' shops were numerous enough; but a glance at the opium section of any textbook of materia medica of the period is enough to show that an even greater variety of preparations was available for the practitioner to use if he chose. Standardization was almost completely absent. One of the public health issues used in debates over legislative restriction of opium was the drug's widespread adulteration (to be discussed in Chapter 8). Even the opium preparations of the textbooks themselves could differ in their formulae. There was no agreement, before the 1858 Medical Act established the British Pharmacopoeia, on what were standard preparations. There were separate Pharmacopoeias in London, Edinburgh and Dublin; and all had different laudanum formulae. Nevertheless the fourteen opium preparations (as well as some preparations of poppy capsules and of morphine) listed in that first national British Pharmacopoeia were witness to the drug's popularity. They were all still there in the 1880s (with, of course, a vastly expanded morphine list); and Squire's semi-official Companion to the Pharmacopoeia had twenty-one opium preparations in medical use.2 When John Murray commented of opium, in his System of Materia Medica and Pharmacy in 1832, that `As a palliative and anodyne, it is indeed the most valuable article of the materia medica, and its place could scarcely be supplied by any other', he was no more than echoing the almost unanimous opinion of his medical contemporaries.3
Opium was by no means a newcomer to medical practice in the nineteenth century. It had been in limited medical use almost since it was first imported. Dr Turner, the apothecary in Bishop-gate Street, London, was selling a compound called Laudanu in 160i. It was said to be `good for alleviating pain', and `will temporarily put a min n a sweate trans'.4 It was from beginnings such as this that opium had, by the eighteenth century, become an accepted part of medical practice. The prevailing monistic system of pathology used `heroic' methods such as blistering, bleeding and purging. Opium was also used in tension pathology, which involved the use of remedies to increase (stimulate) the tone, or lessen it by relieving tensions. The burgeoning of English texts which dealt specifically with the use of the drug - George Young's Treatise on Opium for example, Alston's `Dissertation on opium' or Dr Samuel Crumpe's Inquiry into the Nature and Properties of Opium (1793) - was testimony to its increased importance in English medicine.5
There was greater documentation of medical use of opium in the nineteenth century, simply because many of the standard medical journals were established at this time. Debates over methods of treatment raged more fiercely too, as part of the process of establishment and differentiation of a separate medical profession, and opium came to the fore. The old heroic therapies involved in humoral pathology, whereby an imbalance in body fluids was removed by physical means, gave place to a greater emphasis on drug treatment and a more localized notion of pathology. There were attempts to identify previously unclassified diseases, to evolve a more scientific mode of treatment. The use of opiates spanned both the old system and the new - and indeed the break between them was never so sharp.
Despite opium's importance to medical practice of all varieties, there was still a great deal of disagreement, even in the nineteenth century, over the actual effect of the drug and how it really worked. The debate on whether it was stimulant or sedative had been very much part of eighteenth-century medicine; and there were still echoes of the controversy in the nineteenth. Opium had been assigned by those physicians declaring allegiance to the Galenic School to the `cold' group of drugs because of its soporific and sense-deadening effects. But rival physicians saw it as a `hot' drug, as a stimulant rather than sedative in its action. Perhaps the most noted of all the exponents of the stimulant view was Dr John Brown of Edinburgh, who in his Elements of Medicine laid down what became known as the Brunonian system of medicine and whose influence on Beddoes and the Bristol circle has been described in the preceding chapter. Brown, like them, saw both opium and alcohol as stimulants, increasing the tone of the nervous and vascular systems .6
