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Introduction PDF Print E-mail
Written by Virginia Berridge   
Monday, 04 January 2010 00:00

Introduction

The most acute anxieties of the 1960s `drug epidemic' have quietened. Drug stories appear less often, and more prosaically, in the newspapers. Yet attitudes  towards the use of `dangerous drugs', and `narcotics' in particular, remain restrictive. The legislative control of drugs and public reactions to their use is more stringent than the restrictions on those other recreational substances, tobacco and alcohol. The Misuse of Drugs Act (1971), the latest of a long line of `Dangerous Drugs' Acts, continues the practice of control through fines and imprisonment under the aegis of the Home Office. Since 1968, heroin and cocaine have been available to addicts only through treatment clinics, where doctors licensed by the Home Office may prescribe.(1) For other `recreational' substances, the system of control is much less stringent. For alcohol, the equivalent's, are the liquor licensing laws, the duty on whisky and the sale of  alcohol in pubs and supermarkets. For tobacco, they are the health warnings on cigarette packets and the no-smoking carriages in trains. The contrasts in reaction are instructive.
Regulations and legislation applicable specifically to `dangerous drugs' were not passed until the early decades of the twentieth century. The 1916 Defence
of the Realm Act regulation 40B dealing with cocaine and opium and the 1920 Dangerous Drugs Act were the first legislative measures to establish narcotics as  a matter of social policy.(2) But it was in the previous century that the basesof control were laid down, and new and restrictive ways of looking at opium established.

The nature of the drugs(3)

This book is concerned with the factors involved in that process, with the advent of legislative control over opium in the nineteenth century, with the growth of a view of opium as a `deviant' activity and with the factors which went to make it so. But first it is necessary to be armed with some basic knowledge of the pharmacological, therapeutic and addictive properties of opiates and of some other drugs. The paragraphs which follow attempt to compress a lot of the relevant science into a short space. The aim is not to produce a scientific section of pharmacology, but to deal specifically with issues which are relevant to an understanding of social reactions and perplexities. And although more is known about these scientific issues than a century ago, it must of course be bornein mind that current concepts are no more final than the nineteenth-century ideas which were their predecessors.

A simple classification

To anyone who has no specialized knowledge, the great variety of substances which act on the mind create a rather bewildering situation. Is every drug different or is there some simple way of grouping these substances? There is in fact a simple classification which can help to guide one through the seeming complexities there are just four different basic categories of mind-acting drugs.

1. Opiates. Opiates (or opoids in the American phrase) are drugs of the morphine type, which have the common property of relieving pain and inducing euphoria. Opium is of importance because of the opiates it contains.
2. Cerebral stimulants. This group includes cocaine, a drug which came into the story during the latter part of the nineteenth century. Amphetamines are the familiar present-day representative of the stimulants. These drugs cause excitement and increased mental and physical energy. They can give rise to brief  psychotic illness. Although there are no remarkable physical withdrawal symptoms, the stimulants can be highly addictive.
3. Cerebral depressants. Here can be grouped together a variety of substances which have the common property of inducing sedation and sleepiness : there may also be disinhibition so that the drug appears to be causing stimulation and excitement. Alcohol provides a prime example. In the latter part of the nine-teenth century, chloral, a synthetic depressant, began to enjoy a vogue and gave rise to problems of misuse.
4. "Psychomimeticsubstances, or hallucinogens. Cannabis is probably best placed in this group, although it also has depressant properties. Mescaline is another member of the group, which became known in England during the nineteenth century, while LSD is the well-known modern example. Members of this group have the capacity to induce complex changes in the way the world is perceived and given meaning - experiences which are in short described as transcendental. Acute psychotic disturbances may also result.

Thus the nineteenth century was engaging with a range of drugs which nicely represented the complete spectrum of drug types - opium as the source of opiates,
with morphine and heroin later added, alcohol as the pervasive depressant and chloral as the new medical substance, cocaine as the first encounter of this society with a powerful stimulant, cannabis as a psychomimetic which received quite a lot of attention and mescaline as an exotic.

