This chapter focuses on the ways in which drunkenness was framed by medical doctors and psychiatrists in Santiago, Chile, and in Rio de Janeiro, Brazil, in the nineteenth century. The flows of scientific knowledge from select European countries, especially France and Germany, are traced, and the appropriation of different psychiatric traditions and the adjustments made to better suit local circumstances are examined. The comparative approach allows us to see how a psychiatric disease model came to be adopted within the context of two different industrialising societies in South America. The comparison between Brazil and Chile is particularly instructive as it also tells us that the flow from France and Germany of new theories about and socio-clinical approaches to the over-consumption of alcohol did not follow the same trajectory. There was no single or ‘typical’ South American style of dealing with alcohol-related issues before the transfer and integration of German and French medical practices into existing local methods. Nor was there one single blueprint for the implementation of new ideas and procedures. As the cases of Brazil and Chile show, specific Europe-bred ideas were not only absorbed at different periods over the course of the nineteenth century, but were also variedly modified, depending on the countries’ different economic and institutional infrastructures and shifting socio-political ideologies as well as the strength of different medical sub-disciplines in the various rural and metropolitan areas in highly diverse cultural and socio-geographical localities. Nevertheless, in both countries the framing of alcoholism as a diagnostic category contributed to the pathologisation of alcohol consumption and the institutionalisation of psychiatry as a medical science and field of diagnostic competence and therapeutic intervention. By the end of the nineteenth century, ‘alcoholism’ was the most prevalent diagnostic category in psychiatric institutions in Chile and Brazil, subsequently underpinning intense campaigns of social hygiene.

In this chapter, the importance of professional networks and the role of individual doctors’ agency employed at different institutions is highlighted within the wider contexts of transnational knowledge transfer and personal connections with local elites. The chapter also traces the nexus between Brazil’s place in international trade networks and the flow of alcohol and resulting over-consumption. For the case of Chile, the persistence of traditional medical practices alongside the newly introduced (and locally modified) approaches from Central European countries is mapped. The chapter also discusses the importance of statistics in the configuration of the subject of alcohol over-consumption as a public health and socio-political problem, highlighting the epistemological role of the numerical dimension in the conceptualisation of a medical phenomenon.

Medical dissertations are important primary sources that lend themselves particularly well to an identification of the points in time when specific cutting-edge ideas became known among a new generation of medical practitioners in different localities. On account of the need for medical students to assess which medical theories and practices were considered as outdated or, conversely, as advanced, an analysis of medical dissertations, together with the subsequent publications of former medical students, helps us identify the points at which new ideas were received, modified and implemented and when the prominence of others was seen to have waned.

The colonial and post-colonial context

Chile and Brazil became independent from the Spanish and Portuguese respectively in 1818 and 1822 respectively. Before colonisation, alcoholic beverages were obtained by fermenting a variety of plant species, such as potatoes and corn. From the sixteenth century onwards, the Taíno word chicha was appropriated by the Spanish to designate all types of alcoholic beverages prepared by different groups of indigenous peoples.¹ The various forms of chicha were of great use in pre-Hispanic times and continued to be integrated into rituals and religious ceremonies even during the colonial period.² As the Chilean central zone, which is endowed with a Mediterranean climate, seemed to the Spaniards to be similar to the regions of Andalusia, they introduced the black grape for cultivation and produced a characteristic local wine. Among the indigenous people who populated Brazil, the main beverage was caium, made by fermenting sweet fruits such as yucca, pineapple and cajú, while people who were enslaved from Africa brought with them fermentation techniques, producing a concoction known as pombe, sorghum beer, and palm sap wines called malafo.³

The production of alcoholic drinks shaped Brazilian and Chilean society during Portuguese and Spanish colonial rule from 1500 to 1822 and from 1540 to 1818 respectively. In the Luso-Brazilian Empire, cane cultivation had shaped the economy and colonial society ever since the sugar trade dominated the transatlantic market in the mid-sixteenth century.⁴ This stimulated the founding of sugar mills in the north-east, the massive exploitation of slave labour and the production of cachaça (alcohol distilled from fermented sugar cane).⁵ Cane alcohol and Caribbean rum served as bargaining chips for the purchase of enslaved people in Africa, as international direct trade with Brazil was vetoed by the Portuguese monarchy, which in 1649 unsuccessfully tried to prohibit the manufacture of cachaça in Brazil and its export to Angola. The resistance generated to the measure is highlighted by Carneiro, not only in its economic dimension, but also in regard to the Brazilian liquor having become a symbol of national identity.⁶ Del Pozo comments that at the beginning of the colonial period in Chile, in the sixteenth century, the cultivation of wine was one of the main bases of the consolidation of an agricultural economy.⁷ By the nineteenth century, the Chilean winemaking enterprise was consolidated. Vineyards became a space for socialising for the local oligarchy as well as valuable assets, and, together with Catholicism, a symbol of identity and belonging for the families of the economic, political and institutional elite.⁸