Opium has always been classified in the twentieth century both legally and in popular parlance as a soporific, narcotic drug. Its imaginative literary effects are regarded as something peculiar to a small circle of creative writers. `Stimulant' usage of this type has been seen as abnormal and definitely non-medical. Yet, as discussion of the Brunonian system and' tension pathology indicates, medical practice once took a very different position. Although terms were never closely defined, the drug's claims to what was called a `stimulant' effect were urged by medical writers well into the nineteenth century. An element of euphoria was recognized as being among the effects of opium. Samuel Crumpe strongly disagreed with the compromise position that the drug had both stimulant and sedative properties. If this was the case, he pointed out, one principle would neutralize the other and the drug would turn out inert. In his view, a stimulant would be productive `of most considerable anodyne effects, which conjunctly possesses the greatest degree of stimulant power, the most ready diffusibility, and which is, at the same time, the most suddenly exhausted. The whole of these properties are accordingly discoverable in opium, to a considerable degree'.7
In the following century, the drug's stimulant effects, although still a matter of lively interest, were to a much greater degree isolated from medical practice. Many writers in the newly established medical journals, in the textbooks of materia medica, reserved the drug's stimulant properties for exceptional, non-medical circumstances, seeing its narcotic effects as the true medical ones. Professor Robert Christison of Edinburgh, the greatest authority on poisons in the 1820s and 1830s, maintained that continuous excitement could be sustained by taking repeated doses. But this, as he pointed out, was rarely done in medical practice. The effect of a full `medicinal' dose of three grains of solid opium, or a drachm of tincture, was to produce a general transient excitement and fullness of pulse, with torpor and sleep a short time after. A book by Michael Ward on the opiate friction, or the external application of the drug, also stressed its sedative properties." Most medical men appear to have agreed that the drug's narcotic properties were indeed paramount, even if there was a short period of primary stimulation. Some even disputed that the stimulant effect existed. F. E. Anstie in his Stimulants and Narcotics (1864) thought opium produced `nothing resembling mental excitement'.9 By the end of the century `stimulant' use of opium had been excluded from orthodox medicine.
The question was also bound up with that of how the drug really worked on the body, whether by the medium of the blood, or by `nervous communication'. F. Robinson, a Hammersmith surgeon, gave as his opinion in 1846 that opium would be capable of producing quicker and more' deadly effects on `a person 0f thin spare habit and highly nervous temperament than on a large robust individual of lymphatic sanguineous temperament'.10 There were echoes of the earlier medical emphasis on a humoral pathology, and perhaps the most sensible conclusion was that the effect very much depended on the person and the setting. The use of opium to aid public speaking was a particular example of conflicting tendencies and the differing effects the drug could have. It was also a notable example of the `social' use of this drug which prevailed at the time. Opium was a `pick-me-up' and a `calmer of nerves'. Wilberforce was known to take opium before his speeches in the Commons, and Gladstone, too, took laudanum in a cup of coffee with the same aim. The practice was not unknown in medical circles, and could have some unforeseen effects. A doctor elected President of the Hunterian Society in Edinburgh, through anxiety, took a larger dose of opium than usual before a crucial speech, and promptly fell fast asleep. When another member of the society also took a dose, it induced exactly the opposite effect. He was laughed out of the room, calling and crying out incoherently. The last of the trio, `a crack man of the "Medical" and one of its possible presidents', went to, make a speech on the evening prior to the election. He appeared to others present to be in a state of profound reflection. Time passed; the other speakers finished, and the meeting was declared over. The aspirant to office awakened from his opium stupor to find his chance of the presidency gone." Such. were the wayward and conflicting effects of opium. It could be `stimulant' or `sedative' depending on dosage and tolerance, and also on the consumer himself and his own expectations. Its mode of action remained a matter for investigation. But medical discussions increasingly emphasized its sedative, not its stimulant effects.
