Doctor’s Orders: A Prescription to Drink
In this chapter, considers the use of alcohol by the medical profession. In the last quarter of the nineteenth century, doctors began to debate the efficacy of alcohol as a therapeutic drug and the moral implications of prescribing alcohol to patients. Alcohol was still used to treat a wide range of psychological and physiological illnesses but debates existed over the issue of therapeutic nihilism – whether alcohol did more harm than good and while some doctors held faith in its therapeutic qualities, others disagreed. The chapter draws upon an analysis of hospital records which show that alcohol use gradually declined in the period leading up to the First World War when the financial and moral cost of alcohol began to impact upon its popularity as a prescribed medicine.
During the last few years there has been a decided boom in certain sophisticated wines – ‘dietetic’ or ‘tonic’ or ‘restorative’ beverages. Undoubtedly the public imagination has been captured by the ingenious methods pursued in pushing these productions … [Of] those most puffed in the newspapers and advertised in the press and on public boardings, it may be safely affirmed that they have no appreciable therapeutic influence other than that possessed by any of the ordinary wines on the market. 1
Throughout the Victorian and Edwardian periods, people consumed alcohol for health reasons. This was driven in part by the use of alcohol in medical practice and also by commercial factors, which played a significant role in promoting ideas about the health benefits of consuming certain alcoholic drinks. The quote above is from an article on the sale of tonic wines in the British Journal of Inebriety in 1910. The article offered a scathing attack on what the writer referred to as the ‘ingenious’ and ‘aggressive’ marketing of tonic wines which were accused of holding little therapeutic value and could potentially lead to alcoholism. 2 The writer, a doctor and magistrate, noted the popularity of tonic wines which were one of many types of proprietary remedies widely available in the late Victorian period. This chapter explores the issue of drinking for health in the late Victorian and early Edwardian periods by examining the controversy that surrounded the medicinal use of alcohol. Debates about the efficacy of alcohol as a therapeutic agent circulated in medical journals towards the end of the century. An analysis of hospital records shows that although its usage diminished in the period leading up to the First World War, doctors still relied upon it to treat a range of physiological and psychological illnesses. Alcohol had been used as a staple drug in medical practice since the seventeenth century. 3 Its usage within medicine continued throughout the nineteenth and twentieth centuries and the general public therefore had good reason to believe in its medicinal power. Prescriptions for alcohol became increasingly popular in the nineteenth century when more heroic methods of treatment such as cupping and bloodletting fell out of use. However, doctors came under attack from temperance campaigners both inside and outside of the medical profession because a prescription to drink had moral and medical implications and by the end of the century, its usage within hospitals and asylums had declined.
It is [according to the manifesto] the “moderate” use of alcoholic beverages that is held to be “usually beneficial.” Now, what are we to understand by moderate? The signatories make no attempt to define the word. They should have told us what they regard as the limits of moderation - how much, i.e., a person may drink daily without forfeiting the claim to be considered a moderate drinker. Is moderate indulgence the equivalent of one, two, three, or four glasses of whisky per diem? Are we to take as the standard of moderation, the smallest or the largest quantity of alcohol daily consumed by any one of the signatories, or the mean of their respective total daily consumption? We need explicit information on this head. The term “moderate” is in truth a highly elastic one, possessing very different meanings for different individuals. I recently asked a casual acquaintance what he understood by moderate and he gave as answer “half a bottle of whisky a day.” And I told him that I was going to suggest two glasses, or their equivalent to which he replied that a man who limited himself to so small a quantity was to all intents and purposes a teetotaller! 4
The mouthpiece of the British medical profession, would have you to understand that nine-tenths of you will be benefited in health by the moderate use of alcoholic beverages, but we leave it to you to decide what a moderate quantity is, and you may choose any kind of alcoholic drink your fancy prompts. 5
