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"What Shall we do with the Inebriate?" Asylum Treatment and the Disease Concept of Alcoholism in the Late Nineteenth Century

                                  
     Journal of the History of the Behavioral Sciences.  Volume 21, January 1985, 48-69

    In 1891 Thomas Davison Crothers wrote the following summary of the "scientific methods" of curing the disease of alcoholism for the North American Review:
First legislate for their [alcoholics'] legal control; then organize industrial hospitals in the vicinity of all large towns and cities; tax the spirit traffic to build and maintain such places, ... arrest and commit all drunkards to such hospitals for an indefinite time, depending on the restoration of the patients; also commit all persons who use spirits to excess and imperil their own lives and the lives of others; put them under exact military, medical, and hygienic care, where all the conditions and circumstances of life and living can be regulated and controlled; make them self-supporting as far as it is possible; and let this treatment be continued for years if necessary. The recent cases will become cured, and the incurable will be protected from themselves and others, and made both useful and self-supporting. Who can fully estimate the benefits to society, to morals and to civilization by promptly isolating such persons and keeping them in normal states of living? Who can estimate the relief to the taxpayer by the removal of the perils to both property and life from drunkenness? This is not a theory, but a reality only awaiting practical demonstration. [1]
This "modest proposal" was, of course, more than a method for curing a disease in the narrow sense of that term. It was also a utopian medical solution to one of the great social problems of the nineteenth century--drunkenness. Although his rhetoric was harsh, even for the time, and his proposal seems radical in the late twentieth century, Crothers was not a crank nor were his ideas aberrations. In fact Crothers was the highly respected superintendent of the Walnut Lodge inebriate asylum in Hartford, Connecticut, and the editor of the influential Quarterly Journal of Inebriety. Beginning his career in the 1860s as an assistant physician at the New State Inebriate Asylum in Binghamton, New York, he was, by the 1880s, widely recognized, both in the United States and abroad, as an authority of the "disease of inebriety."[2] His ideas are of interest because they are a logical consequence of that Victorian marriage of a disease concept and the idea of asylum treatment that dominated nineteenth century thinking about the alcoholic. Viewing alcoholism as a hereditary disorder which might be acquired through the toxic effects of alcohol on a weak or sensitive nervous constitution, "inebriety specialists," like Crothers, argued  that it could be cured only by extended treatment in specialized institutions modeled after the insane asylum. because they understood alcoholism in these narrowly physicalistic terms, the power to confine the alcoholic, like the power to quarantine the contagious, became a central goal in their efforts to influence both public opinion and legislation. Ironically, although these efforts were largely frustrated, both in England and in the United States, inebriety specialists did achieve a measure of success in treating alcoholics, and the public became considerably more accepting of the idea of alcoholism as a disease. The close link between the disease concept of alcoholism and efforts to legislate the control of the alcoholic is important because it demonstrates the potential of certain kinds of medical thought to generate paternalistic solutions to social problems. the resistance that met late nineteenth-century efforts to legislate the control of the alcoholic is also of importance, however, because it suggests that biological theories are unlikely to provide a sufficient basis for developing social responses to behavior disorders.
    The history of the disease concept of alcoholism has, of course, been told many times. Some excellent studies such as those of William Bynum and James Cassedy take the story only up to the mid-nineteenth century-- the point at which the inebriety specialist appeared on the scene.3 Others such as those of Albert Ernest Wilkerson and Arnold Jaffe both carry the story into the twentieth century and contain excellent descriptions of the role of the inebriate asylum and its advocates. [4] By failing to emphasize the strong association in nineteenth-century medical thought between the notion of inebriety as a disease and the belief that legislative control was necessary to cure that disease, these studies create the impression that nineteenth-century inebriety specialists were simply forerunners of their twentieth century counterparts. Harry Gene Levine, by largely ignoring the inebriate asylum, treats the nineteenth-century disease concept of alcoholism as merely a part of the ideology of the temperance movement and not a part of medicine's evolving effort to claim a role in the control of alcohol problems. 5 If we focus on Anglo-American efforts to establish specialized institutions for the treatment of alcoholism between 1850 and 1880, however, it can be seen that Crother's proposal was a logical extension of attempts to use the disease concept to justify what was regarded as an effective means of eliminating inebriety, namely, asylum treatment. Believing that extended periods of abstinence were necessary to overcome inebriety, specialists hoped that the disease concept would provide a warrant for imposing such abstinence. At the same time their belief in a narrowly physicalistic model of alcoholism blinded some to the problems inherent in involuntary treatment. A mixed public reaction to the inebriety specialists' program, however, resulted in medicine's limited role in efforts to control drinking behavior during the period. Crothers may have felt that his proposal was a "reality only awaiting practical demonstration," but by the time he wrote it, it was clear that the inebriate asylum would make only a modest contribution to our efforts to learn to live with alcohol.
