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Morphine and Its Hypodermic Use

Professional
involvement in the question of opium use was not limited to the sale
and availability of the drug. In the last few decades of the century
doctors in particular became more closely involved in the way it was
administered and used. Popular use of opium continued and the sale of
’non-medical‘ patent remedies was high, as the previous chapter has
demonstrated. But the increased medical use of a new form of opium, its
alkaloid, morphine, brought a closer medical concern both with
hypodermic morphine-injecting addicts and, through them, with
delineating new medical views of opium eating based on ideas of disease
and treatment.1 It is this involvement and the advent of the new
hypodermic technology of administration which are considered in the
following two chapters.
Although medical concern about hypodermic
morphine use was only a feature of the last quarter of the nineteenth
century, the isolation of morphinn as the active principle of opium was
made early in the century. Responsibility has traditionally been
assigned to three men .2 In 1803, Derosne, a French manufacturing
chemist, produced a salt, his ’sel narcotique de Derosne‘; this was the
substance later known as narcotise, but it also contained some
morphine. A year later, Armand Seguin read a paper before the Institut
de France in which de described his isolation of the active principle
of opium. His communication ‚Sur l’opium‘ was not published until 1814.
Meanwhile Frederick William Serturner, a pharmacist of Einbeck in
Hanover, working on Derosne’s salt, had investigated the composition of
opium more accurately than anyone before. He isolated a white
crystalline substance which he found to be more powerful than opium.
Calling the new substance `morphium‘ after Morpheus, the god of sleep,
he published details in the journal der Pharmazie, in 1 805, 1 806 and
1811, although the significance of his breakthrough was not appreciated
until he wrote again on the subject in 1816. In 1831, the Institut de
France awarded him a substantial prize for `having opened the way to
important medical discoveries by his isolation of morphine and his
exposition of its character‘.
The isolation of morphine was part of
a general systematization of remedies_ and discovery of alkaloids in
line with the growth of toxicology as a science. Quinine, caffeine and
strychnine were all isolated shortly after morphine. Other opium
alkaloids were also discovered – narceine by Pelletier in 1832, and
codeine by Robiquet in 1821 while examining a new process for obtaining
morphine suggested by Dr William Gregory of Edinburgh. Morphine
(sometimes still referred to as ‚morphium‘) first became known in
Britain in the early 1820s, in particular after publication of the
English translation of Magendie’s Formulary for the Preparation and
Mode of Employing Several New Remedies.3

price list 1822

Morphine was manufactured
on a commercial scale quite early on. It was produced by Thomas Morson,
later a founder of the Pharmaceutical Society and one of its
presidents. He had originally gone to Paris to train as a surgeon, and
had picked up his pharmaceutical knowledge there. Morson took over a
retail business in Farringdon Street on his return to England; and it
was in the parlour behind the shop that morphine and other drugs were
produced. Morson’s first commercial morphine was produced in 1821, at
about the time when Merck of Darmstadt also began production of
wholesale morphine. The English variety sold at eighteen shillings per
drachm, with the acetate and sulphate also selling at the same rate.4
Macfarlan and Company of Edinburgh began to manufacture the alkaloid in
the early 1830s, when Dr William Gregory (the son of James Gregory, of
Gregory’s Powder) devised a process for the production of morphia
muriate. British opium collected by Mr Young in his initial experiments
was used. The drug was later purified and more exact processes devised.
In the early years of morphine production, Macfarlan’s received opium
from the London wholesale houses and returned them the muriate. The
drug was still brown and formed a brown solution, for the process then
used did not abstract the resin of colouring matter.
When Macfarlan’s produced a purer white substance, they had difficulty in persuading purchasers to accept it.5
There
was little difficulty, however, in persuading medical men to use the
new drug. The evidence suggests that by the late 1830s or early 1840s
the drug was accepted, and often preferred, in medical practice. It
found a place in the London Pharmacopoeia in 1836. By the end of the
decade, medical men were discussing in some detail the dosage and form
of administration they preferred. In King’s College Hospital in London
morphia was in routine use as early as 1840, mostly for sleeplessness.
The stock of a Liverpool shop in the mid 1 840s had seven ounces of
morphia hydrochlorate (worth £3 4s.I0d.), two ounces of muriate and
three and a half ounces of the acetate.6
The muriate, hydrochloride
and acetate of morphia were all used in these early days; the two
former preparations later became established as standard. Preparations
such as bromide 0f morphine, bimeconate, morphine sulphate and morphine
tartrate came on to the market later. The drug was recommended for
almost as many conditions as opium. It was never even in these its
early years administered solely by mouth. There were morphia
suppositories – Dr Simpson’s Morphia Suppositories, made of morphia and
sugar of milk, dipped into white wax and lard plaster melted together,
produced by Duncan and Flockhart of Edinburgh, were available. One
surgeon was horrified to find that his dog had swallowed a batch of
morphia suppositories made with mutton fat.7 There was also the
endermic use of the drug. Michael Ward, physician to the Manchester
Infirmary, in his Facts Establishing the Efficacy of the Opiate
Friction (1809), pointed out that opium through the skin had a
different effect from opium administered by the mouth.“ Opium was quite
regularly used externally and the endermic method, whereby a section of
the skin was removed, usually by blistering, and the powdered drug
applied to the denuded spot, was particularly popular for morphine.9
For instance, Mr Hanley, in Islington in 1865, was prescribed morphine
hydrochloride in liquid form, also to be absorbed through the skin.