There is no other drug in the pharmacopeia that has such an accommodating action to circumstances. It would seem as if in any particular case we could never predicate as to whether alcohol is going to do good or harm. Surely some indications could be laid down for its use so that we should know beforehand what effect it is going to produce. 6
We can never forget that intoxicating drinks cannot be ordered without some risk of a taste for them being acquired, and the remedy itself proving worse than the original disease. This risk was exemplified in the case of a favourite dog of two maiden ladies of my acquaintance. This animal was seized with an attack of acute pneumonia. The veterinary surgeon gave the dog brandy; and the dog recovered, whether because of or in spite of the stimulant, I cannot tell. Ever since, if he hears anyone speak of brandy, he is up in a moment on his hind legs, begging for the seductive physic. Though I believe the cases of what may be called ‘medical drunkenness’ are not nearly as numerous as is popularly asserted, I have known instances where the medical prescription of strong drinks has been the beginning of a career of excess. 9
This insinuation is a glaring economy of the truth and before such insinuations are published to the world, one would expect any fair minded society or individual to first probe the truth about ‘doctor’s orders.’ There are two sides to a ladder. No drunkard ever takes the blame for his or her degraded condition as the profession so well knows. According to them, their own family circle and nearest friends are their direst enemies; and how often has a chimerical ‘doctor’s order’ been given as an excuse! I could understand our being urgently requested to avoid prescribing alcohol in any form, on account of the moderate use of it becoming a habit and ultimately developing into a craving. The medical profession is as anxious that alcohol should not be abused and that human beings should not suffer in mind and body from its effects, as any teetotaller can possibly be. 11
The general hospitals throughout the country have very materially reduced their expenditure on alcohol in all its forms, but the general hospitals have not abandoned its use in toto … The class of cases in the union infirmaries [where no alcohol was prescribed] are exactly identical with those in the general hospitals. The workhouse medical officer has to treat pneumonia and other acute diseases and grave surgical operations are performed in many union hospitals. At the Leeds General Infirmary alcohol is used. Must we conclude that the staff of Leeds General Infirmary are wrong in continuing this agent? 12
In turning to our Pharmacopeia and our Extra Pharmacopeia for substitutes for alcohol, we are at once impressed with the fact that most drugs have more or less stimulant properties, either local or general, for example, phosphorus, arsenic and iron, chloroform and the ethers, and the various alkaloids – all stimulant in medicinal doses. 14
There are of course habits and fashions in therapeutics as in everything else. Fashions in the past have sometimes been regulated by the prevailing theory of the origin of disease. In the days, for example, when diseases were set down to inflammation, bloodletting was all the vogue, and the use of alcohol was looked on as a perilous enormity. Then came the period when our bodily ills were ascribed to lowered vitality, and the stimulants were administered to therapeutic excess. At the present day, the bacterial origin of disease does not materially affect the employment of alcohol, which is generally given with judgment and discretion. 16
The manifesto discharges a kindly service as a protest against the uncompromising opposition of a body of extremists to the rational use of alcohol. It does more – it applies a spur to the indifference displayed by many medical men with regard to an eminently practical question. It is true that on minor points a divergence of opinion exists, but on fundamental principles there is common agreement. 19
This ‘common agreement’ was evident in hospital records which show that up until the First World War alcohol was still used in large urban voluntary hospitals and asylums. Although its use may have courted controversy among medical men and temperance organisations, the continued use of alcohol indicates that it was still widely regarded as a reliable therapeutic drug. There were very few prescription drugs that offered the same degree of versatility to treat fevers, disease, debility and provide a degree of comfort for patients during the course of illness. Alcohol was the rational drug of choice because it was relatively cheap, widely available and came in a variety of different forms that suited the needs of a wide range of patients.