From the 1870s onwards, Latin American societies experienced an accelerated process of modernisation. Rio de Janeiro and Santiago saw the arrival of thousands of migrants attracted by an incipient industrial development, a process that advanced further during the next century and transformed the urban landscape completely.⁹ In Chile, this process was driven by the extension of its territories following the Pacific War (1879–83), the annexation of the Araucanía (1884) and the consolidation of an export economy based on nitrates in the north of the country. The Brazilian Empire witnessed the abolition of slavery (1888) and the transition from monarchy to republic (1889).¹⁰ The profound changes and the emergence of new urban social actors increased social instability.¹¹ Medical doctors in the different countries began to base their status as experts on the scientific nature of their work. They also presented themselves as qualified to suggest ways of maintaining the desired social peace, while developing a utopia aimed at transforming the lifestyles of the population.¹²

During the early part of the nineteenth century, drunkenness was approached in medical writing mainly in relation to other issues such as food. With the establishment of medical teaching at the Imperial Academy of Medicine in Rio de Janeiro (AMRJ) and at Salvador de Bahia in 1839, and at the Faculty of Medicine in Santiago in 1843, the use of intoxicants was explored in medical dissertations and scientific publications. Valuable insights into the scientific thinking extant at the time can be derived from these dissertations, in which the students assessed and promulgated the prevalent professional views and the knowledge considered valuable within the medical tradition in which they were being trained. For example, a Brazilian dissertation written in 1839 explored the impact of food and drink on the morals of humankind. Its author, Alexandre de Rosario, argued that coffee- and tea-based drinks had modifying powers on the spinal-cerebral nervous system. These ‘modifiers’ could engender modifications in the brain and ‘influence the character of our morals’, while wine produced intoxication and the dullness of faculties.¹³

In regard to Brazil, Santos maintains that the construction of alcoholism as a pathological entity in the nineteenth century coincided with the medicalisation in capitalist societies of traditional behaviours, which was due to the need to prepare individuals for the demands of industrialisation and the consolidation of institution-based medical sciences.¹⁴ Santos and Verani note that medical views about the use of alcohol are part of a process in which people’s daily practices become scientifically inscribed.¹⁵ The ways of life and customs of urban populations fuelled arguments about the use and abuse of alcohol. Fernández makes similar points for the case of Chile. He shows that lower-class drunkenness was represented via the figure of the poor and drunk man, a silhouette that projected a future of national degradation.¹⁶

The industrialisation process in Chile and Brazil also led to important changes in the availability of beverages and ways of drinking. Schivelbusch argues that the industrialisation of distillate production towards the late nineteenth century occasioned radical changes in traditional ways of drinking, just as the introduction of power looms had affected family economies at the end of the eighteenth century.¹⁷ He claims that distillates were part of the generalised acceleration of change in modern times, together with rural exodus and experiences of displacement in hostile cities. Hard liquors maximised the effects of intoxicants and destroyed earlier forms of drinking and socialising, such as wine and beer consumption, causing heightened rates of alcohol abuse and the figure of the solitary alcoholic. In 1875 Ricardo Dávila Boza (1850–1937), a hygienist and medical inspector of the Consejo Superior de Higiene, pointed out that in Chile the most popular alcoholic drinks were aguardiente (strong distilled alcohol), chicha,¹⁸ chacolí (wine)¹⁹ and, in smaller quantities, beer.²⁰ Carvalho listed in his dissertation of 1880 the alcoholic liquids consumed in Brazil, namely the derivatives by distillation of sugar cane, beets and potatoes. He noted that distilled liquor was ‘an extremely detestable liquid, and in our country the opium of the poor class in general, which is usually the cause of alcoholism’.²¹

Alcohol: nutrition, medicine and poison

In Chile and Brazil wine was still found within the available medical arsenal until the late nineteenth century. Following the understanding of the forerunners of laboratory science – the German Justus von Liebig and the Irish physician Robert Todd – that alcohol was fuel for the body, it was recommended to treat a wide range of conditions.²² Quoting von Liebig, the Chilean Salvador Feliú’s dissertation on liver problems of 1879 suggested that alcohol was a form of nutrition and was burned in the ‘bodily economy’ in a way analogous to what happens with sugar and fats.²³ A year later in Brazil, Carvalho, citing Todd, expounded a similar view that alcohol was ‘a food, a fuel for hematosis, a stimulant of the nervous system and at the same time a sedative, moderator of temperature, which fights and prevents delirium and brings a peaceful and beneficial sleep’.²⁴ Carvalho added that alcohol medication had precise indications, which depended on a practical and intelligent judgement.²⁵

In Chile, in his 1873 medical dissertation F. Grohuert wrote about Todd’s treatment of acute pneumonia with alcohol used as an antipyretic, in particular the recommendation of high doses of cognac, port and wine, to reduce pulse rate and temperature.²⁶ Grohuert, however, considered alcohol to be stimulating rather than antipyretic. Grohuert’s thesis was written at a time of radical transformation in therapeutics and testifies to a certain eclecticism, in which approaches such as hydrotherapy and bloodletting were employed alongside emergent science-based medicine. Although he maintained that in cases of alcohol-related pneumonia bloodletting was contra-indicated, he still recommended it, in combination with tartar, for phlegmasia, acute pulmonary oedema and cerebral congestion.²⁷ For alcohol-induced delusions, Grohuert recommended cold baths on account of their calming effect on the nervous system and, above all, chloral hydrate (a sedative).²⁸ Another Chilean medical student, Clotario Salamanca, explored a few years later the link between alcoholism and degeneration, and observed that wine was used for dyspepsia and to lower the pulse and temperature in fever, especially in pneumonia; as a palliative in consumption (tuberculosis) by moderating heat, sweat and vomiting; as a prophylactic in the cure of cholera; and as a disinfectant for wounds and ulcers and, with similar properties to iodine, for serous cavities.²⁹

