The Discovery of Addiction: Changing Conceptions of Habitual Drunkenness in America: References & Appendix

Appendix

A Note on Contemporary Definitions of Addiction

There is no single agreed-upon definition of drug addiction or of alcoholism in current scientific or medical literature, just as there was none in the 19th century. The World Health Organization's 1957 Expert Committee on Addiction-Producing Drugs (104) offered the following definition:

Drug addiction is a state of periodic or chronic intoxication produced by repeated consumption of a drug (natural or synthetic). Its characteristics include: (1) an overpowering desire or need (compulsion) to continue taking the drug and to obtain it by any means; (2) a tendency to increase the dose; (3) a psychic ( psychological ) and generally a physical dependence on the effects of the drug; (4) detrimental effect on the individual and society.

This definition allows for both psychological and physiological addiction, and thus makes compulsion to take the drug, and the tendency to increase dosage, the central characteristics. Although Keller and McCormick (105, p.7) suggest that this definition "was not generally accepted," it does seem, in fact, to be a fairly widespread formulation. As Chafetz and Demone (106) summarize Isbell's position, it is almost identical to the W.H.O. statement:

Isbell has probably devoted more effort toward studying addictive process than any other individual in the United States. He considers addiction as an overpowering desire, need, or compulsion to continue taking a drug, a willingness to obtain it by any means, a tendency to increased dosage, and a psychological and occasionally physical dependence on the drug (p.38)

In alcohol literature, especially in the work of Jellinek and Keller, the most stress is placed on the compulsion to drink as the characteristic of alcoholism:

ALCOHOL ADDICTION = a form of dependence on alcohol characterized by an overwhelming need to drink intoxicating amounts of alcoholic beverages, which the addict will obtain by any means. It is marked by the drive to obtain the gratification of alcohol intoxication or to escape mental or physical distress, and by loss of control over drinking. (105, p.5)

"Loss of control" is a key phrase in this definition of alcoholism, and Keller has tried to be clear about what he means:

Therefore one can say that the essential loss of control is that an alcoholic cannot consistently choose whether he shall drink or not. There comes an occasion when he is powerless, when he cannot help drinking. For that is the essence or nature of a drug addiction. (26, p.162)

Being addicted, they will helplessly drink; enough to satisfy the addictive demand when a critical cue or signal impinges on them. That's what it means that they have lost control over drinking. (26, p.16)

The significance of loss of control is that it denotes helpless dependence or addiction, the essence of the disease" (108, p.128)

Loss of control is the essential mark of alcoholism. (26, p.154)

The question of whether alcoholism should be reserved only for genuine cases of physiological dependence, or whether it should include psychological addiction, has always been a source of disagreement. In 1960, Jellinek (8) listed 33 formulations, including the American Medical Association's, which allow for psychological addiction, and 22 which imply a pharmacological process. In recent years the tendency in all drugs appears to be a shift away from the focus on a physiological basis for addiction. Room (109, p.5) reports that the 30th International Conference on Alcoholism and Drug Dependence, Amsterdam, "marked the abandonment of a physiological dependence as the assumed fundamental 'seat' of drug problems."

Another controversial issue is the use of the word "craving." Dr. William Silkworth (110), the patron saint of A.A., used it to describe the experience of his patients: "These men were not drinking to escape; they were drinking to overcome a craving beyond their mental control" (p. xxvii), he wrote. "[Alcoholics] cannot start drinking without devel oping the phenomena of craving" (p.xxviii). Others, notably Jellinek (8), rejected, or at least questioned, the use of "craving" because of its vagueness. It can be used to refer to withdrawal symptoms, to a desire for alcohol, or to a desire for intoxication which a number of drugs might provide.

