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INTRODUCTION

50,000 PILLS

On a business trip years ago, I had an extra day in London. So like many tourists, I headed to the British Museum. And there I ran across something extraordinary.

In a large, light-filled gallery on the ground floor was a table covered with thousands of pills. It was an exhibit conceived by an artist and a doctor who had come up with a way to display all the 14,000 doses of prescription drugs an average Briton took in a lifetime. These pills, woven into lengths of fabric and accompanied by bits of explanatory text, covered a gallery table that stretched forty-six feet. I couldn’t believe what I was seeing. Did people really take this many pills?

The answer is: No. They take more. The display was geared for Britain. And when it comes to taking drugs, the British don’t come close to Americans. More than half of all Americans take at least one prescription drug on a regular basis, and most of those who fall into that group take more than one (somewhere between four and twelve prescriptions per person per year, depending on which study you look at). One expert estimates that Americans take an average of ten pills per person per day. Add in nonprescription drugs—over-the-counter vitamins, cold and flu remedies, aspirin, and other supplements—and run the numbers: Let’s say a low-ball estimate of two pills per day per American over an average seventy-eight-plus years of life. The total comes to somewhere more than 50,000 pills, on average, in the average American’s lifetime. And there’s a good chance it’s a lot more. America consumes more pharmaceuticals than any other nation on earth, and we spend a lot more to get them: more than $34 billion each year on over-the-counter drugs, and $270 billion on prescription drugs. That’s way beyond what any other nation spends, because our drug prices are a lot higher than any other nation’s. Americans constitute less than 5 percent of the world population but spend more than 50 percent of the money that flows into the world’s drug companies.

No nation in human history has taken as many drugs or spent as much money to get them as the United States does today. And the drugs have had profound effects. They have added decades to our average life spans, playing a central role in the graying of America. Drugs have changed the social and professional options of women. Drugs have altered the ways we view our minds, changed our attitudes toward the law, shifted international relations, and triggered wars.

By these measures, perhaps we should rename our species Homo pharmacum, the species that makes and takes drugs. We are the People of the Pill.

This book will introduce you to how we got here, with a focus on medical (that is, legal, non-recreational, mostly prescription) drugs. It is written as a series of brief, vivid sketches, sort of mini-biographies of ten drugs that changed medical history, linked by common themes, with each story leading into the next.

One of those common themes is the evolution of drugs. The word drug itself comes from old French and Dutch terms for the barrels once used to keep herbs dry. Pharmacists 150 years ago were in many ways like today’s herbalists, extracting and compounding their medicines for the most part from jars of dried plants. That gave doctors in the 1800s a couple-dozen somewhat effective natural medicines to help their patients (along with hundreds of useless, often alcohol-rich elixirs, poultices, and pills made and ballyhooed by local pharmacists). Today we have ten-thousand-plus, ever-more-targeted, increasingly powerful high-tech medicines that can treat and often cure conditions that have confounded healers for thousands of years.

Wrapped in this evolution and guiding its trajectory is humanity’s search for magic bullets, medicines that can unerringly seek out and destroy diseases in our bodies without doing any harm to our health along the way. The goal has always been to find medicines that are all-powerful, but without any risk. That is likely an impossible goal. We haven’t yet found a perfect magic bullet. But we keep inching closer.

Another thread that runs through these chapters tells a bit about the growth of the industry that makes drugs—the trillion-dollar behemoth that critics have dubbed “Big Pharma”—and changes in the ways we regulate that industry. For instance, in the 1880s you could get just about any drug you wanted without a prescription, over the counter, including mixtures laced with opium, cocaine, and cannabis. Now you need a prescription for almost any powerful medicinal drug, and even with a prescription you can’t buy narcotics like heroin (well, at least not in the United States). Drugmakers before 1938 could put just about anything they wanted on the market as long as it didn’t kill you, and they didn’t try to fool you with false advertising. Today, prescription drugs have to be proven both safe and effective before they can be sold. These laws governing our drugs evolved, in sometimes surprising ways, along with the drugs themselves.

Our attitudes have changed, too. In the 1880s, most people considered the right to self-medicate as something close to inalienable. It didn’t matter if a drug was good for you or not, deciding whether to take it was your choice, not your doctor’s. If you wanted to buy one of the many patent medicine horrors available from local drugstores, anything from radioactive water for cancer to opium-spiked syrups for insomnia, well, it was your body. Nobody had the right to tell you otherwise.

Today that’s been turned on its head. Now physicians hold the keys (in the form of their prescription pads) to getting most drugs. Today, when it comes to taking our medicine, we pretty much do as we’re told.

Drugs changed the practice of medicine, too. In the 1880s, doctors were family counselors good at diagnosing ailments and providing solace and advice to relatives, but almost powerless to alter the course of killer diseases. Today, physicians are able to work miracles of lifesaving that their brethren a century ago could only dream of. They are also all too often overscheduled, data-stuffed technocrats more comfortable reading lab reports than holding a patient’s hand.

