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FRIE NDSH IP
& DIV ERS I T Y
CLASS, ETHNICITY AND SOCIAL RELATIONSHIPS IN THE CITY

Carol Vincent, Sarah Neal, Humera Iqbal

Friendship and Diversity
 Carol Vincent
Sarah Neal • Humera Iqbal

Friendship and
Diversity
Class, Ethnicity and Social
Relationships in the City
Carol Vincent Sarah Neal
UCL Institute of Education Department of Sociological Studies
University College London University of Sheffield
London, UK Sheffield, UK

Humera Iqbal
UCL Institute of Education
University College London
London, UK

ISBN 978-3-319-73000-4    ISBN 978-3-319-73001-1 (eBook)

https://doi.org/10.1007/978-3-319-73001-1

Library of Congress Control Number: 2018935410

© The Editor(s) (if applicable) and The Author(s) 2018

This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether
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illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and trans-
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The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
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 Acknowledgements

First of all we wish to thank the teachers, parents and children who took
part in our study and kindly welcomed us and gave us their time and
thoughts. At the time of writing, the children will be in secondary school
and we hope that things are going well for them.
We also would like to thank the Economic and Social Research Council
for funding the research on which this book is based (award number ES/
K002384/1).
We are extremely grateful to Margaret Leggett for her—as ever—
entirely reliable and accurate transcribing, and also to Amani Noor Iqbal
for her careful and beautiful drawings inspired by the children’s friend-
ship maps.
Many people have supported both the research, and us as researchers,
since we started the fieldwork in 2013. We would like to thank our advi-
sory group: Sharon Gewirtz, Gail Lewis, Debbie Weekes-Bernard, Jess
Healy, Daanish Saeed, and Ros George, and the speakers at our dissemi-
nation conference, Ann Phoenix and Tim Butler, for their interest in and
enthusiasm for the project, and their valuable thoughts. Grateful thanks
also to Allan Cochrane for his last minute support!
In addition:
Carol would also like to thank Stephen Ball, Alice Bradbury, Annette
Braun, and Diane Reay for their unstinting academic and moral support.
It is much appreciated. Research students Sara Joiko and Manuela
v
vi Acknowledgements

Mendoza have also helped me clarify my thinking, for which I’m grateful.
Thanks also to all the parents with whom I have stood in a ‘cluster’ in my
children’s playground over the years. Their friendship was and is highly
valued. Finally, much love as ever to Ian, Madi and Dan for always keep-
ing work in its place!
Sarah would like to thank Les Back, Alice Bloch, Rachel Brooks,
Melissa Butcher, Allan Cochrane, Jon Garland, Andrew King, Gail Lewis,
Karim Murji, Greg Noble, John Solomos, Selvaraj Velayuthum, Sophie
Watson, Susanne Wessendorf and Amanda Wise—ever-insightful friends
and wise colleagues. And love and thanks to my moorings—Allan, and
Brock, who grew up in schools like the ones we write about.
Humera would like to thank Michela Franceschelli, Sarah Crafter,
Sophie Zadeh, Susan Golombok and Margaret O’Brien for being great
colleagues; each full of knowledge and great humour. Tabassum and
Zafar for always getting her to the school gates, Marshlee for being a true
friend and Hakim for being just being his wonderful self.
Parts of this book draw on, revise and expand on papers we have writ-
ten previously. We are grateful to the editors and publishers of these jour-
nals for permission to use material from the following papers:

Iqbal, H., Neal, S., & Vincent C. (2016). Children’s Friendships in Super-
Diverse Localities: Encounters with Social and Ethnic Difference. Childhood,
24(1), 128–142. https://doi.org/10.1177/0907568216633741
Neal, S., & Vincent, C. (2013). Multiculture, Urban Middle Class Competencies
and Friendship Practices in Super-Diverse Geographies. Social and Cultural
Geography, 14(8), 909–929. https://doi.org/10.1080/14649365.2013.837191
Neal, S., Vincent, C., & Iqbal, H. (2016). Extended Encounters: Shared Social
Resources, Connective Spaces and Sustained Conviviality in Socially and
Ethnically Complex Urban Geographies. Journal of Intercultural Studies,
37(5), 464–480. Licensed Under Creative Commons Attribution License.
https://creativecommons.org/licenses/by/4.0/. Available at: https://doi.org/1
0.1080/07256868.2016.1211626
Vincent, C., Neal, S., & Iqbal, H. (2016a). Children’s Friendships in Diverse
Primary Schools: Teachers and the Processes of Policy ­Enactment. Journal of
Education Policy, 31(4), 482–494. https://doi.org/10.1080/02680939.2015.
1130859
 Acknowledgements
   vii

Vincent, C., Neal, S., & Iqbal, H. (2016b). Encounters with Diversity:
Children’s Friendships and Parental Responses. Urban Studies, 54(8),
1974–1989. https://doi.org/10.1177/0042098016634610
Vincent, C., Neal, S., & Iqbal, H. (2017). Living in the City: School Friendships,
Diversity and the Middle Classes. British Journal of Sociology. On-line first.
https://doi.org/10.1111/1468-4446.12296
 Contents

1 Why Study Friendships and Diversity? Orientations

and Introduction to the Study   1
Introduction   1
An Emergent Sociology of Friendship    4
Friendship as a Marginalised Sociological Concept?    4
An Established Sociology of Friendship?    9
Approaching Diverse Friendships: Conceptual Orientations
and Methodological Challenges  16
The Pilot Study   16
The Main Project   18
How the Book Is Organised   20
Conclusion  22
References  23