In Brazil, T. Carvalho published his dissertation in 1880 on ethyl alcohol, which he considered to have a ‘very important role as one of the most beneficial medication agents’.³⁰ He noted the physiological impact of alcohol on the digestive tract, nutrition, urinary secretions, blood, circulation and breathing, and on body temperature. The idea of vapour flows inside the human body served to explain the absorption by the lungs of alcohol, reduced to the state of vapour.³¹ In 1883 another doctor even recommended the use of alcohol to control agitation and delirium, suggesting that ‘if, alongside the symptoms of pneumonia or any other acute discomfort, nervous phenomena were revealed by agitation, insomnia and delirium, alcohol will again be indicated for excellent results’.³²

Until the end of the nineteenth century, the medical value assigned to alcohol was ambiguous. This is expressed in Elementos de higiene (Treatise on Hygiene) by the new director of the Institute of Hygiene in Chile, Federico Puga Borne, published in 1892.³³ The chapter on food includes the notion of ‘nervous foods’ (alimento nervino), defined by the Italian doctor Paolo Mantegazza as a group of nutrients that encompassed alcohol and products such as yerba mate (South American holly), coca leaf, coffee, tobacco and sugar cane.³⁴ Referring to the medical value of alcohol, Puga commented that:

However, Puga warned that while alcohol in low doses was a nutritious drink, large doses were ‘absolutely toxic’.³⁶ This kind of view was prevalent in the literature at the time, yet it was not unopposed. In the same year a doctoral student in Chile ranked alcohol among toxic substances, next to lead and mercury. He suggested in his dissertation, entitled ‘Alcoholismo y degeneración’ (Alcohol and degeneration), that ‘the excessive exclusivism of hygienists comes undone when one asks with avid curiosity about or attentively investigates the role that alcohol has come to play in human life’.³⁷ In a similar vein, a Brazilian doctoral student commented in 1884 that intoxication by alcohol resembled true poisoning,³⁸ and in Chile in 1898, Moises Loyns directly quoted Orfila and his treatise on poisons to describe death in cases of ingestion of large amounts of alcohol.³⁹

Alcohol’s effects on body and mind

Alongside the idea of alcohol as nutrition, the focus on liver cirrhosis constituted an early approach to inebriation within the context of the clinical-anatomical paradigm that was so prominent in early nineteenth-century somatic medicine. The path started in the research on liver cirrhosis marked the terms by which alcoholism was constructed as a medical pathology and organic disease in Chile and Brazil. Within this framework, many medical dissertations on alcoholism described the effect of alcohol first on the bodily systems (circulatory, respiratory and reproductive, and the liver, kidneys, lungs and heart) and then on the nervous system. Doctors strove to find organic lesions, mainly in the stomach and liver. In both Chile and Brazil the modification of organic structures due to excessive use of intoxicants became defined as part of a degenerative process.⁴⁰

Nevertheless, in Chile, the miasmatic paradigm remained prominent in the understanding of liver cirrhosis until the mid-nineteenth century. José Juan Bruner (1825–1899), a doctor of German origin who settled in Chile after arriving in 1844 and one of the founders of the Sociedad Médica de Santiago, held that alcohol aggravated the living conditions of the masses and led to liver diseases.⁴¹ He wrote:

In a similar vein, in 1873 the doctor Wenceslao Díaz stated that liver diseases were common in Chile because of the abundance of cases of dysentery, the dryness of the environment, which exaggerated pulmonary and skin evaporation, and the ‘excesses of the regimen of alcoholic beverages’.⁴³

Halfway between the miasmatic tradition and the physiology of the Frenchman and father of experimental medicine Claude Bernard (1813–1878), Salvador Feliú argued in 1879 in his medical dissertation on ‘alcohol as a cause of liver disease’ that the main organs affected by alcohol were the kidneys and lungs. The processing of alcohol by the kidneys was understood by Feliú within the frameworks of physiology, while the effects on the lungs were interpreted in terms of the miasmatic theory, thus explaining ‘drunken pneumonia’. Feliú noted that alcohol

Feliú held that in the same way as the vapours attacked the lungs, alcohol reached the brain through the circulation of the blood, which produced the states typical of acute alcoholism.

