The prohibition era dawned in December 1916 as a temporary measure to ensure public order during World War I. At that time, the government introduced a ban on the sales of alcohol for purposes of indulgence over the Christmas season, but exempted spirits intended for technical, medical and scientific use. In order to obtain spirits legally for the Christmas celebration, people would need to contact their doctor, who was entitled to provide them on prescription. The 1916 Christmas prohibition was extended twice by royal decree during the winter of 1917. In May 1917 it turned into a temporary legislative act, and in 1921 prohibition was made permanent. However, it turned out to be less than permanent: from 1 January 1927 spirits could again be sold legally. The prohibition of fortified wine had an even shorter history: a temporary ban in May 1917, permanent ban in 1921, and freely available again from late winter 1923. However, one effect of the prohibition era still remains. Vinmonopolet was established in 1922, and it was decided that from 1 Jan-uary 1923 all imports of wine and spirits and all sales of table wine should be undertaken through this enterprise.
Until the final years of the 19th century, alcohol was in widespread use as a medicinal drug (1, 2). Scientific analyses, however, were able to demonstrate few positive effects of alcohol as a preventive or curative remedy for illness. As new and alternative drugs gradually appeared, doctors ceased to use or recommend spirits for medical purposes. When the prohibition era dawned, this issue was rendered conspicuously relevant and brought to a head, and it turned out that the medical community remained divided in its views on this issue.
In this article we will look in some detail at the role that doctors played as gatekeepers to the seductions of alcohol during the prohibition era – not those of beer and table wine, but those represented by the stronger stuff. Did Norwegian doctors comply with the expectations that the authorities had of them? To what extent did the doctors’ abuse of prescriptions help undermine the prohibition?
The prohibition era has been extensively described; it is a topic of Norwegian history that in posterity has been regarded as rather exotic. However, few historians have studied the role played by doctors during this period. The criminologist Per Ole Johansen has included some relatively cursory chapters on doctors and their prescription practices in two of his works (3, 4), while the historian Per Fuglum (1924 – 2008) has produced some more elaborate contributions in his account of the history of the Norwegian alcohol prohibition (5).
Our article is based on a review of articles on the alcohol issue in the Journal of the Norwegian Medical Association from the period 1916 – 1926. This material provides a deeper insight into the role of doctors as prescribers of alcohol and their views on alcohol as medicine. The authorities’ attempts to regulate the prescription of alcohol are described in another article (6).
The role of doctors during the prohibition era
Doctors were introduced to their new role as gatekeepers rather hastily. While the 1916 volume of the Journal of the Norwegian Medical Association has no references to doctors and prescription of spirits, the 1917 volume and those that followed brought a number of articles on this topic. The doctors’ role during the prohibition of spirits and fortified wine developed into a key topic for the Norwegian Medical Association and its journal.
If a similar prohibition of alcohol had been introduced nowadays, doctors would have been no more affected than other professions. This is because in our time, spirits and fortified wine are no longer regarded as medicine, but only used for indulgence, whereas in previous eras spirits had a key place in people’s «medicine chests». Even though the idea of the salutary effects of strong drinks was no longer as well-established as before the turn of the century, it was at no point during the prohibition era considered to do away with the doctors’ right to prescribe spirits for medical use. The authorities’ move was to introduce regulations intended to restrict the opportunity to abuse this right (6). The case of fortified wines was a little different. In August 1918, during the ravages of the Spanish flu, a ban was in fact introduced on the prescription of fortified wine for medical purposes. Following widespread protests, not least from doctors, the authorities were forced to retreat only few weeks later (5, p. 121 – 122).
There was a blurred boundary between alcohol as an indulgence and as a drug (Figure 1). Three medical indications can be identified. Some doctors claimed that a dram with food, and with fatty dishes in particular, had a salutary effect. Others recognised the preventive effect, one would take a swig when feeling the onset of some bodily discomfort. This necessitated a bottle for home use «in case of need». Finally, some doctors also claimed that alcohol could have a curative effect on diseases.