    The temperance movement during the early nineteenth century was generally more concerned with the "drink question" and the "liquor traffic" tan with the individual drunkard.6 The result was a number of state and local prohibition laws. Concern with the individual drunkard tended to focus on his disruptive behavior, and short jail sentences were the most common response to this. Many, however, felt that both prohibitory legislation and jail sentences were inadequate responses to what was perceived as a rising tide of intemperance.7 Some, such as members of the Washingtonian movement, an association of reformed drunkards, which flourished during the 1840s, attempted to respond to the individual drinker with moral suasion and pledges of abstinence.8 With the decline of this movement during the 1850s, and mounting fears  about social disorder and the effects of foreign and pauper drunkards, the question of what should be done with the inebriate seemed both pressing and unanswered. Medical men, of course, had been concerned with temperance for a long time, and disease concepts of alchealed had been growing in popularity ever since Benjamin Rush wrote his influential treatise on the subject.9 Prior to the 1850s, however, medical men did not have a particularly effective remedy to offer the drunkard and generally make little effort to treat him. some drunkards were treated in insane asylums; but in contrast to their optimism about the curative value of these institutions for the insane, asylum superintendents were notably pessimistic about their value for the inebriate.10 Isaac Ray, the superintendent of Butler Hospital for the Insane and a leading spokesman for his profession, clearly stated the central dilemma that he and his colleagues faced in trying to treat such people:
On complying with certain [legal] conditions, we are authorized to hold in confinement certain persons who are insane; but no law of the land would justify us in depriving men of their liberty, for any other cause, however commendable the object. Now, the class of persons in question [inebriates], while in the paroxysm, or suffering under its immediate effects, may, in any proper sense of the term, be called insane, and so long we have an unquestionable right to hole him. When, however, this condition passes away, as it usually does within a few days or weeks, and the mind resumes its perfect consciousness, what are we to do" The person claims his liberty, while nobody doubts that he would use it only to advance another step in the road to bodily and mental ruin. Here seems to be a conflict of duties, and with every disposition to do right, I do not see how we can help compromising either the happiness of families or the rights of individuals.11
Ray's helplessness before his "conflict of duties" grew out of early nineteenth-century ideas about asylum treatment and insanity. Asylum treatment at that time was based on the notion that the insane could be healed only if they could be separated from the baneful influence of their environment and exposed to the healing effects of asylum life for a sufficient time. Because the insane might not recognize the need for such treatment, superintendents needed and generally had the the authority to confine such people under specified conditions. One of these conditions, as Ray noted, was the superintendent's ability to demonstrate the patient's insanity through defects in his "perfect consciousness." This definition of insanity was, however, too narrow to warrant confining most alcoholics who did not recognize theneed for asylum treatment. Some attempted to resolve the conflict of duties which troubled Ray with the concept of dipsomania. Defining dipsomania as an "irresistible desire to indulge in the use of intoxicating substances," they argued that the irresistibility rather than the presence of hallucinations or delusions suggested that the dipsomaniac was insane and justified his continuing treatment in an insane asylum.12
    There were at least two obstacles to this approach. First, the dipsomaniac was not easily distinguished from the common drunkard, and asylum superintendents were not anxious to assume responsibility for the latter. Second, experience with dipsomaniacs demonstrated not only that they did poorly in insane asylums but that they interfered with the treatment of other patients. For these reasons as well as the fact that by the 1850s insane asylums were already becoming overcrowded, most superintendents of these institutions were unwilling to actively use the concept of dipsomania to extend their authority.13
    A more promising answer to the question of how to provide medical treatment for the alcoholic lay in the view that alcoholism was not simply a form of insanity but a specific disease. By the 1850s this idea already had international standing. Rush in the United States, Thomas Trotter in England, C. von Bruhl-Cramer in Germany, and Magnus Huss in Sweeden, all, with differing emphases, had provided the intellectual basis for the concept of alcoholism as a specific disease. 14  With this concept in hand, men like Crothers could resolve ray's conflict of duties by claiming that "the inebriate although appearing to be in possession of his mind, will always be found on the other side of that mysterious border-line of mental health." 15 This meant that the alcoholic was mentally ill even if he was not insane. The advantage of this position was that it allowed physicians to claim a role in restoring the alcoholic without having to enlarge the concept of insanity, If to had been widely accepted it  would have also provided a rationale for extending the idea of asylum treatment beyond the restricted scope of the insane asylum. The obstacles to the general acceptance of this position were, however, considerable. On the one hand, the view that the drunkard was not sick but merely vicious was widespread and deeply entrenched, even among physicians. According to this view, the alcoholic was likely to abuse the asylum by using it as a place to dry out between debauches. On the other hand, if such abuse was to be avoided by granting physicians the authority to detain even the alcoholic who appeared to be in possession of his mind, some felt that this would lead to a violation of the "liberty of the subject."  At the outset, however, the greatest obstacle was the pessimism, among both lay people and physicians, that surrounded any plan to restore the drunkard. if this was to be overcome, someone with the optimism and zeal of what has been called a "moral entrepreneur" was needed to promote the idea that asylum treatment could cure the disease of inebriety. 16
    One man with these qualifications was J. Edward Turner. 17 Born in Bath, Maine, in 1822, Turner began his study of medicine with a neighboring physician and was licensed to practice medicine after attending two courses of lectures in Philadelphia. Turner's views on the treatment of alcoholism were apparently colored by his experience as a student, when he had to care for a "dipsomaniac" uncle who insisted that his nephew accompany him on his drinking sprees. In the 1840s Turner began his study of the treatment of alcoholism with a tour of Glasgow, Edinburgh, London, and Paris where he consulted with medical men and visited many hospitals. Turner's argument was that because inebriety was a specific disease, which resembled insanity but was distinct form it, it should be treated in asylums that were distinct form but resembled insane asylums. By 1850 he was seeking subscriptions to finance such an asylum and in 1852 he mad his first to the state of New York for a charter. After a charter was granted in 1854, he continued to work to raise money and saw to the construction of the physical plant of the asylum on land donated by the city of Binghamton. His tenure as superintendent of this institution was short and controversial. His detractors portrayed him as acharlatan and a quack. 18 To his disciples, like Crothers, however, he became a martyr to the idea of treating alcoholism as a specific disease in a specialized institution.