In Brazil, three medical dissertations dedicated to Laënnec’s ‘atrophic cirrhosis’ were published in 1882, agreeing that its aetiological origin was the excessive use of alcohol and that autopsies confirmed lesions in the liver.⁴⁵ These theses owed much to the professor of medicine João Torres Homem, who noted that both in Brazil and in Europe alcohol consumption was becoming widespread. Homem’s clinical experience in Rio de Janeiro led him to suggest that alcohol-related bodily damage varied, depending on the social class of the drinker. He held that in the Brazilian well-off classes, lesions in the heart were more frequent, while among the working classes damage manifested itself in the liver. Although Homem vaguely considered malnutrition among the poor as a factor, he did not develop this aspect any further.⁴⁶

The emergence of a disease paradigm

The first medical texts in Chile that framed alcohol abuse as a disease in itself were written in 1873. They predominantly referenced European publications and adopted new epistemic paradigms, methods of observation and scientific knowledge styles. To some extent they reflected what was at the time considered the state of the art in the medical field.⁴⁷ This was in contrast to Brazil, which lagged somewhat behind North American and European countries, as in Brazil chronic alcoholism was not conceptualised as a mental illness in line with the tradition of French alienism until 1883.⁴⁸ The francophone influence was also apparent in Chile, where the medical establishment had been made up of Spanish and French doctors since independence in 1818 and the Chilean government began to fund medical students’ training in Europe, mainly in France, from 1874. On their return to Chile, the doctors adapted the European models to local circumstances.

Between 1873 and 1890, Chilean medical theses framed alcohol over-consumption as both a ‘social evil’ and a mental illness, distinguishing the latter’s acute and chronic forms.⁴⁹ In Brazil, a comprehensive delimitation of the different mental conditions connected with chronic alcoholism emerged from 1883 onwards, and acute alcoholism was described as a morbid process that affected functional nervous activities such as motility and cognition and caused injuries to organs and tissues.⁵⁰ Azevedo commented that ‘alcohol exerts on the brain an action in which intensity and duration are proportional to the amount absorbed and to the individual’s susceptibility’.⁵¹

In Rio de Janeiro, the anatomical pathologist João Vicente Torres Homem presented a case of hemi-chorea, which, in the absence of rheumatism and other causes, he attributed to the abuse of alcoholic beverages.⁵² In 1878 he published the first work on mental illnesses in Brazil, Lições sobre as moléstias do sistema nervoso (Lessons on Diseases of the Nervous System). Torres Homem’s emphasis on research provided the impulse for laboratory investigations and the foundation of the physiology laboratory at the National Museum. Vimieiro comments that new ideals of science and of civilisation were being forged in Brazil, in the midst of modernisation processes that were driven by the coffee industry and in which scientists felt they had a role to play.⁵³ Medical reforms during the 1880s followed the German model, promoting laboratory disciplines, such as physiology and experimental therapeutics.⁵⁴ This trend was further enhanced when anatomical pathology and histochemical analysis sections were established in the Hospício Pedro II during the late 1880s.⁵⁵

In Chile, laboratories were formed only from the 1880s onwards, although the San Vicente de Paul Hospital had been assigned to clinical-medical teaching since 1872. Chilean alienists were not involved in research on alcoholism, despite or perhaps because of the attention given to the subject by hygienists. Augusto Orrego Luco (1848–1933) is a case in point. He is regarded in the historiography of medicine as a prominent figure of Chilean psychiatry at the end of the nineteenth century.⁵⁶ After graduating in 1873 and working at the Casa de Orates (House for Madmen),⁵⁷ he studied for a year in Paris with the neurologist Jean-Martin Charcot. Upon his return to Chile, he was a devoted disseminator of the anatomical clinical model in his capacity as chair of mental diseases.⁵⁸ In 1884 Orrego Luco published La cuestion social, outlining the social problems that the elite attributed to the Chilean people. He argued in favour of state intervention to regulate the living and leisure spaces of the poor and referred to alcoholism as an eminent problem. However, he did not focus in his own scientific research on the very diagnostic category that at the time was responsible for the largest number of psychiatric patients. In his dissertation on hallucinations, he had described the behavioural effects of alcoholism, asserting that regardless of the moral habits or constitution of an individual, hallucinations were bound to follow frequent use of alcohol. He considered hallucinations identical, independent of the toxin that produced them or induced ‘by an innate or acquired predisposition’.⁵⁹

Adeodato García Valenzuela (1864–1936) is another example of a Chilean doctor who wrote important pamphlets on the ‘alcohol problem’, yet did not focus on it in his own research. Valenzuela was a professor of physiological and pathological chemistry and, from 1899, chief of the General Council of Temperance, which brought together various temperance associations.⁶⁰ In an article that was read at the Chilean Scientific Congress, held in 1896 in the city of Concepción, he built his arguments mainly on German sources and, unlike Luis Orrego Luco, only to a lesser extent on French sources, without presenting studies based on local cases or his own investigations. In 1898 García published a new work on alcoholism, which had received second place in a contest run by the Ministry of Finance that asked for proposals on how to deal with the use of intoxicants by Chileans. García suggested the suppression of alcohol consumption by means of the criminalisation of drunkenness and the creation of doctor-managed specialist asylums for drinkers. He also included a chapter on ‘Alcohol bajo punto de vista químico, fisiolójico i médico’ (Alcohol from a chemical, physiological and physician’s point of view), which was based mainly on German sources, such as Kraepelin’s studies on the influence of alcohol on memory. These interventions led to the prevalence of German theoretical models and approaches in Chilean medical thinking by the end of the nineteenth century.⁶¹

