INTRODUCTION TO VOLUME II
Medicalizing drugs, drink, and the habit
Physicians’ role in defining and treating habituation is undeniable. In his highly influential article “The Discovery of Addiction” sociologist Harry Gene Levine placed the origins of the concept of addiction in the hands of American physician Benjamin Rush.1 Although other historians, most notably those whose work looks outside of the United States, have contested the primacy of Rush in the medicalization of addiction, their debates do not contradict the importance of revolution-era physicians in problematizing habitual consumption of intoxicants.2 It is just that for some the revolution was not American. In Britain, Thomas Trotter was making similar associations in the UK as Rush, and these can be connected to Enlightenment physicians who wrestled with the apparent vacation from reason represented by drunken bacchanalia in an Age of Reason. Investigators from several European continents, meanwhile, were conceptualizing habit as a mental and physical debility in the 1830s with a level of sophistication that English-speaking physicians would not explore for decades.
Although Anglo-American physicians’ ideas about habituation were developing in the early part of the 1800s, it was not until later in the century that concerted effort emerged to define and understand addiction, more broadly construed, and especially to treat it. Giving evidence at the Earl of Mar’s life insurance trial, Robert Christison’s conclusion that there is no convincing evidence of lives cut short by the habit, but its physical effects must reduce lifespan persisted through much of the century. Indeed, inasmuch as the opium habit could cause a disordered physical condition (Christison mentioned especially the effect of opium eating on the digestive system), there is little evidence that physicians spent much time discussing habit as a pathological state until several decades after the Earl had shuffled off his mortal coil.3
The items in this volume trace the various ways that physicians and their scientifically inclined contemporaries examined the nature of habitual use of mind-altering substances. This introduction will explore some of the complicated aspects of inebriety medicine, and how physicians attempted to wrestle with both understanding substance addiction and figuring out how to treat it. Even a superficial reading of the titles demonstrates how persistent a dilemma habit (inebriety, addiction, dipsomania, etc) was for physicians. Nevertheless, as the century drew to a close, more research was being published, and new ideas of the function of the brain affected the ideas about habituation. Simultaneously, increasingly sophisticated pharmaceuticals were being developed or discovered, and when their habit-forming properties became clear, they added to a flurry of discussion. Indeed, one of the singular ironies of the nineteenth-century discussions on habituation was that both cocaine and heroin were originally seen to be near miraculous treatments for addiction.
Although distinct substances, opium, alcohol, hashish, and later cocaine, not to mention a list of therapeutic substances that have since faded from use in medical treatment, such as chloral hydrate and assorted bromides, were often grouped together when medical investigators discussed habituation.4 The connection was natural, given the limited information people had about drug taking, and the broad familiarity with drink. Notwithstanding that DeQuincey called himself an opium “eater” when he was drinking laudanum, the way it was ingested was not as important as the perception that habitual substance use was not merely the result of a substance being habit-forming, but rather caused by some flaw in the individual. To be sure, some investigators theorized about the properties of specific drugs that caused habit, but when contemplating habit itself, the seemingly intractable tendency to want to consume some mind-altering substance, physicians usually saw the process, whether mental or physical, as similar, even if the substance’s effects were significantly different.5
The connection between the habitual use of drugs and alcohol was also an easy slippage because many of the English-language physicians who began discussing “inebriety” were heavily influenced by the temperance movement. As Berridge notes, the British inebriety physicians’ work was so intertwined with the temperance movement that “the true scientific studies of alcoholism took place in the nineteenth century only on the continent.”6 The British Society for the Study and Cure of Inebriety had its roots in the Society for Promoting Legislation for the Control and Cure of Habitual Drunkards (1876), a group that emerged after persistent attempts failed to pass a law to force drunks into treatment.7 The law that passed in 1878 was generally unsuccessful.8 The same might be said for the American inebriety specialists. From its inception, the American Association for the Study and Cure of Inebriety (AASCI) engaged among themselves in arguments about the morality and sinfulness of habitual drunkards.9 Some influential physicians such as Norman Kerr, the founding president of the British Society, did recognize the potential problems of equating alcohol and opium inebriety. Nevertheless the connection between temperance and the opium habit shaped what Ber-ridge calls “a hybrid medical and moral theory.”10 We see such intermingling of moral and physical ideas in phrasing of titles such as “The evil of opium eating” and “The dogma of human responsibility” included in this collection, and books such as H H Kane’s Drugs that Enslave.11
The idea of slavery was an important element of the discussions over the meaning of addiction. As Timothy Hickman explains, addiction has a “double meaning” connected to slavery: it can be passive (to be enslaved by something) and active (to enslave yourself to something). Addiction held both meanings simultaneously, and this “double meaning” of addiction meant that one could be enslaved by something at the same time as being personally responsible for wilfully enslaving themselves. Hickman also notes that the term “addiction” itself was rarely used with respect to drug use before the end of the nineteenth century.12 Nevertheless this notion of willfully binding oneself to a substance did manifest itself in discussions about inebriety, both to liquor and drugs, because the problem of the habit was a problem of free will. Can a rational individual who possesses free will actively enslave themselves to someone? Is that not a form of insanity? These were central issues in the inebriety literature through the century, and these questions persist.