This uncertainty over its action did not prevent the widespread use of the drug for every variety of complaint. It was indeed a palliative. There were few specific cures for conditions in the first half of the century and many diseases were still to be medically defined. Opium, if not the cure-all which its most strenuous advocates saw it as, at least provided a relief from pain and a period of intermission which might aid recovery. It would almost be easier to list those areas where it was never employed than to attempt to deal with every therapeutic possibility. Jonathan Pereira noted in his textbook of materia medica in 1839 that it was used, in general, `to mitigate pain, to allay spasm, to promote sleep, to reduce nervous restlessness, to produce perspiration, and to check profuse mucous discharge from the bronchial tubes and gastro-intestinal canal'. 12 Its popular uses give some idea of the range of minor complaints in which it was invaluable. It performed basically the same function in major illnesses, too. In gout, sciatica and neuralgia it was `a most efficient palliative'; and the pain of cancer, or gangrene, and the effects of ulceration were also dealt with by opium. Its use to `allay spasm' was extensive. Cases of hydrophobia were commonly narcotized with opium, even if the results were never that successful. As in cases of tetanus, it brought often a temporary amelioration which served to confirm the belief in its powers. It was often recommended for cases of intestinal obstruction; and its utility for ague and malarial conditions has already been demonstrated by the case of the Fens.13
It was a recognized standby for bronchial affections. There were no specific cures for tuberculosis, pneumonia or bronchitis and opium helped to alleviate symptoms, subduing coughing, expectoration and pain even if it could not touch the root cause. Discharges of all sorts, too, were dealt with by the drug. Its use in haemorrhage was well-known -'of all the wonderful influences ... exerted by opium, that by which it sustains the powers of life when sinking from haemorrhage, and arrests the flow of blood, is the most extraordinary,' commented a medical journal in 1846.14 In diarrhoea, it was the major remedy, sometimes combined with camphor, sometimes with nitric acid or calomel. Its use in dysentery was common, although it was argued that the constipation it produced could mask other, more serious symptoms. And, of course, for cholera its use remained virtual. challenged. Despite the existence of a rudimentary knowledge of saline intravenous injections, owing much to the work of O'Shaughnessy, the young doctor who also brought cannabis into English medical practice, there appears to have been as much reliance upon opium in the last major cholera epidemic in England, in 1866, as there had been in those of 1831-z and 1849-53.15
In some areas opium was rediscovered. Diabetes was a case in point. Earlier medical texts had noted the drug's utility in the condition; but the method then slipped from notice. Dr Anstie, in fact, was strongly against its use. But in 1869, cases published by Dr F. W. Pavy of Guy's Hospital demonstrated that opium and its alkaloids, morphine and codeine, had the ability to check the elimination of sugar in the urine. The codeine and opium treatment he advocated was not uncritically accepted but it soon became standard. It was still in use in King's College Hospital in the 1890s. William Osler, author of the standard medical text of the period, commented that `opium alone stands the test of experience as a remedy capable of limiting the progress of the
disease'.16
Opium also had a long history in the treatment of `female complaints'. Its efficacy as a palliative came into its own in the treatment of dysmenorrhoea or menstrual pain, and in childbirth perhaps most notably. It was a useful anodyne for puerperal fever. It was occasionally given during labour, in particular to compose a patient during a lengthy delivery; and it was also used to dull 'after-pains', although this practice caused some controversy." It was used for the `nervous disorders' which were thought to be specifically sex-linked. Indeed, it was the medical administration, and consequent self-administration, of hypodermic morphine to `hysterical women' later in the nineteenth century which was said to have originated the problem of hypodermic morphine abuse. The female bias of morphine use is, however, as doubtful as the idea of female fragility and ill-health which informed most discussions. It may well be, too, that, despite many assertions to the contrary, female consumers of the drug were no more numerous than males. Certainly the male death rate from opium overdoses was
higher.18
One of the major medical areas where opium was used - in the treatment of insanity - provided a striking illustration of the changing focus of medical attention and the altered perception of the drug itself. Opium, at the beginning of the century, was seen as a welcome alternative to existing treatments. But by the end of the century, its use was increasingly viewed both as a cause of mental illness and as a form of insanity in itself. The `disease' of opium addiction as then formulated owed much to the diaease view of insanity, a condition with which opium had long been associated as a means of treatment.
