Contrasting medical models of alcohol problems in Victoria around 1900

Contrasting medical models of alcohol problems inVictoria around 1900add_3918 1..9

Caroline Clark1,2

Centre for Health and Society, Melbourne School of Population Health, University of Melbourne, Melbourne,Australia1 and Turning Point Alcohol and Drug Centre,Fitzroy,Victoria, Australia2

ABSTRACT

Aims This paper examines four specialist medical inebriety institutions in Victoria, Australia between 1870 and1930, which positioned themselves in distinct ways. It analyses how the treatment in each institution was locatedwithin wider medical approaches and contemporary medical ideas and practice. Methods Medical journals and texts,newspaper articles, government reports and institutional archives are used in the analysis. Findings and ConclusionsAlcohol treatment institutions in the late 19th and early 20th centuries were of several types, differentiated accordingto treatment approaches and their underlying premises as to the nature of the disease being treated, the particularpatient groups for which they catered and their funding models and capacity to take patients committed for treatmentunder legislation. The institutional types identified in other Anglophone countries in this period can be extended toAustralia, with some local variations in the timing of the appearance of the models, the longevity of institutions andgender of patients. In Australia there was no tradition of mutual patient support, as seen at the time in the UnitedStates. Each institution represented itself differently, in particular in terms of its particular medical model, although thetreatments in practice differed less than in theory. The models employed allowed each institution to position itself inrelation to trends in medical theory and practice, in particular to different conceptualizations of the type of diseasebeing treated. Evaluating treatment models for alcohol problems in terms of medical theory and practice of the timecan explain contrasting approaches.

Keywords Alcohol history, disease models, gold treatment, medical models, moral treatment, treatment models.

Correspondence to: Caroline Clark, Turning Point Alcohol and Drug Centre, 54-62 Gertrude Street, Fitzroy, Victoria 3065, Australia.E-mail: [email protected] 12 July 2011; initial review completed 29 September 2011; final version accepted 9 April 2012

INTRODUCTION

The 19th century saw a growing preoccupation withdrunkenness arising from, among other things, indu-strialization and the need for a reliable work-force, andevident in the high numbers of arrests and imprisonmentfor public drunkenness. Like the medicalization of insan-ity, the move to treat inebriety medically was inspired by‘Enlightenment faith in human malleability . . . throughreason and science’ ([1], p. 136). Impelled by and some-times with the support of the temperance movement,in the second half of the century various medical, legaland institutional systems emerged to treat the disease ofinebriety. Historians of this first wave of medical treat-ment for alcohol problems have identified different insti-tutional and treatment paradigms in operation. These

varied according to funding model (public or private),class and gender of patients catered for and relationshipto the state (ability to take patients committed for treat-ment), to charity and to the temperance movement.

This paper builds upon and contributes to work in thehistoriography of treatment for alcohol problems in thelate 19th and early 20th centuries. There has been someresearch on treatment in North America, Britain andparts of Europe, but no extended study of treatment inAustralia, although treatment efforts and types of insti-tution were comparable with other Anglophone coun-tries. This paper analyses the treatment approaches infour specialist institutions in Victoria between 1870 and1930. It develops previous historical work through a newanalytical strategy of examining treatment approachesthrough the lens of the period’s prevailing medical theory

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ADDICTION HISTORY doi:10.1111/j.1360-0443.2012.03918.x

© 2012 The Author. Addiction © 2012 Society for the Study of Addiction Addiction

and practice and considering different concepts of diseaseand trends in practice. In addressing this issue, I am ableto illuminate current tensions over different medicalmodels of alcohol and other drug problems and associ-ated treatment approaches.