Cocaine and cannabis

As we have seen, these two very different drugs made an appearance in nineteenth-century history, and they will receive some attention in this book. Their importance was, however, very minor compared with the opiates, and here it seems appropriate to dispose of questions relating to their pharmacology and their place in therapeutics very briefly. The coca leaf comes from a shrub known as Erythroxylon coca, which grows in Peru and other parts of South America. When chewed it can be used as a stimulant, and it is still widely used in the Andes for this purpose. Cocaine is the alkaloid obtained from the leaves of the coca bush, and was first isolated by Niemann in 1860. It is a white powder which can be sniffed, or dissolved and injected. Medically it had its importance as a very effective surface anaesthetic.
Cannabis is the general term used to describe the various products of the plant Cannabis sativa. The major natural products are known by many names in different parts of the world, but consist primarily of two types of material - the resinous exudation of the flowering top and leaves, often known as hashish; and the material derived by chopping the leaves and stalks, collectively called marijuana. The activity of both is largely due to a tetrahydrocannabinol, or T.H.C. In the nineteenth century, cannabis or its extracts enjoyed some medical popularity for their analgesic and sedative effects.

Opium, opiates and their preparations

For many of the remedies which make up the doctor's armentarium the history of therapeutics is firstly that of a plant product with medical use going back for thousands of years. Then follows the isolation, chemical identification and extraction in the nineteenth century, or sometimes as late as the twentieth, of the therapeutically active ingredients of that plant. The final stage of development may then be the production and marketing of a synthetic drug identical with the natural product, or of a drug with alterations in chemical structure which result in a substance which in some way improves on nature - the synthetic may for instance be more potent than the original plant extract, or have fewer untoward effects. The pharmacological history of opium and opiates provides an example of this type of general technological sequence.
Opium is the plant product. Its effects on the human mind have probably been known for about 6,000 years, and it had its early and honoured place in Greek, Roman and Arabic medicine.
Opium is the name given to the brown tacky substance which is obtained after drying the milky exudate which oozes when the poppy capsule is incised. The original plant material yielded a crude substance containing all kinds of organic material and extraneous matter. Crude or not, it was this material which, eaten, made up into a drink or smoked, provided the drug in effective form over the millennia, and it was still only in this traditional plant form that the drug was available at the start of the nineteenth century.
The opium poppy - the species cultivated for opium production - is Papaver somniferum, a white poppy growing to a height of certain other varieties of this plant. The poppy is, or has been, grown chiefly in Asia Minor, China, Iran and some Balkan countries.
In the nineteenth century, many preparations based on opium, or patent remedies with opium as their active ingredient, were to be found listed in textbooks and on sale. Among the best known and most widely used were : laudanum, otherwise known as tincture of opium, made by mixing opium with distilled water and alcohol; paregoric, or camphorated tincture of opium ('paregoric' is derived from the Greek word for `soothing' or `consoling'); Battley's Sedative Solution, known officially as `liquor opii sedativus', opium mixed with calcium hydrate, alcohol, sherry and water; Dover's Powder, a preparation first made and used by Dr Thomas Dover and consisting of opium, saltpetre, tartar, liquorice and ipecacuanha. Although a patent preparation, Dover's Powder was widely used in hospital practice in the nineteenth century. Chlorodyne was the best known of the opium-based patent medicines. It was originally made up by Dr John Collis Browne and marketed by J. T. Davenport of Great Russell Street, London. Its main constituents in the nineteenth century were chloroform and hydrochlorate of morphia, although some analysts also detected a small quantity of Indian hemp. Godfrey's Cordial was a `children's opiate', made according to various recipes, but based on laudanum. Other children's soothing syrups included Mrs Winslow's Soothing Syrup, Atkinson's Infants' Preservative, and Street's Infants Quietness.
The active therapeutic principle in many plant medicines has the chemical structure of an alkaloid. Morphine (or morphia) was the first alkaloid to be isolated. It was named after Morpheus, the god of sleep. Many other alkaloids of opium were later identified, but those other than morphine which are of medical interest are few in number, and include codeine, as well as the much less popularly familiar substances thebaine, papaverine and noscapine.
The next stage in technology was in this instance not development of a synthetic, but what is called a semi-synthetic - a substance produced by a chemical process which, taking a natural alkaloid as starting point, modifies in some way the structure of the original substance. Taking morphine as the starting point, a potent semisynthetic which can be produced by a remarkably simple chemical process is heroin. Heroin was first produced in 1874 at St Mary'sHospital in London. It was rediscovered in Germany in the 1890s and marketed by Bayer under the trade name heroin. This probably derived from the German 'heroisch', or large and powerful in medical terminology. It was not used in medical practice in England in the nineteenth century. Weight for weight, heroin is several times as powerful in its drug action as morphine. There have subsequently been developed a host of fully synthetic opiates - drugs such as methadone and pethidine - but these play no part in the nineteenth-century story.