During the past sixty years, the average life expectancy for Americans has lengthened by two months each year—mostly because of drugs. Vaccines have allowed us to completely conquer age-old enemies like smallpox (and we’re closing in on polio). Prescription drugs, along with public health efforts, have made our lives much longer and, in general, healthier.

Not that there aren’t also great risks. Drug overdoses, from both legal and illegal sources, are killing around 64,000 people each year, an annual death toll that exceeds all U.S. military deaths in all the years of the Vietnam War.

Here’s what drugs have done for us: In the bad old days, say two hundred years ago, men lived twice as long, on average, as women (mostly because of the dangers of childbearing and -birth). And everybody in general lived about half as long as they do today. A lot of that was tied to death early in life. If babies made it through the risks and traumas of childbirth, survived the epidemic diseases of childhood—smallpox, measles, whooping cough, diphtheria, and more—and made it to adulthood, they could be considered lucky. Because then they could die of consumption, quinsy, cholera, erysipelas, gangrene, dropsy, syphilis, scarlet fever, or any of a few dozen other diseases that we don’t hear much about anymore. Today we die from heart disease and cancer, diseases of the middle-aged and elderly. People in the old days didn’t worry too much about heart disease or cancer because few people in the old days lived long enough to get them. Thanks to drugs, a group of scientists recently wrote, “People have different diseases, doctors hold different ideas about those diseases, and diseases carry different meanings in society.”

As you’ll see in this book, vaccines and antibiotics moved us from being helpless victims of epidemics to being able to fight them off. Combined with more effective public health measures—cleaner drinking water, better sewage systems, better hospitals—drugs moved us from fearing the diseases of childhood to suffering the diseases of the old. That’s a tribute to medicine in general, and to drugs in particular.

These are technological tools capable of changing our culture. But when you think about them, drugs are even stranger than that. Today’s pharmaceuticals are high-tech, developed in cutting-edge laboratories after investments of tens of millions of dollars, but a kind of high-tech so intimate, so personal, that they have to become part of you to do their work. You have to snort them, drink them, ingest them, inject them, rub them into your skin, make them part of your body. They dissolve inside you and race through your blood from muscle to heart, liver to brain. Only then, when they are absorbed, when they have melted into you and melded with you, does their power unfold. Then they can attach and trigger, soothe and calm, destroy and protect, alter your consciousness, restore your health. They can jack you up or chill you out. They can addict you, and they can save your life.

What gives them this power? Are they animal, vegetable, or mineral? All of the above. Are they good for you? Often. Are they dangerous? Always. Can they perform miracles? They can. Can they enslave us? Some do.

So, ever-more powerful drugs, ever-more powerful physicians, ever-more diseases conquered. Seen this way, the story of drugs looks like a triumphant march of progress. But don’t be fooled: Much of the history of drugs, as you’ll see, is rooted in error, accidents, and lucky breaks.

Writing this book has, however, also convinced me that good old-fashioned progress plays a central role, too, if you define progress as the logical, rational application of a growing number of tested facts. Each new drug tells us new things about the body, and each new understanding of the body allows us to make better drugs. When the system is working well, each new scientific finding is criticized, tested and retested, amended if necessary, and then becomes part of a global library of facts available to other scientists. It builds. This synergy between drug-making and basic science, this dance between lab and pill and body, described in tens of thousands of scientific publications over the past three centuries, is now speeding up in tempo and growing in intensity. It is truly progressive. If we can hold our world together, we are on the brink of greater things.

It is not a scholarly history of the pharmaceutical industry. It contains no footnotes. It ignores—out of necessity, for brevity—many world-shaking drug developments. You won’t find every important drug here. But you’ll find many of the drugs that have shaped both medical history and today’s world. I hope you’ll come away with a better understanding of this fascinating part of society.

It is not a book that will teach drug scientists anything very new, because it was not written for drug scientists. Rather, this book is for people who know just a little about drugs and want to learn more. It is aimed at the general reader, not the specialist—although I hope specialists, too, might come away with some interesting new stories to tell.

It is not a book that will make drug manufacturers happy. Or pro-pharma lobbyists. Or anti-pharma activists. It is neither a screed about the evils of the drug industry nor is it a song of praise for the wonders of science. I have no ax to grind, no agenda to promote.

My hope simply is to entertain you and to introduce you to a new world—the world of drug discovery—in a way that explains not only a lot about the history of medicine, but also something about our lives today, from our relationship with our doctors to the advertisements we see on TV, from the epidemic of opioid abuse to the possibilities of personalized medicine. Drug companies make incredible profits, and yet many of us can’t afford the drugs we need. This book will get you thinking about why.

If there’s one overarching lesson I hope you come away with, it is this: No drug is good. No drug is bad. Every drug is both.