Finally, there is the question of what addiction does to the personality of the addict. Some, like Lindesmith (111) and Duster (6), argue that opiate addiction, at least, has little or no effect on the personality. Others, like Wexberg (9), suggest that addiction of any variety brings about a total transformation of the personality, and a destruction of the individual's moral system. Wexberg, who criticizes the Temperance Movement for being moralistic and condemnatory, is worth quoting at length on the consequences of addiction:

It is my opinion that this process, described under the heading of the malignant habit of addiction, deserves to be classified as a disease in the first place. It is, of course, not specific for alcohol addiction because the same description applies, with some variations, to addictions of other kinds, such as to morphine, cocaine, heroin, and so forth. It also applies largely to sexual pathology, starting with the smallscale 'addiction' of the adolescent mas- turbator, through various forms of oversexedness (nymphomania, satyriasis), to major perversions, such as sadomasochism. What they have in common with addiction proper is exactly their 'malignancy': the more and more compulsive character of the 'irresistible urge,' and especially the 'metastatic' invasion of the total personality and deterioration of its value system. A sadist, for example, is not a normal person who happens to obtain sexual satisfaction in this peculiar manner, but he is a sadist 'as a whole,' with every single area of his life subservient to his powerful urge, with no moral system to check it, no other interests to replace it. (9, p.221)

It should be clear that medical and moral definitions of addiction are not mutually exclusive. And as Wexberg's quote indicates, the l9th century by no means had a monopoly on moralistic views of addiction.

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Early Version

An earlier version of this paper was presented at the annual meeting of the Society for the Study of Social Problems, August 1976, New York City. The research for this paper was supported in part by a fellowship under a training grant (AA-00031) from the National Institute on Alcohol Abuse and Alcoholism.

Social Research Group, University of California, 1912 Bonita Avenue, Berkeley, CA 94704. Received for publication: 4 October 1976. Revision: 9 August 1977.

 The Birth of the Clinic ( 1, p. 199). 
 Quoted by Earle ( 17, p. 5). 
 In this paper I use as equivalents the terms drunkard, 
habitual drunkard, intemperate, inebriate, and alcoholic, to 
describe people who regularly or periodically got drunk. All 
those terms have been commonly used in America. Drunkard and 
habitual drunkard were common in the 17th, 18th and 19th 
century, and habitual drunkard is still sometimes used today. 
Inebriate appears to have come into usage in the early 19th 
century. Alcoholic was coined in the mid-19th century but did 
not come into regular usage until the 20th century. The 
phrase, alcohol addict, was not ordinarily used by temperance 
sources. I use it to make my meaning clear. 
 For a discussion of the various ways Puritans responded to 
habitual drunkards see Lender (21). 
 Edwards was of course a determinist, but determinism as he 
defined it was not inconsistent with liberty with regard to 
moral choices. For a discussion of Edwards's argument see 
Ramsey's (27) introduction to Freedom of the Will. For a more 
general discussion see Miller's biography of Edwards (28). 
 The role of doctors in the development of Temperance 
thought was so important that Wilkerson (31) called the early 
period "the physicians' temperance movement." Following 
Rush's lead were some of the most eminent physicians in the 
United States, including Thomas Sewall of Washington, DC, 
Ruben Mussey of Dartmouth College, Walter Channing of Boston, 
Daniel Drake of Ohio, and Samuel Woodward of the Worcester 
asylum. By 1830 the Philadelphia College of Physicians and 
Surgeons had introduced a course on the pathology of 
intemperance ( 14, p. 140). Also see Cassedy (32) for 
discussion of the role of the medical profession in the 
Temperance Movement. 
 Quoted by Asbury (35, p. 27). 
 Over the course of the l9th century this process worked the 
other way as well. That is, people came to identify 
themselves as alcohol addicts, as drunkards who had lost the 
ability to control their drinking, because of the ideological 
and organizational efforts of the Temperance Movement, just 
as today alcoholics regularly learn in A.A. groups that they 
are individuals who cannot drink moderately. 
 Quoted in Cherrington (36, p.56). 
 