Although psychiatrists and hygienists in both Brazil and Chile used the subject of alcoholism as a means of promoting their status as experts and of expanding their areas of expertise throughout the nineteenth century, differences in the extent of institutional consolidation (or lack thereof) affected the focus of medical discourse in each country. In Brazil, where the Junta Central de Higiene was established in 1852, physicians had consolidated their decision-making power, at least within the limits of Rio de Janeiro and in large cities such as Bahia and São Paulo. In contrast, in Chile, the earlier lack of a centralised health institution, such as the Consejo Superior de Higiene, which was not established until 1892, meant that medical discourses on alcoholism emphasised its serious social consequences, instead of producing research based on the prevailing model of biomedical science and employing the new insights of anatomical pathology and physiology research. Chilean physicians saw this lack of institutional power and scientific focus as a problem, and many strongly emphasised the need to establish specialised medical institutions. However, although they engaged in research and published scientific texts, some of them, such as Augusto Orrego Luco and Federico Puga Borne, ended up opting for political careers as parliamentarians and diplomats.

In Brazil, medical alcohol discourses were based on hygiene theories from the 1880s. But within the context of consolidated spaces of medical expertise, and during the rise of science-based experimental medicine, research on alcohol emerged that approached alcoholism systematically and on the basis of contemporary cutting-edge theories and methodologies, such as anatomical pathology and descriptive symptomology. Thus a greater focus on the tightening of nosological delimitations and the enhancement of clinical psychiatric knowledge was evident among doctors in Rio de Janeiro. As well as engaging with political power, medical professionals in Brazil were also embedded within a more consolidated scientific space than their colleagues in Chile.

The role of statistics

The Hospicio Nacional de Alienados (HNA) in Brazil and the Casa de Orates in Chile were both opened in 1852. By the end of the nineteenth century, they were well-established medical spaces.⁶² The establishment of chairs of mental and nervous diseases in 1881 was an important step towards the consolidation of psychiatry as a medical specialisation in both countries. For doctors in training, mental hospitals provided the opportunity to contrast the theories gleaned from European treatises with their own observations and scientific practices, and to expand the continued influence of Western modes of thinking. The opening of Observation Pavilions in 1893 in the HNA in Rio de Janeiro and, two years later, in the Casa de Orates in Santiago allowed doctors to develop their expertise. Medical internships, too, helped transform hospitals into loci of specialist learning and teaching.⁶³ In the 1890s psychiatrists took an increasing interest in alcohol-related conditions and developed their careers in this field within the context of particular institutions, mainly nursing homes and medical schools. The first systematic work on alcoholism in Chile was carried out by Manuel Segundo Beca (1863–1919), who began his career in internal medicine at the Casa de Orates in Santiago, devoting his dissertation to the statistical analysis of diagnostic practice at the institution.⁶⁴ In 1892 he focused on alcoholism, publishing several articles in which he combined the criminology of Lombroso and French positivism.⁶⁵

In Brazil, Marcio Nery (1865–1911) stands out. After graduating from the faculty of medicine in Rio de Janeiro, he worked at the HNA from 1890. Following the French model, Nery was one of the people in charge of the Clinic of Psychiatry and Nervous Diseases, which was based in the Observation Pavilion. In 1893 he published articles on epileptic phenomena caused by alcohol and on the treatment of alcoholism.⁶⁶ He noted:

Nery and Beca developed similar career trajectories focusing on alcoholism. Both were concerned with tightening the diagnostic category, recording observations, testing treatments and producing the first statistics based on data from the institutions in the respective two countries’ major cities.

The production of statistics on mental illnesses in general and, subsequently, on alcoholism in particular helped establish psychiatry as an important medical field in Chile and Brazil. The creation of data from mental hospital statistics allowed doctors to substantiate their own wider social importance, as they could show that they were tackling a problem that occupied the attention of the authorities. At the same time, the institutions provided spaces for professional advancement. In regard to knowledge construction, research anchored in institutional numbers and graphics constituted a stepping stone towards the objectification of mental illness. Following the positivist tradition in science, diseases became circumscribed in terms of numerical magnitude. The counting of population and disease groups and their numerical representation constituted the foundation for population and disease management and control.⁶⁸ As Golonski has argued, statistical inventories and the production of positive knowledge tend to correspond to the rationality of a political and social governance that aims to manage phenomena such as alcoholism.⁶⁹ The presentation of reality in figures corresponded to an epistemological ideal that had permeated European scientific thought since the end of the eighteenth century. The precision and measurability of social phenomena were strongly grounded in mathematical models as forms of the ideal type of science.⁷⁰ The drive for exact quantification did not, as T. Porter has argued, arise from an inherent condition of scientific practices, but was part of a strategy of de-personalisation that assigned objectivity to representations, which thus could enjoy epistemological authority.⁷¹ The epistemological role of statistics has also been addressed in Nina S. Studer’s chapter in this volume on the understanding of alcoholism by French colonial psychiatrists in Algeria (see Chapter 8).

