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CHAPTER OUTLINE
The recent recognition of addiction medicine as a medical specialty obscures the fact that American physicians have been involved in the treatment of severe and persistent alcohol- and other drug-related problems for more than two centuries. This chapter describes the birth of addiction medicine in the late 18th century, the professionalization of addiction medicine in the second half of the 19th century, and the virtual collapse of addiction medicine as an organized specialty in the opening decades of the 20th century. It ends with a discussion of efforts to have addiction medicine recognized by the American Board of Medical Specialties (ABMS). The review includes early pioneers of addiction medicine, conceptual and clinical breakthroughs, the evolving settings in which addiction medicine was practiced, the larger currents in American medicine, and the evolving social policies that influenced the early practice of addiction medicine.
THE BIRTH OF ADDICTION MEDICINE
The roots of addiction medicine began not in a young America but in the ancient civilizations of Africa and Europe. Special methods to care for those addicted to alcohol were developed in ancient Egypt, and references to chronic drunkenness as a sickness that enslaved body and soul date to Herodotus (5th century BC), Aristotle (384–322 BC), and Seneca (4 BC–65 AD). St. John Chrysostom (1st century AD) provided one of the earliest comparisons of chronic alcohol inebriety to other diseases (1). These earliest intimations of the concept of addiction and its treatment reflect the fleeting observations of individuals rather than an organized cultural response to alcohol and other drug problems.
The earliest American medical responses to alcoholism emerged within the systems of medicine practiced by Native American tribes. Alcohol-related problems rose dramatically in Native America as alcohol became increasingly used as a tool of economic, political, and sexual exploitation in the 18th and early 19th centuries (2,3). Native tribes actively resisted these problems through political/legal advocacy, organizing sobriety-based cultural revitalization movements, and through the medical treatment of those affected. Native American healers used botanical agents to suppress cravings for alcohol (hop tea), to induce an aversion to alcohol (the root of the trumpet vine), and to facilitate personal transformation within sobriety-based cultural and religious revitalization movements (4).
In colonial America, there was pervasive consumption of alcoholic beverages but no recognition of excessive drinking as a distinct medical problem (5). This changed in response to increased alcohol consumption (a near tripling of annual per capita alcohol consumption between 1780 and 1830), a shift in preference from fermented to more potent forms of distilled alcohol, and the emergence of a pattern of socially disruptive “frontier drinking” (6,7). It was in this changing context that several prominent Americans “discovered” the phenomenon of addiction (8).
In 1774, the philanthropist and social reformer Anthony Benezet published a treatise, Mighty Destroyer Displayed, that recast alcohol from its status as a gift from God to that of a “bewitching poison.” He noted the presence of “unhappy dram-drinkers bound in slavery” and observed that drunkenness had a tendency to self-accelerate: “Drops beget drams, and drams beget more drams, till they become to be without weight or measure” (9).
Benezet’s warning was followed by a series of publications by Dr. Benjamin Rush (1746 to 1813). Rush’s work is particularly important given his prominence in colonial society and his role in the history of American medicine and psychiatry. Rush’s 1784 pamphlet, Inquiry into the Effects of Ardent Spirits on the Human Mind and Body, was the first American treatise on alcoholism, and it almost single-handedly launched the American temperance movement. In this pamphlet, Rush catalogued the symptoms of acute and chronic drunkenness, described the progressiveness of these symptoms, and suggested that chronic drunkenness was a “disease induced by a vice” (10). Rush was the first prominent physician to claim that many confirmed drunkards could be restored to full health and responsible citizenship through proper medical treatment and to call for the creation of a special facility (a “Sober House”) to care for the drunkard (11).
Rush’s writings were mirrored in the work of physicians in other countries, most notably the Edinburgh physician Dr. Thomas Trotter, whose 1788 publication, Essay, Medical, Philosophical, and Chemical, on Drunkenness and Its Effects on the Human Body, shared many of Rush’s ideas (12). Another contribution that influenced the subsequent development of addiction medicine in America was the work of Christopher Wilhelm Hufeland, who in 1819 described a clinical condition characterized by uncontrollable cravings for alcoholic spirits that triggered periodic “drink storms.” Hufeland labeled this condition dipsomania. During the same decade, Lettsom, Armstrong, and Pearson described the condition that Thomas Sutton subsequently christened delirium tremens (13).