Another way of saying that is that every effective drug, without exception, also comes with potentially dangerous side effects. This can be easy to forget in the first flush of enthusiasm when a new drug hits the market. Pushed by huge ad campaigns and often buttressed by glowing media reports, newly released blockbuster drugs enter what’s called the Seige cycle (named after Max Seige, a German researcher who first described it early in the last century). It happens time and time again: An astounding new drug is released to intense enthusiasm and wide adoption (that’s stage 1 of the Seige cycle). This honeymoon period is followed within a few years by increasing numbers of negative news articles about the hot-selling new drug’s dangers (stage 2). Suddenly everyone is alarmed that yesterday’s wonder drug is today’s looming threat. Then that, too, passes, and we get to stage 3, a more balanced attitude with a more sober understanding of what the drug can really do, as it settles into moderate sales and its proper place in the pantheon of drugs.

Then, ta-da!, a drugmaker releases its next miracle drug, and the cycle starts all over. When you hear the next breathless news report about the next breakthrough drug, remember the Seige cycle.

As for the ten drugs I’ve chosen to highlight: You’ll likely recognize some, while others will be new to you. The overall idea for this book came from my talented editor, Jamison Stoltz, but the final list is my own.

I didn’t want to trot out the standard “greatest hits” list of drugs throughout history. So I’ve left out some of the usual suspects—aspirin and penicillin, for instance—because there’s already been plenty written about them. In their place you’ll find surprising chapters on lesser-known (but very important) drugs like chloral hydrate (knockout drops, used everywhere from doctors’ offices to Mickey Finn’s bar), and CPZ (the first antipsychotic, the drug that emptied the old mental asylums), along with a sprinkling of more famous drugs from the Pill to Oxycontin. The book includes a lot about opioids in their many forms, from the first prehistoric harvesting of poppy sap to today’s murderously powerful synthetics. Opium’s children are worth the attention because of their historical importance (their thousands of years of refinement and development illuminate much about the history of drug-making in general), their current importance (as agents of today’s epidemic of addiction and overdose), and because their story is full of interesting characters and stories, from a genius medieval alchemist to a despairing Chinese empress to a lab littered with unconscious chemists.

Careful readers might notice that the number of drugs I highlight is more like ten-ish than exactly ten. Some chapters focus on a single chemical (like sulfa), others on a related chemical family of drugs (like statins). So don’t get caught up in the count. That’s not important.

What’s important here is that nobody can pick the ultimate short list of history’s most important drugs—it’s futile to try—so I made choices based on my sense of the drug’s historical importance plus its entertainment value. The writing style is designed to avoid as much scientific jargon as possible in favor of general readability; my preference is for lively stories and memorable characters. This might not make scientists happy. But I hope it works for you. Welcome to the world of drugs.

CHAPTER 1

THE JOY PLANT

You can imagine an early hunter-gatherer in the Middle East looking for that next meal, roaming some new countryside, trying a taste of this or that insect, animal, or plant. Seeds, high in nutritional value, are generally worth trying. So, often, are the pods and fruits that surround them. On this particular day he or she finds a patch of waist-high plants growing in an open area, each head nodding under a heavy, fist-sized, waxy, light green seedpod.

Worth a try. A sniff. A small bite. A grimace and a spit. The flesh of the pod is mouth-twistingly bitter, and this is a bad sign. We are wired to sense a lot of poisonous things as bitter; this is nature’s way of telling us what to avoid. Bitter usually means a stomachache or worse.

So our early explorer turned away from the plants with the big seedpods. Then an hour or two later, something strange. A dreaminess. An easing of pain. A pleasant sense of well-being. A connection with the gods. This plant was holy.

It might have started that way. Or it might have started when a sharp-eyed early human noticed some animal feeding on those same seedpods and afterward acting a bit odd, also a sign from the gods that the plant had power.

We do not know how it happened, exactly, but we know something about when. The long love affair between humans and this miraculous plant started more than ten thousand years ago—before towns, before agriculture, before science, before history. By the time the first human cities on earth were rising in the valleys of the Euphrates and Tigris Rivers, this holy plant’s seeds were being eaten as food, its bitter sap was being used as a medicine, and its praises were being sung. During the excavation of a four-thousand-year-old palace in what is today’s northwest Syria, archaeologists recently found an unusual room near the kitchens. There were eight hearths and a number of large pots, but there was no food residue. Instead, they found traces of poppy along with heliotrope, chamomile, and other herbs known to be used in medicines. Was this one of the world’s first drug-manufacturing sites?

The plant at the center of this ancient attention was a particular strain of poppy. The seedpods, especially the sap in their outer walls, had effects that were so powerful, so healing, that it seemed almost supernatural. A terra-cotta statuette found on Crete and dated back more than three thousand years shows a goddess with a headdress adorned with pods of poppies, incised exactly as the pods are cut today to harvest the sap. “The goddess appears to be in a state of torpor induced by opium,” wrote one Greek historian. “She is in ecstasy, pleasure being manifested on her face, doubtless caused by the beautiful visions aroused in her imagination by the action of the drug.” Some archaeologists have proposed that the room in which this goddess was found was used by Minoans for inhaling the vapors of dried poppy sap.