He was to `dip a little bit of soft lint into the lotion and lay it upon the most painful part occasionally‘.10
At
the same time as these perhaps crude and experimental attempts were
being made to produce a more immediate drug effect, the hypodermic
method of administration was developed.
Intravenous administration
had a much longer history than hypodermic injection, which was a
development of the mid-nineteenth century. Drugs, including opium, had
been injected into both animals and man since the seventeenth century
at least.“ The method was desultorily used, and interest in it did not
revive until the end of the eighteenth century. The new practice then
of inoculation was a further stage in the evolution of the hypodermic
method. Dr Lafargue of St Emilion, in a series of letters and papers in
the 1830s, described his method for the inoculation of morphine. The
point of a lancet was dipped into a solution of morphine, inserted
horizontally beneath the epidermis, and allowed to remain there for a
few seconds. But his researches eventually developed in a different
direction. In the 1840s he was advocating the implantation of medicated
pellets with a darning needle.12
Such methods were in a sense
`curtain raisers‘ for the true hypodermic method. Three men have the
credit for its development: Dr Rynd of Dublin, Dr Alexander Wood of
Edinburgh, and Dr Charles Hunter, a house surgeon at St George’s
Hospital in London. Rynd, working at the Meath Hospital and County
Infirmary in Dublin in the 1840s, described how he had cured a female
patient of neuralgia by introducing a solution of fifteen grains of
acetate of morphine by four punctures of `an instrument made for the
purpose‘. The patient recovered, as did others. Ten years later,
Alexander Wood, apparently unaware of Rynd’s earlier publication,
described his own treatment of neuralgia. He had made several attempts
to introduce morphia by means of puncture needles, and, in 1853, `1
procured one of the elegant little syringes constructed for the purpose
by Mr Ferguson of Giltspur Street, London‘. Experiments with the
muriate on an elderly lady suffering from neuralgia proved the utility
of the method. Papers -published in 1855 and 1858 gave publicity to
it.13
However, it was the use to which the new method was put by Dr
Charles Hunter which revealed its true potential. Hunter had initially
used Wood’s hypodermic method purely as a local means of treating
disease. Sepsis set in; Hunter was forced to use other sites for
injection and quickly realized that the results obtained were as good.
He became an advocate of the `general therapeutic effect‘ of hypodermic
medication, as distinct from the `localization supported by Woods and
others. 14 What he called his ‚ipodermic (and later hypodermic) method
led to a period of sustained and acrimonious debate between Wood and
Hunter. Although the former had, in his 1855 paper, described the
general effects of the method, it was Hunter who developed this aspect,
while Wood clung tenuously to the belief that it was a local means of
treating a local affection. The controversy created such interest that
the Royal Medical and Chirurgical Society, to which Hunter had read a
paper in 1865, appointed a committee to look into the question of
hypodermic medication. Its report, published in 1867, came down
strongly on Hunter’s side. It concluded that `no difference had been
observed in the effects of a drug subcutaneously injected, whether it
be introduced near to, or at a distance from the part affected‘. Belief
in the localization theory lingered on, but Hunter’s method was more
generally accepted.15
He had recommended the hypodermic use of
morphine for its certainty in action and for more rapid absorption.
Morphia injections he advocated as of benefit in melancholia, mania and
delirium tremens, where it did away with the necessity for restraint.
It was useful for chorea, puerperal convulsions, peritonitis, ague,
uterine pain, tetanus, rheumatism and incurable diseases such as
cancer. There were others in the medical profession as enthusiastic,
but no one perhaps more so than Dr Francis Anstie. Anstie was editor of
the Practitioner from its foundation in 1868 until his death in 1873
and his concern about working-class and opium use has already been
mentioned. His particular interests lay in the areas of alcohol and
neuralgia (on which he wrote sections for Dr Russell Reynolds’s System
of Medicine) as well as with opiates. His determined advocacy of new
and apparently better methods was representative of that section of the
medical profession which wished to develop more scientific, more
`professional‘ means of treatment, to elevate the status and develop
the expertise of doctors as a body. In his opening remarks in the first
issue of the new journal, he drew attention to the lack of proper
analysis of remedies and the isolation of more exact means of treating
disease.16
Anstie
was correct in his belief that if the profession was to establish
itself as such, and remain superior to and distinct from the mass of
quacks, herbalists, patent-medicine vendors and manufacturers, it had
to develop its own exclusive expertise, as well as a more scientific
and exact means of treating disease. It was significant, then, that
Anstie’s warmest praise was reserved in the early years of the journal
for the hypodermic method, and for its use with morphia in particular.