    Turner's ideas about alcoholism help explain his optimism about its treatment. According to Turner inebriety was a "disease, first constitutional and hereditary in character." 19 This meant that alcoholism could be acquired by people with a susceptible constitution and then transmitted to their offspring. Turner also felt that the disease of inebriety was widespread and not limited solely to the "lower orders," and he shared common anxieties that the increasing prevalence of inebriety was responsible for the alarming rise in the incidence of insanity and idiocy during the 1840s and 1850s. 20 Although many physicians, particularly between the 1830s and 1850s, regarded alcohol as useful in the treatment of various diseases, turner was critical of this practice because he saw alcohol as a "poison" which produced the disease of inebriety. 21 Turner illustrated his point and gave an idea of the kinds of patients he regarded as suitable for asylum treatment by presenting case reports. For example:
Mr. ___ was a clergyman of great ability and of high moral rectitude, up to the time he was attacked with sciatica. from this disease he was a great sufferer, and his physician prescribed brandy. This stimulant was continued until it had been increased from two to twenty glasses per day. such an excess of alcoholic poison soon undermined his constitution clouded his brain, impaired his memory and sapped his moral rectitude. He became a liar and a thief, and would resort to the most dishonest practices to procure his daily beverages, until friends were obliged to remove him from home and place him under the strictest surveillance. In this seclusion, after fourteen months, he recovered his physical health, mental vigor and moral stamina and is now an upright and conscientious man and a useful citizen. 22
    Viewing alcoholism as the result of the action of a poison on a weakened constitution, turner saw the key to treatment in abstinence. through abstinence and healthful living the patient's constitution could be strengthened and the risk of passing a weak constitution on to his offspring minimized. because Turner could find no evidence that inebriates could abstain voluntarily, he saw enforced abstinence as necessary. Experience had shown that prisons and alms houses were not effective in restoring drunkards and, because Turner believed that inebriety was a disease, they were also not appropriate. [23] Although Turner recognized the insane asylum as " the best institution yet established" for the treatment of inebriety, he felt that placing the inebriate in such an institution was of limited value because it tended to "irritate" the insane and " mentally degrade" the inebriate. [24] For these reasons he believed that a specialized asylum for inebriates which would be modeled after the insane asylum was necessary Placing the inebriate in such an asylum would remove him from the alcoholic poison that was the exciting cause of his malady and put "him at once in the condition of cure." [25] With such an institution Turner believed he would be able to "radically cure seventy out of one hundred patients." [26] In order to achieve such cures, of course, the inebriate, like the insane, had to be exposed to the beneficial effects of asylum life for extended periods of time. Because they might not voluntarily accept such treatment, Turner have confronted the same conflict of duties that had troubled Ray's thoughts about the authority to restrain alcoholics. Turner, however, sidestepped this issue in two ways. First, by accepting the alcoholic's apparent loss of control over his drinking as sufficient to demonstrate his illness, Turner could argue that imposing controls on the alcoholic was necessary for his treatment. Second, by claiming that he did not consider it his "province to point out where the moral  responsibility ceases, and the irresponsibility begins in the a=use of alcoholic stimulants," [27]  he was able to design his asylum as if all his patients were completely unable to take responsibility for their drinking. 

