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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5227_Библиотеки_им_академика_М_И_Перельмана.pdf
CHAPTER SEVEN
A SIN, A CRIME,
A VICE OR A DISEASE?
‘
N
the rules of a ‘retreat for habitual drunkards’ in the London suburb of
Twickenham. The patient had been confined to the institution ‘to be
cured of the habit of taking drugs’, but he had absented himself without
leave and acquired some cocaine for injection. His defence lawyer
argued that that the Habitual Inebriates Act included no mention of
‘people addicted to the use of drugs or narcotics’. In the standard
printed certificate that bound the defendant, the words ‘habitual
drinking’ had been struck out by hand and ‘taking drugs’ written in to
replace it.
This report from the dying days of the nineteenth century is cited by
the Oxford English Dictionary as the earliest example of the secondary
meaning of the word ‘drugs’ – today, perhaps, its primary meaning – ‘a
substance with intoxicating, stimulant or narcotic effects used for
cultural, recreational or other non-medical purposes’. Prior to this point,
‘drugs’ had – as, for example, in the title of the Chemist and Druggist –
referred generally to all medications. Over the previous decades, intoxicating or mind-altering drugs had often been grouped together, but a
qualifying adjective such as ‘poisonous’, ‘inebriating’, ‘dangerous’ or
‘addictive’ had been required to make the meaning clear. With the twentieth century, the single word ‘drugs’ came to incorporate all these mean-
ot an Inebriate’, ran a headline in the 23 December 1899
issue of the weekly Chemist and Druggist journal. The story
was about a young man who had been arrested for breaking
1
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LOST AND FOUND
ings implicitly. ‘Drugs’ became a shorthand for a collection of substances
that, when not used under appropriate medical supervision, carried the
risk of self-poisoning, addiction or mental illness.
The new meaning of ‘drugs’ arrived largely unnoticed: at first in
newspaper headlines, gradually migrating to official documents such as
police reports, and by the time of the First World War to common
speech. The only official objection to it came from the American
Pharmaceutical Association (APA), who were concerned that their
legitimate trade was being tarnished. Pressured by their major corporate sponsors such as Johnson & Johnson, the APA complained about
the casual use of terms such as ‘drug evil’, ‘drug fiend’ and ‘drug habit’,
which they saw as a slur on their entire product range, and urged the
press to use more specific terms such as ‘narcotics’ or ‘opiates’ when
dangerous drugs were involved.2 But the new usage of ‘drugs’ caught
on, and was soon freighted with meanings and associations that
extended far beyond the pharmaceutical trade.
The new century saw the rising tide of what became known as the
Progressive Era, a dynamic vision of modernity in which the benefits
and risks of drugs were sharply recalibrated. The hallmarks of the new
movement were the expansion of government, the growth of citizen
and community activism, and the replacement of laissez-faire politics
and economics with state intervention and regulation. Despite its
name, the great successes of the Progressive Era were achieved by mobilising coalitions from across the political spectrum, uniting progressive
and conservative interests against a shared enemy: the overweening
might of industry, empire and plutocracy. Alcohol prohibition in the
United States, perhaps the era’s most ambitious project, was a case in
point, achieved by an alliance of progressive forces – temperance
campaigners, the women’s movement, working men’s societies, labour
unions and the medical profession – with the conservative voices of the
churches and the old Puritan elites. For some, it was a campaign for
social justice against the breweries and distillers who were eroding the
social fabric for private profit; for others, it was a moral crusade to rid
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A SIN, A CRIME, A VICE OR A DISEASE?
society of the evils of drink. Behind both lay the shared conviction that
intoxication, whether by alcohol or other drugs, was running out of
control, and threatening the civilised society of the future.
Alcohol was the prime target of this coalition, but the same logic
applied to ‘drugs’. Both were viewed as insidious manifestations of predatory big business. The trade in addictive medicines was a huge source of
revenue for corporate interests, from the alcohol, tobacco and pharmaceutical conglomerates to colonial wealth extractors such as the opium
suppliers of British India or the coffee and tobacco magnates of Brazil.
Mass production and new manufacturing techniques were making drugs
ever cheaper, more pervasive, more potent and more dangerous.
Advertising and mass media exploited the vulnerable, selling unattainable fantasies of health while concealing strong drugs in unlabelled
patent medicines. The mass of data that now informed public health
policy – for instance, the actuarial tables of life insurance companies –
showed ever more clearly that life expectancy was shorter and chronic
disease more prevalent among heavy consumers of alcohol and other
drugs. These were social costs, borne by the public and the economy at
large, with all the benefits accruing to big business and private wealth.
* * *
During the nineteenth century, the dangers of intoxicating drugs rarely
went unmentioned. Literary treatments of them almost invariably took
a cautionary tone, and medical professionals in particular had become
careful to offset any endorsement of their benefits with warnings of
their dangers. The prevailing assumption, however, had been that these
dangers were best addressed by medical information and social pressure rather than government bans. Outside the borders of the modern
West, however, the state prohibition of drugs that began with the criminalisation of hashish in French-administered Egypt had become widespread, most recently in the Philippines, where in 1898 the occupying
United States military government prohibited the opium trade. Several
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LOST AND FOUND
27. The first drug prohibitions were applied to ethnic minorities, such as the
1875 ordinance banning opium in San Francisco’s Chinatown.
racially based prohibitions had also been established within the US
itself, beginning in San Francisco in 1875 with an ordinance that shuttered Chinatown’s opium dens while leaving the sale of opium products in pharmacies untouched.