His article of 1868, `The hypodermic injection of remedies‘, marked the
high point of unquestioning acceptance – `of danger‘, he wrote
there
is absolutely none … The advantages of the hypodermic injection of
morphia over its administration by the mouth are immense … the
majority of the unpleasant symptoms which opiates can produce are
entirely absent … it is certainly the fact that there is far less
tendency with hypodermic than with gastric medication to rapid and
large increase of the dose, when morphia is used for a long time
together.17

In this, Anstie was at one with the Committee on
Hypodermic Injection which had recommended the method specifically for
confirmed opium eaters, since smaller doses than those previously taken
by mouth were requisite. In the late 1860s the group of `new men‘ who
formed a distinct medical group round Anstie were enthusiastic about
the `new remedy‘, hypodermic morphine. Clifford Allbutt, later Regius
Professor of Physic at Cambridge and a noted’writer on addiction,
recommended the use of morphia to treat heart disease, although opium
was generally forbidden in that type of condition. He was also using it
to treat dyspepsia and ‚hysteria‘. There was much interest in and
excitement about the new method. Hypodermic injections of morphia and
aconite were reported in use for convulsions; there were morphia
injections for chorea. Dr John Constable described how he had cured a
case of hiccoughs by the subcutaneous method.“
Doctors were engaged
in a more complex process than they realized. Advancing the barriers of
scientific discovery, analysing and utilizing new and apparently safer
or more reliable methods, they were at the same time involved in the
process of establishing their own professional expertise at the expense
of `non-scientific‘, harmful or unreliable remedies. Enthusiasm for
hypodermic morphine was generally accompanied 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 most influential
in English medical circles was that of Clifford Allbutt in 1870.
Allbutt
expressed the progress of his doubts in the Practitioner, in particular
the case of nine of his patients who seemed as far from cure as ever
despite the incessant and prolonged use of hypodermic morphia.
`Gradually … the conviction began to force itself upon my notice,
that injections of morphia, though free from the ordinary evils of
opium eating, might, nevertheless, create the same artificial want and
gain credit for assuaging a restlessness and depression of which it was
itself the cause.““‚ He was not the first to draw attention to this
attendant possibility, and warnings had been published as early as
1864.20 Allbutt’s warning was initially not generally accepted in the
profession .21 Even Anstie himself was unwilling to abandon the
benefits of morphia because of the danger of addiction. He was in
favour of a form of maintenance prescribing, of controlled morphine
addiction on a lower dosage: `Granting fully that we have … a fully
formed morphia-habit, difficult or impossible to abandon, it does not
appear that this is any evil, under the circumstances.’22 In hospital
and general practice, the 1870s marked no particular dividing line;
doctors still wrote enthusiastically to the medical journals of the
good results they had obtained by using hypodermic morphine.
Yet
there was a dawning realization that morphine injections on a repeated
basis could have attendant dangers. Reports of the utility of the
method were tinged with a certain wariness, in. particular as details
of the abuse of the drug on the continent and in America began to
filter through. It was on the continent, too, that concern and a more
exact definition of morphine addiction crystallized. Dr E. Levinstein
of Berlin published in 1877 Die Morphiumsucht nach Eigenen
Beobachtungen, translated into English the following year as Morbid
Craving for Morphia (1878).23 Levinstein’s work was the first
all-embracing analysis of
the condition of morphine addiction to
reach the English medical profession. (Dr Calvet had published an Essai
sur le Morphinisme aigu et chronique in Paris in 1876 but this appears
to have made no impact in Britain.) Levinstein’s book was based on his
own experiences in the institutional treatment of addiction in Berlin,
and
was instrumental in defining ‚morphinism‘ as a separate condition or
disease. As Levinstein himself remarked, others had seen it as
‚Morphinismus‘, ‚Morphia-delirium‘ or `Morphia evil‘. He was the first
to define it as a disease with a similarity to dipsomania, although not
a mental illness. Levinstein still saw addiction as a human passion
`such as smoking, gambling, greediness for profit, sexual excesses,
etc….‘.
Disease
isease theories were developing in many areas at this time; the
elaboration of disease theories of narcotic addiction and the
importance of Levinstein’s work in this respect will be discussed in
the following chapter. What was also important for the English medical
profession, however, apart from the ideas contained in the book, was
the interest in the subject which it stimulated. The 1878 book was
widely reviewed and discussed. In 1879 came a request from Dr H. H.