But in the early 1800s, treatment with opium and other drugs appeared to be a means of progress away from earlier methods_ of restraint. Straitjackets and mechanical means of restraint were replaced by more subtle therapeutic means of control, opium among them. John Ferriar at Manchester, one of the earliest opponents of the `old regime', advocated it as a valuable replacement for `beatings and terror'. 119 Dr John Connolly, physician to the asylum at Hanwell - and one of the leading figures in the new attitude towards the insane - stressed that different preparations could vary in their effects, and also according to individual idiosyncrasy.
With some patients laudanum acts with certainty, and like a charm; others derive comfort for long periods from the acetate of morphia; to some the liquor opii sedativus is alone tolerable. Whatever sedative is employed, the dose should be large. Less than a grain of the acetate of morphia is productive of no good effect whatever; and laudanum requires to be given in doses of a drachm, or at least of forty or fifty drops. I am speaking of acute cases, for in those of longer continuance, use often makes much larger doses necessary ...20

There were those who were suspicious 0f the large claims made for it. W. Smith, at one time resident surgeon at the Lincoln Lunatic Asylum, in 1849 criticized an article by Forbes Winslow in the Psychological journal advocating the sedative treatment. To Smith, the use of narcotics was `merely an old enemy under a new guise', and the drugs, while useful in certain defined areas, were not general specifics .21 Opium, other authorities agreed, could aggravate as well as subdue the symptoms of mania and many were cautious about its use. Haslam, for instance, in his Observations on Madness and Melancholy saw opium as a drug that could excite the patient even further, instead of producing the necessary sedative effect.
Practical experience of the `stimulant' properties of the drug on an already over-stimulated mind brought stricter limits on the advocacy of its use. The uses to which opium could be put in insanity were more clearly established and circumscribed in the 1860s and 1870s. Opium was also a casualty 0f increased specialization in treatment. The elaboration of disease concepts, the _delineation 0f particular forms and varieties of mental illness, encouraged diversification in methods 0f dealing with them. Significantly it was Henry Maudsley, whose name was synonymous with new departures in mental illness, who was much associated with the limitation of opium's use. In a series of articles on the subject beginning in the late 1860s, he noted the generally unsatisfactory definition 0f insanity and the consequent vagueness in the drug treatment. N0 one quite knew how, why and where opium was having its effect. In a piece in the Practitioner in 1869, he recommended that the drug be used only in the early stages of the illness. The sleeplessness, depression and `strange feelings of alarm' which, according to him, often preceded `regular insanity' could be relieved by opium. It was especially valuable in melancholia, or depression, but not in mania .22
In the succeeding years, Maudsley's advice appears to have won increasing support, in particular from medical men receptive to the new departures. Dr Thomas Clouston, Superintendent of the Cumberland Asylum at Carlisle, won a gold medal from the Medical Society of London in 1870 for his demonstration that cannabis indica and bromide of potassium, used in conjunction, were more effective than opium in the treatment of `maniacal excitement'. (Connolly had earlier also pushed the claims of cannabis.) Half a drachm of the bromide and of cannabis tincture was given continuously to his patients over eight months. Clouston found the mixture particularly effective in menopausal women -'I think here we have a palliative of great value and importance.'23
The work of Dr Anstie, too, encouraged a dislike of `strong narcotics', and the appearance of new drugs, in particular the bromides and chloral, hastened the move away from opium. Chloral was being prescribed increasingly in general practice from the 1860s for sleeplessness in cases where an opiate draught or a `composing mixture' would once have been given. The first chloral addicts, Dante Gabriel Rossetti among them, were becoming known. Its use was advocated in insanity, too. Anstie supported the drug's use in the newly founded Journal of Mental Science. Bucknill and Tuke's standard work, Psychological Medicine, was said in 1874 to be in need of revision so far as the position of opium was concerned. Chloral and bromide of potassium, it was thought, `enable us ... to dispense with opium and its preparations, or to reserve them for those cases of melancholia in which they are so
eminently useful'.24