By the late 1820s, the subject of chronic drunkenness was taken up in a number of medical dissertations. Most notable among these were the works of Drs. Daniel Drake and William Sweetser. Drake speculated on the causes of “habitual drinking,” elaborated on Rush’s list of systems of the body effected by alcohol, and hinted at what would later become the concepts of inability to abstain and loss of control (“the habit being once established, he will not, I almost say cannot, refrain”) (14). In 1828, Sweetser provided a detailed account of the pathophysiology of chronic alcohol intoxication, including depictions of the addictiveness of alcohol and the potential role of heredity in chronic drunkenness. He concluded that intemperance created a “morbid alteration” in nearly all the major structures and functions of the human body. Cycles of compulsive drinking were viewed by Sweetser as the product of a devastating paradox: The poison (alcohol) was itself its only antidote (15).
The 1827 publication of the Reverend Lyman Beecher’s Six Sermons on the Nature, Occasion, Signs, and Remedy of Intemperance exerted their own influence on the emerging concept of addiction. Bridging the gap between moral and medical models, Beecher described the intemperate as being “addicted to the sin” and suffering from an “insatiable desire for drink.” Beecher provided two other contributions to this developing concept. First, he described the early warning signs of addiction, linking these to the later signs that Rush, Drake, Sweetser, and others had catalogued. Second, he challenged these very physicians who, in the case of Rush, had tried to get their patients to moderate their drinking by switching from distilled alcohol to fermented drinks such as wine or beer. Beecher’s declaration, “There is no remedy for intemperance but the cessation of it,” marked the call for complete abstinence as a personal and social strategy for the resolution of alcohol problems (16).
Between 1774 and 1829, America “discovered” addiction through the collective observations of her physicians, clergy, and social activists. There was an emerging view that chronic drunkenness was a problem with biologic roots and consequences and thus the province of the physician. These earliest pioneers declared that chronic intoxication was a diseased state, and they articulated the major elements of an addiction disease concept: biologic predisposition, drug toxicity, pharmacologic tolerance, disease progression, morbid appetite (craving), loss of volitional control of alcohol/drug intake, and the pathophysiologic consequences of sustained alcohol and opiate ingestion. Though their treatments could involve such “heroic” methods as purging, blistering, bleeding, and the use of highly toxic medicines, they also used surprisingly modern strategies (e.g., aversive conditioning) and recognized many pathways to the initiation of sobriety (e.g., from religious conversion to witnessing an alcohol-related death). The writings of this period portray addiction recovery not as an enduring process but as a climactic decision. This view focused the attention of the emerging temperance movement on the pledge of lifetime abstinence (from distilled alcohol) as a central strategy in their early attempts at rescue work with confirmed drunkards.
Addiction medicine emerged in the shift from treating medical consequences of alcohol addiction to treating the addiction itself. The earliest practice of addiction medicine predated institutional treatment and was practiced out of the private offices of individual physicians. Alcohol was not the only drug of concern to these physicians. During the 16th and 17th centuries, physicians in Germany, Holland, Portugal, and England had begun to conceptualize opium as “a kind of poison” that required regular and increasing use that, when stopped, created a unique sickness that drove people to return to the drug (17). In 1701, the English physician John Jones (18) provided an exceptionally detailed account of opiate withdrawal in his book, The Mysteries of the Opium Reveal’d. Three events between the early and mid–19th century profoundly altered the future of narcotic addiction in America: the isolation of morphine from opium, the introduction of the hypodermic syringe, and the emergence of a patent drug industry. These events produced drugs of greater potency, created a more efficient and euphorigenic method of drug ingestion, and increased the availability and promotion of powerful psychoactive drugs (19,20).
