Physicians as Suppliers

2015

The great economic importance to Britain and the Netherlands of the intra-Asian opium trade in the 19th century has already been discussed in post The Colonial Opium Trade. But another legal branch of the opium trade evolved in the course of the 19th century, involving the transport of smaller, but by no means negligible, opium shipments from the Levant and South-East Asia to Western Europe and the United States.

In the case of the intra-Asian opium trade, the state monopolies described above disrupted the free interplay of supply and demand, but trade to Europe and the United States was initially unrestricted aside from the usual import duties. Here price mechanisms reigned supreme, and when opium cultivation intensified in the Levant and South-East Asia in the 19th century, prices fell. As the demand for opium soared, a variety of experiments were conducted with the aim of cultivating the poppies closer to the European market. In the period 1740 1870, for instance, there were countless attempts to cultivate the crop on British soil. And much later, in the early 20th century, new harvesting techniques were tried out some in Western Europe the aim being to replace the labourintensive harvesting of opium as an intermediary stage in the process of morphine production with the mechanical extraction of morphine from the entire Papaver plant.

There was a definite increase in the consumption of opiates both in Europe and the United States; the precise figures will be given below. This increase did not go unremarked by the public authorities. Certain types of consumption caused particular concern, such as the injudicious use of chlorodyne, morphine and laudanum. Acting on this concern, the governments of various countries introduced acts of parliament in the 19th century to regulate the production, distribution and consumption of opiates, which had initially been free from all constraints. Almost without exception, such acts were incorporated into the body of legislation on medicinal drugs, and were always national in scope. And although countries’ formal regulatory regimes for opiates had many similar features, each country drew up its legislation independently. There is an essential difference here between these earlier modes of regulation and the later formal regulatory regime for the opium trade, which, as we have seen in post The Colonial Opium Trade, was bestowed and imposed on the various countries of the world from above.

The medical profession played a key role in the establishment of the national regulations on opiates that were introduced in the 19th century. Pharmacists and medical practitioners in Britain and the Netherlands, and later in the United States, successfully claimed a monopoly on the prescription, preparation and sale of these drugs. This chapter will discuss the origins of these national formal regulatory regimes for opiates as they arose independently from one another, in the latter half of the 19th century in Britain and the Netherlands, and somewhat later in the United States.

While opium remained a scarce and exotic commodity in Western societies and remained so until the end of the 18th century it was chiefly supplied by physicians, who prescribed it for medical reasons. Their analgesic properties made opium containing drugs ideal remedies for all manner of ailments. Opium was the ‘universal panacea,’ remarks Geoffrey Harding, in a discussion of this traditional use by medical practitioners. New medicines with which medical practitioners and pharmacists in Europe and the United States established their reputation (and made their fortune) very often had opiates as their main ingredients. Laudanum, a solution of opium in alcohol, was a popular concoction that had been invented (by Paracelsus) as early as the 15th century. From Basel, one of the many towns in which he stayed, laudanum spread throughout Europe, and in the 18th century it figured as one of the standard items on the medical supplies list used by ships of the Dutch East Indies Company.

Another common opiate in the 18th century was papaver syrup, prescribed to induce sleep in children. Given the considerable turnover and popularity of this drug, however, it was almost certainly consumed by adults too. The opium used to prepare opiumcontaining medicinal drugs was not always imported. As trade links with Asia Minor and the Levant were poor, opium supplies were unreliable, and European pharmacists sometimes grew their own Papaver somniferum plants to extract the ingredients needed for medicine.

In the United States too, the main informal use of opium the statutebooks had nothing to say about it was in medical practice [This applied, at any rate, to the use of opiates by Americans of European origin: Chinese immigrants smoked opium recreationally (). These two opium markets were strictly separated. This is clear from the difference in import duties for instance, smoking opium being liable to a far higher rate than medicinal opium]. David Courtwright, discussing the medicinal use of opium in the United States in the first half of the 19th century, writes: ‘By 1834 it was ranked as the single most widely prescribed item in the materia medica.’