Kane of New York, anxious for information about British doctors‘ use of
hypodermic morphia. He was particularly interested to learn if any
cases of opium habit had been contracted in this way. His book, The
Hypodermic Injection of Morphia. Its History, Advantages and Dangers
(1880), was based on the experience of British as well as American
physicians.24 The work of another German expert, Dr H. Obersteiner, was
published in the newly established Brain; and continental doctors were
crowding thick and fast into this newly opened medical field .2b
British doctors themselves were increasingly aware of morphine
addiction. Case histories which had appeared sporadically in the
medical press in the 1870s were, by the end of the decade, greatly
increased in quantity and prominence.28
A report on chloral produced
by the Clinical Society of London in 1880 drew attention to the
possibility of misuse not only of that drug, but of narcotics in
general. The committee’s report was in ha neutral as to the supposed
deleterious effects of the long-contlnued use of chloral. But its
publication was the occasion for comment on the apparent increase
in addiction to all forms of narcotics, chlorodyne and morphine in
particular. The dangers of hypodermic use were highlighted; there
was a contribution in The Times from an addict who had re-used his
original morphine prescription again and again .27 The death of Mr
Edward Amphlett, ‚a nephew of Baron Amphlett and assistant surgeon at
Charing Cross Hospital, who was revealed at the inquest in 1880 to have
been accustomed for years to take chloral and morphia, confirmed fears
of increased use.28 In the Commons, Lord Randolph Churchill
significantly compared Gladstone’s oratory on Home Rule to ‚the taking
of morphia! The sensations … are transcendent; but the recovery is
bitter beyond all experience . . . ’29
Churchill’s views were echoed in the medical presentation of
morphine addiction: Dr Seymour Sharkey wrote on the treatment of
‚morphia habitues‘, citing a case of his, a city manager, whose
business gave him the facilities for getting as much morphia as he
pleased and who had used the drug over a seventeen year period. Sharkey
later expanded, and to a certain extent sensationalized, his views in
-an article on ‚Morphinomania‘ in the Nineteenth Century in 1 $87.30 In
11889, Dr Foot led an extensive discussion of morphinism in a meeting
of the Irish Royal Academy of Medicine. Ascribing a five-fold origin to
the habit – for relief of pain, insomnia, melancholia, curiosity and
imitation – he recognized that the possibility of cure was dependent on
the duration of the habit, the persistence or not of the exciting cause
and the physical or nervous constitution of the patient-31
In the
1880s doctors were as busy elaborating the dimensions of morphinism and
delineating the outlines of the typical morphia habitue as they had
once been in analysing those conditions where hypodermic usage was
invaluable. Case histories of morphine addicts to a great extent
replaced studies of morphine use in the medical journals. Continental
and American influence was still noticeable. Dr Albrecht Erlenmeyer’s
work on morphine addiction, published originally in Germany in 1879,
became known in its English version at the end of the 1880s.$2 The most
persistent `outside‘ influence on British medical thinking on morphine
addiction towards the end of the century was the work of Dr Oscar
Jennings. Jennings, an ex-morphine addict himself, was English, but the
bulk of his working experience, and case histories, came from France.
His ideas on the treatment of addiction led him into much controversy,
yet the sheer volume of his published work – in books like On the Cure
of the Morphia Habit (1890), The Morphia Habit and its Voluntary
Renunciation (1909), The Reeducation of Self-control in the Treatment
of the Morphia Habit (1909), numerous articles and contributions to
journals and conferences – made his name a force to be reckoned with.33
Well-defined
views were held on the origin and incidence of the disease. Most
accepted a stereotype whereby morphine addiction was vastly increased
and increasing, where many addicts had acquired the habit through
original lax medical prescription and through the eventual
self-administration of the drug. Women
were said to be peculiarly
susceptible to morphinism; and not a few doctors recognized that the
medical profession itself was also highly -prone to
addiction.`Morphinomania,‘ Dr H. C. Drury told the medical section of
the Irish Royal Academy in March 1899, `is increasing with terrible
rapidity and spreading with fearful swiftness.‘ The `recourse to
injections under the‘ skin‘ was accordmicing to the Lancet in 1882
`becoming general‘, while Dr S. A. K. Strahan, physician to the
Northampton County Asylum, agreed. The `vicious habit‘ was `undoubtedly
a growing disease‘.“ The greatly increased general number of case
histories and comments on the subject gag substance to a feeling that
an epidemic was threatening.
