Abstract
The American Civil War resulted in massive numbers of injured and ill soldiers. Throughout the conflict, medical doctors relied on opium to treat these conditions, giving rise to claims that the injudicious use of the narcotic caused America’s post-bellum opium crisis. Similar claims of medical misuse of opioids are now made as America confronts the modern narcotic crisis. A more nuanced thesis based on a broader base of Civil War era research suggests a more complex set of interacting factors that collectively contributed to America’s post-war opium crisis.
Introduction
Once again, the USA faces an opioid crisis fully capable of decimating individuals, communities and even society at large. As public attention turns to the causes, arguments gaining traction place the blame on lax prescribing practices and profiteering pharmaceutical companies (Makary, Overton and Wang, 2017). According to this line of reasoning, America’s current opioid crisis bears some resemblance to a similar crisis that unfolded during America’s Civil War era; this similarity is not lost on modern historians seeking parallels by looking back 150 years for clues to the modern opioid crisis in the rubble and aftermath of America’s Civil War.
It seems clear, based on extensive historical research, that opium use increased dramatically during the Civil War. According to one authoritative account, Union medical supplies during the active war years from 1861 to 1865 included 10 million opium pills and 2,800,000 ounces (over 79,000 kg) of other opium containing compounds (Albin, 2002). Taken at face value, these staggering data are implicated by some modern historians as a factor in the proliferation of opium use in the post-bellum period. This argument goes further and posits the indiscriminate and negligent use of opium by Civil War doctors as the central cause of America’s post-war, nineteenth-century opium crisis (Lawson, 2018; Stobbe, 2017). A more nuanced thesis, based on a broader base of research, suggests a far more complex argument.
Background
A starting point for this analysis is a consideration of the sheer volume of injuries and illnesses confronting military medical practitioners as civil war descended on America. Opium use during the active war years was not primarily a matter of recreational use but was due to battlefield demands and unsanitary camp conditions. During the Civil War, Union medical officers treated an estimated 250,000 wounds and more than seven million cases of disease. Pain management with opium had no peer, and the drug’s rapid ascendancy during the conflict reflected that medical fact. Even more compelling and collectively disabling than battlefield wounds were the seven million cases of various diseases, nearly a quarter (1.6 million) of which involved cases of diarrhoea and dysentery. Civil War physicians did not understand the bacterial basis for the conditions, but they surely appreciated its devastating effects, with an estimated mortality rate of 14.31 per 1000 men average force strength (Gillett, 1987: 276)
The Medical and Surgical History of the War of the Rebellion (MSHWR) devoted nearly 250 pages to the aetiology and treatment of diarrhoea and dysentery (Barnes et al., 1870: Section VI); this was a clear indication of the diseases’ pernicious and pervasive impact on combat strength. Based on the evidence presented in this book, both diarrhoea and dysentery (the most prevalent of the camp diseases) resulted from irritation or inflammation of the bowel, but without an understanding of microbiology the aetiological search was speculative in nature. Even so, astute clinical observations cited ‘bad drinking water’, intemperance, indigestible food, exhaustion, hot weather, and various mysterious miasmas as factors associated with the disorders (Section V).
The book’s discourse on the aetiology of diarrhoea and dysentery confirmed the missing link between the bacterial cause and effect which left the extensive narrative on treatment focused on managing the symptoms. Any notion that military surgeons blindly opted for opium as the only remedy for these diseases will instead discover that some doctors undertook extensive pharmacologic experimentation to arrest the morbid disorders.
As the war progressed and illness took an even greater toll, the importance of prevention gained ground and centred on sanitation and camp hygiene. When the exigencies of war permitted, enlightened officers considered available water and food supplies in selecting camp locations, but even improved sanitation did not halt the contagion. Treatment focused on the prudent use of alcohol, digestible soups, fruits and vegetables, and avoidance of bloodletting. In terms of medications, vigorous debates accompanied the use of emetics, purgatives such as the controversial use of calomel, and diuretics (Barnes et al., 1870: 55).