Opiates, however, continued to be used in the treatment of the mentally ill at the end of the century, even if advocacy was less eager or all-embracing than half a century before. Allbutt had reported on his introduction of electric treatment in the West Riding Lunatic Asylum reports in 1872. Digitalis, calabar bean and hyoscyamus also had their devotees. But opium was not completely abandoned, and its use in everyday circumstances in asylums and hospitals could have been more extensive than the academic texts indicate. John Cumming Mackenzie, assistant Medical Officer at the Northumberland County Asylum, still considered, as late as 1891, that opium was the major hypnotic in the treatment of the insane -'experience but widens the field of its application while other hypnotics pass away'.25
In another area of insanity, delirium tremens, the continuing link between opium and alcohol was again demonstrated. Opium and alcohol had often been counterposed in eighteenth-century medicine, even if Dr John Brown had classified both as stimulants. As already mentioned in Chapter 3, the drug was popularly used as a means of sobering up. The connection between the two reemerges at many stages in nineteenth-century society - in the working-class opium-eating `scare', for instance, or in the concept of `inebriety' and the formulation of disease theories of addiction (see Chapters 9 and 13). In the treatment of D.T.s the connection entered medical practice. Jonathan Pereira himself had known an alcoholic doctor who for many years took a large dose of laudanum if he was called out to see a patient while drunk. On one occasion, however, `being more than ordinarily inebriated', he swallowed too much and died of apoplexy. 26 Such treatment was rather irregular in those circumstances, but was certainly standard medical practice in the first half of the century. Opium was the 'sheet-anchor' of the condition. It was in use in hospital practice in 1850; Thomas Jones, an intemperate `gentleman's coachman' admitted to King's College Hospital and reported as seeing devils running about, was sustained on a diet of porter, beef tea and brandy, with laudanum every three hours.27
Its use in D.T.s was, though, the subject of increasing criticism from about this time. Isolated voices were raised against its efficacy and new treatments were suggested. Tartar emetic was found useful, and a supporting diet `of an unstimulating nature' recommended. An onslaught by Professor Laycock, Lecturer on Medical Psychology at Edinburgh University, in 1858, marked the beginning of serious debate. Laycock questioned the total medical reliance on the use of narcotics. He himself had treated twentyeight cases without opium or stimulants and all had recovered rapidly. Recommending that the patient be kept warm and on a suitable diet, he urged the abandonment of opium -'while many have recovered without opium, and some in spite of it, none can be said to have died for the want of it'. George Johnson, Professor of Medicine at King's College, in a series of lectures on delirium tremens, supported Laycock's views. Large doses of opium were, in his opinion, to be avoided, although the drug could be given in small quantities and often worked best when combined, surprisingly enough, with alcohol.28 It was a remedy with as many possibilities for evil as for good. Anstie, always opposed to the free use of opiates, supported this line of reasoning. `The idea that patients in delirium tremens require to be narcotized into a state of repose, may now be said to be abandoned by those best qualified to speak on the subject,' he wrote in 1866.29 The drug nevertheless remained in limited use in particular varieties of the conditions. Few were prepared to recommend its use in large quantities indiscriminately. Dr Latham, however, told the Cambridge Medical Society in 1882 that patients in moderate health could be given opium without risk - I or I grain injections of morphia were best until the delirious person fell asleep. But for those in broken health, opium should only be given with great caution.30
Opium indeed continued as one of the most valuable drugs in medical practice well into the 1860s and 1870s. It was not simply recommended in the official texts, but actually used in everyday practice. How much opium was in fact prescribed and dispensed must remain in doubt. Between the mid 1840s and 1860s, for instance, around i4-2o per cent of prescriptions dispensed by one Islington pharmacist were based on opium (234 out of 1,677 prescriptions in 1845). George Daniel, a chemist in the Holloway Road, dispensed a similar proportion; I6 per cent of his prescriptions in 1866 and 18 per cent in 1876 used opium.31 Hospital case notes, too, for King's College Hospital, for instance, and the General Lying-In Hospital in London, show that opium was indeed regularly used for the conditions for which the textbooks recommended it. Most dispensing of prescriptions still took place in the doctor's surgery, and practice records have rarely survived. The amount of opiates generally dispensed must remain conjectural. Yet there can be little doubt of the established medical popularity of the drug in the first half of the century, nor of the way in which the range of complaints commonly self-treated with opium found their parallels in established medical practice.