Medical susceptibility to morphine
addiction was established. Drury, for instance, thought that
morphinomania was particularly prevalent among the medical profession,
and a standard medical text like Sir William Osler’s The Principles and
Practice of Medicine (1894) saw doctors forming one of the main classes
of addicts .35 Conventional ideas about the weakness of the female sex
were-al-so soon linked with the spread of morphine use. As the Lancet
put it, `Given a member of the weaker sex of the upper or middle class,
enfeebled by a long illness, but selfishly fond of pleasure, and
determined to purchase it at any cost, there are the syringe, the
bottle, and the measure invitingly to hand, and all so small as to be
easily concealed, even from the eye of prying domestics.‘ Most medical
writings on the subject were united in seeing women pecukarly at risk
.36 Female susceptibility was linked with the iatrogenic origin of most
morphine addiction, and also with the idea of selfmedication. The
apparent willingness of practitioners to hand over control of injection
either to a nurse or to the patient herself was stressed, and this
usurpation of the professional role of the doctor was a continuing
theme in discussions of morphine addiction. Dr Macnaughton Jones told
the British Gynaecological Society in 1895 that no patient should be
allowed to inject herself. Levinsein, too, attributed the spread of the
disease to the carelessness bf medical menrin allowing patients to
inject .37
These questions of the amount of increased usage of the
drug (and its hypodermic usage in particular), the numbers of addicts
at this period, and their social class and gender badly need more
extended examination if the reality of the picture presented in the
medical journals is to be assessed. In certain respects, it is clear
that the medical profession was myopically exaggerating the dimensons
of a situation it had helped create. How much morphine was actually
being used in England at this time is difficult to estimate. To arrive
at any picture of overall home consumption of morphine is almost
impossible. Duty on imported opium ceased in 186o and no actual `home
consumption‘ figures are available after that date. Estimates of home
consumption of all narcotics, including morphine, after 186o can only
be obtained by subtracting the amount exported from that imported. This
is an uncertain method of assessing anything but the most general
trends in overall consumption. These moved upward for the first fifteen
years after the abolition of duty in 1 860, but decreased between the
mid 1 870s and the 1890s.38 General trends reveal little about the
production and home consumption of domestic morphine. Morphine was not
separately incorporated into the trade statistics until 1911 (and then
largely because of the demands of the 1911 Hague Convention for the
collection and production of morphine and cocaine statistics). Until
this date, it was included in the `drugs, unenumerated‘ section and
measured only in terms of financial value. The trade statistics are of
little direct value in an examination of morphine production. Yet there
was a widening post-186o gap between imports and exports. This strongly
suggests that much of the imported drug was being used to make
morphine, since even the best Turkey opium would yield only around 10
per cent morphine. The general trend of home consumption also bore a
strong relation to the business cycle. The connection with the onset of
the `Great Depression‘ of the 1870s was particularly marked, and
consumption appears to have declined. Fluctuations like this again
suggest a connection with the overall fortunes of the morphine industry.
Yet
how much morphine Thomas Morson and Son, J. and F. Macfarlan and T. and
H. Smith in Edinburgh were actually producing and exporting at this
time remains uncertain. Wholesale business records show that morphine
was popular, but no more so than other opium preparations and
derivatives. The Society of Apothecaries for instance, one of the major
wholesaling organizations, was producing large quantities of morphine
preparations in the 1860s, but fewer a decade later. Yet the importance
of morphine should perhaps not be overemphasized or singled out. The
Society was still making large quantities of other opium preparations,
too – it had twenty-six on its laboratory list in 1871. There were
thirteen batches of paregoric, ten of laudanum, nine of powdered opium,
and also of gall and opium ointment. Morphine at this wholesale level
was only a part of the whole spectrum of
opiate use. 39
This is
also the picture which emerges of ‚grass-roots‘ usage in the second
half of the century. In everyday medical and pharmaceutical practice
morphine was in increased use. But there was nothing like the epidemic
of rising consumption which the medical accounts suggested. Nor was
everyday medical practice a matter of hypodermic injection alone.
Morphine was used in many varied forms and there is little evidence 0f
extensive self-administration of the hypodermic syringe. The evidence
of prescription books shows that morphine was in quite regular use in
the second half of the century, but that dispensing 0f the drug was not
rapidly escalating. An Islington pharmacist, for instance, dispensed
fiftyfive morphine prescriptions in 1855 (from a total 0f 378), or 14.5
per cent of the whole number of opium-based remedies. By 1865, the
number had risen t0 sixty-four (out of 316), or 20 per cent. But
figures in 1875 and 1885 were lower.40 Re-dispensing must be a matter
of conjecture, since chemists noted only new prescriptions and did not
re-enter a copy each time an old prescription was dispensed. Clearly,
however, the picture of morphine prescribing at the level of general
practice differed from the conventional stereotype. Doctors were likely
to administer hypodermic injection themselves either in the surgery or
on home visits. Yet if the self-injection which the medical accounts
postulated were reality, some of it would have come to light through
the dispensing of doctors‘ prescriptions by pharmacists. There is
little sign of it. The poisons register for an Eastbourne pharmacist’s
practice, giving details of transactions under the Pharmacy Act in the
1880s and early 1890s, shows entries for morphia and ipecacuanha
lozenges for cough, but only one entry in a six-year period between
1887 and 1893 for sol. morph. hypo, or hypodermic morphia.41
Nevertheless cases where the hypodermic drug was recklessly prescribed
are not hard t0 find. Alfred Allan, given hypodermic morphia `very
frequently‘ in King’s College Hospital, was discharged in July 1870,
partly at his own wish, partly because the `Sisters got tired of him‘.42
Even
quite limited administration of the drug in this way, in unwise
quantities or on an extended basis, could have resulted in a serious
escalation of addict numbers. But there is little evidence that there
were large numbers of morphine addicts in the late nineteenth century.