Alcohol Use in Hospitals and Asylums
There are a number of weak, helpless bed-rid patients, especially in the East House, suffering from various diseases of long standing, many of whom were organically affected on admission … While all the patients require to be well nourished and supported and are so, these patients, in consequence of their greater want of vitality, often require food to be expressly prepared for them and with stimulants to be administered both night and day with a large amount of kind and considerate treatment. 27
Mr H has resided at Kirkmichael House all winter and has had shooting all the season. He has been fairly contented as long as he had unlimited meal and drink. His appetite was enormous and at a meal he has been known to eat a leg of mutton with the usual accessories…and finish off with half a dozen eggs…he has been allowed three glasses of whisky daily and as much beer as he chose to drink. He usually took the whisky undiluted. 28
This case highlights the differences in treatment with alcohol among private and pauper patients. Even if viewed as a necessary therapeutic agent, alcohol was an additional expense in the course of treatment and perhaps one that hospitals with larger numbers of pauper patients could ill afford. In addition to the asylums, alcohol was also used in the treatment of infectious diseases in Belvedere (fever) Hospital in Glasgow. In the 1866 annual report the medical superintendent of Belvedere noted that during the typhus epidemic of 1861 and 1862, the hospital admitted 1837 patients and of these, 1289 were typhus cases. 29 The alcohol consumed during this period was: 62,754 ounces of wine, 8440 ounces of whisky and 2611 ounces of brandy. 30 The Medical Superintendent, Dr Russell believed that it was important to weigh up the therapeutic benefits of ‘alcoholic stimulation’ with the economic considerations. He stated that during the typhus epidemic, Belvedere Hospital and Glasgow Royal Infirmary had admitted similar numbers of typhus cases and that both hospitals had used alcohol in the treatment of patients. Yet Belvedere had successfully treated patients with a more judicious use of alcoholic stimulants than the Royal Infirmary. In fact, Dr Russell claimed that there were fewer deaths from typhus in Belvedere than in the Royal Infirmary and that the average length of stay was considerably less in the former. 31
The use of alcohol in treating fevers and other illnesses was reported in medical journals. Aside from the financial implications of alcohol use, some doctors believed that it only held therapeutic value in certain cases and in particular stages of illness and disease. In an article in the British Medical Journal in 1880, Dr H. McNaughton a physician in The Fever Hospital Cork, provided evidence to support his claim that alcohol should be prescribed carefully in fever cases. 32 He kept records of his patients from January 1873 to June 1879, a period in which he treated 889 fever cases mainly typhus, typhoid and simple fever. On average 30% of patients were treated with alcohol during this period. 33 Most fever cases were treated using brandy, claret and wine. He provided a patient case study of a girl he described as being one of the worst cases of typhoid fever he had ever treated. In the early stages of her illness he prescribed no alcohol but instead treated her using milk, beef extract, foul-broth, digitalis, ipecacuanha (an expectorant sometimes used to treat dysentery), Dover’s Powders, quinine and opium. In the later stages of illness, he prescribed a mixture of brandy and milk every four hours and one ounce of claret every two hours. The girl recovered completely. 34
Certain types of drinks like porter and port wine remained popular over the 30-year period. Sherry fell out of use but champagne and claret were in more demand towards the end of the century. Coleman’s Wincarnis Tonic Wine was purchased for the first time in 1891 with a sizeable order totalling £61 3s 12d, which in today’s money equates to an annual spend of around £3665 on tonic wine. 36 The data from the Glasgow hospitals suggests that between 1870 and 1914, the types of alcohol purchased by hospitals changed, and that although there was an overall trend towards spending less on alcohol, its usage continued.
We cannot believe that any wines whatever are necessary for a healthy adult in good physical strength, taking a fair amount of daily exercise and with no excessive mental strain. Most light wines taken sparingly with meals do no harm to a person under the same conditions and are quite as consistent as the consumption of tea, coffee etc. which generally take their place. Indeed, strong tea, strong coffee and (we would add strong tobacco) have much to answer for in the production of indigestion and nervous palpitation … To the invalid, the wines are frequently of great value and in some of the acute fevers the most powerful alcoholic beverages have sometimes to be prescribed … [However] the patient’s daily question “what shall I drink?” requires more consideration than is usually devoted to it before the medical advisor gives the stereotyped reply “Oh you can take a little claret”. 37
In cases of anaemia, ordinary debility from overwork, feeble digestion etc., a sound red claret is almost as good a prescription as most of the tonic drugs in the Pharmacopeia and is always an advantageous adjunct to this class of remedies. Of course, it must only be taken with the meals and in no case should more than half a bottle be permitted with the meal. In this quantity, the amount of alcohol is very small. 39
Although the articles aimed to give a scientific analysis of the therapeutic value of wine, each instalment also provided information on sourcing the best vintages and brands. For example, an analysis of white Bordeaux wines used ‘an excellent Sauterne 1870 from The Cafe Royale’ to highlight the therapeutic qualities of that particular type of wine. 40 Another article in The Lancet in 1894 looked at the medical value of ‘tonic’ champagnes such as Laurent-Perrier Grand Vin Brut Champagne Sans Sucre and Coca Tonic Champagne Sans Sucre which were recommended for use in treating diabetic patients. Chemical analyses of both drinks concluded that they were palatable and of a similar quality to other ‘high class’ champagnes. 41 Although there was no medical consensus on the therapeutic value of alcohol as a generic drug there did seem to be some agreement that if alcohol were to be used, it should be of the best quality and type. This is hardly surprising, given that most doctors were middle-class men and many of their fee-paying patients were also middle and upper class. The range of illnesses that were financially treatable with a ‘sound claret’, coca champagne or a good quality brandy were therefore likely to be middle or upper-class illnesses such as fatigue, neurasthenia, exhaustion from overwork and digestive complaints. In this sense, doctors were only prescribing the types of alcoholic drinks that their patients would normally drink anyway, so in effect it was a prescription to drink well.