    The New York State Inebriate Asylum at Binghamton reflected Turner's understanding of alcoholism by providing extensive institutional controls to take the place of the self-control its patients had apparently lost. In 1857 its charter was amended to give it the power "to receive and retain all inebriates who enter said asylum, either voluntarily or by order of the committee of any habitual drunkard." [28] In 1864 power was granted to judges to commit inebridangerous to the asylum upon receiving affidavits from two " respectable practicing physicians and two respectable citizens... That such inebriate is lost to self control, unable, from such inebriation, to attend to business, ordangerous to remain at large." [29]  In 1866, one year before he was deposed, Turner also managed to have the trustees of the asylum empowered "to appoint tow or more of the attendants as special police." [30] The twenty-seven rules and regulations of the asylum reflected the same perspective. Among these were not only rules forbidding the use of alcohol,, tobacco, and narcotics, but also rules prohibiting patients from holding conversations with workmen employed at the asylum, walking within three hundred feet of public roads, or possessing money or postage stamps. In addition, it was required that " all letters, papers pamphlets, and packages shall be opened in the presence of one of the physicians." [31] Although Turner's zeal in implementing this authoritarian program no doubt contributed to his downfall, his ideas continued to influence those who followed him. By 1891 Crothers may have lost some of his teacher's optimism, but his draconian method for curing the disease of alcoholism is clear testimony to Turner's influence.
    Whatever Turner's troubles at Binghamton may have been, the establishment of the institution was, itself, an important event. Many factors combined to make the times right for the creation of inebriate asylums. Frustration over the shortcomings of prohibitory legislation and the recidivism of those jailed for drunkenness as well as the influx of Irish and German immigrants gave the temperance question a certain urgency. At the same time the temperance movement, as a political force, was in decline in the 1850s and `860s as the nation was drawn into the Civil War. This left a vacuum in which medical initiatives could flourish. Popular enthusiasm for asylum treatment, which would decline later as these institutions became overcrowded, was still high at mid-century. In this context Binghamton acted as a catalyst for the development of a number of similar institutions. By 1870 the superintendents and trustees of six of these institutions were ready to form the American Association for the Cure of Inebriety (AACI). [32] Membership in this organization during its early years was quite heterogeneous. Some member institutions were modeled directly after the asylum at Binghamton; one, the Kings County Asylum in Brooklyn, New York, was created for the sole pragmatic aim of relieving the overcrowding of a local jail; and others were not founded on medical principles but inspired by the Washingtonian movement. Although Turner, who had been discredited by this time, was not a member of the association, his ideas influenced its proceedings. Its statement of principles, formulated in 1870, declared both that "intemperance is a disease" and that "the law should recognize intemperance as a disease, and provide other means for its management than fines, stationhouses and jails." [33] That the association regarded the authority to control those who had lost their ability for self-control as a central objective was made clear by  a model law developed by its committee on legislation in 1872. In addition to provisions for committed patients that were identical with the 1859 version of the Binghamton asylum's charter, this model law also sought to tighten up that charter's provisions for voluntary patients. It allowed the directors of any inebriate asylum to
retain such [a  voluntary] inebriate for a period of not less that six (6) months nor  longer than twelve (12) months; and ... [to] have over such inebriate the same legal power of restraint as is given them by this act in the case of inebriates who have been committed directly by any court... Or transferred to said asylum from a prison or penitentiary. [34]
    Although this emphasis on control remained an important policy objective of the association, not all of its members shared this view in theory and there is evidence that many of them deviated from Turner's ideals in practice. Those homes or reformatories that were inspired by the Washingtonian movement, for example, believed that "religion, education and pledges [were] sufficient to restore the victim" of alcoholism. [35] It is also likely that they used the method of public recounting of experiences which had been discovered by the Washingtonians in the 1840s and which was rediscovered by Alcoholics Anonymous a hundred years later. [36] In any event, their principles were clearly set out by Dr. Robert Harris of the Franklin Reformatory Home of Philadelphia in his first annual report to the AACI in 1872. There he declared that "as we do not either in our name or management, recognize drunkenness as the effect of a diseased impulse; but regard it as a habit, sin and crime, we do not speak of cases as being cured, as in a hospital, but 'reformed.'" [37] Taking such a stand at a meeting of the AACI, it should be clear, was quite heretical. Indeed, it provoked a storm of protest and his report was published only in a revised form. [38]
    Because physicians like Turner and Crothers made the issue of controlling the inebriate central to their treatment plans, the inebriate asylum became the subject of public debates. on the issue of control, however,it was not only the members of the AACI who advocated increased authority for the inebriate asylum. In 1876, for example, the Association of Medical Superintendents of American Institutions for the Insane passed a resolution that stated that inebriate asylums had been a failure because they lacked this authority and urged state legislatures to grant such authority. [39] In 1879,  when the governor of New York ordered the inebriate asylum at Binghamton transformed into an insane asylum, he did so in part by arguing that its failure to restrain patients in the post-Turner era had made it nothing more than a "hotel for the entertainment of wealthy inebriates." [40] In England, advocates of the Habitual Drunkards Bill accepted the arguments of the AACI and insisted that legal control was central to the effective treatment of inebriety. [41] Behind all of these opinions lay the notion that the inebriate lacked self-control because of a physical disease. Echoing Ray, the British M.P. Mr. Dunlop clearly expressed this position when he said that