Manuel Beca performed the first statistical analysis related to alcoholism in Chile at the Casa de Orates in Santiago in 1884. Among the 486 patients resident that year, diagnoses of alcohol-related intoxication (dementia and alcoholic mania) did not surpass 7 per cent, in contrast to other diseases such as mania (47.75 per cent) and dementia (27.56 per cent).⁷² By 1890/91, when the new diagnostic categories of ‘acute alcoholism’ and ‘chronic alcoholism’ were in use, alcohol was reported as the main cause of hospitalisation for 57 per cent of men.⁷³ In a later article, Beca established a link between alcoholism and criminality based on the diagnosis of thirty-six alcoholics among fifty-five prison inmates admitted to the Casa de Orates between 1883 and 1892.⁷⁴

The alcohol statistics also had a political dimension. The conversion of the complex problem of drunkenness into seemingly clear-cut numbers allowed psychiatrists to isolate the phenomenon and visualise it in graphics, making it easier to plan interventions. The numerical data thus enabled psychiatrists to present their work as part of objective knowledge, establish a dialogue with the political powers that be, and channel and access the distribution of state resources for the implementation of policy measures.

In the wake of Beca’s work in Chile, the first statistical report commissioned by the government was concerned with alcoholism. The aim was to base the implementation of public policy measures on actual figures gleaned from institutional and population surveys. The French engineer Francisco de Bèze was employed to produce the first official study, entitled El alcoholismo, estudio y estadística (Alcoholism, Research and Statistics), an investigation that was based on data collected by public institutions in 1895.⁷⁵ The report established the per capita consumption of aguardiente or distilled liquor (which apparently amounted to 60 litres per year); a significant annual expenditure on spirits; arrest rates for drunkenness (4.67 per cent of the population); the proportion of inmates in prisons who offended while intoxicated (12,013 people, equivalent to 40.79 per cent of the prison population); and hospitalisation in the Casa de Orates for alcoholism (57.11 per cent of men and 14.7 per cent of women).⁷⁶ The figures highlighted the extent of the alcohol problem, but Bèze did not suggest any medical measures to contain it. Instead, he proposed punitive actions such as forced patient work and confinement of ‘incorrigible drunkards’ in agricultural penal colonies.⁷⁷

In Brazil, more comprehensive statistical data were collated in 1910 by the medical student Duque Estrada, who calculated that, between 1899 and 1909, 2,007 of the 8,228 people at the HNA were admitted because of alcoholism, representing 24.42 per cent of the total.⁷⁸ Similarly, that same year the psychiatrist Henrique Roxo, who, along with Marcio Nery, was in charge of the Clinic of Psychiatry and Nervous Diseases at the Imperial Academy of Medicine in Rio de Janeiro, compiled the first official statistics of the diagnoses assigned to patients in the HNA Observation Pavilion between 1895 and 1900, showing that 31 per cent of the patients (1,257 people) were assigned the diagnosis ‘alcoholic psychosis’ as the main cause for admission.⁷⁹

In 1914 Hermeto Lima provided a wide range of statistical data in his dissertation, arguing that alcoholism was a cause of crime and of intellectual degeneration.⁸⁰ He included photographs of bars in the city and representations of alcoholics as well as a diagram that showed the numbers of people imprisoned for different crimes, deaths and hospitalisations due to the use of intoxicants. The diagram revealed that in Rio de Janeiro alone alcoholism was implicated in 6,000 of 7,500 cases of prisoners; 4,000 of the 5,000 people awaiting conviction; 2,700 of 4,100 deaths from tuberculosis; 1,200 of 1,900 suicides (between 1908 and 1912); and 1,200 of 1,500 hospital admissions.⁸¹

From delirium tremens to psychosis

A main challenge for doctors was to identify which organs were affected by alcohol consumption. Within the prevalent anatomical-clinical framework, the brain and hence the nervous system were seen to be implicated the most, leading to profound changes in drunken people’s behaviour and mood. In regard to Brazil, Santos suggests that a ‘whole array of enduring mental disorders’ was seen to be ‘produced by the prolonged intoxication of the nervous system by alcohol’ and that ‘this phenomenon was seen as a form of inflammation, often appearing under the term neuritis’.⁸² In Chile, similar views were held, as is evidenced by a dissertation from 1873: ‘There is a form of delirium tremens that closely resembles the frenzy of madness; in this case there is always an actual inflammation of the brain.’⁸³

The concept of delirium tremens was well represented in Chile from the 1860s onwards. Dr Wenceslao Díaz pointed out that delirium tremens had ‘become very common because of the excesses [caused by the consumption of] alcoholic beverages’.⁸⁴ A decade later, A. Zenteno offered in his dissertation a complete systematisation of delirium tremens, which he described as a transitory and nervous pathological state. He noted that this state was characterised by disturbances in brain and nervous functions, such as insomnia, delirium and hallucinations, and was accompanied by tremors and a tendency to collapse, which disappeared after a prolonged sleep. He suggested that for the phenomena ‘to be truly delirium tremens they must be preceded by excessive abuse of spirits’.⁸⁵ The Chilean doctor also referred to the presence of visual, tactile or auditory hallucinations and noted that, although the patient might initially be aware of the non-reality of these phenomena, as the disease progressed, hallucinations tended to overcome judgement to the point that ‘the drunkard believes in the reality of the visions that float before his eyes’.⁸⁶ Zenteno also highlighted the resemblance of alcohol-induced delirium episodes to delusional states caused by intoxication from other substances, such as opium, coffee, belladonna, lead and mercury.