Actions of opiates

Opiates can produce a great, variety of effects which will be modified by expectation, but of prime importance to medicine is their ability to relieve pain. Any young medical student who sees for his first time the acute relief which an injection of morphine can bring about when, say, a person with a badly broken leg is brought into an Accident Department must have a sense of being in the presence of something almost magical. Very severe pain is brought rapidly under control, and from being in a state of agony and apprehension the patient is calm and at ease. Opiates are used in daily practice throughout the world for trauma and accident, for the relief of post-operative pain, in childbirth, and for the control of the pain of advanced cancer and some other very painful conditions. The difference here between the present and the nineteenth century is that, though they are still essential drugs for relief of pain (it is almost impossible to think of medical practice without the availability of opiates), these drugs are now used almost exclusively by doctors and, by them, much more conservatively and with stricter criteria for their deployment and dosage. Today opiates are, for instance, not drugs to be prescribed or self-prescribedfor toothache or for ordinary menstrual pain - aspirin and similar non-narcotic analgesics do that sort of job adequately and without the same dangers. But aspirin was not introduced until 1899, and the popularity of opiates for all manner of pain relief in the nineteenth century can be seen in one sense as related to lack of any alternative.
Closely allied to the pain-relieving effect of opiates is their ability to influence mood. This effect is again a property of great value to medicine and very much the therapeutic ally of the pain-relieving effect; even when the severe pain of a spreading cancer is not fully abolished by the drug injection, the mood effect can make the residual pain more tolerable and generally produce a lessening of emotional distress. The patient is in a way emotionally distanced from what is happening, and floats as it were on the surface of his experience. The drug has a euphoric effect. It is difficult to describe a complex feeling in precise words, but the tranquil pleasantness of this experience can be very positively enjoyable. This effect is not exactly equivalent to sedation, for neither do the opiates bring about the type or degree of drowsiness that barbiturates produce, nor do the barbiturates produce the same type of euphoria as the opiates. The euphoric effect of opium is what was meant by the nineteenth-century term the `stimulant' use of the drug. As we have seen, opiates are in present terminology not classified as stimulants, and to apply this word to a class of drugs which produce drowsiness and passivity today seems rather bizarre. The word obviously had a different connotation in the last century, and may be taken as broadly meaning the pleasure-seeking use of the drug. In general the effects of the opiates, like those of any other drug, can vary enormously according to the expectation of the user and setting in which the use takes place.
Opium and the opiates are also sometimes classified, along with other drugs, as narcotics. Technically narcotic drugs are those which have a sedative and sleep-inducing effect. The description of opium's pain-relieving and mood-altering effects already given indicates that this `narcotic' designation is not wholly accurate. The term `narcotic' has also been applied in control legislation to drugs like cannabis and cocaine which do not have any true family resemblance to the opiates, and the word might indeed be seen as something of a vehicle of confusion. So much then for a brief account of the two medically most important actions of opiates - pain relief and mood effect. The pharmacological element in the history of nineteenth-century opium use can largely be seen in terms of the history of these two attributes of the drug: the history of a pain reliever which had no rival or substitute ,and of an euphoriant and tranquillizer with a usage which was in part `medical' but which easily crossed over the borderline to what was then termed the `stimulant' use of the drug. These two aspects, pain relief and mood alteration, are thus the essential and primary pharmacological themes for understanding the nature of the actual drug with which society was dealing. They are the fundamental attributes of the drug which proposed its use and brought reacting social processes into play, and this whether it was the story of `infant doping', the use of opium by Romantic poets and Fenland labourers, the enormous and uncontrolled sale of opium as a popular remedy, or the medical utility of the drug.