Among the majority white populations of liberal democracies,
meanwhile, individual choice had prevailed. The principle was often
formulated in the terms set by John Stuart Mill’s On Liberty (1859),
which addressed the question directly: ‘What, then, is the rightful limit
to the sovereignty of the individual over himself? Where does the
authority of society begin?’3 Mill’s response was that the individual was
sovereign over his own conduct; if that conduct led to social harms or
law-breaking, such infractions should be punished in their own right,
rather than by restricting the freedoms that enabled them. The abuse
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A SIN, A CRIME, A VICE OR A DISEASE?
of freedom, he believed, was properly sanctioned not by law but in the
court of public opinion. A person who:
cannot live within moderate means – who cannot restrain himself
from hurtful indulgences – who pursues animal pleasures at the
expense of those of feeling and intellect – must expect to be lowered
in the opinion of others, and to have a less favourable share of their
favourite sentiments; but of this he has no right to complain.
4
Mill’s argument fitted with the widely held opinion that the nineteenth
century was the first true era of the individual. Nation after nation had
thrown off its imperial yoke, its people choosing to define themselves
by their language, community and culture rather than fealty to
monarchs or emperors. The rank and file of society had been freed
from statutory obligations such as church tithes and religious attendance, and were able to define themselves according to their own lights,
as property owners, voters and consumers.
By the early twentieth century, however, the cult of the individual and
the loosening of social responsibilities had become the source of gross
inequalities and fierce resentment. Progressive thinkers attacked the
destructive ‘hyper-individualism’ that encouraged selfishness and greed.
The classic study Suicide (1897), in which the founder of sociology Emile
Durkheim demonstrated that even the most private acts had a social
dimension that could be statistically quantified, diagnosed the twin
threats of modernity as ‘egotism’ and ‘anomie’: a social condition that left
individuals isolated from one another and bereft of the traditional support
of community and its established norms. The solution to these problems
was the regeneration of civil society. The philosopher John Dewey introduced the term ‘social capital’ to describe the new communitarian ideal,
and US Protestant churches preached a ‘Social Gospel’ in opposition to
the plutocracy and zero-sum economics of the Gilded Age.
5
From this perspective, those who used drugs were not only voluntarily enslaving themselves to the profiteers of unscrupulous big
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LOST AND FOUND
business, but were mindlessly and selfishly destroying the social fabric.
Whether by alcohol or morphine, hashish or cocaine, they were
choosing to absent themselves from the shared world of their fellow
citizens, abusing their individual freedom by retreating to a solipsistic
private reality. Altering consciousness was an extreme form of hyperindividualism; drug users were free-riders who detached themselves
from their fellows while still expecting them to pick up the costs of
their habit. As these costs were soberly quantified, alcohol and other
drugs were increasingly viewed through the lens of their risks, harms
and dangers.
The new terms of debate were memorably framed by Norman Kerr,
a British physician who in 1884 launched the medical profession’s
temperance organisation, the Society for the Study and Cure of
Inebriety. In the inaugural address, Kerr posed the question of ‘whether
inebriety is a sin, a crime, a vice or a disease’. If it was a sin, it was a
matter for the individual conscience or religious instruction; if it was a
vice, it should be dealt with by social sanction, along the lines recommended by John Stuart Mill, and perhaps subjected to government
taxation as a luxury. If, however, it was a crime or a disease, it should
be addressed with medical or legal controls. No fifth possibility was
admitted. Kerr defined inebriety – intoxication by alcohol or other
drugs – a priori as a problem; the task at hand was to decide what kind
of problem it was. He coined the term ‘narcomania’ to describe it, and
his personal opinion was that ‘it is sometimes all four, but oftener a
disease than anything else, and even when anything else, generally a
disease as well’.
6
* * *
One of the early successes of the Progressive Era was the US Pure Food
and Drugs Act of 1906, the federal response to a wave of consumer
campaigns against adulterated foods and medicines. This had been
dubbed ‘The Great American Scandal’ by Collier’s Weekly in a long-
246
A SIN, A CRIME, A VICE OR A DISEASE?
28. The Collier’s magazine campaign against unlicenced patent medicines
culminated in the US Pure Food and Drug Act (1906).
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LOST AND FOUND
running series of exposés, and became a burning issue in 1905 with Upton
Sinclair’s shocking series of investigations into exploitative and unhygienic
conditions in Chicago’s meat-packing plants, adapted the following year
into his bestselling novel The Jungle (1906). The campaign had the profes-
sional support of the American Medical Association, at that time
controlled by a group of reform-minded doctors who were lobbying for
more rigorous licensing of medicine, the expansion of funding for medical
schools and a federal department of health. Opposition to the Act was led
by corporate lawyers representing the canning, whisky and patent medicine industries. It was steered into law by the unstinting efforts of
Dr Harvey Wiley, head of the Federal Department of Agriculture’s chemistry division, who would become known as ‘the Crusading Chemist’.