Delirium tremens presented a new condition for psychiatry, which became further circumscribed in 1869 following John Hughling Jackson’s conceptualisation of the tremors observed in the morbid process of delirium tremens as discharges similar to the seizures of epilepsy. At this stage, the alcoholic came to embody two of the most significant contemporary signs of mental disease: delusion and seizures. Santos and Verani argue that once psychiatry began to align symptoms of excessive drunkenness to madness, doctors also started to identify mania, melancholy, paranoid ideas, persecutory hallucinations, auditory and visual hallucinations, disorientation and mental confusion in cases of alcoholic intoxication.⁸⁷ Between the 1870s and the 1890s, both Brazilian and Chilean doctors increasingly began to talk about ‘alcoholism’, a new diagnostic category coined in Europe. Clinical attention shifted towards behaviours that then came to stand as symptoms for either acute or chronic versions of one specific condition.

An analysis of medical journals and dissertations in Chile attests to the continued influence of the French school of alienism until the early twentieth century. This influence was also present in Brazil, but from the 1880s onwards doctors there were particularly interested in identifying the physiological localisation of the sources of the behavioural alterations observed in alcoholics, and in mapping a systematic delimitation of different pathological conditions. For example, in 1883 Antonio de Azevedo argued that ‘delirium tremens is an acute epiphenomenon of chronic intoxication’ by alcohol, distinguishing it from lipemanic insanity, another mental illness caused by alcoholism.⁸⁸ Brazilian physicians located delirium tremens in the encephalon, as affirmed by Loureiro in 1884, who noted that ‘the cephalo-spinal nervous system is the theatre of disorders produced by alcohol abuse’.⁸⁹ This enabled them to explain delirium as located in the brain as well as the discharge of tremors through the nerves and spinal marrow. As Loureiro put it: ‘the delirium is the tremor of the encephalon, just as tremors are the delirium of the marrow’.⁹⁰

In 1890 the term ‘toxic psychoses’ appeared in Brazil to encompass delusions caused by alcohol and other intoxicating substances. The notion of psychoses was coined by the Austrian physician, poet and philosopher Ernst von Feuchtersleben in 1845 to label cases of extreme mental problems arising from a brain dysfunction that nonetheless presented no underlying pathological changes.⁹¹ Later, psychosis was mobilised as a synonym for mental disorders per se and contrasted with neurosis.⁹² The notion appears in Jeronymo de Moraes’s dissertation, ‘Psicoses de origem tóxica’ (Psychoses of toxic origin), a systematisation of the different alterations caused by substances such as alcohol, morphine and cocaine. He argued that the challenge was to ‘define what the essential primitive disorder is’ for each form of psychosis.⁹³ Alcohol-related conditions and psychosis became progressively entangled in Brazilian psychiatry. This was not so in Chile. The different ways in which delirium tremens was framed by Brazilian and Chilean doctors puts into sharp relief how knowledge transfer from European countries to Latin America was not a uniform process but characterised by local adaptations and innovations.

Degeneration and dipsomania

Since the 1880s, one particular phrase has been widely quoted in scientific writing in both Brazil and Chile: ‘A drop of sperm from an alcoholic contains a whole neuropathic family.’ It was coined by the French alienist Jean-Martin Charcot and provides, in a nutshell, the emerging framework for alcoholism in Latin American psychiatric science. This framework appropriates the theory of degeneration, according to which mental illnesses were hereditarily transmissible forms of degeneration.⁹⁴ Originally developed in 1857 by the French alienist Benedict Morel (1809–1873), the theory was developed further by his fellow Frenchmen Valentin Magnan (1835–1916) and his disciple Paul Legrain (1860–1939), who used experiments with absinthe on animals to investigate the assumed morbid process to which the degenerate body was seen to succumb irreversibly.⁹⁵ The theory of degeneration opened the way for French medicine to adopt a strongly biologicist view on alcoholism, leaving environmental and social conditions second.⁹⁶ In contrast to developments in Chile and Brazil, an initial distance to and, from the 1890s, absorption of Morel’s and Magnan’s theories has been explored by Ricardo Campos in this volume in regard to the Spanish context (see Chapter 2).

As early as 1879, the Chilean physician Clotario Salamanca recognised the medicinal uses of alcohol, while at the same time suggesting that the dipsomaniac was an alcoholic and the product by inheritance of the vice of the parents, who in turn would have epileptic, insane, deaf-dumb, cretin and suicidal children, as well as bandits and murderers.⁹⁷ In Brazil, Emilio Loureiro announced in 1884 that ‘all mental discomforts can be caused by the abuse of spirits’. He added that ‘if we consult the annals of human teratology, we will see that the greatest physical and intellectual monstrosities appeared in alcoholics’.⁹⁸