It was against this background of debate about ineffective and noxious medications, combined with the overwhelming frequency of diarrhoea and dysentery, that opium became a staple treatment. It was often combined with other medications, such as calomel, and widely prescribed by:
[the] majority of medical officers [who] united opium with almost every medicine employed to check the progress of the disease, and in spite of the sad experience of failure, which became more and more universal as the war progressed, continued to make use of it, though with ever-diminishing hopes of success . . . (Barnes et al., 1879: 743)
More astute medical surgeons understood and weighed the benefits and risks of opium, but as one author in Barnes et al. (1879) aptly observed:
the sufferings of the patient continue to be so great that it becomes imperative to resort to some anodyne for their relief; and although opium is by no means the only drug that answers this indication, it is undoubtedly the most uniformly successful, and will very often afford a respite from present distress when all other means fail. Under such circumstances the judicious practitioner will not hesitate to employ this powerful drug. . . . (p. 746)
The book recognized that ‘this powerful drug’ could result in habituation, and the same concerns were published in reputable nineteenth-century journals and books. The general medical journal The Lancet published articles such as ‘Teetotalism and opium taking’ in 1851, warning readers that ‘since the crusade of the teetotalers against spirit drinking there is great reason to believe that the practice of taking opium is on the increase’ (Medicus, 1851: 169). An even earlier 1837 medical treatise briefly addressed modifying the narcotic’s use among ‘opium-eaters’ (Steggall, 1837: 225).
An 1860 advertisement promoted an ‘Asylum for inebriates’ and offered treatment for ‘the ruinous effects of opium . . .’; this was a testament to opium’s abuse and the need for treatment just before the Civil War began. Dr T.T. Semyle (1860) made it clear that prospective patrons in his Cleveland, Ohio, program must ‘be willing to submit to the most implicit control’. Central features of Semyle’s program were a balance of ‘kindness’ and ‘firmness’, which indirectly conveyed the moral nature of the treatment.
Even though MSHWR recognized the potential for habituation, it did not include any tabulations of opium abuse (Moore and Smart, 1888: 884–96). As this book is the main source of medical information, the lack of data makes establishing the frequency of actual opium abuse during the Civil War practically impossible. What is known is dependent on scattered incidents of abuse, and these were often more innuendo than factual.
Civil War opium abuse
Specific examples of opium abuse were rarely documented, and speculation about misuse often replaced real evidence. General William S. Rosecrans was among those caught in a web of conjecture about opium misuse – a charge that gathered momentum after the Battle of Chickamauga. Newspapers staked out various positions on the matter, with some accepting the claim while other reports exonerated the General based on eyewitness accounts (Moore, 2014; 1863b; 1864a 1 ). A beleaguered Rosecrans broke a month-long silence to forcefully rebut the claims, arguing: ‘I never used opium, either in excess or otherwise, in all my life.’ In pondering the origins of the ‘slander’, Rosecrans’ directed his ire at what he considered was a small group of politically motivated newspaper reporters (Rosecrans, 1864).
Another senior officer ensnared in controversy was Confederate General John Bell Hood. Hood suffered an injury to his left arm at Gettysburg and a more serious wound later at the Battle of Chickamauga, which ultimately led to the amputation of his right leg. After a lengthy period of recovery, Hood returned to active service. When compared with his pre-injury leadership, his uneven military performance in the waning days of the Confederacy led some modern historians to speculate that laudanum and morphine addiction had contributed to his decline (Ellis, 2003: 311; Sword, 2017: 147).
John Thompson Darby, the physician caring for Hood during his protracted recovery, made detailed, daily notes which cast a different light on the General’s supposed opium abuse (Hood, 2013, 2014). According to his records, Darby prescribed morphine only for sleep and judiciously increased the dose during the General’s rehabilitation, followed by a reduction and discontinuance at the end of his recovery. Darby’s medical notes indicated occasions when Hood refused the proffered morphine. Darby adjusted the dose range between a quarter grain and one grain, with the most common being one half grain. It seems clear, based on Darby’s meticulous notes, that the dose was adjusted based on Hood’s clinical condition and when no longer needed was stopped, as indicated by an entry on 21 November 1863: ‘sleeps well at night without morphia’ (Hood, 2013; 2014: 38).