While he would have some difficulty agreeing to take away a man's liberty, merely because he was injuring his health, or dissipating his means or his family subsistence, he had no difficulty in holding that a man subject to the cravings of a disease, which, when indulged in, brought [him] into a state in which he was likely to commit injury to others and to himself, was a fit object of restraint. [42]

Opposition to views such as this was, however, not lacking. The layman's discomfort with this medical paternalism can be seen in a story published by Catherine Beecher in Harper's Magazine in 1866. Here she suggested whimsically, I believe, that perhaps obnoxious smokers might also be "cured" by confining them indefinitely in a asylum like the one run by Doctor Turner. [43] More serious opposition can be seen in the ruling of Judge Balcom of the Supreme Court, at Binghamton, that the forcible detention of an inebriate at the asylum was an unconstitutional proceeding. [44] In England, opposition to the Habitual Drunkards Bill also centered around fears that inebriates would be wrongfully confined in private asylums through the collusion of unscrupulous and profit-seeking relatives and superintendents. [45] These objections were so strong that when the Habitual Drunkards Bill became law in 1879 it "required every inebriate seeking admission to a licensed retreat to convince two Justices of his addiction and his willingness to sign away his freedom." [48] Although some inebriety specialists regarded such opposition as representing unwarranted libertarian fears, it was clear by the end of the 1870s that the disease concept would not provide sufficient grounds to quarantine the alcoholic. [47]
    Because the issue of control was co closely linked to the idea of inebriety as a disease, debate over this idea was intense during the period. Among those who defended the alcoholic's liberties during the 1879s were men who regarded drunkenness as a vice. One of the most influential of these was Dr. John Charles Bucknill. The author of a leading nineteenth-century textbook on psychiatry, Bucknill was widely respected in England and the United States. Although he acknowledged that there were "diseased drunkards," he felt that "if you are able to watch these cases for some time, you will see short outbreaks of mania not due to drink; and [he regarded]... Them as a true class of lunatics whose cure is extremely difficult." [48] Most of the patients that he observed in inebriate asylums were, in contrast, "devoid of any real signs of mental infirmity." [49] for these people, he argued, physicians ought not to be made "gaolers." [50] Although this position resembled Ray's, Bucknill was not plagued by the same conflict of duties. He resolved this by holding that most drunkards who were not insane were vicious; that is, they could control their drinking but chose not to. This view was close Robert Harris's. Indeed, Bucknill was sympathetic with Harris's efforts to reform the drunkard. [51] His real sympathies, however, lay with the "great conservative law of the Survival of the Fittest." [52]  If the  "race of the drunkard dies out in two or three generations," as the popular theory of degeneration predicted, then according to Bucknill, this was so much the better for civilization. On this view, treating the drunkard by confining him in an asylum was both illogical because he was not sick and detrimental because he was best left to die of the consequences of his drinking. 
    While this struggle between narrowly physicalistic and moralistic views of alcoholism was taking place, some inebriety specialists were advocating intermediate positions. One commonly held view was though drunkenness might begin as a habit or vice, at some point a change of character, indicating the presence of a disease, could be noted. While attempting to bridge the extreme positions of Turner and Bucknill, this view, by relying on a disease concept similar to Turner's, still gave a central role to detention in the treatment of inebriates. [53] A more interesting approach was that of Albert Day. Although subscribing to the disease concept, he held that on the crucial question of self-control" the victims [of inebriety], themselves ... Know that self control though weakened is notwholly lost." [54] By taking the position that his patients were sick but suffering from only a partial loss of self-control, Day was able to identify with these people and to encourage them in their struggle with their disease. This allowed him to develop a "moral treatment" which stressed that " the patient should be encouraged, that his disease can be cured, and at the same time impressed with the belief that it rests mostly with himself... [to do so]." [55] This hybrid position had an influence not only on his work with individual patients but also on his work as a superintendent. When Day, who began his career at the Washingtonian Home in Boston, was brought in to replace Turner as the superintendent of the Binghamton asylum in 1868, his theory strongly influenced his reorganization of that institution. There he sought to exclude involuntary patients as far as possible and to treat only patients who would voluntarily submit to mild restraints designed to give them an opportunity to prove their "courage" and their "honor." [56] That Day's treatment achieved good results apparently troubled some advocates of legal restraint. One such critic argued that Day was successful at the Washingtonian Home in controlling his patients "by the moral influence of kindness, cheerful associations and amusements" because most of his patients were native-born and therefore of a " higher intellectual and moral status." [57]