 I do not mean to imply that some new style of drinking 
emerged which had not existed before and which was then 
labeled addiction. Colonial society could show as great a 
variety of styles of habitual drunkenness as the 19th 
century. Further, some alcoholism experts have read 
descriptions of drunkards as far back as ancient Greece and 
concluded that the drinking patterns they identify with 
alcoholism existed then. What was new in the l9th century was 
the legitimacy of a particular way of interpreting the 
experience and behavior of drunkards. In colonial society 
there may have been isolated individuals who felt 
"overwhelmed" by their desires for drink, but there was no 
socially legitimate vocabulary for organizing the experience 
and for talking about it; it remained an inchoate and 
extremely private experience. In the l9th century the 
drunkard's experience was so familiar it became stereotyped. 
 McCormick (40) has noted that in the 18th-century English 
novel drunkenness was treated casually and comically. Only in 
19th-century fiction does the modern alcohol addict appear. 
For example, a woman in Mrs. Caskell's Mary Barton of 1848 
reports, "I could not lead a virtuous life if I would.... I 
must drink... Oh! You don't know the awful nights I have had 
in prison for want of it" (pp.975-976 ). 
 Beyond such statements of support, however, temperance 
organizations did relatively little to develop inebriate 
asylums and they did not make asylums a major part of their 
programs. Some temperance people did oppose asylums because 
of their cost and because of questions about their 
effectiveness. Like many middleclass Americans in the l9th 
century, temperance supporters believed strongly in the power 
of voluntary associations and self-help societies. Thus local 
temperance groups, especially the fraternal organizations, 
made reform work an important part of their community 
activities. 
 For much of the period the Good Templars claimed a 
membership in the United States of around 300,000 ( 67 ). 
There is almost nothing written about the Good Templars in 
20th-century accounts of the Temperance Movement. This 
enormous oversight eliminates any discussion about a major 
strand of grassroots temperance organization and activity. 
Further, the lack of understanding of the self-help activities 
of the Good Templars and other fraternal groups 
obscures the real continuities between the Temperance and 
alcoholism movements. For example, like A.A., Good Templars 
believed that in order to ensure his own sobriety the 
reformed inebriate "must go to work to save others. To help 
himself he must help others. To grow stronger himself, he 
must give strength to others" (68, p.59). A.A. is not only 
similar in form and purpose to self-help temperance groups, 
it is of a historical piece with them. For a discussion of 
the Good Templars' approach to reform work see Sibley (70, 
ch. XIV). 
 I am not claiming that an addiction model is invariably 
couched in disease language or that it always is coupled with 
a sympathetic attitude toward the addict. I am suggesting 
that the first modern addiction conception (Rush) employed 
disease language, that many temperance people used disease 
language, and that in general temperance supporters were 
sympathetic to the drunkard's plight. 
 Quoted by Rothman (22, p. 212). 
 I have restricted my discussion of the development of the 
idea of addiction to the United States. It should be noted, 
however, that much of the process described here applies to 
Europe as well. That is, there was no popular or medical 
concept of addiction before the l9th century. Eighteenth- 
century England, for example, had a "gin epidemic" and the 
level of public drunkenness among the poor promoted efforts 
to cut consumption (83). Yet England developed no addiction 
model of habitual drunkenness and no Temperance Movement 
until the 19th century. Thomas Trotter is probably the best 
known and most important of the early European physicians who 
forwarded an addiction model of drunkenness (31, 84). The 
Temperance Movement developed first and most completely in 
the United States, but its arguments, literature and 
organizational forms were picked up by Europeans, especially 
the British and Scandinavians ( 85, 86 ) . On medical defini- 
tions of alcoholism in the 19th-century Europe see Bynum ( 87 
). Several critiques of the addiction model and suggestions 
for alternative approaches have been made recently (5, 88- 
103). See also, ROIZEN, R. Drinking and drinking problems; 
some notes on the ascription of problems to drinking. 
Presented at the 21st International Institute on the 
Prevention and Treatment of Alcoholism, Helsinki, Finland, 
June 1975. 
 Isbell and White (107). 
 For discussion of this see Jellinek ( 8 ), Clark ( 102), 
Chafetz and Demone (106, pp.47-50).