The Greeks associated the plant with their gods for sleep (Hypnos), night (Nyx), and death (Thanatos), and put its image on coins, vases, jewelry, and tombstones. In myths, the goddess Demeter was said to have used poppies to soothe the pain of losing her kidnapped daughter, Persephone. The ancient poet Hesiod wrote eight centuries before Christ of a town near Corinth in Greece called Mekonê, which translates roughly as “Poppy Town,” which some historians believe got its name from the extensive poppy farms that surrounded it. Homer mentions the plant in the Iliad, and in the Odyssey he tells the story of Helen making a sleeping potion, assumed by many to include poppy sap. Hippocrates mentioned poppy frequently as an ingredient in medicines. It was part of temple rituals, carved into statues, and painted on tomb walls. Dried and eaten or smoked, it was early man’s strongest, most soothing medicine. Today it is among the most controversial. It is the most important drug humans have ever found.

In a way it’s amazing that early humans ever discovered any natural drugs at all. Consider that 95 percent of the three-hundred-thousand-odd plant species on earth are inedible by humans. Go out and start randomly munching the greens in your local woods, and the odds are twenty to one that you’ll double over, throw up, or die. Among those few plants that are digestible, the chance of finding useful medicine is close to zero.

Yet our ancestors did it. Through trial and error, inspiration, and observation, prehistoric peoples around the world slowly found and built a store of herbal medicines. Early healers were locavores, using what grew close to home; in northern Europe effective herbs included mandrake root (for just about anything from stomach problems to coughs to sleeping problems), black hellebore (a strong laxative), henbane (to allay pain and ease sleep), and belladonna (for sleep and eye problems). Other early drugs, like cannabis, traveled on trading routes from points south and east. Many spices eagerly sought from traders in the Middle East and Asia, such as cinnamon and pepper, were used as medicines as much as seasonings. Early healers knew not only what their local herbs were but how to use them. A Greek physician in Nero’s army in the first century, Pedanius Dioscorides, summarized what was known at the time in his multivolume De Materia Medica, one of the earliest and most important guides to drugs. In addition to listing hundreds of herbs and their effects, he described their preparation and recommended doses. Plant leaves could be dried, crushed, and added to potions brewed over slow fires; roots could be harvested, cleaned, smashed into pastes, or eaten fresh. Some could be mixed with wine, others with water. Medicines could be swallowed, drunk, inhaled, rubbed on the skin, or inserted as suppositories. Dioscorides’s work guided the use of drugs in medicine for more than one thousand years.

He described the poppy, summarized its effects, and outlined its dangers: “A little of it,” he wrote in De Materia Medica, “is a pain-easer, a sleep-causer, and a digester, helping coughs and abdominal cavity afflictions. Taken as a drink too often it hurts (making men lethargic) and it kills. It is helpful for aches, sprinkled on with rosaceum; and for pain in the ears dropped in them with oil of almonds, saffron, and myrrh. For inflammation of the eyes it is used with a roasted egg yolk and saffron, and for erysipela and wounds with vinegar; but for gout with women’s milk and saffron. Put up with the finger as a suppository it causes sleep.”

The plant and its magical juice accrued many names as it traveled from culture to culture, from the ancient Sumerian hul gil for “joy plant” to the Chinese ya pian (from which we derived the expression “having a yen” for a drug). The Greek word for juice is opion, which gives us today’s word for the raw drug made from the poppy: opium.

You can’t get it from just any poppy. There are twenty-eight species of poppy, members of the genus Papaver, on earth. Most of them are showy wildflowers that don’t produce more than a trace of opium. Only two of the twenty-eight make appreciable amounts of the drug, and only one of these grows easily, suffers few pests, and doesn’t require much irrigation. Its scientific name is Papaver somniferum (somniferum comes from Somnus, the Roman god of sleep). This single plant, the opium poppy, still provides the world with almost all of its natural opium.

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Opium poppy (Papaver somniferum): white flowers, seed by M. A. Burnett. Wellcome Collection

Researchers today debate whether this particular poppy was always so opium-rich, or whether early humans cultivated and bred it specifically to boost the amount of the drug. Whichever, by ten thousand years ago it was being grown in much the same way that it is today, and its medicine was being processed pretty much the same way.

Two thousand years ago, Dioscorides described how to gather the juice. It’s remarkably simple: After a brief flowering, the poppy petals fall off. Within a few days the plant produces a waxy green seedpod that grows to the size of a hen’s egg. Harvesters watch closely as the pod starts drying to a dull brown, and at the right moment they make a series of shallow cuts into its skin. These cuts weep the juice that contains the magic. The sap produced in the skin of the pod is where the drug is most concentrated (poppy seeds, used widely in baking and flavoring, contain very little opium).