‘The medical model’ is a term in common use but, inanalysing societal responses to alcohol problems, sociolo-gists Kettil Bruun and Robin Room have argued that itmakes better sense to speak of multiple medical models,each of which frames the condition differently. In 1970Bruun [2] referred to descriptive models of drug addictionand alcoholism whose value, he argued, is not so much asan accurate typology (which they may not provide) but inthe connections between aetiology and the appropriatesocietal response to the drinker. Any model determineswhich institutions and professions are involved in treat-ment, along with the rights and duties of the alcoholic(and their family and society). The lack of consensuswithin the medical profession on a single model meantthat it made better sense to talk about more than one‘medical model’. Similarly, Room has analysed theimplications of different kinds of disease definition ofalcoholism: ‘ “a disease like bronchitis” or “an allergy” or“diabetes” ’ ([3] p. 54). That is, he also argues that thereare different ‘disease’ models. The choice of model bothshapes and is influenced by relations among the profes-sional groups involved in providing treatment, and byrelations between the treatment provider and patient.Room’s observation in 2001, that analyses of problem-atic drinking continue to give little attention to the idea ofmultiple medical models [4], still applies.

INSTITUTIONAL TYPES IN HISTORIESOF ALCOHOLISM TREATMENT

Historians of the ‘inebriate asylum movement’ ([5], p.107) are broadly consistent in their classification of insti-tutional types, with variation in timing in different places.In American treatment, Bauhmohl & Room distinguish‘homes’ or ‘retreats’ from asylums. Inebriate homes weretypically small, urban, community-based, private, chari-table institutions linked to the temperance movement.Admission was on a strictly voluntary basis for up to 3months. Doctors who cared for drinkers in the homesworked from religious conviction and emphasized mutualaid and moral reform. Baumohl & Room describe theclientele as mainly middle-class; White distinguishesbetween ‘homes’ catering to poor drinkers (Valverde callsthem ‘temperance homes’) and ‘retreats’ treating thedisease of the affluent. Asylums, modelled on insaneasylums, were large medically directed institutions, withlegislated powers of confinement. Initially many wereprivate, but by the start of the 20th century more stateinstitutions opened. Doctors who ran them were more

likely to hold somatic and hereditarian views on alcohol-ism [1,5–8]. Outside these medically endorsed institu-tions were chains of franchised institutions providingpatent remedies, the most famous and successful ofwhich was the ‘bichloride of gold’ cure pioneered byLeslie Keeley; thousands underwent his 4-week treat-ment regime [5,7,8]. As early optimism waned, a fewlarge hospitals and farm colonies were established, pro-viding custodial control of those considered beyondmedical redemption [1,5,6,8].

Historians have organized institutional types inBritain according to the categories that legislation pro-vided for. Legislation passed in 1879 allowed for licensedprivate inebriate retreats taking voluntary patients whoagreed to be detained for up to 12 months. Retreatswere run by doctors or by religious organizations withtemperance backing. Most were gender-specific, and classdistinctions were observed in the degree of residentialcomfort and the requirement, or not, for manual labour.Under new legislation in 1898 convicted ‘habitual in-ebriates’ could be sent for up to 3 years to licensedreformatories such as retreats or government penal-style reformatories for those considered unreformable[7,9,10]. Working-class women comprised the majorityof drinkers committed to government reformatories.This was a means of addressing concern about racialdegeneration, where most hereditary alcoholism wasunderstood to come from the mother [11–13].

Everywhere else, and in other types of institutions,patients were either mainly or exclusively men; a fewinstitutions were established specifically to treat women.Several historians have analysed the pervasive languageof moral heroism that made treatments distinctly mascu-line, a means of regaining and enacting a lost manhood.Women inebriates were doubly stigmatized for failing intheir role as protectors of morality. For them, treatmentwas about restoring respectability and capacity to fulfiltheir domestic role [5–7,14].

Broadly, then, there were private homes that took vol-untary patients and emphasized moral education orreform; public and private asylums that made more oftheir medical credentials and took involuntary patients;private institutions using patent remedies; and correc-tional institutions whose role was more custodial thanremedial. Following the asylum doctors’ own presen-tation of themselves, historians have characterizedasylums as ‘more medical’ than the homes [1,6,8]. Morerecently Prestjan, writing about Swedish institutions, hasargued that asylums were not more ‘medical’, but thatthe homes gave more weight to the ‘moral’ [15]. In NorthAmerica and Britain, few institutions were still in opera-tion after 1919.