But as the supply of opium on the Western markets grew during the 19th century, medical practitioners gradually lost their traditional, informal monopoly on the preparation and prescription of opiumcontaining substances. Opium became more readily available and knowledge about its effects spread to those outside the medical profession. In the 19th century in particular, more and more opiumcontaining preparations found their way into the home outside medical channnels. Patent remedies such as Dover’s Powder, Godfrey’s Cordial and Mrs Winslow’s Soothing Syrup, which were especially for children and even chlorodine, a registered pharmaceutical remedy achieved both fame and notoriety as members of the assortment of opiumcontaining drugs used in the 19th century. These preparations were primarily intended to meet the huge demand for affordable drugs by practitioners of popular medicine and by quacks. For even people unable to afford qualified physicians took substantial quantities of opiates in the first half of the 19th century, whether as selfmedication or on the informal advice of unqualified medicine men. Then there were the itinerant ‘miracle doctors’ exalting the virtues of the opiates they offered for sale and demonstrating their wondrous properties above all, in the realm of pain relief.

Sometimes the informal use of an opiumcontaining drug would enter popular medicine from overseas. A good example is Dr Bleeker’s potion, or ‘Bleeker’s drops’ as they were called. This potent mixture, which contained opium wine, peppermint oil and ether with methylated spirits, was originally a Javanese home remedy for cholera. So when a cholera epidemic broke out in the Netherlands in 1866 to which the medical establishment of the time had no answer some local administrators saw fit to distribute Bleeker’s drops to their fellow villagers. The response of one contemporary, an authoritative medical officer (the medical inspector for the provinces of Overijssel and Drenthe) is illustrative of the fervour with which medical practitioners protected their monopoly of the distribution of opium: ‘On Java, opium is a very common home remedy in general use, and that may perhaps be all well and good; but here, where it may, at the right time and in the right place, and in the hands of a medical practitioner, be a superb medicinal drug, in the hands of ordinary people it must without a doubt be regarded as an extremely dangerous home remedy!’

Popular medicine, with its home remedies and miracle cures, was an area that the medical establishment preferred to give a wide berth. But it also represented a market that they were loath to forego. This ambivalence blurred the distinction between official and popular medicine. ‘There was no clear dividing line in the first hair or the [19th] century between strictly medical remedies and those used in selfmedication, so patent medicines were often used in medical practice, or medical men made their own semipatent remedies.’ Medical practitioners would also sometimes purchase the instructions to make up a secret remedy and use the preparation to treat their patients. Some of these patent remedies acquired an international market, but most were sold exclusively in one country or even in a particular region.

Opiumcontaining preparations were immensely popular in the 19th century, especially among the lower classes. Their relatively low price made it possible to market them among all sections of the population. This is clear from the numbers and nature of the retailers who sold them. According to an estimate made by Virginia Berridge, in the mid19th century Britain had between 16,000 and 25,000 opiate retailers: from chemists and grocers to a miscellany of tradesmen. In the Lancashire town of Preston, those who earned a little extra money selling opiates, around 1865, included a shoemaker, a basket maker, a tailor, a factory operative and a baker.

On the basis of the figures for opium imports, Berridge has calculated opium consumption levels for Britain in the 19th century. They are very high. In 1827 the weight of opium consumed per head of the population was 600 mg, and by 1859 average annual consumption had risen to 1,410 mg. These figures were not evenly distributed among the population: agricultural labourers from certain areas, such as the marshy Fens, consumed above average levels of opium preparations.

The status and sales of opium preparations in the United States followed a similar pattern in the United States, where their use in established medical practice was every bit as common as in Britain. ‘Opium remained a popular therapeutic agent throughout the first half of the 19th century. When Alexander Hamilton lay dying, a bullet lodged in his shattered spine, it was for the laudanum bottle that his physician instinctively reached to alleviate his patient’s suffering.’ But opiates also sold well outside the doctor’s surgery, as the main ingredients of patent medicines. In his study Dark Paradise David Court-wright describes the early history of Scotch Oats Essence, one of the many opiumcontaining patent remedies of the day. ‘One day the originator of this remedy, a young man with an eye on the main chance, asked his physician in an offhand manner how he would prepare a successful patent medicine. ‘Oh well,’ replied the doctor, ‘make the basis whiskey; put in some opiate; disguise the whole with a bitter tincture; get highsounding testimonials or indorsements, and especially give it an attractive, ‘taking’ name. Then extensively advertise it from ‘Dan to Beersheba’ and the thing is done.’ The young man, evidently impressed with the simplicity of the scheme, did precisely that. Scotch Oats Essence enjoyed a successful, if devastating, career as a nerve tonic, until someone analysed the solution and announced that it contained morphine.’1Countless remedies like Scotch Oats Essence, containing opium or morphine, were readily available to the public.