Among the few scattered reports of actual opium-related abuse among soldiers during the Civil War was the tragic story of Private Charles F. Noll, 8th Regiment, Company I, New York Infantry, who committed suicide after attempting to murder Mary Strure. Noll obtained both opium and laudanum from a local druggist before surreptitiously administering the drugs to the unsuspecting woman. Strure survived but the 29-year-old soldier died from his self-ingested opium (1863c).
Special Order #35, issued by the War Department, Adjutant General’s Office on 23 January 1865, reported the dismissal of First Lieutenant Maximilian Rosenberg, Company G, 54th New York Volunteers for ‘incompetency, habitual drunkenness, neglect of duty, and the constant use of opium . . .’. 2 Curiously, a few months later the War Department rescinded the previous order and returned Rosenberg to active duty.
Assistant Surgeon Christian Miller assigned to the 8th Regiment, United States Colored Troops, was not so lucky. By General Order #117 issued from the Headquarters, Army of the James, dated 1 October 1864, General Benjamin F. Butler dismissed the physician from military service for dereliction of duty after having been found ‘intoxicated from, as he says, a grain and a half of morphine and a half a gill of whiskey . . .’ (Butler and Marshall, 1917: 205; Miller, 1863).
Although the medical perils of opium use were discussed in MSHWR and references made to its potential for habituation were discussed, there were no cases documenting abuse. A balanced historical explanation for this seeming omission relies on the state of medical practice at the time. Modern culture and medical practice understand the disease concept of addiction, but this was not the situation during the Civil War (Lewy, 2014). Addiction was not even a widely used term, with the words habit or habituation more commonly expressing the prevailing moral concept of substance abuse. Opium abuse was aetiologically viewed little differently from alcohol abuse, with both castigated as moral weaknesses. As a consequence, treatment relied on improving a person’s moral flaws, which was not the province of medicine but more in the realm of moral counselling, usually by clergy. Roughly a decade after the Civil War, the problem of addiction slowly started evolving towards a more medical approach, but vestiges of the moralizing approach still linger in modern times (Royce, 1985).
The Government Hospital for the Insane provides another example of mental disorders and substance abuse during the Civil War. Dr Charles Nichols supervised the hospital’s opening in Washington, DC, in 1855. Just a few years later, Nichols recognized the urgent need for medical support during the Civil War and agreed to treat sick soldiers in this hospital which would become known as the St. Elizabeths Army General Hospital. Dr Bela Stevens was the medical director of this hospital and Dr N. Pinckney was in charge of a separate Navy hospital. Over 1900 service members received care, with most suffering from infections such as typhoid. Hospital doctors treated roughly a quarter of that number for battlefield injuries (Otto, 2013).
An examination of the register of cases for the St. Elizabeths Hospital from 1861 to 31 December 1865 provided diagnostic details on admissions to the Hospital. Although the Hospital continued to provide care for civilians during the Civil War, the steady flow of soldiers and sailors grew ever larger. Alcohol abuse was diagnosed among both civilians and service members, beginning in 1862 and classified as either intemperance or dipsomania; the latter was a contemporary term denoting alcoholism. During the period studied, doctors diagnosed 28 cases of dipsomania among 11 soldiers and 17 civilians and further diagnosed another 15 cases of intemperance among soldiers. 3 Clearly doctors recognized the perils of alcohol, but the register of cases for the Hospital did not record any cases of opium abuse.