Opium before the nineteenth century 4

A knowledge of the utility of opium was not, of course, confined to the nineteenth century, or even particularly novel at that time. The properties of the drug, and its use as a `stimulant' and in dealing with pain, had already been widely known for many centuries. References to the juice of the poppy occur in the Assyrian medical tablets of the seventh century B.C., and in Sumerian ideograms of about 4000 B.C. the poppy is called the `plant of joy'. Mesopotamia saw the growth of the opium poppy, and in both Egypt and Persia doctors treated patients with opium from at least the second century B.C. In fragments of the veterinary and gynaecological papyri and in the Therapeutic Papyrus of Thebes of 1552 B.C., opium is listed among other drugs medically recommended. From Egypt, growth of the poppy plant spread to Asia Minor and from there to Greece. Descriptions by Theophrastus and Dioscorides show that the toxic effects of the drug were already well-known. Even the famous nepenthe of Helen is likely to have been an opium draught. Homer states in the Odyssey that when Telemachus visited Menelaus in Sparta and memories of the Trojan war and the death of Ulysses made them depressed and tearful, Helen brought them as a drink a drug dissolved in wine which had the power to bring `forgetfulness of evil'. Although the effects of the drink have been attributed to hashish rather than to opium, Helen's draught seems to have produced the euphoria of opium rather than the excitement of the other drug. Roman medicine was as familiar with opium. Galen was enthusiastic about the virtues of opiate `confections' or mixtures, and Virgil mentioned it as a soporific both in the Aeneid and in the Georgics. It was so popular in Rome that, as in nineteenth-century England, it was sold by ordinary shopkeepers and itinerant quacks. The Arab physicians used opium extensively, writing special treatises on its preparations; Avicenna himself, who recommended it especially for diarrhoea and diseases of the eye, is said to have been an opium addict or at least to have died from an overdose of the drug. Arab traders spread the use of opium over a much wider area - to Persia, India and China. When they penetrated into the eastern part of the Roman Empire - into Egypt, North Africa and Spain - they took opium with them. During the Mohammedan conquest of the tenth and eleventh centuries, the opium trade was firmly established in Europe, and returning Crusaders, too, brought back knowledge of the Arabs' use of thedrug.
By the sixteenth century at least, then, opium was well established in Western European medicine. The famous German physician Philippus Aureolus Theophrastus Bombast von Hohenheim, better known as Paracelsus (1490-1540), owed much of his success to the way in which he administered opium to his patients. He is said to have carried opium in his saddle pommel and to have called it the `stone of immortality'. His followers were as enthusiastic: Platerus of Basle strongly recommended it in 1600, and Sylvius de la Boe, a well-known Dutch physician, declared that without opium he could not practise medicine. In England the drug had early been used, chiefly for its narcotic properties. In the middle of the fourteenth century John Arderne used salves and elixirs containing opium to procure sleep and also apparently, externally applied, as a form of anaesthetic during operations : `he schal slepe so that he schal fele no kuttyng...'. The drug's soporific and narcotic qualities reappear in Chaucer's Canterbury Tales and in Shakespeare, in particular in the famous passage from Othello:

Not poppy, nor mandragore,
Nor all the drowsy syrups of the world,
Shall ever medicine thee to that sweet sleep
Which thou ow'dst yesterday.