Fresh poppy juice is watery, whitish, cloudy, and almost entirely inactive. But after exposure to the air for a few hours it turns into a brown, sticky residue that looks something like a cross between shoe polish and honey. That is when its medicinal powers are freed. It is scraped off the pod and formed into sticky little cakes, the cakes are boiled to remove impurities, and the resulting liquid is evaporated. The solid that’s left, raw opium, is rolled into balls. And those dark, gummy balls changed history. Drugs before the nineteenth century were more than just bundles of herbs drying in the back rooms of witches, medicine men, and priests. They were processed and combined in ways part therapeutic, part magical—boiled into brews and elixirs, shaped into pills, mixed with everything from mummy dust and unicorn horn to powdered pearls and dried tigers’ droppings, formed into elaborate concoctions for wealthy patients.

Opium was a prize ingredient. It could be dissolved in wine or blended into mixtures with other ingredients. It worked no matter how you took it—orally, nasally, rectally, smoked, drunk, or swallowed as a solid. One method might be a little faster than another, but no matter how it was delivered, it had the same range of effects, from making users sleepy and dreamy to killing their pain.

Most important—a sort of heavenly bonus—it made patients happy. It raised their spirits. It was more than a medicine; it was a doorway to pleasure. As one historian put it, “Opium was appealing because it always soothed the body while romancing the imagination. . . . Psychic and physical discomfort was replaced with hope and a halcyon calm.” This was a truly seductive package of effects: a respite from pain, a feeling of well-being, a sense of exhilaration, an invitation to dream. Early users and caregivers often employed the same word to describe its effects: euphoria. Opium made it possible to bear the pain of disease and injury and at the same time to deeply rest. It was a perfect tool for early physicians (as long as it was used carefully; early healers, too, knew that too much could easily ferry patients from sleep to death).

It’s no wonder the use of the drug spread across time through the Middle East and the Western World, from the Sumerians to the Assyrians to the Babylonians to the Egyptians, and from Egypt to Greece, Rome, and Western Europe. The best opium in the ancient world was said to come from the area around Thebes; one Egyptian medical text records its use in some seven hundred different medicines. The armies of Alexander the Great carried it with them as they conquered their way from Greece to Egypt to India, introducing it to local populations as they went. Poppy flowers became symbols of sleep both temporary and permanent, associated with the gods of slumber, dreams, and transformation, marking the passage from life to death.

The poppy’s association with death was more than poetic. As early as the third century BCE, Greek physicians were already keenly aware that opium could be as dangerous as it was euphoric, and they debated whether the value of the medicine was worth the cost to patients. The Greeks worried about overdosing patients; they also realized that once patients started using opium, it was difficult to get them to stop. They wrote the first descriptions of addiction.

But the dangers of opium seemed far outweighed by its benefits. By the time Rome ruled the world in the first and second centuries CE, opium was said to be as widely consumed as wine and was sold on Roman streets in the form of poppy cakes—unbaked, malleable sweets made of opium, sugar, eggs, honey, flour, and fruit juice—used to lift the spirits and ease the minor aches and pains of the populace. Emperor Marcus Aurelius was said to take opium to help him sleep; the poet Ovid was also reputed to be a user.

After the Roman Empire’s fall, opium found new markets thanks to Arab traders and merchants, who made the substance—lightweight, easy to transport, and worth its weight in gold for the right buyers—a standard part of caravan freight, spreading its use through India, China, and North Africa. One of the greatest of all Islamic physicians, Ibn Sina (called Avicenna in the West), wrote around 1000 CE that opium is one of Allah’s signal gifts for which he should be thanked every day. He very carefully described its many beneficial uses as well as its dangers, such as its ability to cause memory and reasoning problems, its constipating effects, and the dangers of overdose. Avicenna himself had seen a patient die from the rectal administration of too much opium. This great healer’s thousand-year-old conclusion about opium sounds very much like the attitudes of today. “Physicians should be able to predict the duration and severity of pain and patient’s tolerance and then weigh the risks and benefits of opium administration,” he wrote, advising its use only as a last resort, and then recommending that physicians use as little as possible. It is likely that Avicenna was himself an early opium addict.

He and other Arab physicians worked it into cakes, infusions, poultices, plasters, suppositories, ointments, and liquids. Arab physicians of the Middle Ages were the world’s best medicine makers, greatly expanding the art of drug-making by developing the use of filtration, distillation, sublimation, and crystallization, all part of a practice they called “al-chemie” (thought to be derived from the word khem, for Egypt, thus, roughly, “the Egyptian science”). The basic idea of alchemy, as it became known in the West, was to work with nature’s raw materials to bring them to perfection, to help natural things evolve from their rough, raw states into more refined, more pure forms—to release their pure, inner spirits (this idea is embedded in our language: The alchemical distillation of wines and beers released the powerful liquors we still call “spirits”). Alchemy was at the same time a method of making useful items like medicines and perfumes, an exploration of the natural world, and an almost religious pursuit of the soul in all things.