Figure 1: The boundary between alcohol as an indulgence and as a form of medication remained blurred until well into the 20th century. Here, the artist Jens R. Nilssen (1880 – 1964) has depicted an episode in a pharmacy in the satirical magazine Hvepsen [The Wasp], no. 9/1921. Drawing by © Jens R. Nilssen/BONO.
If a doctor prior to the prohibition was of the opinion that the patient should be treated with alcohol, he would not normally write a prescription. This was unnecessary, since people could freely purchase whatever they needed without having to go to a pharmacy. For using alcohol for prevention the doctor was also not required, since this was almost a part of medical folklore. Suddenly, this type of issue was thus brought into the doctor-patient relationship. During the prohibition era the number of consultations thereby increased because of the requirement for a prescription, and most prescriptions were likely to concern alcohol for use in case of need. Formerly, the patient had decided, now the doctor was in charge. The doctor did not have any natural authority in this field, such as he would otherwise have as a professional with exclusive knowledge of diseases and therapies. No wonder that neither the doctor, nor the patient felt comfortable with this new situation.
The doctors’ views on alcohol as medicine
In August 1917, the general secretary of the Norwegian Medical Association, the temperance advocate Rasmus Hansson (1859 – 1934), who was also co-editor of the association’s journal, wrote that there were «very few indications to prescribe spirits for medical use» (7), and in another article in November of the same year he added that everybody would have to agree that the benefits of alcohol for curing diseases had constantly declined in importance (8).
It was not that simple, however. Norwegian doctors were concerned with issues associated with alcohol as a medicinal drug, and many attached decisive importance to people’s belief in the salutary effects of alcohol. In Norwegian medical journals, the abuse of alcohol and its effects were not on the agenda, unlike in the United States, where the doctors collaborated more closely with the temperance movement. The Norwegian medical community appears to have adhered to the notion of alcohol as a suitable form of medication for a longer period of time than in many other countries (4, p. 58; 5, p. 121).
In the autumn of 1917, Director of Health Michael Holmboe (1852 – 1918) endorsed a recently commissioned statement from Edvard Poulsson (1858 – 1935), Professor of Pharmacology, on the use of alcohol as medicine (9). The professor was of the opinion that alcohol could occasionally be useful as a nutrient in case of diseases involving digestive problems. In case of serious forms of diabetes «alcohol is very valuable, both as a nutrient and as a means of making the monotonous, fatty diet more tasty.» Alcohol in small doses could also have a positive effect in case of various kinds of anorexia, as an appetite stimulant. Poulsson concluded his statement by saying that doctors were fully legitimate in prescribing «the accustomed digestive» alcohol to healthy, especially elderly, people who were accustomed to having a dram with their food, preferably with so-called «hearty diets», i.e. fatty, hard-to-digest food. Even this view was endorsed by the Director of Health (9).
Little was mentioned about the negative health effects of alcohol. The journal editor, Rasmus Hansson, and some others with him reacted to this assertion about a dram with food. Hansson referred to modern research, and countered Poulsson’s views. However, the views promoted by Poulsson and Holmboe met with little opposition in medical circles. Naturally enough, most doctors would rather listen to the signals from the Director of Health than to the admonishments from Hansson the temperance advocate.
Norwegian doctors were, however, more divided in their views on the salutary effects of alcohol than may be indicated by the absence of public debate up to this point. This became clear when the Spanish flu struck in the summer of 1918. The pressure put on doctors to prescribe alcohol appears to have increased dramatically over a short period of time. In an editorial on 16 July, the Aftenposten daily claimed that there was at least one medicine that according to definitive experience would help and protect better than any other – cognac (10).