Concerns about opium
Public concerns about opium misuse began before the Civil War and were subsequently amplified in the post-war years. In a short article repeated across the country, various newspapers in 1859 complained about the ‘wholesale abuse of opium’ (1859f) by referencing US Custom reports documenting the importation of 300,000 pounds of the drug in the preceding year; it was claimed that an estimated ‘nine-tenths’ of the drug was diverted for non-medical use. Among the most ardent recreational users were ‘lawyers, doctors, clergymen, and literary men . . .’ (1859a; 1859b; 1859c)
One reporter noted opium’s sway among professionals, women and even theologians, and correctly predicted in 1859 that ‘the use of opium will become as generally prevalent as that of alcohol’ (1859d). Henry Ward Beecher lectured in 1860 that ‘when a person has once commenced the habit of opium eating, his life is as good as ended’ (1860a). A small insert quoting a medical journal in 1859 urged mothers not to give their infants opium containing patent medicines, by starkly noting that ‘by quieting a babe, [opium] may enable you to attend a ball or party . . . and may leave you childless’ (1859e).
Newspapers reinforced the concerns. A lawyer’s suicide in 1860 was directly attributed to the opium habit (1860e). A woman who ‘sought refuge from unendurable domestic affliction’ committed suicide in 1861 with six cents worth of laudanum (1861b). Two women mourning the battlefield deaths of their husbands poisoned themselves with laudanum (1862). Although opium was not a common means of suicide among soldiers, some did resort to the drug (1864b; 1867; see also Lande, 2011)
Just after the Civil War began in 1861, an anonymous ‘discoverer’ posted a small advertisement in a Vermont newspaper appealing ‘to those in the habit of taking opium’. For three dollars and a pledge of secrecy the advertisement promised enough of the patent medication to completely quiet the nerves through the duration of the painful opium withdrawal. As a side benefit the cure could ‘be given by friends secretly to one having the accursed habit’ (1861c).
An even more vigorous public crusade against opium misuse began roughly a decade after the battlefields lay quiet. Newspapers led the charge through an information campaign highlighting the horrors of ‘opium eating’, a common term of habituation used in the nineteenth century. These stories ran the gamut from the fanciful to the factual, but all served to publicize the social epidemic.
In one example, an alert physician cured a former Civil War officer’s opium eating. Both men served during the war, and the military surgeon recalled the officer’s morbid injury: a bullet wound in the neck with unrecoverable fragments (1873). Three years later an emaciated man, almost unrecognizable as the former officer, consulted the physician. During their reunion, the officer’s desperation was palpable as he alternated between suicidal and homicidal ideation, stemming from his intractable pain, and opium-eating guilt. While listening patiently, the doctor decided to examine the old wound, and in doing so discovered the long lost bullet fragments lodged in the man’s head. It would require an exquisitely delicate, dangerous operation to remove the fragments, to which the patient readily assented. It was a successful operation which removed not only the fragments but also the opium habit, while also indirectly suggesting a link between the two.
In 1872, New York newspapers reported the proceedings of the Stokes murder trial (1872). Edward S. Stokes shot the noted and controversial New York financier James Fisk Jr in the arm and abdomen. Fisk received prompt medical attention including surgery, but died from the wounds. The subsequent trial included the defence’s contention that physicians’ malpractice based on excessive opium administration during the surgery contributed to the man’s death. Former Army Surgeon General William Hammond testified for the prosecution, noting ‘I have a very large experience of gunshot wounds . . . the proper treatment of a wound in the intestines is to keep the bowels as quiet as possible . . . by the use of large quantities of opium . . .’. Hammond testified that the amount of opium given to the injured man was medically appropriate, given the nature of the wound and the man’s acute pain. As the Stokes trial illustrated, optimum opium dosing produced divergent medical opinions based on a consideration of the drug’s risks and benefits; Hammond clearly favoured the latter.
