by Lucy Inglis
Chapter Six
THE AMERICAN DISEASE
Pioneers and Patent Medicines
‘From sea to shining sea’1
North America’s relatively brief relationship with opiates is as short and dramatic as its history, and as wide as its geography. Absence of records make it difficult to know if the earliest settlers travelled with laudanum or opium, but it seems unlikely that they would make such a perilous journey without a reliable painkiller to hand. And it seemed somewhat unwise to rely upon doctors like John Cranston of 1663, who was granted a licence to ‘administer physicke and practice chirurgery’ after paying the appropriate fee to the General Court in Rhode Island.2 It is much more likely that people purchased their drugs from someone like Mr Russell at the Galen’s Head, before setting out for their new homes.
Doctors arrived in America with degrees from respected international medical schools, but America did not have its own formal medical institutions until the College of Philadelphia opened in 1765, and King’s College in New York two years later. Based on European models, they established themselves rapidly as centres of learning and turned out practical, knowledgeable doctors (if rather young at twenty-two) for a growing nation.
Nathaniel Chapman was born in Virginia in 1780 and studied both in Edinburgh and under Benjamin Rush in Philadelphia, where he was later in charge of materia medica. He regarded opium as essential to the physician, ‘there being scarcely one morbid affection or disordered condition, in which, under certain circumstances, it is not exhibited, either alone, or in combination’.3
There had been shortages of opium in America, as the earlier Dr Thaddeus Betts observed in the Connecticut Journal in 1778: ‘opium is an article which no physician ought ever to want . . . no substitute will supply its defect’.4 Betts grew his own poppies so that he could ensure a steady supply.
Connecticut was particularly prone to outbreaks of smallpox and other diseases, and Dr Vine Utley – practising in Lyme County from 1798, and who introduced America to the idea of vaccination – recommended the liberal use of opium in cases like the 1812 typhus epidemic. But in more rural areas, it seems it was far harder to obtain. Elias P. Fordham was an English immigrant and the original surveyor of Indianapolis, and he recorded on his travels in Chesapeake, Virginia around the same time that ‘The fever and ague are very common here. I gave away in these visits all my bark and laudanum. They would send a negro five miles through the woods, and as far with a canoe on the water, for one or two doses.’5
For Thomas Jefferson, who was growing white opium poppies in the flowerbeds at Monticello in the year of the Connecticut outbreak, there was presumably no shortage of opium, should it be required – although visitors to the estate were not always complimentary: ‘There are few plants whose flowers are so handsome, but having an offensive scent and being of short duration, they are not much regarded.’6
Regardless of Jefferson’s offensive ornamental Papaver somniferum, early America relied on patent medicines, and English ones, such as those imported by Mr Russell, were the most popular for a long time. In the eighteenth century, Europe had experienced a rise in luxury goods and standards of living, but for many who moved to America, particularly those who settled in the centre of the continent, luxury was not a part of everyday life. For the cash- and time-poor settlers, patent medicines offered a way to treat the ills of all the family from one handy and easily available bottle. Advertisements for English patent medicines become regular after 1750 in the small East Coast newspapers, indicating the availability was increasing, and patent medicines are one of the very earliest products advertised in America.
Supply stopped with the American Revolutionary War in 1775, and afterwards the patent medicines returned, although in much smaller quantities. In a move that shadowed China’s isolationism, revolutionary Americans argued that America had all her people needed, and to boycott goods from Britain. But people still wanted their trusted English brands, and American manufacturers, known as nostrum makers, stepped into the breach. In 1824, a twelve-page pamphlet appeared with the title Formulae for the preparation of eight patent medicines, adopted by the Philadelphia College of Pharmacy, the first professional pharmaceutical body of America, founded in 1821. All of the recipes were English, and they included the famous Godfrey’s Cordial.