References

1. For the position of the medical profession in the first half of the nineteenth century, see, for example, N. and J. Parry, The Rise of the Medical Profession. A Study of Collective Social Mobility (London, Croom Helm, 1976), pp. 109-31 ; I. Inkster, `Marginal men: aspects of the social role of the medical community in Sheffield, 1790-1850', pp. 128-63 in J. Woodward and D. Richards, eds., Health Care and Popular Medicine in Nineteenth Century England. Essays in the Social History of Medicine (London, Croom Helm, 1977); and M. J. Peterson, The Medical Profession in Mid- Victorian London (Berkeley, University of California Press, 1978).
2. For an example of an early pharmacopoeia, see Royal College of Physicians, London, Pharmacopoeia (London, G. Woodfall, 3rd edn 1815). British Pharmacopoeia (London, Spottiswoode, 1858), and a later edition of 1885, also list standard opium preparations in medical use. See also P. Squire, A Companion to the Latest Edition of the British Pharmacopoeia (London, J. and A. Churchill, 14th edn, 1886).
3. J. Murray, A System of Materia Medica and Pharmacy (Edinburgh, Adam Black, 6th edn 1832), P. 94.
4. Notes and Queries, 2nd set. 3 (1857), P. 445.
5. 'G. Young, A Treatise on Opium Founded on Practical Observations .(London, A. Mular, 1753); C. Alston, `A dissertation on opium', op. cit., pp. 110-76; S. Crumpe, An Inquiry into the Nature and Properties of Opium (London, G. G. and J. Robinson, 1793).
6. J. Brown, The Elements of Medicine (London, J. Johnson, 1795); the influence of Brown's ideas on Beddoes and the literary and scientific circles at Bristol is described in A. Hayter, op. Cit., pp. 27-8; and M. Lefebure, op. cit., pp. 61-2.
7. S. Crumpe, op. cit., pp. 19o-91.
8. R. Christison, A Treatise on Poisons (Edinburgh, Adam Black, 2nd edn 1832), p. 617; M. Ward, Facts Establishing the Efficacy of the Opiate Friction (London, C. Wheeler, 1809), p. 55.
9. F. E. Anstie, op. cit., p. 79; T. C. Allbutt, `Opium poisoning and other intoxications', pp. 874-920 in his System of Medicine (London, Macmillan, 1897), vol. 2.
10. F. Robinson, `On the utility of a knowledge of the temperaments in connexion with the diagnosis and treatment of disease', Lancet, I (1846), p. 360.
11. `The action of opium', Medical Times and Gazette, 12 (x845), pp. 1656.
12. J. Pereira, op. cit., vol. 2, p. 1301.
13. Any medical journal of the period can give a multitude of examples of the reliance placed on opium. For the use of opium in the conditions mentioned here, see, for example, G. B. Wood, A Treatise on Therapeutics (Philadelphia and London, J. B. Lippincott and H. Bailliere, 1856), PP. 739-44, 745, 748, 750-58 etc. Also the articles on gout, rheumatism, convulsions, neuralgia, obstruction of the bowels, etc. in J. Russell Reynolds, ed., A System of Medicine (London, Macmillan, 1866-79), vols. n-5.
14. `Review of Dr Griffin's Medical and Physiological Problems', British and Foreign Medical Review, 21 (1846), pp. 105-7.
15. For O'Shaughnessy, see N. Howard-Jones, `Cholera therapy in the nineteenth century', journal of the History of Medicine and Allied Sciences, 27 (1972), pp. 373-96. For examples of cholera treated with opium, see British and Foreign Medico-Chirurgical Review, 40 (1867), pp. 9, 18, 26, 36. `Cholera mixtures' based on camphor, turpentine and laudanum, sometimes with the addition of brandy or `best Irish whiskey', are often to be found in prescription books of this period.