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Avicenna Expounding Pharmacy to His Pupils. Wellcome Collection

Ancient Islamic writings made it clear that while opium could do great things, it could also enslave its users. Manuscripts also include descriptions of opium addicts, with their dangerous illusions, sluggishness, laziness, and diminished mental powers. “It turns a lion into a beetle,” one writer warned, “makes a proud man a coward and a healthy man sick.”

European use of opium declined after the fall of Rome, then grew again as soldiers trekking home from the Crusades brought the drug back with them from the Holy Land. By the sixteenth century it was being used from Italy to England to treat everything from ague, cholera, and hysteria to gout, itches, and toothaches.

Among its boosters was one of the strangest and most fascinating figures in medical history, a Swiss alchemist and revolutionary healer with the impressive name of Philippus Aureolus Theophrastus Bombastus von Hohenheim. Today he is better known as Paracelsus. He was a one-of-a-kind medical genius, part rebel, part con man, a bit mystical, a bit mad, a larger-than-life figure who trekked from town to town across Europe with his bags of remedies and instruments, carrying a huge sword with a pommel said to hold the Elixir of Life. He would come to a town, talk to the locals, hawk his skills, heal the sick, argue heretical new theories, pick up tips from local healers, and rail against the entrenched medicine of the day. “In my time there were no doctors who could cure a toothache, never mind severe diseases,” he wrote. “I sought widely the certain and experienced knowledge of the art [of medicine]. I did not seek it from only learned doctors: I also enquired of shearers, barbers, wise men and women, exorcisers, alchemists, monks, the noblemen and the humble people.” He listened, he argued, he learned, and he applied the best ideas to his patients.

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Portrait of Paracelsus, whole-length. Wellcome Collection

Along the way he penned several books, most of which were not published until after his death. These were written in a style that one historian called “very difficult to read and more difficult to understand,” a mishmash of fantastic alchemical symbols and magical allusions, astrological references and Christian mysticism, medical recipes, divine inspirations, and philosophical ruminations. But underneath much of it lay a core of breakthrough ideas in medicine.

Paracelsus thought that most physicians were “vainglorious chatterers” who grew rich by simply parroting the mossy old ideas of the ancients, regurgitating the received wisdom of Roman and Greek and Arab authorities, repeating old mistakes. To this Paracelsus offered a simple alternative: True seekers of knowledge should read the book of nature. Instead of blindly following old texts from ancient authorities, physicians, he believed, should rely on what they see working in the real world, open themselves to all the wonders that nature offers, find new approaches, use new medicines in new ways, see what happens, and then use that knowledge to improve the art of healing.

Paracelsus experimented with his medicines, trying new mixtures and seeing what worked. (It’s important to note that this was not experimentation in the modern scientific sense. It was more along the lines of “Here’s something that looks interesting. I’ll try it and see what happens.”)

Chief among his successes was a mysterious and miraculous little black pill that seemed to ease almost any ill. “I possess a secret remedy I call laudanum and which is superior to all other heroic remedies,” he wrote around 1530. One of his contemporaries remembered it this way: “He had pills which he called laudanum, which looked like pieces of mouse shit, but used them only in cases of extreme illness. He boasted he could, with these pills, wake up the dead, and certainly he proved this to be true, for patients who appeared dead suddenly arose.”

Paracelsus’s laudanum became the stuff of legend. We now know his secret recipe: About a quarter of each pill was raw opium; the rest was a fanciful (and mostly inactive) mix of henbane, bezoar stone (a solid mass gathered from the intestines of cows), amber, musk, crushed pearls and coral, various oils, bone from the heart of a stag, and, to top it off, a dash of unicorn horn (a much touted and certainly imaginary ingredient in many medieval medicines; what passed for “unicorn horn” in the day was most often the tusks of narwhals). Most of laudanum’s effects came from opium.

Paracelsus was so sure of his views, so certain when he stated things like “The ignorant physicians are the servants of hell sent to torment the sick,” or when he ostentatiously burned one of Avicenna’s books in a public bonfire, that many considered him an arrogant braggart. But he was no charlatan. He was, instead, one of the fathers of pharmacology, a man who single-handedly helped wrestle drug studies away from the stranglehold of ancient theory and stand them on a more modern footing. He is said, for instance, to have studied opium by using it on himself and his followers, then tracking the effects—a practice of self-experimentation that would become common among physicians in coming centuries.

By the time Paracelsus died in 1541, the European appetite for opium was growing. Columbus had been briefed to look for and bring back opium from his voyages of discovery, as did explorers like John Cabot, Ferdinand Magellan, and Vasco da Gama. The reason was that opium, as opposed to many other Renaissance pills and potions, worked. As its popularity grew, so did the ways physicians found to use it. Some bright physician dissolved opium into a solution with mulberry and hemlock, then cooked the brew into a sea sponge. When this drug-infused “Sleepy Sponge” was dampened and heated, it released fumes that could both ease pain and put patients to sleep, making opium one of the first anesthetics. Venetian treacle, a mixture of opium with up to sixty-two other ingredients ranging from honey and saffron to viper’s flesh, was used to treat everything from a snakebite to the plague. The popularity of treacle was so great that it helped spur the first drug regulations in London. In 1540, Henry VIII empowered physicians with the right to search apothecaries’ shops and report any medicines found to be dangerous or defective, including treacle. By Shakespeare’s day, only one man in London was allowed to make it, and even he had to show it to the College of Physicians before selling it.