When we look at overall opium consumption in the United States during the 19th century, the picture that emerges is similar to that for Britain. Courtwright has calculated annual opium consumption in the US for the period 1846-1850, on the basis of import figures, and arrives at a figure of 1,036 mg per head of the population [The spread of this medical/paramedical form of opium consumption in the United States, between 1840 and 1850, was completely separate from the use of smoking opium by Chinese immigrants () which was a later development].

No quantitative data are available for the Netherlands, to my knowledge, concerning opium consumption in the 19th century. There is however some evidence to suggest that, just as in Britain and the United States, a wide range of opiumcontaining patent remedies were available there. The ‘patent remedies industry’ targeted the lower classes in particular, and played a leading role in popular medicine. This is clear from the advertisments of these remedies that appeared in daily newspapers. The same advertisements, it should be said, were published in medical journals: in the Netherlands too, it appears, the medical establishment had not yet broken away entirely from the informal marketplace with its myriad wonder cures.

A pleasant sense of intoxication which apparently also possessed medicinal value, as it provided pain relief for a small amount of money. This, in a nutshell, is the formula that explains the immense demand for opiates among factory workers and agricultural labourers. Opiates went some way towards dulling the recollection of the pain and exhaustion that resulted from heavy toil, it helped to induce sleep, and was particularly useful as a remedy to suppress coughing. On top of this, opiates helped to pacify children, enabling their mothers to carry on their work in the factory or on the land.

Karl Marx has an illuminating footnote on this subject: ‘During the cotton crisis caused by the American Civil War, Dr. Edward Smith was sent by the English government to Lancashire, Cheshire and other places to report on the state of health of the cotton operatives. He reported that from a hygienic point of view, and apart from the banishment of the operatives from the factory atmosphere, the crisis had several advantages. The women now had sufficient leisure to give their infants the breast, instead of poisoning them with “Godfrey’s Cordial” (an opiate).’ This passage reveals the origins of Marx’s famous definition of religion as ‘the opium of the people.’

Yet the popularity of pills, powders and potions containing opium, around 1850, was far from being an exclusively lowerclass phenomenon. (The smoking of opium, the usual mode of consumption in China, was virtually unknown in Britain, the Netherlands and the United States, except among Chinese travellers or immigrants). Prosperous citizens too availed themselves of opium-containing remedies which in their case were generally prescribed by qualified physicians.

Many of them were men of literature, who soon discovered that opium had more to offer than mere pain relief in disease and discomfort. Samuel Coleridge and Thomas de Quincey in England, Charles Baudelaire in France, Edgar Allen Poe in the United States, Willem Bilderdijk and Francois Haverschmidt (a pharmacist’s son!) in the Netherlands they all used the intoxication of opium to enhance their artistic work. Several of them sang its praises, although a certain ambivalence became apparent when its less attractive qualities impinged on them. ‘Woe to those who abuse it! This substance so drastic / in effect, so formidable, so devastating to strength and spirit!’ An artistic panegyric of this kind appealed to the imagination of others, who took to imitating these artists in their use of opiates, sometimes with fatal consequences [In his biography of De Quincey, Grevel Lindop writes: ‘Not all the influence of the Confessions, however, was literary. In 1823 a young man died from an overdose of opium. It appeared that he had been experimenting with the drug, and at the inquest a doctor testified that there had lately been an alarming increase in the number of such cases, “in consequence of a little book that has been published by a man of literature, which recites many extraordinary cases of taking opium”’].

All in all, the consumption of opiates, in both Britain and the United States, was a conspicuous phenomenon in the first half of the 19th century. And the situation in the Netherlands is unlikely to have been very different. This widespread use of opiates was not accompanied by any form of statutory regulation. In a few cases, municipal authorities restricted consumption, but for those who wanted them, opiates were inexpensive and easily obtainable. And since opium and related substances was frequently used as a raw ingredient in the patent remedy industry, people were sometimes quite unaware that they were consuming it.