In Australia, development followed British and Ameri-can trends. All colonial or state governments passed

2 Caroline Clark


inebriate legislation at some point and set out plansfor institutions, although few ever opened. In addition,private institutions emerged, some offering the bichlorideof gold cure, others run by philanthropic bodies with reli-gious affiliations and a few initiated by doctors. Most didnot last long [16].

INSTITUTIONS IN VICTORIA

Institutions in Victoria were an exception to the patchypicture of treatment provision in the rest of Australia: thefour institutions described in this paper lasted between 15and 40 years. They exemplify types of medical treatmentinstitutions found in the United States and Britain in thesame era. Where they are different is in the timing ofthe institutions, their longevity and gender of patients.The Northcote Retreat (1873–1889) was representativeof moral therapy dispensed by charismatic doctors. TheBichloride of Gold Institute (BGI) (1892–1932) is arche-typical of the specific-remedy claim. Lara (1907–1937)epitomizes the model of rural state-run asylum. Bright-side (1910–1945) exemplifies the religiously based insti-tution, operating with a medicalized approach. Table 1sets out the similarities and differences in their organiza-tional configuration.

All but the BGI had the capacity to take patients com-mitted for compulsory treatment. The Inebriates Act 1872was early by international standards, and was legislatedspecifically for the Northcote Retreat. Consistent withchanges to treatment for insanity, a new law in 1888

prohibited private institutions from taking committedpatients. In response to lobbying in the late 1890s andearly 1900s a subsequent law in 1904 made provisiononce more for licensed institutions along with state-runinstitutions.

The Northcote Retreat

In the international context, the Northcote Retreat wasan early specialist institution framed as a medical estab-lishment styled on insane asylums. It was situated on 32acres in what was then rural Northcote. Its founderand Medical Superintendent, Charles McCarthy, was amember of the British and American specialist inebrietytreatment societies. He drew upon his correspondencewith leading medical specialists in those countries for hisapproach to treatment provision, and for arguments topersuade the Victorian public and legislators that in-ebriety was a disease that could be cured under medicalinstitutional care. The institution was financed originallythrough public fund-raising and a government grant, butwas run as an entirely private institution after a newgovernment withdrew grant aid after 1875. In 1889 itslicence was withdrawn under the new Inebriates Act.McCarthy had, in any case, run into problems: the insti-tution had been running at a loss since the final govern-ment grant and when he tried to claim ownership of theproperty (an arrangement he had made in return fortaking on the institution’s debt) he was called before aRoyal Commission and subsequently sued for return ofthe property to public hands.

Table 1 Organizational characteristics.

Northcote RetreatBichloride ofGold Institute Lara Brightside

1873–1889 1892–1932 1907–1937 1910–1945

Location Rural Urban Rural UrbanAuspices Private, with some initial

government fundingPrivate Public Private (government

subsidy for poor patients)Subject to government

oversightSubject to government

oversightNumbers

treatedAnnual average: 36 Annual average: 1901–18:

31Annual average

1908–28: 140Annual average 1910–28:

45Sex of

patientsMixed Mixed (figures not available) Men WomenApprox 25% women

Class ofpatients

Those who could affordfees

Those who could affordfees

Wide social range(excluding criminal or‘disreputable’ drinkers)

Wide social range (butalmost none with acriminal record)No records of patients Some wealthy (admitted

under pseudonyms);some less affluent

Sliding scale of fees Part or whole governmentsubsidy for ~45%

Admission Voluntary and involuntary Voluntary Voluntary and involuntary Voluntary and involuntary

Contrasting medical models around 1900 3


The BGI

The BGI used an imitation of the Keeley bichloride of goldcure. While most Keeley institutes lasted fewer than 10years and the bichloride of gold cure was in decline inter-nationally by 1900 [8], the Victorian institution carriedon for another 30 years. Keeley’s treatment purportedlyinvolved injections with bichloride of gold. He and hispartners died without revealing the formulae for hismedicines but these days it is assumed, as it was at thetime, that gold was not one of the ingredients [8,17–19].The recipes for the medicines used at the BGI remain,however, with the archives, and reveal that the ‘internalremedies’ contained ‘Chloride of Gold and Sodium’ [20].