Early Professionalization and Medical Advancements (1830 to 1900)
In 1828, Dr. Eli Todd, superintendent of the Hartford Retreat for the Insane, called for the creation of a physician-directed inebriate asylum. Under his influence, the Connecticut State Medical Society passed a resolution supporting this idea in 1830 (21). A year later, Dr. Samuel Woodward, superintendent at the Hospital for the Insane at Worcester, Massachusetts, wrote a series of influential essays echoing the Connecticut recommendations. He declared:
A large proportion of the intemperate in a well-conducted institution would be radically cured, and would again go into society with health reestablished, diseased appetites removed, with principles of temperance well grounded and thoroughly understood, so that they would be afterwards safe and sober men (22).
Woodward argued that intemperance was a physical disease requiring medical remedies and, breaking with Rush, declared that “the grand secret of the cure for intemperance is total abstinence from alcohol in all its forms” (22). This total abstinence position was given greater weight in light of the failed efforts to cure drunkards through the use of public pledges to refrain only from distilled alcohol. The number of drunkards who continued their debauchery through fermented alcoholic drinks contributed to the temperance movement’s shift from the partial pledge to the T-total pledge (23).
What followed in the 1830s and 1840s was a series of clinical contributions to the understanding of chronic drunkenness that exerted considerable influence on the emerging field of addiction medicine (24). First, there were new experiments and clinical observations on the pathophysiology of alcohol, such as those of Prout, Beaumont, and Percy on the effects of alcohol on the stomach and the blood (25). Dr. Robert Macnish’s Anatomy of Drunkenness (1835) (26) offered one of the earliest typologies of alcohol addiction, noting seven clinical subtypes. Macnish also referenced a subject that continued as a medical controversy for much of the 19th century: the claimed spontaneous combustion of alcohol inebriates (27,28).
In 1838, France’s leading expert on drunkenness, Dr. Esquirol, argued that the disease of intemperance was a “monomania”—a “mental illness whose principal character is an irresistible tendency toward fermented beverages” (29). This was followed in 1840 by Dr. R.B. Grindrod’s text, Bacchus, in which he declared, “I am more than ever convinced that drunkenness is a disease, physical as well as moral, and consequently requires physical as well as moral remedies” (30–32).
One of the most significant milestones in the history of addiction medicine was the 1849 publication of Magnus Huss’s text, Chronic Alcoholism. After an extensive review of the chronic effects of intoxication, Huss declared:
These symptoms are formed in such a particular way that they form a disease group in themselves and thus merit being designated and described as a definite disease … It is this group of symptoms which I wish to designate by the name Alcoholismus chronicus (33,34).
Huss’s text stands as the landmark addiction medicine text of the mid–19th century. It contributed a clinical term—alcoholism—that came into increasing medical and public popularity in the transition between the 19th and 20th centuries.
The Washingtonian Revival of the 1840s and the fraternal temperance societies and reform clubs that followed brought the issue of recovery from alcoholism onto center cultural stage. Local Washingtonian groups encountering “hard cases” needing more than an occasional sobriety support meeting began organizing lodging houses that evolved into America’s first addiction treatment institutions. A multibranched treatment field emerged in the mid–19th century. Inebriate homes emerged out of alcoholic mutual aid societies that viewed addiction recovery as a process of moral reformation (35). There were medically directed inebriate asylums, the first of which was the New York State Inebriate Asylum, chartered in 1857 and opened in 1864, under the leadership of Dr. Joseph Turner (36,37). There were also privately franchised, for-profit addiction cure institutions such as the Keeley, Neal, Gatlin, and Oppenheimer Institutes. These institutions generated considerable controversy over their claim to have medicinal specifics that could cure addiction (38) and their practice of hiring physicians who were in recovery from addiction (39,40). Inebriate homes and asylums and the private addiction cure institutes competed with bottled patent medicine addiction cures (most containing alcohol, opium, morphine, or cocaine), some of which were promulgated by physicians, and religiously sponsored inebriate colonies and rescue missions (21). By the late 1870s, large urban hospitals, such as Bellevue Hospital in New York City, had also started opening inebriate wards (41). Annual alcoholic admissions at Bellevue rose to 4,190 by 1895—a number that continued to climb to more than 11,300 per year in the opening decade of the 20th century (21).