In the decade after the end of the Civil War, northern newspapers started focusing on the evils of opium, with The Sun penning an influential piece in 1875 dramatically titled ‘Satan’s own man-killer’ (1875c). The paper soberly noted that in the preceding year America imported 200 tons of opium with only one-fifth supposedly devoted to legitimate medicinal use, thus leading the reader to conclude that the remainder was illicit. In building the argument condemning opium, but without offering any supporting evidence, The Sun claimed that during the Civil War ‘immense quantities [of opium] were disposed of in Washington to the soldiers, and a lively and lucrative business was done in opium by liquor dealers, sutlers, cigar vendors . . .’. Authorities supposedly recognized the problem and took steps to curtail the trade, but The Sun credited clever entrepreneurs who somehow avoided the restrictions and still supplied the drug so that the ‘soldier when entering battle took a sufficiently large dose not only to quiet his nerves, but render him utterly indifferent to the terrors of the conflict’. The Sun also lamented the attention given to the Temperance Movement and clearly wanted their readers to vilify opium in a similar manner. Helping the cause was an interview with Dr Alexander Mott, who described clinical examples of those ‘addicted to the vice’ and freely admitted that ‘it is difficult to eradicate the habit’. The Sun’s article (1875c) reverberated across the country as other newspapers broadcast the story (1875a; 1875b).
Two years later at the Eighth Annual Meeting of the Association for the Cure of Inebriates, Dr J.B. Mattison claimed that ‘fully eighty percent of the cases of opium inebriety in this country may be directly or indirectly traced to opiate prescriptions’ (1877a). In words that are echoed nowadays, the New York Times published a double-barrelled assault on the ‘medical fraternity’ for its complicity in the opium crisis and its lack of interest in countering it (1877b).
A northern newspaper made it clear that opium abuse was also spreading south, reasoning that ‘the great change which has destroyed much of the wealth of the South, and left people in poverty . . .’ is the source of the scourge (1878b; 1878c). Another newspaper joined that chorus, prompting a spirited southern newspaper to protest the accusation by publishing a rebuttal (1878b; 1878e).
After declaring ‘there are over 200,000 opium habituates in this country . . . more than two-thirds, are from the best classes . . .’, the northern newspaper restated its proposition that negligent physicians were the chief culprits (1878d). The same paper also pointed to the public’s rampant use of patent medicines, many of which contained opium, laudanum or even morphine, and could be obtained without a physician’s input; this observation seemingly undermined their condemnation of physicians.
Opium use among women also increased in the post-war years, a situation attributable in some cases to its use for dysmenorrhoea and emotional conditions such as neurasthenia and depression (Adams, 2014; Bollet, 2002). Evidence seems to suggest that Mary Todd Lincoln used various opium preparations for chronic headaches, a use that may have accelerated following her husband’s death (Beidler, 2009). Mary Boykin Chesnut admitted her use of opium in a continuing effort to relieve anxiety (DeCredico, 1996).
Newspapers sometimes took aim at patent medicines. The tragic death of a child prompted an article excoriating the widespread use of tonics and elixirs to quiet young children. With more hyperbole than evidence, the story claimed that the ‘cordial and soothing mixtures annually lay low their tens of thousands . . . if only parents could be given to understand that the active principle in all these infant cordials is opium . . .’ (1879a).
Throughout the Civil War era, advertisements touted the benefits of ‘Mrs. Winslow’s Soothing Syrup’ for teething children (1860c; 1860d; 1865; 1883). This was among a large group of heavily advertised patent medicines that contained opium (Ebert, 1897; Hiss, 1898). Not surprisingly, inventive patent-medicine makers also took aim at opium habituation, offering tonics guaranteed to prevent the ‘moral prostration’ from quitting the drug (1878a).
Physicians, druggists and, to a lesser degree, patent-medicine makers were the typical targets of nineteenth-century, reform-minded thinkers. From a broader perspective, an interesting article published in 1879 linked the opium habit to the Temperance Movement, which condemned the use of any alcohol. ‘The result was that the less hurtful and sometimes positively beneficial stimulant [alcohol] having been removed, a far more dangerous and deadly one – a narcotic . . . was resorted to in secret’ (1879b).
If nothing else, patent-medicine makers knew their market and regularly developed products tapping the public’s wishes. Countering the numerous opium-containing products were innovators hoping to capitalize on a growing subset of Americans recognizing the dangers and looking for non-narcotic alternatives. An 1860 advertisement for ‘Hunnewell’s Universal Cough Remedy’ claimed to treat coughs and also all nervous complaints, including delirium tremens, with an opium-free formulation (1860b). A year later, Hunnewell’s Universal Cough Remedy promoted their brand because ‘opiates . . . not only run down the system, but destroy all chance of cure’ (1861a).