The BGI was established by a Baptist minister whobrought the treatment from Chicago and subsequentlysold it to the Wesley Central Mission (WCM) in 1900. TheWCM expected that income from fees would subsidizetreatment for poor drinkers, but this never eventuated.It had several comfortably appointed addresses, andin 1922 the business was prospering well enough topurchase a substantial suburban property. By 1932,however, the depression meant it was no longer finan-cially viable and it was closed [21]. The BGI encountereddifficulties with the local medical professional associa-tions because of its use of a patent medicine and becauseits medical officer was answerable to a non-medical direc-tor of a private institution.

Lara

The Inebriates Act 1904 was given effect in 1907 with theopening of a state institution for men on a 640-acre farmat Lara, about 35 miles from Melbourne. A doctor basedin the treatment system for the insane provided medicalsupervision. By the end of the 1920s the Inspectorof Inebriate Institutions, discouraged by the difficultyin effecting a cure and the increasing number of re-admissions, stopped writing reports. In 1937 it wasclosed and the remaining patients transferred to agovernment psychiatric hospital.

Brightside

Brightside, modelled on similar Salvation Army institu-tions in England [7], first opened in 1907 as a home forinebriate women. In 1910 it was upgraded and licensedunder the 1904 legislation to take patients committedfor treatment. Together with Lara, there was now a statesystem of publicly funded inebriety treatment for bothwomen and men. Government interest in Brightsidedeclined along with patient numbers from the early1930s, and its licence was finally revoked in 1945. Theremaining patients joined the male inebriates at a govern-ment psychiatric hospital.

TREATMENT MODELS IN THE CONTEXTOF CONTEMPORARY MEDICAL THEORYAND PRACTICE

Treatment in each of the four institutions was medicallyframed. We can link the type of treatment provided ineach institution to conceptions of alcoholism and tobroader trends in medical practice at the time. The treat-ment approach, underlying disease concept and associ-ated medical model for each institution are set outin Table 2. Among historians of alcoholism treatment,Tracy [5] and Garton [22] have discussed the contextof wider medical practice, although not linking it todifferent treatment approaches.

The Northcote Retreat

Effective treatment at the Northcote Retreat was ‘naturaland simple; total abstinence, pure country air, and exer-cise . . . kind consideration on the part of the MedicalSuperintendents, studying each person’s peculiarity andthe cause of his fall’ ([23], p. 8). This description anchorsit in the ‘moral treatment’ approach used in treating theinsane, which repudiated punitive and coercive practices,opting instead to engage with the patient’s moral capac-ity by providing incentives to reassert their ability toexercise self-restraint. The aim was to create an environ-ment conducive to restoring the patient’s self-controlthrough pleasant surroundings, diet, education, disci-pline, regular routines, recreation and profitable em-ployment, under the paternal guidance of the medicalsuperintendent [24,25]. Founder and medical superin-tendent McCarthy described inebriety as a disease of thenervous system [26]. It was like other constitutionaldiseases that lay dormant until aroused by an exciting(or immediate) cause [27].