One surprising omission in the welter of discussions on treatment
methods, the origin of ‚ addiction and the characteristics of the
addict was any serious consideration of how many of them there really
were. It is only through examination of numbers of addicts admitted for
treatment that some estimate can be made. An inebriates‘ home or a
lunatic asylum were the two possibilities, and clearly only those whose
habit was out of control would be admitted there. As Dr Robert
Armstrong-Jones pointed out in 19o2, it was difficult on that basis to
calculate how large the class of addicts really was, since `only the
repentant sinner visits the consulting room‘. Repentance must have been
limited; for the numbers of admitted addicts were always very small.
Jones himself reported eight admitted to the Claybury Asylum by 19o2
(within an unspecified period). Four of these were taking morphia
hypodermically and one by mouth; the others took opium in various
forms. At Bethlem Royal Hospital, few addicts were admitted. There were
only nine cases between 1857 and 1893, two of these taking morphia.43
More cases were admitted to inebriates‘ homes. The Dalrymple Home at
Rickmansworth took in addicts as well as alcoholics. Between 1883 and
1914, one hundred and seventeen drug cases had been admitted. Forty-six
of these were taking morphia and fifteen both morphia and cocaine, a
rate of admission of approximately two addicts a year .44
There were
few signs of hypodermic usage of epidemic proportions here. Dr
Armstrong-Jones was of the opinion that, for every case admitted to an
asylum, there were probably scores outside with the habit whose mental
and moral state was on the borderline of insanity. Yet he gave no
evidence to support his assertion; and the low level of admissions, if
not a guide to the general morphine addict population, at least
indicated that only a small number were unable to lead some form of
active life. Nor did the `female‘ emphasis in medical writing bear much
relation to reality. Prescription books show that as many men as women
were initially prescribed morphine (although this does not take into
account the possible sex bias of re-dispensing). Morphine was
undoubtedly popular in the treatment of specifically female complaints
– for period pains, in pregnancy and during labour – and also for those
ailments such as neuralgia, sleeplessness and `nerves‘ in general,
which were considered to have a hysterical origin and so to be
particularly common among female patients. There were wellknown female
addicts like G. B. Shaw’s actress friend Janet Achurch.45 Yet Jones’s
own case histories of 1902 were evenly divided between male and female;
and whereas three 0f the four males used hypodermic morphia, only one
0f the females did so. The morphia cases admitted t0 Bethlem were all
male.
The identifiable hypodermic morphine-using addict population
at this date in fact appears to have had a medical or professional
middle-class bias. There was n0 morphine-using drug sub-culture to
parallel the beginnings 0f self-conscious recreational use of other
drugs like cannabis and cocaine described in Chapter 16. Like the
disease theory formulated to encompass addiction, the focus of morphine
injection was very much a professional one. Virgil Eaton, in a study 0f
opiate dispensing in Boston in the late 1880s, found the lowest
proportion of morphine dispensed in the poorer quarters of the town. In
England, too, morphia was always the more expensive drug and
opportunities for addiction more easily available to better-off
patients 46 There undoubtedly was addiction t0 hypodermic morphine; and
from this time forward hypodermic use of the drug was, in medical eyes,
the major part of the `problem‘ of opium use. Nevertheless part of the
contemporary medical stereotype of the incidence and nature of the
practice remains unproven. It is probable that, in numerical terms
alone, morphine addicts bore no comparison to those dependent on opium.
Much opiate consumption had always been outside the medical ambit of
control, whereas morphine had always been primarily a `medical‘ drug.
The profession, by its enthusiastic advocacy of a new and more
`scientific‘ remedy and method, had itself contributed to an increase
in addiction. The new technology of morphine use – the hypodermic
method – did indeed create new objective problems in the use of the
drug. The drug effect was more immediate, and smaller doses had a
greater effect. But the profession showed a clear social bias in
singling out this form of usage when there were still far larger
numbers of consumers taking oral, opium. The quite small numbers of
morphine addicts who happened to be obvious to the profession assumed
the dimensions of a pressing problem – at a time when, as general
consumption and mortality data indicate, usage and addiction to opium
in general was tending to decline, not increase.

References

1.
G. Sonnedecker, `Emergence of the concept of opiate addiction‘, Journal
Mondiale Pharmacie, No. 3 (1962) pp. 275.90 and No. I (1963), pp.
27-34, deals with the emergence of the use of hypodermic morphine, but
the articles are marred by an automatic acceptance of a `problem‘
framework deriving closely from current concerns.
2. Details of the
process of discovery are in W. R. Bett, `The discovery of morphine‘,
Chemist and Druggist, 162 (1954), pp. 63-4; J. Grier, A History of
Pharmacy (London, Pharmaceutical Press, 1937) P. 93; AC. Wootton,
Chronicles of Pharmacy, op. Cit., p. 244.
3. For an early notice of it, see ‚Morphia, or morphine‘, Lancet, 1 (18223), pp. 67-8
4.
`Messrs Morson give up the retail‘, Chemist and Druggist, 57 (1900), p.
650; A. Duckworth, `The rise of the pharmaceutical industry‘, ibid.,
172 (1959), R 128; `Letter about the manufacture of morphine‘, Pharmaceutical
Journal, 4th ser. 5 (1897), p. i9; T. Morson, `List of new chemical
preparations, 1822′, Pharmaceutical Society Pamphlet 8745.