16. F. W. Pavy, `Report of a case of diabetes mellitus successfully treated by opium', Transactions of the Clinical Society of London, 2 (1869), pp. 44-56. Pavy's researches were widely publicized in the leading medical journals. See also Royal College of Physicians, King's College Hospital case notes, `Case of Maurice Ward, labourer with diabetes mellitus', Dr Yeo, vol. 79, and W. Osler, The Principles and Practice of Medicine (London, Y. J. Pentland, 1892) P. 304.
17. For some discussion of the use of opium in childbirth, see F. A. B. Bonney, `On the effect of opiates upon labour and after pains', Lancet, 2 (1844), pp. 71-2; E. Murphy, `Lectures on the mechanism and management of natural and difficult labours', ibid., 2 (1845), P. 29; J. Craig, `On the use of opium in uterine haemorrhage', ibid., 2 (1846), pp. 10-12. Case notes also provide illustrations of its use: e.g. `Case of Anne Hoskins', 1827, Greater London Record Office, General LyingIn Hospital case notes (GLI/B19).
18. Ideas of female ill-health are discussed in L. Duffin, `The conspicious consumptive: woman as an invalid', pp. 26-56 in S. Delamont and L. Duffin, eds., The Nineteenth Century Woman: Her Cultural and Physical World (London, Croom Helm, 1978). The sex variation of mortality statistics is discussed in V. Berridge and N. Rawson, `Opiate use and legislative control: a nineteenth century case study', Social Science and Medicine (1979).
19. J. Ferriar, Medical Histories and Reflections (London, Cadell and Davies, 2nd edn 181o), pp. 136-7.
20. J. Connolly, `Clinical lectures on the principal forms of insanity', Lancet, 2 (1845), P. 526.
21. W. Smith, `Practical observations on the treatment of insanity', Medical Times and Gazette, 20 (1849), pp. 197-9.
22. H. Maudsley, `Opium in the treatment of insanity', Practitioner, 2 (1869), pp. 1-8.
23. T. S. Clouston, `Observations and experiments on the use of opium, bromide of potassium and cannabis indica in insanity, especially in regard to the effects of the two latter given together', British and Foreign Medico-Chirurgical Review, 46 (1870), pp. 493-511; 47 (1871), pp. 20320.
24. F. E. Anstie, `On certain nervous affections of old persons', journal of Mental Science, i6 (1870-71), pp. 31-41; `Psychological medicine', ibid., 20 (1874-5), PP. 224-35.
25. J. C. Mackenzie, `The circulation of the blood and lymph in the cranium during sleep and sleeplessness, with observations on hypnotics', Journal of Mental Science, 37 (1891), pp. 18-61. 26. J. Pereira, op. cit., p. 1304.
27. `Case of Thomas Jones', 1850, Dr Todd's cases, King's College Hospital case notes.
28. T. Laycock, `Clinical illustrations of the pathology and treatment of delirium tremens', Edinburgh Medical Journal, 14 (1858-9), pp. 289305; G. Johnson, `On delirium tremens, its symptoms, pathology and treatment', Lancet, r (1866), pp. 419, 449, 607, 712.
29. F. E. Anstie, `Alcoholism', p. 88 in J. Russell Reynolds, op. cit., vol. 2 (1868).
30. `Cambridge Medical Society', Lancet, r (1882), p. 65.
31. These conclusions are based on an analysis of prescription books from London, Manchester and Yorkshire. Prescription book of an Islington chemist, Wellcome Library Mss. 3875-3993; Manchester prescription book, Wellcome Ms. 6471; Prescription book of George Daniel, chemist of Holloway Road, Wellcome Ms. 2033; Prescription book of William Armitage, Wellcome Ms. 978.