‘Bryan’s Life Pills’ promised users that ‘the pernicious habit of Opium eating and dram drinking is overcome by use of them’ (1863a). A patent medicine named ‘Reay’s elixir chloral hydrat’ also claimed to be a safe alternative to opium and morphine (1870b). Another advertisement touted ‘Chloraline’, which ‘possesses all the advantages of opium, and none of its disadvantages’ (1870a). Puck cigarettes even targeted discerning smokers concerned that their tobacco might be laced with opium (1879c).
Discussion
Modern historians studying the Civil War years come to different conclusions when examining the subsequent social impact of opium use. They divide into three broad camps, with one group arguing that liberal opium use during the Civil War contributed to a surge in usage in the following decades (Courtwright, 1978, 2009; Kamieński, 2017). A contrarian view asserts the opposite, based in part on the absence of compelling factual data supporting a surge of opium habituation among veterans of the Civil War and the increase in opium importation beginning in the 1870s (Musto, 1999; Quinones, 1975). The third viewpoint argues that incomplete Civil War data complicates claims linking war use with the post-bellum surge (Logue and Barton, 2007).
Reports from the managers of the various asylums for disabled Civil War veterans in the decade following the War gave some credence to the dearth of opium-related diagnoses among former soldiers (National Asylum for DVS, 1869, 1872, 1876). Although the numbers were small, there was a trend of reporting opium and ‘morphonism’ or morphine addictions in later reports. Based on his extensive clinical practice at the time and his familiarity with the subject, Dr Thomas D. Crothers considered morphonism was under-reported in veterans because ‘the addiction is often concealed to prevent the possibility of imperiling their application for a pension’. He identified two types of morphonism in these men. Among cases in the early post-war years, Crothers related the addiction to chronic pain from war wounds, but another larger group emerged unscathed from the war and developed morphonism many years later – an outcome attributed to a ‘decline in bodily vigor’ (Crothers, 1902: 77).
Crothers’ analysis makes drawing a straight line between the presumed malpractice of Civil War physicians’ opium-prescribing practices and the post-war opium crisis seem too simplistic, and it also neglects other unique nineteenth-century factors. In an interesting hypocrisy, newspapers that roundly condemned doctors for causing the surge in post-war opium misuse had no qualms in accepting endless advertisements from opium-laced patent medicines. Orange Judd, publisher of the American Agriculturist, launched a lonely crusade attacking patent-medicine makers and vainly urged other publications to ban their advertisements (Lande, 2016: 203).
The post-war rise in opium use must be understood in terms of nineteenth-century psychological factors and social forces. From a modern vantage point, it seems reasonable that the Civil War contributed to emotional distress (Courtwright, 1983). But aside from scattered reports of nostalgia, which was a forerunner of today’s depressive and post-traumatic stress disorders, scant medical attention was paid to psychological problems, and consequently there was little reason for doctors to prescribe opium for presumed emotional problems (Lande, 2015, 2016).
Although it is impossible to precisely tease apart the various motivations prompting the use of opium, which can roughly be grouped as physician prescribed, self-medication, and recreational, it is important to consider them. The value of such an approach lies in understanding whether the aim was the treatment of actual or hidden medical conditions or simply the apparent pleasure derived through use of the drug. During the Civil War years, doctors administered the bulk of opium, laudanum and morphine for illness and injury. After the war, there was a growth in the sales of opium-containing patent medicines, which presumably soothed nerves and lifted spirits at a time when few alternatives to treating or even acknowledging emotional disorders existed; this suggests their possible use as self-prescribed interventions for anxiety and depression.
Both alcohol and opium also found refuge in patent medicines as a result of the tide of reform-minded temperance advocates that spread across the nineteenth-century landscape. Alcohol in particular faced withering scrutiny and social disapprobation, which culminated in its legal prohibition (Okrent, 2010).