5. W.
Bett, op. cit., pp. 63-4; W. Gregory, `On a process for preparing
economically the muriate 0f morphia‘, Edinburgh Medical and Surgical
Journal, 3S (1831), PP- 331-8.
6. Examples of the early use and
availability of the drug are in `Professor Brande on vegetable
chemistry‘, Lancet, 2 (1827-8), pp. 389-90; King’s College Hospital
case notes, op. cit., 1840; Clay and Abraham, `Stock of a Liverpool
shop‘, 1845 Pharmaceutical Society Ms. 40619; W. Bateman, Magnacopia,
op. cit., pp. 33-4.
7. ‚Dr Simpson’s morphia suppositories‘, Medical
Times and Gazette, new ser. 14 (1857), p. 141; ‚Apomorphia‘, Lancet, r
(1883), P. 577.
8. M. Ward, op. cit., p. vii; see also the standard
article on the development of the hypodermic method, N. Howard-Jones,
`A critical study of the origins and early development 0f hypodermic
medication‘, journalof the History of Medicine, 2 (1947), PP. 201-49.
9. Review of Dr Ahrenson’s book, British and Foreign Medical Review, S (1838), P. 348.
10. Islington prescription book, op. cit., 1865 entry.
11.
Details of experiments by Christopher Wren are given in D. I. Macht,
`The history of intravenous and subcutaneous administration of drugs‘,
Journal of the American Medical Association, 1916, p. 857.
12. M.
Martin-Solon, `Review of a report on the inoculation of morphine, etc.
proposed by Dr Lafargue‘, British and Foreign Medical Review, 4 (1837),
p. 506  N. Howard-Jones, op. cit., pp. 203-4.
13. See N. Howard-Jones, op. cit., and `The evolution of hypodermics‘, Chemist and Druggist, 159 (1953), p. 607.
14. Letter from Charles Hunter in Medical Times and Gazette, 2 (1858), PP. 457-8, cited in N. Howard-Jones, op. Cit., p. 222.
15.
Hunter was in fact right, for the drug’s essential pain-relieving
action is on the central nervous system. From the injecting site, it is
absorbed into the blood stream and carried to the brain. C. Hunter, ‚On
the ip0dermic/hypodermic treatment of diseases‘, Medical Times and
Gazette, r8 (1859), pp. 234-5, 310-11, 387-8; C. Hunter, On the Speedy
Relief of Pain and Other Nervous Affections by Means of the Hypodermic
Method (London, John Churchill, 1865).
16. F. E. Anstie, Editorial,
Practitioner, r (1868), pp. i-iii; for further details of Anstie, see
his entry in the Medical Directory (London, J. Churchill, 1874), p. 48,
and H. L’Etang, ‚Anstie and alcohol‘, Journal of Alcoholism, 10 (197S),
pp. 27-30.
17. F. E. Anstie, `The hypodermic injection of remedies‘, Practitioner, r (1868), PP. 32-41.
18.
Examples of medical enthusiasm for the hypodermic method are in T. C.
Allbutt, `The use of the subcutaneous injection of morphia in
dyspepsia‘, Practitioner, 2 (1869), pp. 341-6; `Review of the West
Riding Lunatic Asylum Medical Reports‘, Journal of Mental Science, i7
(18712), P. 559; J. Constable, `Case of persistent and alarming
hiccough in pneumonia, cured by the subcutaneous injection of morphia‘,
Lancet, 2 (1869), pp. 264-5.
19. T. C. Allbutt, `On the abuse of hypodermic injections of morphia‘, Practitioner, 5 (1870), PP. 327-31.
20.
T. C. Allbutt, `Opium poisoning and other intoxications‘, in his System
of Medicine (London, Macmillan, 1897), vol. 2, p. 886.
21. G.
Oliver, `On hypodermic injection of morphia‘, Practitioner, 6 (1871),
pp. 75-80, is one example of a dissentient from Allbutt’s views.
22.
F. E. Anstie, `On the effects of the prolonged use of morphia by
subcutaneous injection‘, Practitioner, 6 (1871), pp. 148-57.
23. E. Levinstein, Morbid Craving for Morphia (Die Morphiumsucht) (London, Smith, Elder, 1878).
24.
H. H. Kane, The Hypodermic Injection of Morphia. Its History,
Advantages and Dangers (New York, Chas. L. Bermingham, 188o). For
Kane’s inquiries in the English medical journals, see `Hypodermic
injection of morphia‘, Lancet, 2 (1879), p. 441.
25. H. Obersteiner,
`Chronic morphinism‘, Brain, 2 (1878-8o), pp. 44965; and `Further
observations on chronic morphinism‘, ibid., 5 (18845), PP. 323-31.
26.
Both the British Medical Journal and the Lancet had much discussion and
correspondence on hypodermic morphine addiction and its treatment at
this time; e.g. J. St T. Clarke, `The sudden discontinuance of
hypodermic injections of morphia‘. Lancet, I (1879), p. 70; C.