McCarthy’s approach was consistent with acceptedmedical practice at the time. Illness and disease wereunderstood as an imbalance in the individual constitu-tion or somatic temperament. One cause of systemicimbalance might be found in diet and life-style, so alco-holism as a disease made sense in this context. Heredityalso played a role. Medical interventions were attemptsto restore balance or equilibrium: depletive therapies foran over-stimulated person and supportive or stimulatingtherapies for those who were depleted. Drugs were cat-egorized according to effects on individual constitutions,not according to diseases. From early in the 19th centurythis approach was coming under challenge from the newParis medicine, which emphasized empirical research,clinical and post-mortem examination of the body andstatistical analysis, and sought to identify localizedlesions as the source of pathology. In this new epistemo-logical schema disease was not related to the individual’sconstitution, but caused by specific identifiable disease

4 Caroline Clark


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entities usually originating externally to the body; butwhile this latest theory emphasized disease specificity,therapeutically a more traditional approach persisted.French medicine was modern, but had not led to thera-peutic novelty; it was scientific, but was no help clinically;doctors still talked and practised in terms of constitu-tional states. In any case, specific disease entities wereseen as fluid and subject to environmental influences. InMcCarthy’s time, the role of the doctor was still to allevi-ate symptoms while allowing the healing power of natureto take its course, and medical effectiveness was stillunderstood by both doctor and patient to rely on famil-iarity with the patient’s constitutional idiosyncrasies[28–30]. The French shift in understanding of diseasehas been characterized as a move in medical paradigmsfrom a holistic or physiological view to an ontologicalview [31,32]. McCarthy’s treatment was grounded firmlyin the physiological view.

The BGI

The treatment approach at the BGI was clearly very dif-ferent from that at the Northcote Retreat. The differencelay not so much in the employment of bichloride of gold,which by the 1890s was given widely for symptomaticrelief [7,33], but in the claim that it was a ‘specific’, atargeted drug cure that went to the seat of a somaticdisease and eliminated the craving: ‘It takes away thecraving for alcohol permanently in practically every case’[34]. This was a drug therapy that treated the disease, notthe person. It could therefore be given uniformly in allcases. The BGI ran according to a precisely timed dailyroutine and ‘strict regularity’ was important in the treat-ment. The treatment regimen positioned the cure withprogressive medicine, where pathology was not caused bya systemic imbalance but was situated in a local lesion.This is an explicit association with the ontological view,where disease is a specific entity separate from the sickperson and the goal of treatment is to destroy or expel thisentity.

In emphasizing a standardized form of treatment, theKeeley cure and its copycat forms such as that used atthe BGI sought to associate themselves with the latestmedical knowledge. This was not, however, the wholestory. Historical assessments of the Keeley cure haveemphasized the ‘social milieu that surrounded hisremedy’: employment of former patients, the ‘creation ofa supportive atmosphere’ and the provision of aftercarethrough mutual support clubs of former patients ([8],p. 63). Commentators at the time made similar observa-tions. In addition to the routinized drug treatment atthe BGI, cases were considered individually, and adjunc-tive individual treatment prescribed. This was contrastedpointedly with the Keeley cure, with its wholesale

approach that did not treat patients individually andwhich eliminated moral and spiritual elements from thecure. In Victoria, there was not the mutual support seenamong American Keeley patients and graduates, butrather an emphasis on the support and influence of itsempathetic staff and the aftercare provided. The WCMmade much of the leadership by the Matron who pro-vided the day-to-day care. Under its management therewere just three Matrons, and they were all credited withbeing instrumental in many cures [21,35].

Lara

At Lara there was no explicit single treatment philosophy:‘In addition to medication [there is] moral teaching, edu-cation and prophylaxis, as well as vapour baths, massage,physical culture, outdoor exercises and regular occupa-tion’ [36]. Its Government Medical Officer had sat on aparliamentary committee in 1902–03 which investi-gated inebriety treatment. The committee was unable toendorse any particular approach, and recommended‘strict application of all kinds of remedial measures’within a state-run institution [37], and this seems to havebeen what he did. There was a 6–8-week regimen ofmedicines: sedatives in the first few days, followed byhypodermic injections to counter the craving for alcoholand ‘gastric tonics’ and ‘nerve stimulants’ ([38], p. 14). Inan echo of Keeley, the ingredients of the medicines andtonics were not published, but details were available todoctors on request [39]. At the same time any associationwith ‘secret cures’ was eschewed ([40], p. 13). Comple-menting the medical therapeutics were educational andoccupational activities [36,38]. Occupation was boththerapeutic and productive, as farm work contributed tooperating costs. The staff were acknowledged in everyreport for their devotion to their work, their efficiency andpatience, and their skill developed over many years thatsaw little staff turnover: their ‘sympathetic advice’ had asignificant ‘curative influence’ ([41], p. 7). The eclectictreatment approach is seen in the nerve stimulants whichare in the tradition of constitutional medicine (in theearly years, the statistical reports for Lara and Brightsideincluded tables on constitutional temperaments), thespecific treatment which was more modern and theadjunctive care which was an example of classic moraltreatment.