    By the 1890s Turner's optimistic belief that alcoholism could be cured by enforced abstinence had resulted in very few legislative enactments. Voluntary treatment of alcoholism was, however, thriving. As earl as 1883, for example, one inebriety specialist noted that 94 percent of all patients treated in American inebriate asylums were treated voluntarily. [58] By 1902 this success could be seen in the existence of over one hundred such institutions [59] this was no doubt due to the fact that though the public was unwilling to accept broad programs for the legislative control of alcoholic patients, such as that suggested by Crothers, they were increasingly willing to accept the notion that inebriety was a disease. This public acceptance can be graphically seen in the profusion of advertisements for homes and sanitaria for the treatment of inebriety. [60] Many of these were regarded by inebriety specialists as quack establishments which offered quick cures such as the injection of "bichloride of gold" used by the notorious Dr. Keeley. [61] Even Crothers, however, found that he could attract a steady stream of patients by advertising his Walnut Lodge as offering "the best surroundings, and ever appointment of an elegant residence." [62] 
    Of course treatments such as these were reserved for people who could afford them. For the poor alcoholic the jailhouse remained virtually his only refuge from a debauch; and a great many people continued to be jailed for drunkenness. In 1898, for example there were 20,222 penal commitments for drunkenness in Boston alone. [63] Some pauper alcoholics were committed to state insane asylums, but resistance to this form of treatment remained great through the end of the century. [64] by 1909 there were only three state hospitals that specialized in the treatment of inebriety. [65]
    The first of these state inebriate asylums began operation in Foxborough, Massachusetts, in 1893. Although its founders disavowed any association with Turner's ill-fated efforts at Binghamton, it is worth considering briefly because it illustrates some of the problems inherent in Turner's ideas, perhaps more clearly than Turner's won experiment. Until provision was made for the admission of voluntary patients in 1906, only patients committed as inebriates were treated. [66]  The first difficulty, noted in the asylum's first annual report, was the large number of escapes. Over the years other problems with involuntary  treatment also emerged: police misled patients to think that their stay would be short one, families committed patients for punishment, and patients refused to participate in treatment. The superintendent, Marcello Hutchinson, attempted to respond to these problems creatively, but one additional problem emerged which overshadowed all the rest. Chronic "hopeless" cases accumulated, making the treatment of "hopeful" cases impossible. Pleas to the judiciary to commit only hopeful cases were of no avail. Even obtaining authority to discharge patients he felt could not benefit from hospitalization did not help Hutchinson stem the tide of chronic cases. [67] Finally, in 1908, the hospital was reorganized. The rationale for this reorganization was that the inebriate required two methods of treatment, namely, "remedial and custodial." The former demanded "minimal institutional treatment and maximum out-patient care" whereas the latter required "more prolonged institutional detention." [68] With this reorganization Turner's optimistic views about the role of detention in curing the alcoholic had finally been abandoned.
    The experiment with involuntary treatment at Foxborough, however, was an exception. Crother's vision of "industrial hospitals in the vicinity of all large towns and cities" never came near to realization. Perhaps growing pessimism over the value of the insane asylum as well as concerns about the wrongful detention of the insane overtook those who wanted to use the insane asylum as a model for the treatment of the alcoholic. Perhaps moralism about the alcoholic and the growing strength of prohibitionist sentiment were too great to allow for fundamental reform in the treatment of alcoholism. Whatever the reasons for the failure of Turner's optimistic vision of curing alcoholism through detention of the alcoholic in specialized institutions, one must wonder why this idea had so much appeal in the first place. In part, some of its appeal was due to the spectre of foreign and lower-class alcoholism and fears of social disorder which were so prevalent during the 1850s when the first inebriate asylum came into existence. Although such social factors were certainly of significance, it should not be forgotten that Turner believed that the disease of inebriety did not only affect the "lower orders" but might also affect people such as the clergyman cited earlier. I would like to suggest that, in addition to whatever social factors were at work, the importance given to restraint in efforts to cure the alcoholic during the nineteenth century resulted from a narrowly physicalist view of alcoholism and an overestimation of the value of asylum treatment. According to this view, physical illness resulted in the alcoholic's total loss of self-control, and only prolonged care in the healthful environment of an asylum could restore it. For men like Turner and Crothers, this seemed like an advance over the narrowly moralistic view which held that the alcoholic's behavior was due to moral depravity and deserved punishment. By excluding moral factors from their understanding of alcoholism, however, they denied the alcoholic the status of a moral agent and were able to compare to power to control the alcoholic with the power to quarantine the contagious. Although such nineteenth-century medical paternalism may seem obviously unjustifiable and unworkable, the problem of mixing threats with therapy for the alcoholic has by no means been resolved in the late twentieth century. [69]



NOTES
1. Thomas D. Crothers, "ls Inebriety Curable'?” North American Review 153 (1891). 359-360.
2.   Autobiographical sketch of Crothers, probably written by Crothers can be found in the Quarterly Journal of Inebriety 24 (1902):97-98. Also see "Report of a Reception Given to T.D. Crothers," Minutes of the Colonial and International Congress on Inebriety, London, England, 7-8 July 1887 (London: John Sears and Sons, n.d.).