Bullein's Bulwarke of Defence against all Sicknesse, Soarenesse and Woundes of 1579 likewise recommended the white poppy, which 'hath all the vertues', and
opium made from the black poppy, `which is cold and is used in sleeping medicines : but it causeth deepe deadly sleapes'. The stock-in-trade of a Lancashire apothecary of the same period had its half ounce of opium (valued at sixpence).
Opium was to be found too in the four great standbys of the medicine of that period: mithridatum, theriaca, philonium and diascordium. The last-named, a product of the early sixteenth century, mentioned among its principal ingredients cinnamon, cassia wood, scordium, dittany, galbanum, storax, gum arabic, opium, sorrel, gentian, Armenian bole, Lemnian earth, pepper, ginger and honey. Such preparations remained popular as general palliatives and antidotes, but opium was used more specifically, too. It was Paracelsus who first used the term laudanum to describe an efficacious opium compound, but his was probably in solid pill form. The alcoholic tincture which is now known as laudanum was originated by the English physician Thomas Sydenham in the 1660s. Sydenham's enthusiasm for the drug is well-known and his praise unstinting:

...here I cannot but break out in praise of the great God, the giver of all good things, who hath granted to the human race, as a comfort in their afflictions, no medicine of the value of opium, either in regard to the number of diseases it can control, or its efficiency in extirpating them ... Medicine would be a cripple without it; and whosoever understands it well, will do more with it alone than he could well hope to do from any single medicine.

With this widespread use of opium, addiction was known, but quite rarely discussed and generally calmly accepted. Thomas Shadwell, the Restoration dramatist  and poet, was an opium addict whose habit was a matter for jest rather than concern. Shadwell was the subject of Dryden's MacFlecknoe, the Prince of Dullness, who `never deviates into sense'. But neither Dryden nor Tom Brown, who wrote a mock epitaph on Shadwell, considered him in the modern terminology of addiction, nor did they apparently consider his use of opium had any effect on him or his readers:

Tom writ, his readers still slept o'er his book,
For Tom took opium, and they opiates took.

In general, the reaction to sustained opium use at this time was calm, and indeed the subject was rarely discussed. Dr John Jones's Mysteries of Opium Reveal'd, published in 1700, was one of the earliest books specifically to treat addiction, but its tone was not hysterical. In fact Jones, although listing unpleasant physical and mental symptoms from excessive doses, was also inclined to emphasize the pleasurable aspects of opium use, those which the nineteenth-century writers might have termed its `stimulant' effects. After taking opium, '... if the person keeps himself in action, discourse or business, it seems ... like a most delicious and extraordinary refreshment of the spirits upon very good news, or any other great cause of joy ... It has been compared (not without good cause) to a permanent gentle degree of that pleasure which modesty forbids the name of ...' Medical authors, too, in the eighteenth century, such as George Young in his Treatise on Opium published in the 175os and Dr Samuel Crumpe in his Inquiry into the Nature and Properties of Opium of 1793, stressed the main features of addiction and the possibilities of withdrawal, but with no sign of moral condemnation or alarm. Crumpe himself reported that he had taken opium frequently and had experienced its euphoric effects. Nevertheless, the majority of descriptions at this time still saw opium eating or smoking as a peculiarly Eastern custom. In Dr Russell's History of Aleppo for instance, or the tales of Baron de Tott, the Eastern opium eater was a regular feature of the travellers' tales of the period, an object of interest and wonder, but not of condemnation.

