The debate over addiction as a disease has raged practically from the day man first imbibed. In 1747, the French philosopher Condillac called inebriety a disease and petitioned for state-funded treatment.
History is replete with descriptions of addiction and alcoholism. This timeline series focuses on the shift in attitudes toward addiction and treatment. Picking up after the first article in 1920, this installment explores the genesis of the disease concept and the evolution of the public mind regarding culpability. These timelines owe a debt of gratitude to the work of William White, Ernest Kurtz, Ph.D. and Caroline Acker, Ph.D., whose combined addiction disease chronologies provide a logical, cohesive structure to this debate.
Prohibition and the AMA
The second decade of the 20th century begins with a nationwide proscription on alcohol. Backers of the 18th Amendment fervently believe alcohol is the root of all evil in America. Temperance leagues and ministers sing the praises of abstinence. In short order, bootleggers and organized crime capitalize on Prohibition to supply alcohol to a thirsty nation. Al Capone earns $60 million annually from bootlegging, speakeasies and prostitution.
As Capone profits, the American Medical Association (AMA) solidifies its position on addiction. In 1920, it publishes the “Report of the Committee on the Narcotic Drug Situation.” The report castigates doctors who advocate drug maintenance as treatment and ridicules the disease concept as sheer pretense. The organization publishes the names of physicians arrested for drug possession under the Harrison Act in its industry journal.
Eugenics II, Bureau on Social Hygiene and a psychopathic personality type
From 1923 to 1929, a second round of mandatory sterilization laws targets addicts and alcoholics. Despite prevailing public opinion that addicts and alcoholics are weak-willed, there are still empathetic voices. In 1924, William G. Somerville writes in the Southern Medical Journal, “We know that drug addiction is a disease … the craving for opium is a symptom of disease as pain is of peritonitis and headache of meningitis.”
The Bureau of Social Hygiene – founded in 1921 by John Rockefeller, Jr., to study prostitution – responds in 1924 to clamor that physicians are to blame for opiate addiction, turns its focus to the prescribing practices of physicians.
Lawrence Kolb is the Public Health Service’s chief psychiatrist in 1925. In an example of the badminton match that has become the public debate on addiction, Kolb publishes articles in which he claims addicts have pre-existing defects of personality. In a sense, Kolb appeases the majority who view addicts and alcoholics as deviants. He also somewhat assuages a vocal minority that holds steadfast to the idea that addiction and alcoholism are disease.
Repeal of Prohibition and a quiet thaw
1926 through 1933 mark a subtle change in public opinion regarding addiction. In 1931, Elwood Worcester and Samuel McComb publish “Body, Mind and Spirit.” They describe the alcoholic’s inability to assert control. “He will go on drinking as long as his money or credits holds out.” After a sobering statement that few have recovered from the condition, they present the current psychoanalytical diagnosis of the alcoholic: inferiority complex coupled with inner conflicts. They do add a new element to the mix: mild homosexuality.
The end of Prohibition in 1933 ushers in new opinions on drinking. More is better. Drinking is in. Liquor sales soar. In 1934, William Silkworth, M.D., visits Bill Wilson in the hospital. Silkworth explains his concept of alcohol as an allergy. That year, the American Psychiatric Association includes drug addiction in its “Standard Classified Nomenclature of Disease.”
Alcoholics Anonymous and the lumbar region
In 1935, Bill Wilson founds Alcoholics Anonymous (AA). In 1937, Charles Durfee publishes “To Drink or Not to Drink.” Durfee writes alcoholism is not a sin; it’s a disease. Alcoholics are not morally degraded. Their drinking is an expression of mental trouble, which requires treatment like any disease. Silkworth publishes an expanded description of alcoholism as an allergy in “Medical Record.”
The years prior to World War II are characterized by a growing acceptance that alcoholism is not moral lassitude. Publications cite “psychic allergy,” “normal and abnormal drinker” and “mental malady.” The year 1939 is a watershed moment for alcoholics. “Alcoholics Anonymous” is published; it contains much of the same text that appears in the current edition. From this moment forward, AA permeates the debate on addiction. Even Kolb, now Assistant Surgeon General, alters his tune. In the Quarterly Journal of Studies on Alcohol he writes, “Many of these people could be saved if, in the early state of their chronic alcoholism, they were handled like sick people instead of being treated like criminals.”
As the nation girds for war, more doctors espouse the disease concept. In 1941, Edward Spencer Cowles publishes “Don’t Be Afraid.” He writes, “Chronic alcoholism is not a crime. It is a definite brain-chemistry disease.” Cowles attributes the disease to a buildup of brain fluid. Unfortunately for alcoholics, Cowles’ remedy is to alleviate the pressure by a series of lumbar punctures. He happily reports many alcoholics lose their desire to drink and some even find the smell of alcohol repugnant.
The war years, semantics, the 1950s and Jellinek
While the country throws itself in the war effort, doctors wage a battle of words on the home front. Dwight Anderson publishes a polemic in Quarterly Journal of Studies on Alcohol in which he writes, “Sickness implies, to some extent, the individual is not responsible for his disease.” He champions the use of malady or ailment over disease. In the midst of this battle for semantic hegemony, AA gains traction. It publishes the AA Grapevine. This periodical contains the canons of AA and stories from recovered alcoholics.
The 1950s see more of the same dialectic. The disease concept receives its most elegant and coherent expression from E.M. Jellinek with the publication of “The Phases of Alcohol Addiction” in 1952. Where Jellinek improves on the work of his contemporaries is his delineation of drinking types. Jellinek argues against extending alcoholism to encompass anyone who is a hard drinker. Jellinek advances the disease concept by clearly distinguishing the true alcoholic as an individual beset by both physical addiction and mental unrest.
As the decade ends, literature on alcoholism and addiction takes a different tenor. Papers on marijuana are published. There is a movement to reopen maintenance clinics. But ambivalence persists. In his 1955 essay, “The Psychoanalytical Approach to Alcoholism,” Karl Menninger, M.D., asks for clarity on the word “disease.” It is a fitting denouement that the Sixth Annual National States Conference on Alcoholism revives the age-old argument. In one of the many papers to emerge from the conference, Harry Tiebout, M.D., writes, “I cannot help but feel that the whole field of alcoholism is way out on a limb which any minute will crack and drop us all in a frightful mess.”
The final article in this series begins with the 1960s and continues to the present day.
Follow this series
Read the main overview of this timeline as part of our State of Addiction Policy editorial series here. Check back regularly for updates on the campaign at SovHealth.com, Facebook or LinkedIn. You can also follow us on Twitter and the discussion by searching for #StateOfAddictionPolicy and #SovTalk.
About the author:
Darren Fraser is a content writer for Sovereign Health Group. He worked two and half years as reporter and researcher for The Yomiuri Shimbun until they realized he did not read, speak or write Japanese and fired him. Undeterred, he channels his love of research into unearthing stories that provide hope to those dealing with addiction and mental illness. Darren loves the Montreal Canadiens hockey club and horror films and would prefer to enjoy these from the comforts of his family’s farm in Quebec. For more information about this media, contact the author at firstname.lastname@example.org