With a large number of Americans living in extremely rural circumstances, with little or no access to healthcare, they had come to rely on folk remedies and home cures. Many used Thomsonian Medicine, created by Samuel Thomson in the first part of the nineteenth century, who came from a Unitarian pig-farming background and was raised in remote circumstances. Having spent time with a root or herbal doctor as a young man, he used plants to cure himself of an ulcerated ankle injury, strengthening his belief in plant remedies. He published the New Guide to Health; or Botanic Family Physician in 1822, and practised in New Hampshire, although his influence was far more widespread as it seemed perfect for people living in the wilderness, with access to plants but not expensive doctors. Ohio’s Botanico-Medical Recorder even claimed excitedly in 1839 that the Cherokee Nation had abandoned their ancient botanic practices and adopted Thomsonian Medicine, although this seems unlikely. Thomson’s system was regularly jeered at by medical professionals, and the debate often divided around class issues – due to his farm-labouring background – and jealousy of his obvious success. However, Thomson was highly influential in the way many early nineteenth-century Americans regarded medicine: simple, allegedly safe and cheap.
One element of frontier individualism was a scorn for education and sophistication, so Thomson’s method of self-medication, and therefore self-reliance, held a special appeal. This was also true of the patent medicines, which were sold as safe, family friendly and increasingly had comforting images and words on the bottles. Now manufactured on a large scale in America, these home-made medicines contained opium as often as the British ones. (Opium shortages in America appear to ease almost exactly in line with the American involvement in the Chinese opium trade.) The most famous of all of them was Mrs Winslow’s Soothing Syrup. Sold by Curtis and Perkins of Bangor, Maine, this patent medicine was supposed to have been invented by Mrs Charlotte Winslow in the 1830s, although there is no evidence she existed. Despite containing over sixty milligrams of morphine per fluid ounce, it was marketed directly at fraught mothers. As with Godfrey’s Cordial, it was recommended for teething children, to relieve ‘the little sufferer at once’, and ‘produces a natural, quiet sleep by removing the child from pain’. It also promised to relieve wind and stop diarrhoea, and after all this the child would awake ‘as bright as a button’.7
Mrs Winslow’s Soothing Syrup appeared in the 1830s, just as the advertising industry was starting in earnest in America, and Curtis and Perkins exploited this to the full. Images of beautiful, relaxed mothers and happy, round-cheeked children feature on each ad. Many of the nostrum makers saw the potential of this new, dynamic advertising industry to open up new markets. The distances involved meant that mail order was on the rise. Men were moving from the land to factories, leaving wives in the home looking after the children. Busy, yet bored, Mrs Winslow’s Soothing Syrup was soon not just for children. It was also notorious amongst the medical community for being responsible for a significant number of infant deaths, as the superintendent of health for Providence reported in 1873:
The decedent from poisoning in March was a child killed by a dose of Mrs Winslow’s Soothing Syrup. It has long been well known to physicians that the soothing properties of this medicine are due to opium in some form, and that the quantity of opium is so large to make it a decidedly dangerous nostrum. There is no doubt that a considerable number of deaths each year should be recorded ‘Mrs Winslow’s Soothing Syrup’.8
Another ‘dangerous nostrum’ native to America was Ayer’s Cherry Pectoral. James Cook Ayer, one of nineteenth-century America’s success stories, was born in Connecticut in 1818, and attended the University of Pennsylvania Medical
School. He never practised medicine but went straight into compounding medicines, working in Lowell, Massachusetts. At twenty-two, he purchased an apothecary shop with $2,486.61 borrowed from his uncle, and managed to return the money in three years. His success came not from the effectiveness of his medicines, but the almanac he put together and distributed widely, and the reputed $140,000 he spent on advertising. The Ayer’s Almanac announced proudly that it was aimed at ‘Farmers, Planters, Mechanics and All Families’. Around 5 million almanacs were printed, with editions in English, French, German, Portuguese and Spanish. His most popular products were sarsaparilla, which he claimed purified the blood, Hair Vigor, which was equally useless, an Ague Cure containing cinchona bark, which was helpful in cases of malaria, and the Cherry Pectoral, containing three grams of morphine per bottle. Ayer’s Cherry Pectoral’s entry in the almanac of 1857 declared that ‘Every comfort, encouragement and support that can be afforded, should be provided. The mind should be cheerful, free from depressing cares. Courage helps to conquer.’9
Ayer is clear that Cherry Pectoral is an emotional cure as well as a physical one. One charming undated advertisement in black and white shows a small girl in her Sunday best and a bonnet, trying to reach into a giant bottle with a spoon, and announces, ‘It is in every sense An Emergency Medicine’. It was hugely popular, and helped Ayer amass a fortune of $20 million.