The origins of national medical regimes for opiates

Around the mid19th century, the free market in opiates was gradually subjected to restrictions. The Netherlands and Britain were first to introduce constraints, but the United States soon followed suit. Marx has another pertinent comment in this regard. He distinguishes the three elements on which the social unease about opiates centered in Britain: ‘In the agricultural as well as the factory districts of England the consumption of opium among adult workers, both male and female, is extending daily. ‘To push the sale of opiate ….. is the great aim of some enterprising wholesale merchants. By druggists it is considered the leading article’. Infants that received opiates ‘shrank up into little old men’, of ‘wizened like little monkeys’. We see here how India and China have taken their revenge on England. Hence a variety of factors the irresponsible and injudicious use of opium by workers and their children, the explosive growth of the retail trade in opiates, and the reviled colonial opium policy combined to arouse public indignation: at length, the calls for government intervention no longer fell on deaf ears. The medical profession, not exactly a disinterested party, was in the vanguard of the formalizers of the regulatory regime for opiates: that is to say, as far as the campaign to curb the irresponsible consumption of opium by workers and their children was concerned, and the clampdown on the burgeoning retail trade. The denunciation of the colonial opium trade, on the other hand, was a cause largely associated with organizations such as the Society for the Suppression of the Opium Trade, and its consideration was deferred. In the various countries of the Western world a coalition of physicians and pharmacists claimed a nationwide monopoly on the preparation, description and retail sale of opiates. Given the high levels of consumption, considerable economic interests were at stake. The medical professions eventually secured this coveted monopoly, which included financial support from the state. In the Netherlands, the turning point was the passing of the Preparation of Medicines Act 1865. A few years later Britain passed similar legislation in its 1868 Pharmacy Act. In the United States things moved a little more slowly: the Pure Food And Drug Act was not introduced until 1906. Each of these national laws made the preparation, prescription, and distribution of the majority of opiates the exclusive prerogative of medical practitioners and pharmacists. The hypothesis advanced in the present chapter is that the formal, medical regulation of the supply and management of opiates was a major determining factor in the professionalization of these medical groups in the countries concerned [In the literature on theories of professionalization, three key criteria are given for assessing the level of professionalization achieved by a particular occupational group: a mandate from above, autonomy within the group itself, and the (one-sided) dependency of their clientele].

The medical regulation of opiates in the Netherlands

The medical regulation of opiates in England

The medical regulation of opiates in the United States

Morphine and the hypodermic syringe

Two things in particular intensified the formal medicalization of the regulatory regime for opiates in the latter half of the 19th century: first, the isolation of the powerful opiate morphine (at the beginning of the 19th century) and second, the popularization among physicians of a new technique of medical administration: the hypodermic syringe.

Almost immediately after the morphine purification technique had been mastered, medical practitioners and pharmacists succeeded in gaining exclusive control over the drug. The discovery of morphine was the product of a branch of science that was undergoing immensely rapid development at this time: the medical line of applied chemistry, from which the pharmaceutical industry would emerge in the 20th century. Morphine was the first of a group of compounds which became available in purified form with the advent of modern chemistry. Within a short space of time, a variety of other alkaloids were isolated, including narcotine, strychnine and quinine.

Although the principle of subcutaneous administration was known a good deal earlier, the definitive breakthrough of the technique of injection in medical practice is attributed to British physicians around 1840. In the 1850s the technique became widely known after articles on its use had appeared in trade journals. Outside Britain too, medics sat up and took note: In less than a generation the hypodermic kit took the world’s medical profession by storm. In the late 1850s, few practitioners had heard of it. By the 1870s, it was a standard article in the doctor’s bag. Morphine injection in particular soon came to be viewed as a medical intervention, which enabled physicians to distinguish themselves from people with no medical training. New types of hypodermic syringe were designed by and for physicians, specifically for the administration of morphine. The medical monopoly on the technique of injection had the effect as did every use of specialist instruments of increasing doctors’ social status, at the same time as consolidating the ongoing professionalization of their group. In the 1860s and 1870s the injection of morphine was actually propagated in Britain as a remedy for people who were addicted to the oral use of opiates and wanted to quit the habit.