At the same time, three senior consultants at Ullevål Hospital came forward to warn against the use of cognac, which because of the epidemic was reported to have reached a hitherto «unprecedented use as a medical drug». Lyder Nicolaysen (1866 – 1927), Olaf Scheel (1875 – 1942) and Yngvar Ustvedt (1868 – 1938) were of the opinion that there could be no talk of a preventive effect from cognac. People would be better advised to protect themselves by washing their hands and face before each meal, and avoiding contact with infected persons. They were not as categorical about alcohol as a curative drug, but claimed that any directly positive effect on diseases had never been conclusively proven and remained highly unlikely (11).
The reactions were not long in coming. Carl Stoltenberg (1865 – 1939) found the statement of the three senior consultants to be the right words at the right time. He had recently been visited in his surgery by an elderly gentleman who demanded cognac. Since the doctor, who was neither a temperance advocate, nor an adherent of the prohibition, could see no reason to write a prescription, the man exclaimed: «Would a doctor really endeavour to refuse a patient his cognac?!» (12). Most of the contributions were negative, however. Dr. Bjarne Eide (1869 – 1929) proclaimed the Ullevål doctors’ statement to be «a presumptuous and arrogant impertinence to the Norwegian medical community» (13). Axel Holst (1860 – 1931), an influential professor of hygiene and bacteriology, pointed out that animal experiments with certain bacteria had proven that cognac might well have a preventive effect. «Why should there be no similar effect on the Spanish infirmity?» he asked (14) (Figure 2). Holst was joined by a number of his colleagues in this view of alcohol, which does not appear to have changed noticeably during the entire prohibition era.
Figure 2: Axel Holst (1860 – 1931) was Professor of Hygiene and Bacteriology at the University of Kristiania and head of the University’s Institute of Hygiene from 1893 to 1930. Holst was a skilful scientist, but was less critical in his views on alcohol as medication. Photo: Ludvig Forbech, University History Photographic Archives, approximately 1900.
The doctors’ attitudes to their role as gatekeepers
Even though the doctors in general were rather displeased with the role assigned to them during the prohibition era, their willingness to bear this burden was greater at the initial stage than would come to be seen later. In March 1918, the board of the Norwegian Medical Association submitted a statement to the Ministry of Social Affairs in which they actually took a positive view of the doctors’ role as gatekeepers. In the course of the year, however, attitudes changed. At the 17th national doctors’ assembly in September 1918, following a heated debate, the participants adopted a proposal (with 161 votes to 9) submitted by Axel Holst, demanding that doctors should be freed from their role as gatekeepers. Instead, the assembly called for a strictly limited rationing system accompanied by an arrangement for individual control. A medical committee was appointed to elaborate a proposal (15).
This medical committee, which was chaired by Axel Holst and with Stian Erichsen (1867 – 1953), President of the Norwegian Medical Association, among its members, recommended that doctors should continue to be allowed to prescribe certain amounts of alcoholic mixtures to patients. In addition, every upstanding adult should be allowed to purchase a half-bottle of spirits or a whole bottle of fortified wine every other month (16, 17). This would free the doctors from what they saw as pressure put upon them by patients to have alcohol prescribed as a household remedy. The medical committee’s recommendation, which was submitted to the government in March 1919, failed to gain acceptance. If the referendum on the prohibition had been held six months or so later, it is highly likely that some kind of rationing scheme would have been chosen (18).
The Journal of the Norwegian Medical Association published letters from doctors who protested against this «disenfranchisement of the doctors» (19). All the restrictions and controls associated with their prescribing produced an unaccustomed sensation of being held under scrutiny. The doctors perceived their prescribing rights as practically sacred, and during the national doctors’ assembly in September 1918, one of the participants had proposed a declaration demanding that the prescribing rights of doctors should be retained in unabridged form – in other words without any interference from the health authorities. This was seen as a step too far, and the doctors themselves obviously deemed this to be an unrealistic option.
What did the Norwegian Medical Association do?
The doctors and their association were in a difficult position. They wished to be freed from having the monopoly on providing spirits and fortified wine to the population legally as medication. Finally they saw no other way of escaping from this responsibility than a certain liberalisation of the alcohol policy. The Director of Health, and the President of the Norwegian Medical Association even more so, claimed that alcohol could be recommended for a substantial number of disorders and afflictions. This made the temperance organisations see red. Could the doctors really be trusted?