In 1870, Dr. Joseph Parrish led the creation of the American Association for the Cure of Inebriety (AACI), which brought together the heads of America’s most prominent inebriate homes and asylums. The AACI by-laws posited that
(a) Intemperance is a disease. (b) It is curable in the same sense that other diseases are. (c) Its primary cause is a constitutional susceptibility to the alcoholic impression. (d) This constitutional tendency may be either inherited or acquired (42).
The AACI held regular meetings to exchange ideas and published the first specialized medical journal on addiction—the Journal of Inebriety. The Journal, edited by Dr. T. D. Crothers during its entire publication life (1876 to 1914), was filled with essays by addiction medicine specialists and with advertisements promoting various treatment institutions (43,44). A similar inebriety treatment movement was under way in Europe during the last decades of the 19th century, and the first international meetings of addiction medicine specialists were held during this period (45).
American physicians specializing in addiction began releasing texts on the nature of addiction and their treatment methods in the 1860s: Dr. Albert Day’s Methomania: A Treatise on Alcoholic Poisoning and Dr. W. Marcet’s On Chronic Alcoholic Intoxication. The production of such literature virtually exploded in the 1880s and 1890s. Among the most prominent texts either written in America or that exerted a significant influence on the practice of addiction medicine in America during this period were Dr. H. H. Kane’s Drugs That Enslave: The Opium, Morphine, Chloral and Hashish Habits; Dr. Fred Hubbard’s The Opium Habit and Alcoholism; Dr. Joseph Parrish’s Alcoholic Inebriety: From a Medical Standpoint with Cases from Clinical Records; Dr. Asa Meyerlet’s Notes on the Opium Habit; Dr. T. L. Wright’s Inebriism; Franklin Clum’s Inebriety: Its Causes, Its Results, Its Remedy; Dr. T. D. Crothers’ The Disease of Inebriety from Alcohol, Opium and Other Narcotic Drugs; Dr. Norman Kerr’s Inebriety or Narcomania: Its Etiology, Pathology, Treatment, and Jurisprudence; and Dr. Charles Palmer’s Inebriety: Its Source, Prevention, and Cure (21).
The central organizing concept of 19th-century addiction medicine specialists was that of inebriety. Inebriety was viewed as a disease that manifested itself in numerous varieties. These varieties were meticulously detailed by clinical subpopulation and drug choice. Addiction medicine texts were often organized under such headings as alcoholic inebriety, opium inebriety, cocaine inebriety, and ether inebriety. Inebriety was viewed as a disease that sprang from multiple etiologic pathways, unfolded in many diverse patterns, and had a variable course and outcome. Inebriety specialists talked eloquently about the need to individualize treatment and, by the 1880s, had begun to recognize and study the problem of posttreatment relapse (46).
The treatment methods of the two physician-directed branches of the inebriety movement (the inebriate asylums and the private addiction cure institutes) were quite different, and the conflicts between these branches reflected allopathic and homeopathic approaches to medicine in this period. The inebriate asylum physicians advocated a sustained (1 to 3 years), legally enforced course of treatment that consisted of drug-assisted detoxification, collateral medical treatments, and a sustained period of institutional convalescence. The addiction cure institute physicians boasted medicinal specifics (daily hypodermic injections and liquid tonics) that could “unpoison” the addict’s cells and destroy the craving and compulsion to use alcohol, opiates, and cocaine—all in 4 short weeks—cash in advance. Drug treatments within both branches included such substances as cannabis, cocaine, chloral hydrate, paraldehyde, strychnine, atropine, hyoscine, and apomorphine. Although some addiction medicine specialists used cocaine as a tonic during detoxification, most warned of the addictive properties of the drug (21).
Most inebriate asylums and addiction cure institutes treated all drug addictions, whereas others, such as Dr. Jansen Mattison’s Brooklyn Home for Habitues (opened in 1891), specialized in the treatment of opiate and cocaine addiction (47). The inebriety literature of this period is filled with debates over whether medically supervised opiate withdrawal should be abrupt, rapid (over days), or sustained (over weeks and months). One also finds discussions of such contemporary issues as the addictiveness and psychological toxicity of cocaine, the problems of drug substitution, and the management of the relapsed patient (45).
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