Wiley was rewarded with the leadership of the new agency established by
the Act, the Federal Food and Drug Administration.
The Pure Food and Drugs Act used the term ‘drugs’ in its broad
traditional sense, and was only peripherally concerned with intoxicants, but it strengthened the perception that they should be treated as
a public health problem. As well as the use of toxic industrial additives
in the food supply, it took aim at the profusion of patent medicines,
which by 1900 made up over 70 per cent of the US pharmaceutical
market. Chemical testing by Wiley’s scientists exposed their unlisted
narcotic additives and – equally concerning to temperance campaigners
– their high levels of alcohol, in some cases at 50 or 60 proof.7 The
1906 Act stipulated that all medicines sold in interstate trade must list
the drugs they contained, but Wiley saw it as a first step to eliminating
the sale of narcotics and stimulants altogether. Even trace levels of
cocaine were no longer permitted in patent medicines: as Harvey Wiley
told one pharmaceutical attorney, ‘the amount makes absolutely no
difference’.8 He envisaged a future in which, as he put it, ‘the whole
commerce in so-called patent medicines containing these habitforming drugs would be practically destroyed’.9 He was firmly opposed
to ‘drugs’ in the new sense of the word, and hoped that his Act would
be followed by a federal ban on their trade. Its immediate effect was to
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A SIN, A CRIME, A VICE OR A DISEASE?
remove cocaine almost entirely from public sale and to reduce the trade
in narcotic-containing patent medicines by a third.
10
The Progressive Era’s effect on scientific self-experiments with drugs
was chilling, and dovetailed with a wider trend in psychology: the shift
from introspection to objective and measurable data, and from subjective reportage to group and cohort studies. Emil Kraepelin, the psy chiatrist whose taxonomy of mental illnesses underpins the classificatory
system that still prevails today, began his career in the Leipzig laboratory of Wilhelm Wundt, measuring the mental effects of nervina –
‘nerve poisons’ – including alcohol, caffeine, chloroform, amyl nitrite
and hashish. Despite Wundt’s view that intoxicating drugs, like dreams
or madness, were a form of inner experience not susceptible to experimental investigation, Kraepelin devised techniques for measuring
them. In a series of papers published between 1881 and 1892, he
established the changes in reaction time induced by various drugs at
different doses, using a newly designed chronoscope that captured
reactions to the millisecond.
Kraepelin included himself in these trials, but did not identify
himself among the subjects or publish any first-person reportage.
He produced a series of tables that correlated drugs, dosage and the
number of volunteer subjects with reaction times, reading and number
skills, and dynamometer readings of the kind that Freud had used in
his cocaine experiments. His results were criticised by some psychologists as inconclusive, with too many uncontrolled variables, and he
admitted that the results he elicited ‘might be independent of the drug
and caused by different influences’.11 But his methods anticipated the
direction in which psychology was travelling, and provided the foundations for a rigorous, statistically based science of psychopharmacology. When he took up a professorship in psychiatry at Heidelberg in
1890, he began to compare drug-induced ‘model psychoses’, as he
named them, with those experienced by mental hospital patients:
studies that led to the new disease categories of schizophrenia and
manic depression.
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LOST AND FOUND
These researches convinced Kraepelin of the dangers of alcohol and
led him in 1892 to join the ranks of the teetotal. ‘To my surprise,’ he
wrote in his memoirs, ‘I found that there was really no reasonable
motive for drinking unless one wanted to improve one’s mood.’ Until
this point he had regarded alcohol simply as a fact of social life; now he
co-founded a society of abstinent doctors and an alcohol-free public
house in Heidelberg, and campaigned to raise awareness of the links
between alcoholism and mental illness. It was, in Germany at least, an
eccentric position, but one whose time had come:
The worst problem was that I was constantly involved in endless discus-
sions on alcohol. My strange views were gradually accepted and an
increasing number of people assured me that I was quite right and they
hardly drank either, only now and again on social occasions. I caused a
sensation. I am quite sure that my entire scientific work did not make
my name as famous as the plain fact, that I did not drink alcohol.
12
In 1896 Kraepelin was joined at Heidelberg by a young British
researcher, W.H.R. Rivers, who was studying the effect of alcohol and
other drugs on mental fatigue. Rivers’s work was part of a project to
quantify the harms caused by drugs across a broad sample of subjects, in
particular their effect on industry and productivity. The ‘scientific
management’ of factory work, established by the mechanical engineer
Frederick W. Taylor in 1883, had ushered in the ‘time and motion’ study,
in which industrial processes were broken down into their elementary
units and timed with a stopwatch. Rivers hoped that measur ing the
mental fatigue produced by alcohol and other drugs would not only
provide a reliable index of drug effects but allow industrialists to quantify the productivity lost to them.
Rivers was a physician with a keen interest in the ‘psychical factors’
in medicine: he had written papers on hysteria, neurasthenia and the
physiology of vision. He was also a confirmed self-experimenter, who
had recently collaborated with his colleague Henry Head on a daring
250