One problem for early physicians using opium was that they never knew how strong the drug would be. Because opium came from different countries with different processing methods, there was no way to tell exactly what you were getting in a given ball. One pill maker’s medicine might contain two or three or fifty times the dose of another’s. Physicians had to try each new batch on their patients and hope for the best. Patients paid their money and took their chances.

The first steps to standardize the drug were taken in the 1600s by a renowned British doctor named Thomas Sydenham. Sydenham was a huge opium fan, a believer that this God-given substance was far superior in healing value to anything humans would ever be able to concoct on their own. He became famous for his own special tincture of opium dissolved in wine, with the bitterness of the drug offset by adding sweet port, cinnamon, and clove. Sydenham’s liquid opium was easier for patients to swallow than pills. But the most important thing was that his preparation could be roughly standardized, the amount of opium in each bottle more carefully allocated, the doses more carefully measured. Sydenham made a fortune off this liquid form of opium, which he called—perhaps in honor of Paracelsus—“laudanum.”

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Portrait of Thomas Sydenham. Wellcome Collection

Sydenham’s laudanum was a hit, spurred by his own proselytizing; he so loudly sang its virtues that his friends nicknamed him “Dr. Opiophile.” As sales grew, so did scientific interest in more precisely measuring its effects. British researchers like Christopher Wren and Gideon Harvey began experimenting with opium on cats and dogs, learning more about just how much was needed to achieve certain effects. They found new ways to test strength and ensure quality. Opium was helping to turn medicine from an art into a science.

It was also used for pleasure. One of the first books written in English specifically about the drug was The Mysteries of Opium Reveal’d, published in 1700 by the doctor John Jones. Jones told readers that the drug not only released one from anxiety but was also good for “Promptitude, Serenity, Alacrity, and Expediteness in Dispatching and Managing Business . . . Ovations of the Spirits, Courage, Contempt of Danger, and Magnanimity . . . Satisfaction, Acquiescence, Contentation, Equanimity,” and so on. Opium raised feelings like “a most delicious and extraordinary refreshment of the spirits upon very good news, or any other great cause of joy.” He compared its effects to a permanent orgasm. He sounded a lot like an opium addict.

The use of opium to alter mood rather than ease pain caught on at all levels of the social ladder. On March 23, 1773, the famed diarist James Boswell wrote, for instance, “I breakfasted with Dr. Johnson whose heaviness of spirits of yesterday was much relieved having taken opium the night before.” The drug was being taken to ease depression.

Uses of all sorts rose along with a flood of new opium-containing medicines through the late 1700s, with names like Dover’s Powder, Quaker Drops, and Dr. Bates’ Pacific Pills. They could be purchased easily from doctors, at local pharmacies, even in grocery stores—no prescription necessary. Without laws to limit the use of these medicines, opium spread everywhere.

The public in Europe was eager for it. This was the era of the Industrial Revolution, when fast-growing populations of factory workers faced terrible working conditions. Underpaid workers living in growing slums needed a cheap release. Gin was one option, opium another.

Its popularity grew hand in hand with changes in disease patterns. Tuberculosis was one example: Fast-growing, close-packed urban industrial centers were breeding grounds for epidemic diseases like TB, a slow killer that often left victims in an agony that could only be relieved by opium. And there was cholera, carried in polluted water supplies and ragingly contagious, another disease that grew along with the slums. Cholera killed by causing uncontrollable diarrhea. Thankfully, one notable side effect of opium was its tendency to cause constipation; its use in cholera patients likely saved lives as well as soothed the dying. Growing numbers of prostitutes were among the drug’s most faithful users, taking laudanum to ease the daily pains of their profession, to counteract the symptoms of venereal disease, and to lessen their despair. Sometimes they introduced their customers to the habit. Sometimes they used the drug to kill themselves. Doctors acted as sales agents for opium, promoting it to their patients and making a bit of money along the way. Chemists’ and apothecaries’ shops could count on opium-containing medicines to be among their best sellers and advertised accordingly.

And that was the thing about opium: Depending on how and when it was used, it could be a painkiller or a party drug, a lifesaver or a means of suicide. It was so popular in Western Europe by the end of the eighteenth century that some historians have linked it to the birth of the Romantic Era, with that period’s emphasis on spontaneity, personal experience, relaxed morals, flights of fancy, and dreamy fantasies. It is certainly true that many of the leading artistic and political figures of the Romantic Age, from Byron and Berlioz to George IV and Napoleon, used the drug to one degree or another. Percy Shelley, drunk on opium, once burst into the rooms of Mary Wollstonecraft Godwin (with whom he was madly in love, although he was married to another woman at the time), a pistol in one hand and a bottle of laudanum in the other, declaring, “Death shall unite us.” They lived long enough to marry; Mary’s half sister, however, died of a laudanum overdose in 1814. Keats downed heroic doses. Samuel Taylor Coleridge and Thomas De Quincey were full-blown addicts.