Although for much of the first half of the nineteenth century the main substance of concern was alcohol, numerous observers recognized opium as an intoxicant, and considered its effects to be similar to those of to alcohol. In his Essay … on Drunkenness, Thomas Trotter did mention other drugs, including opium and cannabis (which he calls bang), but noted that these were not so problematic as alcohol even though they could bring on “delirium, stupor, and other phenomena of ebriety [sic].” The difference for Trotter was that even though these drugs could “produce nearly the same phenomena, and their habitual use almost the same diseases” they were not as common in Britain as alcohol.13 Rush made a similar distinction, noting that opium was a dangerous poison and its use in suicide was familiar to many, but he saw the drink habit as much more problematic, even likening it to a “gradual suicide.” He also argued that, unlike the drink (by which he meant the spirits) habit any opium habit was “easily broken” something also characteristic of the wine habit.14 Scottish physician Robert MacNish noted that opium could also cause a habit, as seemed to be the case with all “stimulants and narcotics.” Yet he, like Rush and Trotter, did not see opium (or, indeed, porter or ale) as nearly as problematic as spirits.15 Alcoholic beverages, most notably stronger spirits, were the major intoxicants of concern.
Although aware of opium’s habit-forming tendencies, English-speaking physicians tended not to be all that concerned about them at least before the middle of the century. Berridge notes that a major contribution to the changing face of opium was due to its poisonous nature. Public health concern about the number of deaths by opium (suicide, homicide and accidental deaths) “marked the beginnings of sustained medical intervention on the question of opium.”16 It was these drugs’ poisonous nature that also fuelled discussions leading to the creation of pharmacy acts, which placed dangerous drugs on a “Poisons Schedule” and thereby restricted access to these products.17 Berridge argues that physicians did not become concerned about opiate addiction treatment until a more nuanced disease concept emerged, something that was being debated more clearly with respect to the drink habit.
While people like Christison were arguing whether opium affected longevity, European physicians, as James Nicholls explains, were developing much more sophisticated ideas about habit as a pathological state. German-Russian doctor C. von Brühl Cramer coined the term dipsomania in 1819 as a sort of “manic thirst” but by the 1830s this had transmogrified into something much more serious.18 Jean Etienne Esquirol linked dipsomania to a broader concept of monomania, a condition in which an individual developed an inability to control themselves with respect to a specific behaviour. Dipsomania was not just a manic thirst, but an inability to control oneself when it came to drink. The term “alcoholism” was first used by Swedish physician Magnus Huss in 1849 to describe prolonged and heavy drinking. Huss also distinguished between chronic and acute alcoholism. As Nicholls explains “chronic alcoholism could involve constant drinking without the drinker necessarily ever getting blind drunk, while acute alcoholism was characterised by bouts of extreme intoxication.” So “dipsomania” was often used by people who saw the condition of habitual drunkenness as a specific type of mental illness, while alcoholism was more often used to define a physiological condition.19 Yet throughout the period, uncertainty persisted, and the terminology often overlapped.