Murchison, `The causes of intermitting or paroxysmal pyrexia‘, ibid., I
(1879), p. 654.
27. The Times, 30 January 188o; editorial comment in Lancet, z (188o), p. 100.
28. Amphlett’s death was reported in the British Medical Journal, 2 (188o), P. 484.
29. Hansard 3rd ser. 304 (1886), col. 1343.
30.
S. Sharkey, `The treatment of morphia habitues by suddenly
discontinuing the drug‘, Lancet, 2 (1883), p. 1120; and his
‚Morphinomania‘, Nineteenth Century, 22 (1887), pp. 335-42.
31.
Foot’s discussion was widely reported in the medical journals, for
example `Royal Academy of Medicine in Ireland‘, Lancet, 2 (1889),
p.1336.
32. There was also continuing American influence through the
work of Drs Crothers and Mattison, as in T. D. Crothers, Morphinism and
Narcomanias from Other Drugs. Their Etiology, Treatment and
Medico-Legal Relations (Philadelphia and London, W. B. Saunders, 1902);
and J. B. Mattison, The Mattison Method in Morphinism. A Modern and
Humane Treatment of the Morphin Disease (New York, 1902). Mattison also
spoke and wrote for the Society for the Study of Inebriety.
33.
Jennings‘ works and papers are too numerous to be listed
comprehensively here. See, for example, O. Jennings, On the Cure of the
Morphia Habit (London, Bailliere, Tindall and Cox, 1890); `On the
physiological cure of the morphia habit‘, Lancet, 2 (1901), pp. 360-68;
The Morphia Habit and its Voluntary Renunciation (London, Bailliere,
Tindall and Cox, 1909).
34. H. C. Drury, ‚Morphinomania‘, Dublin
Journal of Medical Science, 107 (1899), PP. 321-44; `Reckless use of
hypodermic injections‘, Lancet, r (1882), p. 538; S. A. K.
Strahan,’Treatment of morphia habitues by suddenly discontinuing the
drug‘, Lancet, r (1884), pp. 61-2.
35. W. Osler, op. cit., p. 1005.
Osler’s conclusion was not universally held. Ronald Armstrong-Jones,
medical superintendent at Claybury Asylum, openly disagreed with it: R.
Armstrong-Jones, `Notes on some cases of Morphinomania‘, Journal of
Mental Science, 48 (1902), pp. 478-95. There were some notable doctor
addicts, for example George Harley, Professor of Practical Physiology
at University College Hospital: A. Tweedie, ed., George Harley, F.R.S.
(London, Scientific Press, 1899) P• 174.
36. T. D. Crothers, op.
cit., p. 87. For examples of supposed female susceptibility, see W. A.
F. Browne, ‚Opiophagism‘, Journal of Psychological Medicine, n.s., r
(1875), pp. 38-55, and W. S. Mayfair, `On the cure of the morphia and
alcoholic habit‘,Journal of Mental Science, 35 (1889), pp. 179-84. J.
L’Esperance, `Doctors and women in nineteenth century society:
sexuality and role‘, in J. Woodward and D. Richards, eds., op. cit.,
pp. 105-27, analyses how the medical profession validated women’s
position in society. See also The Times, 12 January 1880; T. C. Allbutt
(1897), op. cit., p. 895. Allbutt did however later revise his ideas
about the female preponderance among morphine addicts; Armstrong-Jones
also doubted the validity of the stereotype.
37. H. C. Drury, op. cit., p. 327.
38.
The difficulties of using trade statistics to arrive at home
consumption data are discussed in V. Berridge and N. Rawson, op. cit.,
p. 355. Comparison of published home consumption figures prior to 1860
calculated per 1,000 population, with estimated figures derived from
subtracting the amount of opium exported from that imported, show that
estimated home consumption after 1860, then the only statistic
available, can be used only to indicate general trends.
39. Information derived from analysis of the Society of Apothecaries laboratory process book, op. cit.
40. Islington prescription book, op. cit.
41. Poisons Register, c.1886-93, Pharmaceutical Society Ms.
42. King’s College Hospital case notes.
43.
R. Armstrong-Jones, op. cit. (1902); and his `Drug addiction in
relation to mental disorder‘, British Journal of Inebriety, 12 (1914),
pp. 12548. Bethlem Admission Registers 1857-1893, Bethtem Royal
Hospital.
44. Homes for Inebriates Association, Thirtieth Annual
Report, 1913-14, P. 13, P.P. 1884-5, X V : Fifth Annual Report of the
Inspector of Retreats under the Habitual Drunkards Act, 1879, p. 32. A
breakdown of cases admitted shows not one had an associated narcotic
habit.
45. G. B. Shaw, Collected Letters, 1874-97, ed. Dan. H. Laurence (London, Max Reinhardt, 1965), pp. 503, 581.
46. V. G. Eaton, `How the opium habit is acquired‘, Popular Science Monthly, 33 (1888), pp. 663-7.

 

 

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