3. William F. Bynum, "Chronic Alcoholism in the First Half of the 19th Century," Bulletin of the History of Medicine 42 (1968): 160-185; and James H. Cassedy, "An Early American Hangover: The Medical Profession and Intemperance 1800-1860," ibid., 50 (1976) 405-413.
4. Albert Ernest Wilkerson, Jr., "A History of Alcoholism as a Disease” (D.W. diss., University of Pennsylvania, 1966); Arnold Jaffe “Reform in American Medical Science: The Inebriety Movement and the Origins of the Psychological Disease Theory of Addiction 1870-1920,” British Journal of Addiction 73 (1978):139-147; and Jaffe, "Addiction Reform in the Progressive Age: Scientific and Social Responses to Drug
Dependence in the United States, 1870-1930’ (Ph.D. diss., University of Kentucky, 1976). Also see Mark Edward Lender and James Kirby Martin, Drinking in America: A History (New York: Free Press, 1982), pp.119-122, and Mark Lender,  “Jellinek’s Typology of Alcoholism: Some Historical Antecedents,” Journal of Studies on Alcohol 40 (1979): 361-375.
5. Harry Gene Levine “The Discovery of Addiction: Changing Conceptions of Habitual Drunkenness in America,” Journal of Studies on Alcohol 39 (1978): 143-174.
6. Lender and Martin, Drinking in America; W. J. Rorabaugh, The Alcoholic Republic: An American Tradition (New York: Oxford University Press, 1979);  Ian Tyrell, Sobering Up: From Temperance to Prohibition in Antebellum America (Westport, Conn.: Greenwood Press, 1979).
7. See, for example: A Reformed Drunkard, Back from the Mouth of Hell or Rescue from Drunkenness (Hartford, Conn., 1878), p.76.
8. Milton A. Maxwell, "The Washingtonian Movement,” Quarterly Journal of Studies on Alcohol 11 (1950): 410-451.
9. Benjamin Rush, An Inquiry into the Effects of Spiritous Liquors on the Human Body (Boston, 1790).
10. See,  “Proceedings of the Annual Meeting of the Association of American Medical Superintendents of Institutions for the Insane (AAMSII)," American Journal of Insanity 17 (1860): 45-52.
11. Quoted in Journal of Psychological Medicine 8 (1855): 172.
12. Proceedings of the Annual Meeting of the Association, pp. 45-52.
13. For a discussion of the development of the insane asylum during this period,  see Gerald Grob, Mental Institutions in America: Social Policy to 1875 (New York: Free Press, 1973).

14. See Bynum, "Chronic Alcoholism."
15. Thomas D. Crothers, "what Shall We Do with the Inebriate?" Alienist and Neurologist 2 (1861):175
16. For a discussion of moral entrepreneurs, see Howard S. Becker, Outsiders: Studies in the Sociology of Deviance (New York: Free Press, 1966) pp. 147-163.
17. Thomas D. Crothers, "Sketch of the Late Dr. J. Edward Turner: Founder of Inebriate Asylums," Quarterly Journal of Inebriety 11 (1889): 1-25; Charles H. Shephard, "The First Inebriate Asylum and its Founder," Journal of Inebriety 20 (1898): 1-22; James Edward Turner, The History of the First Inebriate Asylum in the World by its Founder (New York, 1888).
18. See, for example, Frederick Norton Manning, Report on Lunatic Asylums (New South Wales, 1868) p. 149.
19. J. Edward Turner, "A Letter of the Corresponding Secretary of the New York State Inebriate Asylum, to Hon. Edwin D. Morgan, Governor Elect of the State of New York," 30 December 1858, p. 98.
20. New York State Inebriate Asylum, Fourth Annual Report (1866), p. 24; and Turner, "A Letter," pp. 104-105.
21 John Harley Warner, "Physiological Theory and Therapeutic Explanation in the 1860s: The British Debate on the Medical Use of Alcohol," Bulletin of the History of Medicine 54(1980): 235-257..
22. New York State Inebriate Asylum, Fourth Annual Report, p. 31.
23. Turner. “A Letter," p. 114.
24. Ibid.
25. Ibid.. PP. 117-118.
26. Ibid. 35
27. New York State Inebriate Asylum, Fourth Annual Report, p. 35. "
28. "Report of the Committee on Legislation," Proceedings of the American Association for the Cure of Inebriety (AACI), 8 October 1872, p. 64.
29. Ibid. pp. 64-65.
30. Ibid., p. 65.
31. The Charter and Bylaws of the New York State Inebriate Asylum (New York, 1866), pp. 24-27.
32.  Leonard Blumberg, “The American Association for the Study and Cure of Inebriety,” Alcoholism: Clinical and Experimental Research 2 (1978): 235-240.
33. Proceedings of the AACI, 29, 30 November 1870, p. 8.
34. "Report of the Committee on Legislation," Proceedings of the AACI, 8 October 1872, p. 72.