Opium and history

At the opening of the nineteenth century, then, doctors and others still thought of opium not as dangerous or threatening, but as central, to medicine, a medicament of surpassing usefulness which undoubtedly, found its way into every home. It is with the way in which these attitudes changed and the restrictions placed on opium use during the course of the nineteenth century that the rest of this book will deal. These historical roots of contemporary events have already attracted a certain amount of attention. The `drug consciousness' of the 196os was in particular marked by an interest in historical material which could provide `relevance' for the contemporary debates. Often this was quite superficial. A reference to the mid-nineteenth-century opium wars, or a mention of De Quincey's Confessions of an English Opium Eater, did duty as historical input to the debate. This interest in the historical dimension was particularly noticeable in the United States. The discussions which took place there in the 1960s over the direction which American drug-control policy should take were marked by continual references to, and analyses of, the past. The struggle to graft disease ideas of addiction, the view of the addict as a patient rather than a criminal, on to a policy which still stressed a penal approach established in the 1920S was rooted in historical as well as scientific and medical discussion. Detailed and valuable work was done on the historical roots of American narcotic policy. 5 The historical background was used as a vantage point from which to criticize current American policy. In the work of the anti-psychiatrist Thomas Szasz, perhaps the best-known exponent of such views, historical material was used to criticize both penal and medical approaches to drug control. Szasz's Ceremonial Chemistry (1975) argued that heroin and marijuana are different from alcohol and tobacco not for chemical but for ceremonial reasons and put forward a view of medicine as social control, not an agent of progress .6
To any historian, the deficiencies of many such polemical approaches are obvious. The lack of a certain socio-cultural or class perspective in Szasz is notable. Easily accessible historical examples from a variety of cultures and social structures have often been a substitute for a more rigorously researched analysis of drug use in a particular society. In another sense, too, the history of narcotics has been misused in the contemporary debates. There has been a tendency to read the preconceptions and values of the present too directly into the past. A recent study of the historical origins of social policy makes very much this point. Matters have been looked at `through the wrong end of the telescope; taking insufficient account of the difficulty of understanding past events in the very different context of their time'.7 Those concerned with present policy have been too intimately involved with the assessment and selection of material from the past. Facts and opinions to a large extent divorced from their historical context have been used to provide `relevance'. Narcotic history has been used in a mechanistic way to justify particular departures in policy or specific ways of looking at drugs. The statistics of the past have been quoted in comparison with those of the present with little realization of the pitfalls of historical data, the very different cultural and social situations of drug use in historically distant societies.
Writers on opium and other narcotics, seeing a problem of contemporary drug use, have discussed opium in the past within the same problem framework. But what most needs analysis is not the dimensions of a problem - the statistical and epidemiological approach has spilled over in historical discussions from its dominance of contemporary scientific writing on drug use - but the definition of it. It is the establishment of attitudes and perceptions, of shifts in focus and ways of looking at drug use which should concern us. The description just given of opium use before the nineteenth century is an indication of rather different reactions to opium and its regular use. The nineteenth-century story makes this differing reaction more explicit. How did a drug like opium, on open sale in Britain in the early nineteenth century, its use widespread for what would now be termed 'non-medical' as well as `medical' reasons, come to be seen as a problem? In the 1850s, opium could be bought in any grocer's or druggist's shop; by the end of the century, opium products and derivatives and opium-based patent medicines were only to be found in pharmacists' shops. Regular opium users, `opium eaters', were acceptable in their communities and rarely the subject of medical attention at the beginning of the century; at its end they were classified as `sick', diseased- or deviant in, some way and fit subjects for professional treatment. It is these broader questions A shifts of focus which need explanation, the establishment of a whole new way of looking at drug use which requires analysis.
An obvious explanation would lie in the inherently dangerous properties of the drugs themselves, the obviously profligate way in which they were used when freely available. This, indeed, is the type of drug-centred explanation which has often been adopted. The restriction of opium use has been seen as little more than a public health matter. The public health issues which concerned nineteenth-century society are considered in Chapters 7 and 8 of this book, and indeed some accounts of opium use and restriction have dealt with them alone. The testimony of official reports and inquiries has been taken at face value rather than analysed as a product of the values and perceptions of the society of the time. For drug use must also be considered in relation to its social context; individual and drug-centred explanations of use and control need replacement by a consideration of the whole socio-cultural setting in which such use was established. Most obviously, narcotics have been a scapegoat for wider tensions within society. There were undoubtedly problems associated with its open sale. The adulteration of the drug and the high level of overdosing and mortality from opium were the most obvious. Even these issues, however, were closely allied with the social situation of opium users. The large number of deaths from opium poisoning were the outcome of established popular traditions of self-medication and the lack of continuing -accessible medical care. The popular acceptability and utility of opium as an everyday remedy in such a situation badly needs reconstruction; it has in the past signally failed to emerge from the concentration on child `doping' and poisoning.8