The downside of a course of treatment with morphine injections soon became clear: ‘Enthusiasm for hypodermic morphine was generally accompaniment by a denigration of opium; the ‘medical’ remedy was seen as more effective. But the profession was also creating its own problem by the advocacy of hypodermic usage, and it was not long before the first warnings of the increased incidence of addiction began to appear.’

The injection of morphine was enormously popular among medical practitioners. As long as the dangers of addiction were not yet fully appreciated, large numbers of patients were treated with morphine for the most diverse of disorders, both in Britain and in the United States. This unchecked practice took its toll in the United States: ‘In spite of repeated warnings, therapeutically engendered addiction remained a serious problem until the early 20th century, when the American medical profession largely abandoned its liberal use of opium and morphine.’

Most 19th-century American morphinists thus owed their addiction to a course of treatment that had been prescribed by their doctor. This explains why opiate addiction was most prevalent in 19th-century America (aside from the Chinese users) among white middle class women. They belonged to the category of people who could afford a physician. Another factor that helped to expedite the spread of morphine use in the United States, which had thus partly been caused by the quick rise to popularity among the medical profession of the technique of injection, was the Civil War. For though morphine had no curative value whatsoever, it did alleviate distress: it rapidly acted to relieve war casualties of their pain. Once morphine injections had proved their worth in the army hospital, they soon spread to other areas of medical practice. The hypodermic syringe and stethoscope together served as status symbols which not only distinguished medical practitioners from quacks, but also characterized the user, within the profession, as advanced and up-to-date: ‘Promoters [of the hypodermic syringe] played upon professional insecurities, noting that practitioners of standing were quick to avail themselves of the advantages of the syringe and implying that those who did not were in danger of falling behind. The percentage of American physicians practicing hypodermic medication grew dramatically during the 1870s; by 1881 virtually every American physician possessed the instrument.’

In Britain and the United States (and probably in the Netherlands) morphine was not only prescribed frequently to the patients of qualified medical practitioners, it was also used by numerous physicians, dentists and nursing Staff [To my knowledge figures have never been researched for the Netherlands comparable to the studies of Berridge and Edwards and Courtwright]. (Pharmacists were subject to stricter controls, and therefore had greater

difficulty gaining access to the drug). What may well have started as ‘professional self-medication’, would soon become an entrenched habit. The estimates of users among the medical professions in the United States are highly divergent: 6%-23% of all physicians are believed to have belonged to the population of regular morphine users at the beginning of the 20th century. Moreover, the wives of medical professionals all too often found relief in the intoxication induced by morphine injections prescribed by their husbands.

With almost fifty years of experimentation with morphine injections behind them, physicians were painfully aware of the consequences of morphine treatment. The risk of addiction provided them with an additional argument to bolster their demands for a monopoly on the control of all opiates. Medical supervision was essential for all opiates, including injected morphine, both to prevent incompetent use and to militate against the development of an addiction. This argument was incorporated into the successful medical campaign for a statutory scheme to regulate the preparation, prescription and sale of opiates. As a result of the new legislation, the medical profession had a state-sanctioned monopoly position: from that time on, they were the state’s sole curators in the supply of opiates.

The monopoly on opiates contributed, as has already been noted, to the professionalization of the groups concerned. The new legislation meant that people wishing to obtain opiates were more dependent than in the past on the mediation of physicians and pharmacists. This sharpened the dividing line between these latter groups and traditional opiate retailers. But this nationwide medical monopoly not only contributed to the professionalization of these medical groups, it was also a product of it. So the formal medicalization of opiates was embedded in this far wider process of professionalization.

This formal medical regulatory regime brought to an end the legal recreational consumption of opiates, nor did any scope remain for the legal self-administration of opiates as a form of self-medication. The prohibition of the use of opiates without medical intervention — and the prosecution of offenders — was an inevitable consequence of the government sanctioned monopoly obtained by the medical profession. This reduced the scope for more informal types of regulation to the small circle of a largely deviant subculture. At worst, this led to the criminalization of the users of illegal opiates. Moreover, where users succeeded in obtaining their intoxicant from their doctor, they were stigmatized, and their use of opiates was justified by invoking a Pathology [ The consequences of this medical monopoly for the supply of opiates outside the medical circuit — i.e. the black market]

 

Selections from the book Jan-Willem Gerritsen: “The Control of Fuddle and Flash: A Sociological History of the Regulation of Alcohol and Opiates”, 2000.