Ayer was not America’s first quack, nor the last, but he was the most successful. The almanac was a superb piece of advertising that hit all the right notes with bone-weary, lonely farmers, worried housewives and factory workers. He had also industrialized the nostrum business, and perfected mail order, providing a model for the many who followed him, although few with his rapid success. With his plain, printed book and comforting tones, Ayer was perfect for the emerging Middle America, a million miles from the barking sideshow snake-oil men who were rampant at the time. Yet, seemingly, the one person in America who Cherry Pectoral couldn’t help was James Ayer himself. ‘Anxiety and care brought about a brain difficulty, and for some time prior to his death he was confined in an asylum.’10 He died there on 3 July 1878.
At the time of his death, America’s medical advertising was at a peak. From the 1850s onwards, agencies had sprung up in Philadelphia, Boston, Chicago and in particular in Lower Manhattan. Advertising was suddenly big business, and it was moving away from adorable pictures of little girls and upright wholesome mothers to women dressed in negligees lounging on a bed with a giggling child, all in lush colours, or bold catalogues of the new farm machinery. Brighter and more promising in every sense, America was changing into a land of efficient consumers.
The Rise of Morphinism
The isolation of morphine had been a huge commercial success, although sadly not for Friedrich Wilhelm Sertürner. It was soon available across Europe and America, most often as a powder. Yet it wasn’t perfect, and doctors knew that administering morphine solution under the skin with minimal damage would be infinitely preferable for the patient, preventing ‘the subcutaneous cellular tissue being torn up with a common probe to make room for the reception of a drachm of solution of morphia.’11
The invention of the hypodermic needle was the answer. Syringes had existed since Galen used them to inject cerebral vessels with fluid, and da Vinci used them to inject the blood vessels of corpses with wax. They had no needle, but were used to flush wounds or apply medicines in hard-to-reach places. Crude but effective, they were an essential part of the physician’s hardware. The Dutch doctors of the late Renaissance, around 1600, coined the term inject, meaning to drive in, and referred to their attempts at blood transfusions using tubes and bladder systems. Christopher Wren had used an animal bladder to push opium into the dog’s vein in 1657. Dominique Anel (1679–1730), a French surgeon who studied under the royal physician, began to refine the syringe at the turn of the eighteenth century. In 1713 he began to publish on his small syringe, which he used to treat eye problems. The ‘Anel syringe’ is immediately recognizable, and although Anel never used it with a needle, it was the start of the hypodermic revolution.12
Throughout the eighteenth century, physicians refined syringes and began to use them more widely, but manufacturing had yet to create a hollow needle fine enough to inject through the dermis. From the 1820s, the most common form of administration was for a small cut to be made through the skin and a flap lifted, often with trocars and lancets, into which the powder was sprinkled. This obviously carried the risk of local infections through irritation, or total systemic infection through blood poisoning. Morphine powder, however, had the great advantage over opium in that it didn’t have to be ingested, thus bypassing nausea or cramps, or smoked, and it could be applied to the whole system through one or two small cuts. The method had been invented in France, and was soon popular across Europe and America, particularly for neuralgia, such as the case John Locke had encountered.
By the middle of the nineteenth century, needles could be made fine enough to break the skin and deliver medicine. This development was taken up by various scientists and doctors, but three came to the forefront, two of whom were Irishman Francis Rynd (1801–61), and Alexander Wood (1817–84), a Scot. Rynd probably invented the hypodermic as we know it today in 1844, but he was so secretive he only revealed his findings after 1855, when Wood published ‘New Method of Treating Neuralgia by the Direct Application of Opiates to the Painful Points’, in the Edinburgh Medical and Surgical Journal.13 Both were using hypodermics to treat patients with morphia for pain, and Rynd was treating a woman with neuralgia. The third doctor, Charles Gabriel Pravaz (1791–1853) in Lyons, was also an early developer, and his design became the default in Europe.