Brightside

Treatment at Brightside was described as being ‘muchthe same’ as at Lara [40] and included rest, fresh air,exercise, a ‘non-stimulating diet’, recreation and aregime of medicines [42,43]. In practice it was akin totreatment at the BGI (although with greater emphasison religious redemption), but framed quite differently,

6 Caroline Clark


with accounts emphasizing the uplifting moral supportprovided by the staff. The work was handed to theSalvation Army in the first place because of the need for‘staff full of enthusiasm, who might be able to make. . . some impression on the emotional side of theirpatients’ [40]. There was also an explicitly religious com-ponent: Bible class, Salvation Army meetings and dailyprayers. At the same time, medicine as prescribed by themedical officer was integral to the treatment. In the earlyyears, at least, some patients also received ‘Dr McBride’sroutine’, consisting of hypodermic injections which hada ‘specific action’ [44].

Institutional types and medical models

The BGI, Lara and Brightside all employed a specific drugtreatment intended to counter a disease entity, combinedwith supportive care. That they were not so different isconsistent with Tracy’s argument that in America, insti-tutional distinctions were ‘more fluid than previouslyacknowledged’ ([5], p. 144), and Baumohl and Room’scaveat that the asylum they depicted was more ideal typethan accurate description [1]. While these three institu-tions were similar in practice, the ways in which theystyled themselves remained distinct. At the BGI, as itsname indicated, the drug therapy featured as the centralelement, and central marketing strategy, with suppor-tive care having an adjunctive role. Lara emphasizedits standing as the state institution operating undermedical leadership, similar to government insaneasylums. Brightside presented itself as primarily provid-ing religiously based pastoral care; its staff, in their whitenurses’ uniforms and government endorsement, addedthe legitimacy of proper medical practice. These differentframings were critical in their implications for funding,marketing, medical professionalism and relations withthe state, factors that were central to institutional healthand survival. It was no accident that the patent medi-cines of the 19th century were referred to as such; then,as now, the patent protected the proprietors’ businessinterests.

Across the four institutions we find distinct medicalmodels of alcoholism. The potential for variation intheories of aetiology, treatment approaches, therapeu-tics, medical theory as well as medical politics, fashionand patient expectations, make a single ‘medical model’unlikely, as Bruun and Room suggested. Although hewould have been familiar with newer models of disease,McCarthy described and treated alcoholism in tradi-tional, physiological terms; its cause lay in the interac-tion of individual constitution and environment. In thelater institutions, treatment drew more on up-to-datemedical theory. Keeley depicted alcohol as a type ofgerm, an external disease entity. A drug cure with

individualized treatment made the BGI at once bothprogressive and traditional: a breakthrough type ofcure combined with the personalized attention that itsmainly well-to-do private fee-paying clientele would haveexpected. This placed the BGI on the medical fringe,however, partly because of its association with patentmedicines which doctors saw as out-and-out quackery,and partly because of their scepticism about specifictreatments. Use of a specific, although consistent withnewer trends in medical understanding associated withthe ontological view, was not in keeping with contempo-rary medical practice, which was still grounded largelyin the physiological view. The medical model at bothLara and Brightside was a mixture of old and new: medi-cines similar to those at the BGI were used, but withmilder claims about their power to cure, and combinedwith a greater array of physical and psychological thera-pies. The language similarly employed both constitu-tional categories and disease entities. The differentmodels (and in the case of the BGI, the medical response)reflect the state of medical theory and practice morewidely: McCarthy’s approach was consistent withaccepted practice; two decades later the BGI was perhapsahead of its time; 15 years later still, Lara and Brightsidereflect a field in transition.