35. Thomas D. Crothers, “Inebriate Asylums and Their Work," lecture delivered before the Young Men‘s Christian Association, 2 October 1888, p. 6.
36. "Clinical Notes and Comments," Quarterly Journal of Inebriety 10 (1888): 281.
37. Robert P. Harris, “Report of the Franklin Reformatory Home for Inebriates," Proceedings of the AACI, 8 October 1873, p. 80.
38. Ibid., pp. 80-86.
39. “Proceedings of the Association," American Journal of Insanity 32 (1876): 364.
40. George Burr, “The New York State Inebriate Asylum-- A Defense of Its Management and Operations," Transactions of the Medical Society of New York (Syracuse) (1881): 318.
41. Drs.  Parrish and Dodge “testified before a Parliamentary select committee in 1872. See "Editorial," Quarterly Journal of Inebriety 1-2 (1876-1878): 232-235; and “Report from the Select Committee on Habitual Drunkards, British Sessional Papers, House of Commons 1872 v. 9, p. 419.
42. Discussion of a paper by Alexander Peddie, "On the Desirableness of Some Legalized Arrangements for the Care and Treatment of Dipsomaniacs," Edinburgh Medical Journal 3 (1857-1858): 760.
43. Catherine Beecher,  "The Little Black Dogs of Berkshire,” Harper’s New Monthly Magazine 33 (1866): 722-730.
44."Pamphlets, Reports, Transactions of Societies etc.," American Journal of Insanity 32 (1876): 567.
45. Hansard's Parliamentary Debates, third series, vol. 243 (1878-1879): 1159, 1383-1384, 1704-1722.  For discussions of analogous concerns about the confinement of the insane, see Peter McCandless, "Liberty and Lunacy: The Victorians and Wrongful Confinement," in Madhouses, Mad Doctors and Madmen, ed. Andrew Scull (Philadelphia: University of Pennsylvania Press, 1981) pp.339-362; and Gerald Grob, Mental Illness and American Society, 1875-1940 (Princeton: Princeton University Press, 1983), pp. 47-49.
46. Roy M. McLeod “The Edge of Hope: Social Policy and Chronic Alcoholism in England 1870-1900." Journal of the History of  Medicine 22 (1967): 226.
47. Joseph Parrish “Annual Address," Proceedings of the AACI, 28 September l875, pp. 32-51.
48. John Charles Bucknill, Habitual Drunkenness and Insane Drunkards (London, 1878), p. 11.
49. Ibid., pp. 11-12.
50. Ibid., pp. xxviii.
51. John Charles Bucknill, "Habitual Drunkenness: A Vice, Crime or Disease?" Contemporary Review 29 (1877): 433.
52. Ibid., p. 441.
53. See, for example, Joseph Parrish, Alcoholic Inebriety (Philadelphia, 1883), pp. 15-16; and Theodore L. Mason, "Inebriety A Disease," Quarterly Journal of Inebriety 2 (1877):20.
54. Albert Day, Methomania (Boston, 1867) p. 49.
55. Ibid., p. 33.
56. Albert Day, "Superintendent's Report, " New York State Inebriate Asylum, 1868, pp.6-7.
57. Theodore L. Mason, "President's Anniversary Address," Quarterly Journal of Inebriety 1 (1876): 10-11.
58. Parrish, Alcoholic Inebriety, p.121.
59. "Editorial," Quarterly Journal of Inebriety 24 (1902): 94. Crothers noted in the same year that there were thirty asylums devoted to "medical treatment." Presumably the others were regarded as quack establishments. Thomas D. Crothers, "Clinical Treatment of Inebriety," ibid. 24 (1902: 131.
60. For example, See Quarterly Journal of Inebriety 28 (1906): 145-150.
61. Lender and Martin, Drinking, pp. 122-124.
62. Advertisement in Quarterly Journal of Inebriety 18 (1896): 208.
63. Lewis D. Mason, "The Relation of the Pauper Inebriate to the Municipality and the State from an Economic Point of View," Quarterly Journal of Inebriety 26 (1904): 329.
64. T. W. Fischer, "Inebriates in Insane Asylums," Quarterly Journal of Inebriety 9 (1887): 73-77.
65. Robert A. Woods et al., Drunkenness in Massachusetts: Conditions and Remedies (Boston: Wright and Potter Printing Co., 1910), pp. 51-52.
66. Foxborough State Hospital, Annual Report, 1906, Appendix, p. xv.
67. Hutchinson's growing frustration can be followed in the annual reports of the Foxborough State Hospital from 1893 until 1908 when he resigned.
68. Irwin H. Neff, The Practical Treatment of Inebriety in an Institution (Boston, 1911), p.1.
69. For a discussion of some of the twentieth-century issues see Allan Luks, "Alcoholism: Do Threats and Therapy Mix?" Hastings Center Report (December 1982): 7-11.






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