The financial aspect of prescribing alcohol was perhaps more of a concern for public hospitals and asylums that had to justify expenditure on the poorer working classes. The Glasgow hospital and asylum records show a general decrease in spending on alcohol during a period when it’s continued use within medicine courted controversy. Although some doctors wanted to distance the profession from the moral taint of intemperance, many were prepared to carry on prescribing alcohol because they had faith in its therapeutic value. One important point to consider is that alcohol was still being bought and used within hospitals and this suggests a lack of viable alternatives at that time. In other words, doctors simply had no other choice but to prescribe alcohol and perhaps the real pressure was to do so judiciously. This could certainly account for the decrease in the use of alcohol in the decades leading up to the First World War.
Boothroyde J. S. ‘Medicated Wines and Alcohol Addiction’: British Journal of Inebriety : Volume 7:3: 3 January 1910: p. 146.
Curth L. H. 2003. ‘The Medicinal Value of Wine in Early Modern England’: Social History of Alcohol and Drugs: Volume 18.
‘The Call to Drink’: British Journal of Inebriety: Volume 5:1: July 1907.
Barr J. ‘Alcohol as a Therapeutic Agent’: British Medical Journal: 1 July 1905.
Kerr N. ‘Ought We to Prescribe Alcohol and How?’: The British Medical Journal: 5 September 1885.
Macfie C. ‘On the Duty of the Profession with Regard to Alcohol’: The British Medical Journal: 22 September 1899.
‘Alcohol in Workhouses and General Infirmaries’: The British Medical Journal: 24 May 1890.
Macfie C. ‘On the Duty of the Profession with Regard to Alcohol’: The British Medical Journal : 22 September 1899.
MacDonald J. ‘An Address on the Remedial Use of Alcohol’: The British Medical Journal : 30 July 1909.
Cage R. A. 1987. ‘Health in Glasgow’, in (ed.) Cage R. A. The Working Class in Glasgow 1750–1914: Kent: Croom Helm: pp. 56–77.
NHS Archives (NHS): HB142/8: Glasgow Royal Infirmary Annual Reports: 1871–1914.
Thirty-Seventh Annual Report of the Registrar General for Scotland: http://www.histpop.org/ohpr/servlet/PageBrowser?path=Browse/Registrar%20General%20%28by%20date%29&active=yes&mno=660&tocstate=expandnew&display=sections&display=tables&display=pagetitles&pageseq=38&zoom=5: accessed 1/2/2016.
NHS: HB13/51-80: Gartnavel Royal Asylum Annual Reports: 1875–1885.
NHS: HB6/3/2: Western Infirmary Annual Reports: 1880–1905.
NHS: HB24/3/2: Hawkhead Asylum Annual Reports: 1907–1913.
NHS: HB13/5/125: Gartnavel Royal Asylum: Patient Case Notes: James Mackay: January 1888.
NHS: HB/3: Gartnavel Royal Asylum Annual Report: 1871.
Chrichton Royal Infirmary Archives: CRI 1989.139: Case of Thomas Hoare admitted August 1886, single gentleman, age unknown.
NHS: HB65/11: Annual Report of Belvedere Hospital: Medical Superintendent’s Report: 1866.
NHS: HB65/11: Annual Report of Belvedere Hospital: Medical Superintendents Report: 1866.
‘Alcohol in Fever’: The British Medical Journal: Volume 1:8 May 1880: p. 687.
NHS: HB14/2/8: Glasgow Royal Infirmary Annual Reports: 1871–1891.
Calculated Using The National Archives Currency Converter: http://www.nationalarchives.gov.uk/currency/results.asp#mid: accessed 12/12/2015.
‘The Lancet Commission on the Medical Use of Wines’: The Lancet: 26 June 1880.
‘The Lancet Commission on the Medical Use of Wines’: The Lancet: 24 July 1880.
‘Analytical Records Form the Lancet Laboratory’: The Lancet: 13 January 1894.
This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made. The images or other third party material in this chapter are included in the chapter's Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the chapter's Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.