Ian David Smith, “Doctoring in a whisky-injured nation: the medical response to the “alcohol question” in Scotland, 1855-1925” (M.D. thesis, Glasgow, 2018).  Available from EthOS.

Scottish people have a reputation for being high consumers of alcohol. Certainly this is the case today and was also the case throughout the nineteenth century – the most obvious comparison to be made, a comparison often made both then and now, is with supposedly more moderate English drinking habits. Less well known is the reversal of this perspective during the inter-war years (1918–1939), when Scotland was held in many quarters to be more sober than England. This turnaround was brought about by changes in popular culture alongside specific alcohol control legislation that had a greater impact in Scotland. This thesis is not an exploration per se of why alcohol consumption rose in nineteenth-century Scotland, fell in the first half of the twentieth century and rose again to damaging levels at the end of the twentieth century. This high level of consumption persists in 2017 and the Scottish government is still acting to reduce alcohol-related harm by a variety of measures. Rather this thesis seeks to explore the response of the Scottish medical profession to the changing conditions in relation to alcohol over a seventy-year period from 1855 to 1925. (Chapter 3 and Chapter 4 set the scene). The starting point of 1855 for the period examined in this thesis is taken from the 1855–57 Inquiry by the Scottish Lunacy Commission, which led to the Lunacy Act (Scotland) of 1857. This report demonstrates that Scottish psychiatry was already having to deal with the mental consequences of alcohol and describes oinomania, an early term for alcohol dependence. The report introduces the idea that alcohol can itself cause insanity – an estimated 20% or more of the cases in asylums were caused by intemperance around that time and this figure was deemed to rise as the century wore on. This seems like a curious and excessive causal attribution from today’s perspective. In this thesis I trace how the idea of a persistent form of alcoholic insanity evolved in the Scottish context (Chapters 4 and 6), and I outline changing terminology and ideas around the mental consequences of alcohol (Chapters 5, 6, 7 and 8). These ideas were expounded by physicians and alienists/psychiatrists in the public arena of parliamentary inquiries in the second half of the nineteenth century (Chapter 4) as well as in the specialised literature of the time (Chapters 5, 6, 7 and 8), including the medical reports within the Annual Reports of asylums. Original to this thesis in relation to primary sources is an in-depth analysis of the alcohol cases received by the Delirium Ward at the Royal Infirmary of Edinburgh between 1856 and 1867, in the May to July period of each of these years (Chapter 5). These 178 recorded cases (57% of all admissions with threatening or actual delirium) illustrate that alcohol problems in the form of incipient or established delirium tremens were a common reason for admission to hospital at this early date and that such cases were of particular interest to physicians. It is striking that beyond the acute episode of what was erroneously thought to be an intoxication-induced illness there is no apparent attempt to help the person with their underlying intemperance (Chapter 5). The idea that later emerged of an underlying condition of inebriety, differentiated from insanity, was to have practical consequences in that it led to the setting up and running of Inebriate Reformatories in Scotland, as elsewhere in the British Isles, in the first quarter of the twentieth century (Chapters 7 and 8). I trace this story in detail through to the closure of the Inebriate Reformatories in 1925,whilst examining this in a Scottish context. Other scholars have looked at the era of the Inebriate Reformatories in Scotland from the perspectives of sociology, of history and of feminist theory. I review the previous literature in Chapter 2, and provide a historiography spanning the last hundred years. I also bring a fresh medical perspective to the topic in Chapter 7, which uses records not available to some of the previous scholars, and produce a very detailed analysis of the female cases sent to the Glasgow Reformatory (Girgenti House). This is presented in Chapter 8. The time period cut-off of 1925 for the end of the thesis is made for pragmatic reasons, as the trends in the conception of alcoholism and alcohol use disorders, and in treatment provision, since 1925 would merit separate full consideration. I do, however, sketch out these trends for this later period in a Postscript (Chapter 9) in order to give a context for drawing out some historic lessons from 1855–1925 in my Conclusion and Discussion (Chapter 10) about the “alcohol question” in the Scotland of today. The period I cover therefore includes an historic high in alcohol consumption in the late nineteenth century and an historic low in the 1920s. I aim to show how practice and theory interconnected during these years in the work of medical men such as Thomas Laycock, David Yellowlees, Sir Thomas Clouston, William Tennent Gairdner, James Craufurd Dunlop, John Cunningham and Sir David Henderson. I also describe some of the connections between these key medical figures within the Scottish system in Chapter 4. The post-1920 period also illustrates a sea change from a time where psychiatrists were arguing for the separation of the “inebriate” from the “lunatic” in terms of service provision to one where the “alcoholic” is seen as deserving of new forms of psychiatric help. This shift in practice, around the end of the period of my study, is seen in the context of a changing emphasis from a more biological view of the problem to a more psychodynamic, or dynamic, view as seen in the work of Henderson and others. The fact that this shift in theory and practice coincides with a decline in the alcohol problem is discussed in the light of Skog’s idea that our concerns around alcohol vary in relation to where we are in relation to “waves of consumption” (Chapter 10). My overall aim in this thesis, then, is to set out how from 1855 to 1925 medicine in Scotland responded to the idea that habituated use of alcohol might represent a disease in its own right. The idea of such a “disease of the will” remains both legally and philosophically controversial to this day. This is perhaps why our diagnostic systems continue to change in this area without final resolution. An associated aim of the thesis is to look at three aspects of the “drinking disease”, in Scotland, namely delirium tremens, alcoholic insanity and inebriety, where practice can be examined from case records and related to theory as represented in a range of publications. I also prove, and highlight the fact, that institutionalised medicine cannot escape engagement with the problem of alcohol. From the beginning, Scottish doctors in both infirmaries and asylums were presented with the consequences of heavy drinking in a sizeable proportion of patients. As with recent epidemiological analyses, alcohol consumption levels in the general population during the nineteenth and early twentieth century are shown to correlate highly with the incidence and prevalence of such disease consequences from the Scottish national and local statistics available. Then, as now, doctors were inevitably drawn into the issue of how best to respond to the underlying habit of drinking both at an individual and societal level. I draw lessons from my study of the past for our continuing struggle in this regard.