The perception of issues like these as part of an opium `problem' owed more to structural change. The `problem' of opium was, at various stages in the nineteenth century, seen very much as one of lower-class use, as Chapter 9 makes plain. Opium use by the working class was much more likely to be considered problematic than use of the drug in any other class. The belief in working-class `stimulant' use of opium helped justify the first restriction on the drug in the 1868 Pharmacy Act. Consumption of chlorodyne - as a patent medicine, a preparation with much popular utility - brought further control in the 1890s. Fear of the spread of opium smoking among lower-class Chinese in dock areas encouraged more restrictive attitudes. The question of who used the drug was central; and the control of lower-class deviance was undoubtedly important. The problem of opium use was in this sense the outcome of the class basis of Victorian society. It was in part a question of social control. Despite recent criticism of the unthinking overall application of this concept, control of lower-class usage of opium was at certain stages in the nineteenth century a clear aim in the formulation of legislation.9
The changed perception of opium and its use also demonstrated the establishment blishment of the ideological and practical dominance of opium use by the medical and pharmaceutical professions, the former in particular. The medical profession was in the process of legitimizing its own status and authority; opium was translated into a problem in the process. In a practical sense, this was achieved by professional controls over availability and use, as discussed in Chapters 10 and 11. The restrictions of the 1868 Act the 'professionalization' of the sale of patent medicines, the curbs on prescriptions - were part of the establishment of a professional elite. Controls symbolized the substitution of a new view of opium use for the popular culture which had hitherto existed. It was notable, too, how the profession, in helping to forge a problem out of opium use, concentrated attention where it was least needed in objective terms. Once the 'stimulant'scare was over, working-class use was largely ignored. Instead as Chapter 12 indicates, doctors concentrated on the question of hypodermic morphine, where a small number of injecting addicts were magnified by the medical perspective on the drug into the dimensions of a pressing problem.
The medical dimension to the `problem' of opium use was more than a case of professional strategy. There is a danger, in stressing the theme of professionalization in connection with narcotics, that doctors come to be seen as some autonomous body, working out their designs on opium in an isolated way. This is one of the deficiencies of the approaches which simply stress social control. For in reality the medical profession merely reflected and mediated the structure of the society of which it was the product. Social relations lay under the apparent objectivity of medical concepts and attitudes. This was at its clearest in the new ideological interpretation of narcotic use which began to be established in the last quarter of the century. What Michel Foucault has called `the strict, militant, dogmatic medicalization of society...', found its expression in the nineteenth century in the establishment of theories of disease affecting a whole spectrum of conditions.10 Homosexuality, insanity, even poverty and crime were reclassifieded in a biologically determined way. Concepts of addiction, discussed in Chapter 13, of `inebriety' or 'morphinism' in the nineteenth-century terminology, were part of this process. These emphasized a distinction barely applied before between what was seen as `legitimate' medical use and `illegitimate' non-medical use.
They established an apparently objective system of ideas which in reality had its foundation in social relations. For the `disease model' of addiction arose through the establishment of the status of the medical profession in society. It was formulated by a section of the middle class, and the model of addiction
thus presented was peculiarly attuned to the characteristics of addicts of the same status. Lower-class addicts were notably neglected in disease theory. The
respectable addicts to whom the theories were most often applied accepted their provenance; and, at that level, the need for medical intervention was rarely
questioned. The `problem' of opium use found a major part of its origin in the establishment of this form of ideological hegemony. Putting forward individual
rather than social explanations, it nevertheless proposed the scientific objectivity of disease views as a means of progress towards greater understanding.
The moral prejudices of the profession were given the status of value-free norms.
This was never a monolithic process. Many doctors, particularly those in general practice (as opposed to the expanding numbers of addiction specialists),
doubted the necessity for treatment and intervention even if they accepted the conceptual framework of disease. And at the lower levels of society, opium use
and self-medication was still quite calmly accepted even at the end of the century. Theories of disease were in any case rarely applied to the working-class addict; the response here epitomized in the agitation over chlorodyne in the 189os simply emphasized that the availability of the drug should be limited. The distinctive ideological shift had nevertheless already taken place. Drug use was a developing social problem by the end of the century. Opium was already contolled; certain of its users were classified as `deviant' or`sick'." The rest of this book will examine how and why this was the case.