Temperance changed social attitudes towards alcohol consumption many years before prohibition culminated in the Eighteenth Amendment to the US Constitution. The social consequences of prohibition were debatable then, as they are today. If the goal of ardent prohibitionists was a dry nation, then they utterly failed; this left the proponents claiming that the Eighteenth Amendment’s success was instead based on a substantial reduction in per capita consumption. Even this is open to challenge, since quantifying historical per capita alcohol consumption is problematic. When faced with this conundrum, proponents of prohibition pointed to the decline in social harms, such as arrests for public drunkenness, as evidence of prohibition’s benefits (Aaron and Musto, 1981).
A critical analysis of the Temperance Movement and prohibition finds more harms than benefits. It can be credibly argued that both the Temperance Movement and prohibition diverted legal consumption of sedatives such as alcohol and opium underground, leading to a more socially accepted spike in patent medicines containing those ingredients. Temperance reformers claimed credit for closing public drinking establishments, but this was a pyrrhic victory as discrete venues gradually replaced their more visible counterparts (McGirr, 2015: 491; Miller, 2012).
Between 1875 and 1890, 4 states enacted prohibition and another 10, including Texas, South Carolina, Florida, Georgia and Virginia, enacted legislation permitting local jurisdictions the option of becoming dry. By 1910, Georgia, Mississippi, North Carolina, Tennessee and Alabama adopted state-wide prohibition. Arkansas, South Carolina and Virginia legislated prohibition in 1916, Texas in 1918, and Florida in 1919 (Paullin et al., 1932: 128).
Patent medicines benefited by offering a socially acceptable and supposedly medically justified pathway to both alcohol and opium products. As a matter of speculation, it seems plausible that the social and political demonization of alcohol contributed to some of the increase in opium use. Consumers might have also turned to patent medicines for relief of nervous and mood disorders at a time when psychiatry was in its infancy and effective alternatives simply did not exist (Lande, 2016: 182).
Civil War medical practice cannot be judged through the lens of modern medicine (Devine, 2014). At the start of the Civil War, medical training was haphazard, influenced by a smaller core group of European-trained physicians, and doctors were absolutely overwhelmed by the vast numbers of wounded and ill soldiers; for example, the one-day Battle of Antietam forced military doctors to manage over 17,000 wounded soldiers. Against this background, these doctors relied on tried and trusted treatments such as opium for injuries and illness.
The rise in post-bellum opium use cannot be analysed in a vacuum, as if other social forces were non-existent; this is a particularly salient point when considering the gathering momentum of the Temperance Movement. As politicians increasingly adopted legislative mandates as the cure for alcohol’s pernicious social effects, more jurisdictions joined the effort to restrict or ban its production, distribution and marketing. Southern states experimented with different policies, not always successfully, that attempted to straddle the divide by developing a middle ground between prohibition and promotion (Aaron and Musto, 1981: 148–9).
Historical comparisons between the post-bellum use of opium and the modern opioid crisis are particularly difficult, because today’s biopsychosocial constructs of substance-use disorders simply did not exist during the Civil War era. Clearly there are individual differences in a person’s susceptibility to a disorder due to substance use, but then, as now, not everyone develops an opioid-use disorder. Modern-day physicians have access to knowledge which can help to identify potential scenarios that may increase the risk of misuse, such as the complex interplay between regulatory actions, prescribing practices, a drug’s pharmacology, a person’s genetic attributes, environmental factors, and various psychological states (King et al., 2014; Mistry et al., 2014).
In the final analysis, Civil War medical practice responded to a lengthy humanitarian crisis with nineteenth-century knowledge. As the war continued, medical practices adapted and contributed knowledge that shaped future clinical care, with embryonic developments borne from America’s bloodiest conflict. Clearly the post-bellum growth in opium use was multifactorial, with greater availability from patent medicines a central factor, along with advertising, the Temperance Movement and the state of nineteenth-century medicine. Today, as then, the opium crisis cannot be reduced to simple, single causes.
Footnotes
Funding
The author received no financial support for the research, authorship and/or publication of this article.