“Nineteenth-century literature is steeped in laudanum,” wrote one historian. And its appeal spread far beyond the intelligentsia. By midcentury, opium was as cheap as gin and more widely available in Britain than tobacco. Its use spread to the working classes, farmers, and the poor. Women took it for a break from the tedium of their lives, then gave it to their children to blunt their hunger and stop their crying. Men took it to ease their aches and forget their troubles. If there was some left over, they gave it to their farm animals to help fatten them for market.

One isolated and swampy rural area in England, the Fenlands, became infamous as the kingdom of the poppy. Malaria, with its recurrent fevers, was common there; so were rheumatism and the ague. Quinine (a malaria remedy from the bark of a South American tree) was too expensive for the local farmers. So were doctors. The poverty-stricken farmers turned to opium, not merely as a medicine but, as one observer noted, to “lift its user out of the mire of Fenland muck and the drudgery of agricultural life.” A medical officer who visited the area in 1863 wrote, “A man may be seen occasionally asleep in a field leaning on his hoe. He starts when approached, and works vigorously for a while. A man who is setting about a hard job takes his pill as a preliminary, and many never take their beer without dropping a piece of opium into it.”

It was considered a relatively harmless vice, certainly less dangerous than liquor. For every story about some baby inadvertently poisoned by too much opium-laced soothing syrup, there were others about long-term users doing just fine. Opium peddlers in the 1850s told the anecdote of an eighty-year-old woman who took a half ounce of laudanum daily for forty years without an ill effect. And didn’t Florence Nightingale herself, the Lady with the Lamp, the very symbol of nursing care, occasionally use the drug? Of course she did. Would she do that if it was bad for you? Opium sales in Britain grew 4 to 8 percent each year between 1825 and 1850. To feed this growing national habit, the British encouraged poppy plantations in India, which soon became the source of much of the world’s supply. The East India Company got into the business of shipping it around the world. Fortunes were made growing it, processing it, moving it, and selling it. And England was just the start. If opium was this popular at home, what might it be worth to traders if other countries were encouraged to use more of it?

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A busy stacking room in the opium factory at Patna, India. Lithograph after W. S. Sherwill, c. 1850 by W. S. Sherwill. Wellcome Collection

India was one possibility. But the British needed their subjects in the Raj to have their wits about them. There were other targets, however: Countries where the opium trade could be expanded to Britain’s benefit. Countries that might, in British eyes, be better off weakened by the drug. And so opium came to the most populous nation on earth: the Celestial Empire, China.

The Chinese already knew a thing or two about opium. They had learned about it first in ancient times, at least as far back as the third century. Arab traders had made it available, and Chinese alchemists had found it an interesting medicine. It was used in small amounts by the upper classes for treating dysentery and calming the concubines of wealthy men. For more than a thousand years there had been little more to it than that.

Then the first European sailors arrived. They wanted desperately to trade. They brought with them a number of items they thought the Chinese might value. But what did the Chinese need with scratchy British woolens or stiff Dutch linen when they had silk? What did they need with inferior Western pottery when they had porcelain?

There were a few things, however, that the Chinese did want. One was a pleasant new herb, the dried leaf of a plant from the Americas called “tobacco.” The Chinese were fascinated by the sight of foreign sailors packing shreds of this leaf into small pipes and setting it on fire, breathing clouds of aromatic smoke. It had desirable effects. The Chinese elite quickly adopted the tobacco habit, and smoking became a seventeenth-century Chinese fad. The Europeans, happy to find something tradable, sold it in Canton by the shipload. If supplies ran low, the Chinese stretched their tobacco with other things, including adding shavings of opium and arsenic. The additions were thought to help stave off malaria. They certainly provided an extra kick.

Smoking became so popular in the Celestial Empire, and the addictive nature of the habit so obvious, that in 1632 the emperor felt it necessary to ban tobacco in all its forms. Just to make sure, he also ordered that all known tobacco addicts be executed. Tobacco disappeared. And during the ensuing drought, a few Chinese took to smoking opium alone.

There things stood until the early eighteenth century, when yet another valuable dried plant entered the picture. This one had long been grown in China, and, when steeped in boiling water, created a beverage with a pleasantly energizing effect. The British called it tea. And it quickly became as big a craze in England as tobacco had been in China.

CONTENTS

INTRODUCTION

50,000 PILLS

CHAPTER 1

THE JOY PLANT

CONTENTS

INTRODUCTION50,000 PILLS

CHAPTER 1THE JOY PLANT

INTRODUCTION

50,000 PILLS

CHAPTER 1

THE JOY PLANT