references
1. P. Laurie, Drugs. Medical, Psychological and Social Facts (Harmondsworth, Penguin Books, 1974), gives a good introduction to present-day use of and attitudes towards drugs.
2. The war-time `emergency' leading to the introduction of the first stringent controls is analysed in V. Berridge, `War conditions and narcotics control: the passing of Defence of the Realm Act Regulation 4oB', Journal of Social Policy, 7, No. 3 (1978), pp. 285-304.
3. This section on the nature of the drugs has been contributed by Professor Edwards.
4. This section is based, among other works, on C. E. Terry and M. Pellens, The Opium Problem (Montclair, New Jersey, Patterson Smith, 1970; first published 1928); L. Lewin, Phantastica. Narcotic and Stimulating Drugs, Their Use and Abuse (London, Kegan Paul, 1931); M. Goldsmith, The Trail of Opium (London, Hale, 1939); A. Hayter, Opium and the Romantic Imagination (London, Faber and Faber, 1968); D. Macht, `The history of opium and some of its preparations and alkaloids', Journal of the American Medical Association, 64 (1915), PP477-81; and R. S. France, `An Elizabethan apothecary's inventory', Chemist and Druggist, 172 (1959) P. 50.
5. For examples of this approach, see D. Musto, The American Disease. Origins of Narcotic Policy (New Haven and London, Yale University Press, 1973); and T. Duster, The Legislation of Morality (New York, Free Press, 1970). B. Inglis, The Forbidden Game. A Social History of Drugs (London, Hodder and Stoughton, 1975),analyses English drug use, although his book is not based on any substantial original research. J. L. Himmelstein, `Drug politics theory : analysis and critique', journal of Drug Issues, 8 (1978), pp. 37-52, adopts a usefully critical approach to some of the historical/polemical analyses of U.S. drug policy.
6. T. Szasz, Ceremonial Chemistry. The Ritual Persecution of Drugs, Addicts and Pushers (London, Routledge and Kegan Paul, 1975)•
7. P. Thane, Introduction, pp. 11-20, in P. Thane, ed., The Origins of British Social Policy (London, Croom Helm, 1978).
8. Seethe paper by E. Lomax, `The uses and abuses of opiates in nineteenth-century England', Bulletin of the History of Medicine, 47 (1973), pp. 167-76.
9. Social control has been criticized as an analytical tool because of its associations with functionalism and a static, not class-antagonistic social model, in particular by G. Stedman-Jones, `Class expression versus social control?', History Workshop, 4 (1977), pp. 163-70.
lo. 'M. Foucault, The Birth of the Clinic. An Archaeology of Medical Perception (London, Pantheon Books and Tavistock Publications, 1973), p. 32. Anyone working in the area of medically defined deviance must be influenced by Foucault's ideas and my debt to him in certain chapters will be obvious.
I1. Earlier brief surveys of the main issues are in V. Berridge, `Opium and the historical perspective', Lancet, 2 (1977), pp. 78-80; and V. Berridge, `Victorian opium eating: responses to opiate use in nineteenth century England', Victorian Studies, 21, No. 4 (1978), PP. 437-61.

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