Although the ideas of Magnan had been referenced in earlier Latin American publications, it was only from the 1890s that dissertations in Chile and Brazil adopted his framework of degeneration in relation to alcohol.⁹⁹ In 1892 the medical journal Brazil médico published Magnan’s book of 1874 De l’alcoolisme, des diverses formes de délire alcoolique et de leur traitement (On Alcoholism: The Various Forms of Alcoholic Delirium and their Treatment) with the new title ‘Da dipsomania’ (On dipsomania).¹⁰⁰ To judge from the wide range of dissertations published from the 1890s onwards, degeneration became the core concept for the framing of alcoholism in Brazil until the first decades of the twentieth century.¹⁰¹ In Chile, Beca, for example, configured the notion of ‘dipsomania’ as a disease that could produce other diseases and ‘hereditary psychological degeneration’ in alcoholics’ offspring.¹⁰² He regarded it less as a special mental illness than as a syndrome of spontaneous appearance in individuals predisposed through heredity, presenting as mental obsessions and impulses, such as the wide range of manias of the time, for example kleptomania and nymphomania. In both countries, alcholism was also discussed in combination with other pathological phenomena like cirrhosis and alcoholic pneumonia (conveying lingering miasmatic ideas¹⁰³), as well as epilepsy,¹⁰⁴ neuroses¹⁰⁵ and hysteria.¹⁰⁶

The description of alcoholism was also linked with and compared to general paralysis of the insane (GPI). In 1879, for example, the Chilean Salamanca suggested that ‘the general evil of the lower classes of modern nations is the immoderate and excessive abuse of alcoholic drinks, causing dementia and general paralysis’.¹⁰⁷ In a similar vein, in 1900 the Brazilian Jonathas Pedrosa suggested that morbid inheritance was a neuropathic state that could affect the entire organism or a specific organ. He argued that ‘both in chronic alcoholism and progressive general paralysis, lesions of the brain and spinal cord are palpable’, and listed symptoms such as frequent peripheral lesions, the gradual disorganisation of intelligence, and a drastic dissolution of cognitive ability.¹⁰⁸

Conclusion

From the second half of the nineteenth century onwards, doctors in Brazil and Chile conceptualised alcohol over-consumption and its morbid forms by appropriating the theoretical and epistemic models of European science. Previously, the nutritional qualities of the various types of alcohol were widely promulgated, but discarded once liver cirrhosis became understood in an anatomo-clinical vein as a consequence of excessive alcohol consumption. As Santos, Santos and Verani, and Leyton and Fernández have pointed out, in both Chile and Brazil the emergence of over-drinking as a medical problem occurred within the context of industrialisation. Furthermore, in both countries alienists had established psychiatry as a scientific discipline and consolidated its practice and working spaces. Medicine came to offer prescriptions for social problems on the basis of psychiatry’s scientific authority. In Chile, late nineteenth-century medical discourses had a hygienicist emphasis, which lent itself to the objectification of social problems as diseases. This allowed physicians to assume new competences in urban spaces while it also strengthened the institutionalisation of their profession. Similarly, in Brazil, around the same time as the establishment of the Republic in 1888, doctors began to develop their own theories, independent of those promulgated by European scientists. However, in neither country did the epistemological model mobilised to interpret the use of intoxicating beverages escape the Western medical framework. The link between excessive alcohol consumption and madness was seen to be delirium tremens, characterised by the delusions of chronic alcoholics in its advanced stage. Here the alcoholic’s body became the focal point of two old concerns of nineteenth-century psychiatry, namely delirium and seizures. Over the years, the concept of delirium tremens evolved into the notion of alcoholic psychosis.

Although psychiatric communities in both countries shared certain paradigms and theoretical models in regard to alcohol, they also emphasised different focus points. In Brazil, doctors privileged the production of anatomo-clinical knowledge, whereas doctors in Chile focused on the compilation of statistical databases on alcoholism. While Chilean doctors gathered separate sets of detailed statistics on alcoholism from 1892 onwards, in Brazil such figures were presented alongside other diagnostic categories. These differences can be accounted for by the effort on the part of the Chilean medical profession to consolidate its spaces of competence, as the collation of statistics regarding alcoholism allowed them to encourage interest from the authorities in their work. In contrast, in Brazil psychiatrists had gained wide-ranging social and political legitimisation earlier on.

By the beginning of the twentieth century, the excessive use of alcoholic beverages was framed as a form of mental alienation in both Brazil and Chile. The definition of alcohol abuse as a psychiatric diagnostic category was initially informed by the French anatomo-clinical model and subsequently by the theory of degeneration and German organicism. The connection between over-drinking and mental illness was established during an era when large asylums were established for what were considered incurable chronic patients. These institutions became spaces par excellence for the professional performance of psychiatry. By the 1920s, patients suffering from alcohol-related problems constituted the largest number among hospital inmates.

As this chapter shows, the use of a comparative perspective has enabled us to identify the similarities and differences in two South American countries’ psychiatric responses to the over-consumption of alcohol. The transnational focus highlighted the extent to which German and French medical theories and practices were transferred to, or re-fashioned in, Chile and Brazil, and brought into sharp relief differences in the ways in which alcoholism emerged as a disease category within very different socio-cultural, economic, political and institutional localities. At the same time, a Euro-centric analytical gaze was avoided by means of a close reading of medical dissertations that mapped the development of new, locally bred ideas and practices alongside those imported from other regions. Medical dissertations clearly constitute an invaluable primary source base for a history of knowledge transfer and knowledge production.