Although there are many squabbles over which doctor first used the modern hypodermic, it’s likely that many doctors were working on similar lines, but didn’t publish or achieve any fame. What secured the lasting notoriety of these three men was the instant uptake of their new invention. By the time Charles Hunter (1835–78), a London surgeon, first used the term ‘hypodermic’, meaning under the skin, in 1863, the apparatus was already being manufactured on a large scale. Hunter had realized that introducing a drug into the bloodstream meant that injections didn’t need to be administered at the exact site of the malady, which was particularly helpful for neuralgia patients who couldn’t bear their head to be touched, let alone injected.
Pain theory, so important to the history of opium, was also central to the development of the hypodermic needle. Neuralgia, although well known before, had first become a much debated concern around 1800, when it was described as ‘a modern disease’ because it was a nervous problem with no obvious cure or cause. The pain in the head, jaw and teeth for a neuralgia sufferer is almost unbearable during an attack, and it is a condition associated with suicide in sufferers who can no longer endure it. So it seems natural that Wood, and others, would be trying to find a way to relieve the pain of neuralgia sufferers. Hypodermic administration of morphine for unidentified pain became an instant success, and crucial early papers in respected medical publications such as the British Medical Journal all refer to the hypodermic treatment of neuralgia with morphine.
The hypodermic had the great advantage on many fronts. Many of the first patients found the immediacy of the effects of subcutaneous morphine injections nothing short of miraculous. As important as patient experience was the dosage control the hypodermic gave to doctors. The small, relatively simple piece of equipment allowed for a measure of preparation and theatre before the magic medicine was delivered, which then brought instant relief.
By 1857, American firm Fordyce Barker was manufacturing in the United States where, in the middle of the nineteenth century, the finest medical instruments in the world were being made. For the discerning buyer, it was soon possible to purchase hypodermics with gold needles and shagreen cases. But not all medical professionals were convinced the hypodermic was the right route to take with morphine solution in particular. Regulatory bodies in the
UK, the US and Germany all preached caution in the face of this new cure. One warning voice in America was that of the physician Robert Bartholow, who wrote a manual on the safe use of hypodermics and said that ‘The possibility of communicating disease by inoculation of specific matter should not be overlooked.’14
Yet, such was the perception that only the oral consumption of morphine or laudanum created an addict, because it stimulated an appetite, injecting below the skin seemed a straightforward way of stopping the problem: ‘When long-continued use of morphia is required, the danger of the habit of opium-eating will be avoided if we inject the opiate.’15
Thus, doctors in the first few years thought that hypodermic injection did not create morphine tolerance. Their error was soon apparent. Such was the demand for this new, efficient method of delivery that doctors were soon discussing what might be done. Firstly, it was recommended to ‘Never under any circumstances teach a patient how to use a hypodermic syringe.’16 This had been a sticking point for some doctors, who, when treating middle- and upper-class patients, particularly women, would hand over medicines or treatments to a carer or a husband.
Furthermore, doctors were using it too much, said German physician Felix von Niemeyer: ‘I know many physicians who never go out to their practice without a Pravaz’s syringe and a solution of morphine in their pocket, and who usually bring the morphine-bottle home empty.’17
Lack of proper sterilization and injecting in dirty conditions was also becoming an obvious problem. One doctor wrote about the morphine addict who had come to his office: ‘The entire surface of the abdomen and lower extremities was covered with discoloured blotches . . . the marks of injections. He was spotted as a leopard. For four years he averaged three or four a day – an aggregate of between five and six thousand blissful punctures! The right leg was red and swollen, and I discovered a subcutaneous abscess extending from the knee to the ankle and occupying half the circumference of the limb.’18 Niemeyer had written about the dangers of such addiction to hypodermic injections of morphine in his manual on practical medicine: ‘If injections of morphia have been made for some time . . . the patients begin to feel an absolute need of the injections.’19