Locating the seat of inebriety was not only important philosophically, but also therapeutically, because it could affect an understanding of the way to treat the condition. A disorder of the mind would be treated differently than a disorder of the body. Physicians who specialized in mental illness dealt with various ways that an individual could be alienated from “right reason,” which is why doctors who dealt with mental illness were often called “alienists.” If inebriety were a mental illness, treatment would involve retraining the mind away from its vicious appetite. In contrast, if the condition were physiological, treatment would involve physical intervention to treat the source of biomechanical dysfunction: remove the substance, strengthen the body with tonics and other medicines, and the addiction would be healed. This “somatic approach” had many modifications.20
Generally, however, most physicians recognized that treating drug or alcohol inebriety involved treating both the mental and physiological state. Discussions of institutional treatment of alcohol and drug habits included ways to deal with the physical condition, but also how to manage patients whose mental faculties were harmed or affected in different degrees. The extent to which a habit was considered mental or moral drove a range of therapeutic options. For example, the British Habitual Drunkards’ Act (1878) was designed to keep drunks in the inebriate’s home until they were healed. In a concession to the idea of liberty, the original act did not force drunks into these homes, they had to go voluntarily. However, once they were in the home, they had to remain there until the treatment regimen was complete, and if they left, they would forcibly be returned. Similar strategies were needed, so went the common wisdom, for other types of addictions. Kind and gentle or brutal and forceful, treatment required control over the patient and management of symptoms.21
A further disagreement by inebriety physicians was about how quickly to end the ingestion. Some advocated abrupt cessation of consumption, while others advocated varying lengths of time for withdrawal. This was especially the case with opium addiction since many opium addicts who ended up in institutional care were middle or upper class, and were considered often less constitutionally capable of handling the trauma of abrupt withdrawal. Partly this was a consideration of the physical difference between a labourer and a brainworker, and partly this related back to the idea of how an addiction took hold. Neurologists like George Beard argued that the brain of elites was more complex and sophisticated than the brains of workers, and yet more fragile and prone to neurological shocks and damage. This is what, he and others argued, caused the addiction in the first place.22 So to withdraw the drug abruptly would do damage to an already fragile neurosis. Many similar debates about the cause of addiction, the relationship between free will and physical disease, and the best way to end an addiction, persist in different ways today.
Debates about treatment took place in an environment of experimentation with patients willfully submitting themselves to medical treatment for their habits. Medical efforts to address the drink habit emerged from the temperance movement’s ideas about drunks having lost their capacity to act freely. Physicians took the social problem of drunkenness and surrounded it with medical concepts; habitual drunkenness was redefined as the medical idea of inebriety. Inebriety treatment institutions grew out of the “therapeutic temperance” efforts of reformed drunkards to help their drunken colleagues break the habit. Some temperance organizations created “homes” where recovering drunks could live as they tried to recover. Jim Baumohl and William White note that these homes had a “simultaneously supportive and controlling character.”23 The earliest homes in the United States opened in Boston (1857), San Francisco (1859) and Chicago (1863). These places may have included medical support, but the main feature of such homes was the voluntariness of residency, the smallness of the institutions themselves, and the relatively short duration of stays.24
Inebriate homes were a grass-roots solution normally founded by voluntary associations, but as temperance reformers articulated concerns about the impact of inebriety on the family and the state, many pushed governments to create more institutional support for drunks. The nineteenth century was an era of asylum building, so many reformers figured the state should also take some responsibility for treating drunks.25 Nevertheless, the value of such an institution was highly debated and at times could have limited support. American physician Samuel Woodward, who might be considered the founder of the medical temperance movement, published a series of essays making the case for inebriate asylums in the 1830s. Governments remained inactive until 1854 when the New York State legislature granted a charter for the creation of a United States Inebriates Asylum with the stipulation that the asylum be funded by public subscriptions, and that the operations would not begin until the asylum’s backers could raise 10% of the estimated $50,000 needed to build it. The asylum, renamed the New York State Inebriate Asylum, did not open for another decade.26 In 1850 Edinburgh physician Alexander Peddie began developing a plan for government-run institutions for the treatment of “the drinking insanity” with a goal of protecting drunkards who were normally subject to censure by the law, when, as he said, they had no control over their condition.27 These efforts faced continued scrutiny: the findings of a Select Committee on Habitual Drunkards (1872) led to the eventual passing of an Habitual Drunkards Act (1879) that allowed local governments to permit private organizations to set up inebriate retreats, but there were few takers.28 Elsewhere state-run inebriety treatment had similar trouble catching on. In Canada physician James Bovell submitted a Plea for Inebriate Asylums to the legislature of the Province of Canada in 1862, but little appears to have been done for another decade. Even then it sputtered. Ontario passed the Inebriate Asylum Act in 1873 and a building was constructed in Hamilton, but owing to overcrowding in other provincial insane asylums, it was repurposed to a general asylum for the insane before it opened.29 In the Australian colony of Victoria, private efforts in the 1870s to build inebriate asylums had limited success before a Royal Commission on Asylums for the Insane and Inebriate (1886) mandated that the state take over treatment. The Inebriate Asylums Act (1889) resulted the government estab...