Interpreting the apparently contradictory formulations of the Norwegian Medical Association was not so simple. When President Erichsen implored doctors to adhere to the regulations of December 1919 to the letter, this meant that doctors should make sure to toe the line and avoid scandals. The whisky doctors threatened the reputation of the medical community, but the president would not impose stronger sanctions than exclusion of those members whose prescribing practices caused offence. The further prosecution of such doctors should be left to the police and the courts. In 1920, Erichsen rejected a proposal to establish collegial control, i.e. internal monitoring, which some doctors had called for on repeated occasions (20, 21).
In November 1920, the Kristiania doctor Rudolf Krefting (1860 – 1942) described the erosion of practices that had taken place over that year. He was ashamed to belong to a profession that had become so demoralised during the prohibition, he wrote. It had gone so far that not just a handful of doctors were referred to as whisky doctors, the public now characterised «a considerable number» in this manner. It was claimed that a doctor could be persuaded to do anything for money. If these practices could not be halted, Krefting claimed that the doctors should be stripped of their right to prescribe alcohol. He requested the Norwegian Medical Association and The Medical Society to address the matter (22).
Krefting received a response from Otto Mejlænder (1865 – 1944), a doctor in Trysil. Most likely, his views rather than Krefting’s were shared by the majority of doctors. He also admitted that the situation was approaching «shameless» dimensions, but the reproach should not be addressed to doctors as much as to the Norwegian government, which had imposed this task on them. He rejected Krefting’s recommendation to the medical association to take action. As late as the national doctors’ assembly in August 1920, the president of the Norwegian Medical Association had warned the participants against «making fools of themselves» by formulating any sort of resolution regarding the alcohol issue – the previous one from the winter of 1919 had fallen on completely deaf ears (23).
Most of the doctors in Kristiansand agreed on another alternative (24). Since the limits on the use of alcohol as a form of medication were so vague, they decided to write such prescriptions only in exceptional cases. Moreover, those which were written should be free of charge. General Secretary and editor Hansson was enthusiastic and appealed to the medical community to follow the example set by these doctors (25, 26). Others, however, including Senior Consultant Olaf Scheel, claimed that making prescriptions free of charge would only cause a hike in demand (27).
There was a widespread notion among Norwegian doctors that a distinction should be drawn between prescriptions for home remedies and prescriptions for diagnosed diseases. The former group was the source of requests and demands from the public, whereas the latter was in the doctor’s expert domain. Therefore, it is unsurprising that the national doctors’ assembly in 1920 unanimously voted that obtaining alcohol as a home remedy on prescription was unsatisfactory to the public as well as to the doctors.
In March 1920, the daily Trondhjems Adresseavis pointed out that it was difficult to thwart the whisky doctors by way of the courts (28). The issue of what the medical community itself could do to halt these practices thus increased in relevance. Halfdan Bryn (1864 – 1933), who was President of the Norwegian Medical Association in 1921 – 1922, responded by marginalising and demonising the whisky doctors. At the same time, he praised the medical community in general for its resilience in the face of the strains imposed on them by the prevailing alcohol regulations. He concluded his article by making light of the situation and by sending a repartee to the adherents of prohibition: «And should all those doctors who according to the prohibition fanatics have committed any infringements be pilloried, I am afraid that not so many decent doctors would be left.» (29).
Figure 3: The doctor Gustav Michelsen (1862 – 1926) wrote more than 48 000 prescriptions for spirits in 1923. He headed the list of whisky doctors, which was the designation used for doctors who abused their prescribing rights for the sake of personal gain. Here, the artist Jens R. Nilssen (1880 – 1964) has portrayed a whisky doctor in the satirical magazine Hvepsen[The Wasp], published as early as in no. 35/1917. The caption ran as follows: «The doctor: He is at death’s door you say? Well, it doesn’t matter, I have other matters to attend to now during the pickling season.» Drawing by © Jens R. Nilssen/BONO
Did the doctors undermine the prohibition?