CONCLUSION

Baumohl and Room describe a pattern of development ofinebriate treatment in English-speaking countries whichwent ‘from small homes and retreats under temperanceor religious auspices to large medically run asylums; frommoral therapy with voluntary patients to physical thera-pies with compulsory patients; from hope to a more pes-simistic prognosis’ ([1] p. 160). Such types are seen inthese four Melbourne institutions, although the timing oftheir emergence was different and, away from the classextremes of Britain, Australian institutions were less dis-tinguished by class. The Northcote Retreat was archetypi-cal of the medically based secular institution run by aninspiring doctor providing moral therapy and routinemedical treatment. It was an early institution interna-tionally and resembled the medically directed inebriateshomes in the United States and Britain. It differed in thata substantial minority of the patients were women. TheKeeley cure is archetypical of the specific-remedy claim—and of the general medical approach which becamedominant with the hegemony of biomedicine (somewhatironically given its ‘patent’ designation). The BGI wasestablished at the height of the international popularityof the bichloride of gold cures, but outlasted almost all ofthem. Lara typified the ideal large, public, rural medicalinebriate asylum taking voluntary and involuntarypatients that Baumohl & Room [1] identified in the United



States much earlier. As a religiously based institution,Brightside was a good two generations later than theintroduction of its American counterparts. If for no otherreason than that it operated under the Inebriates Act, itwas also under medical supervision and used the medi-cations of its time. The ‘habitual drunkards’ who filled thecourts and prisons and who in many places provided therationale for medical treatment were not catered for inany of these institutions, as they were in at least oneAustralian state and in Britain in the early 20th century[1,7,16].

Medical theory and practice have changed in the last100 years. In one long-term trend, western medicine has‘sought to localise disease within the body, to identifyspecific pathological lesions, first in organs, then tissues,then cells and now molecules’ ([45], p. 247). Researchinto dependence on alcohol and other drugs continuesto focus on specific disease entities with neuroimagingstudies searching for the biochemical ‘lesion’ in the brainand variations in DNA that might constitute geneticmarkers. A dominant medical frame is that of chronicdisease management, which has strong medical backingand combines medication, supportive care and the moralobligation of the patient to participate in their care bybeing ‘compliant’. This model can be seen in the charac-terization of addiction as a ‘chronic relapsing condition’requiring ongoing management, medication or both. Thesearch for the specific cure continues, with drug treat-ments for opioid dependence comprising agonists thatsubstitute dependence and antagonists to reduce crav-ings [46]. Social and medical optimism about treatingdependence still waxes and wanes.

Perhaps ironically, in view of the dominant medicalview of the time, the BGI can be seen as the most‘modern’, the antecedent of this most prestigious ofmedical models today. Brightside’s combination ofmedical care with spiritual guidance and counselling canbe seen as an antecedent, for instance, of many 12-Step-based treatment institutions. Counterparts to the charis-matic medical leadership of the Northcote Retreat, with astrong but more secular moral component, can be foundin many contemporary residential treatment institu-tions, perhaps particularly among those for more affluentclients. Then, as now, there was no clear criterion bywhich to assess which one approach was more successfulthan another. From the point of view of potential clients,the existence of distinctive models offered (and continuesto offer) a spectrum of alternatives, potentially givingclients more options and the opportunity to try anotherif one method failed.

Declaration of interests

No interests to declare.

Acknowledgements

The author thanks the Wesley Mission Victoria and theSalvation Army, Australian Southern Territorial Head-quarters, for making their archives available. An earlyversion of this paper was given at the 37th AnnualEpidemiology Symposium of the Kettil Bruun Society.The author is also most grateful to Robin Room for adviceon structuring the paper and to Bridget Roberts forcomments on drafts.

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Documents

Contrasting medical models of alcohol problems in Victoria around 1900