It is a fact that few doctors were temperance advocates (30). Since the doctors’ proposal for a solution included a form of rationing of spirits, they were inevitably frowned upon by the most ardent defenders of the prohibition. Strong tensions arose between the majority of doctors on the one hand and temperance advocates such as Scharffenberg and Hansson on the other. In 1922, the Journal of the Norwegian Medical Association published a series of articles which amounted to something of a campaign against the journal’s comprehensive coverage of the alcohol issue. Partly, Hansson was accused of being biased and having lost his objectivity, partly it was claimed that the issue had been settled long ago (30, 31). Hansson responded that the Norwegian Medical Association should not only de-fend the interests of the profession, but also emphasise those aspects of social medicine that the doctors were facing on a daily basis.
Not only were few doctors temperate, but many were also opponents of the prohibition policy and praised the blessings of alcohol as medicine. But was this sufficient reason to brand the entire profession as disloyal to the authorities’ alcohol policies? According to Johan Scharffenberg (1869 – 1965), the doctors were «our most insidious enemies, second only to the alcohol capitalists and their lackeys» (32). The historian Per Fuglum claimed that the doctors in particular helped undermine the Norwegian prohibition at its most critical stage. He emphasised «the general scepticism» regarding prohibition and «the scandalous abuse» which was revealed on the part of some doctors (5, p. 436, 620) (Figure 2).
At an early stage, the Norwegian Medical Association emerged with a condemnation of the whisky doctors. For the adherents of prohibition, however, it was surely disheartening to see such prominent doctors as City Medical Officer and hospital doctor Einar Onsum (1876 – 1963) and MD PhD Harald Natvig (1872 – 1847) react with such vehemence against the prescription regulations enacted by Paal Berg (1873 – 1968), Minister of Social Affairs, who in December 1919 introduced stricter routines for prescriptions and the control of them. In an ar-ticle in Aftenposten, Natvig asked how Prime Minister Gunnar Knudsen (1848 – 1928) could have this association with Berg on his conscience. Onsum wrote a double op-ed in Aftenposten on «Spirits and fortified wines as home remedies». People who lost their way through the mountains, «when they finally arrive in a hamlet, half-dead from icy rain and exertion», by virtue of the care provided by Paal Berg, were «barred from obtaining the medicine that in that moment can enliven and reinvigorate them better than anything else» (33, p. 233).
It was also common knowledge that the new Director of Health, Harald Gram (1875 – 1929), who was appointed in 1919, was an opponent of the prohibition (34, p. 424). One might obviously ask how much effort an opponent of the Prohibition Act would devote to the prosecution of those of his peers who were pushing the envelope. The doctors who were chiefly to blame included those 30 – 50 who gradually prescribed large quantities of alcohol. They were kept under careful scrutiny, and many of them faced sanctions and were reprimanded by the health authorities. Some were also charged with criminal offences, even though this rarely resulted in convictions (6).
In the referendum held in October 1926, a total of 56 % of the votes were in favour of repealing the prohibition, whereas 44 % voted against. Despite the fact that the largest strain on the doctors, the burden of prescribing alcohol as a household remedy, had been taken off them in 1924, the proportion of doctors who voted in favour of repealing the prohibition was most likely higher than the national average (5, p. 636 – 637; 32). There can be no doubt that the doctors were to some extent responsible for the erosion, and thereby also for the final demise of the prohibition. Over time, some doctors prescribed large quantities of spirits and fortified wine. However, there were relatively few genuine whisky doctors of the kind comparable to the smugglers and bootleggers of the prohibition era. The main responsibility for the situation with regard to prescriptions should nevertheless be ascribed to the health authorities, who failed to establish a functioning set of laws and regulations, and the Storting, which during the years 1921 – 23 needed three recommendations to decide how the Prescription Act should be formulated (6).