2 Encounter, Conviviality and the City: New Directions

in Theorising Interaction Across Difference  29
Introduction  29
Multiculture and the City  30
Gentrification and Super-Diversity  33
Beyond Romanticising Encounter   38
Conviviality  40

ix
x Contents

Habitus: Disruption and Possibility   42

A Return to Place   48
Conclusion  49
References  51

3 Back at School: Research Methods, Design and Reflexive

Dramaturgy  59
Introduction  59
The Research Environment: The Case Study Primary Schools
and Their Geographies  62
Leewood School: An Area of Established Gentrification   64
Junction School: An Area of Emerging Gentrification   65
Fernhill School: An Area of Partial Gentrification   66
Back to School: The Primary School as a Total Institution?   68
Back to School: Dramaturgy and Managing Research
Environments  73
Research Design and Processes   77
The Children and Their Interviews   79
The Adults and Their Interviews   81
Conclusions  84
References  86

4 The Children’s Friendships: Difference, Commonality

and Proximity  89
Introduction  89
Children’s Friendship Relations Across Ethnic and Social
Difference: A Review  92
Bridging Different Worlds?  92
Friendship in Middle Childhood: Being Eight and Nine Years
Old  94
Friendships in Super-Diverse Classrooms   98
Social Networks  100
Crimson Class, Leewood School  104
Burgundy Class, Junction School  105
 Contents
   xi

Scarlet Class, Fernhill School  106

Recognising Difference: Convivial Dispositions?  109
Fluid Identifications and Complex Friendship Practices  114
Conclusion 116
References 119

5 Children’s Agency and Adult Intervention: Children’s

Friendships Through Adult Eyes 123
Introduction 123
School Policy and Practices  124
Managing Friendships and Feelings  126
Teachers’ Readings of Children’s Friendships  129
Reflections on Teachers’ Management of Children’s
Friendships 135
Parental Responses to Children’s Friendships: Social Mix
and Mixing 137
The Ease and Comfort of Similarity  138
After School Activities  140
Conclusion 144
References 147

6 Extended Social and Spatial Encounters in Primary School

Worlds 151
Introduction 151
Connecting and Making Up Social Space: Primary Schools,
Encounter and Places  153
Convivial Space? Social Exchange and Friendship-Making
in Primary School Worlds  157
Schools as Connective Conviviality Sites  162
Home Spaces, Social Intimacy and School-­Based Friendships  167
Conclusions 173
References 175
xii Contents

7 Antagonisms, Ambivalences and Association: Parents’

Friendships and Strategies for Managing Difference
in Everyday Life 179
Introduction 179
A Continuum 180
Refusing Diversity  181
Accepting Homophily  183
Reflexive About Homophily and Difference  188
Enablers 192
Privileged Clusters?  198
Conclusion 202
References 204

8 Conclusion: Understanding Friendship and Diversity 207

Introduction 207
Contributing Themes  209
Civility and Conviviality  212
What Weighting for Friendships?  217
References 220

Appendix 223

Index 235
 About the Authors

Humera Iqbal is a Lecturer in Psychology at UCL Institute of Education and

based at the Thomas Coram Research Unit. She is interested in identity and the
migration experiences of families and young people; in particular, how they
engage with institutions in new settings, parenting and the impact of genera-
tions on family life. She is also interested in mental health and wellbeing in
young people, particularly from minority groups. Humera uses mixed methods
and arts- and film-based methods in her research. Her recent work has focused
on ‘child language brokers’—young people who translate for their families fol-
lowing migration to a new host setting.
Sarah Neal is Professor of Sociology at the University of Sheffield.
Sarah researches and writes in the fields of race, ethnicity, multiculture, com-
munity, belonging and place. Recent publications include The Lived Experience
of Multiculture: The New Spatial and Social Relations of Diversity (Routledge
2018 with K. Bennett, A. Cochrane and G. Mohan); ‘Living in the city: school
friendships, diversity and the middle classes’, British Journal of Sociology (2017
with C. Vincent and H. Iqbal); and ‘Sociologies of Everyday Life’, Sociology
(2015 with K. Murji). She is co-editor of Current Sociology and an editorial
board member of Ethnic and Racial Studies.
Carol Vincent is a Professor of Sociology at UCL Institute of Education. She
has written and researched extensively about parents’ relationships with educa-
tion and schools and the ways in which those relationships are shaped by social

xiii
xiv About the Authors

class and ethnicity. Other research interests include education policy, and the
teaching of citizenship and values in schools. She has been awarded a Leverhulme
Major Research fellowship to explore the teaching of ‘British values’ in schools.
Previously funded research projects have included the educational strategies of
the Black middle classes and the childcare choices of working and middle class
parents. She is a Lead Editor for Journal of Education Policy and an Executive
Editor for British Journal of Sociology of Education.
 List of Figures

Fig. 4.1 Friendship map of Crimson class. (NB: The social class
information featured in Figs. 4.1, 4.2 and 4.3 is derived from
parental occupation and education, so is only available for those
children whose parents also participated in the research. Please
also see endnote 1 on ethnic categorisation)101
Fig. 4.2 Friendship map of Burgundy class 102
Fig. 4.3 Friendship map of Scarlet class 103

xv
 List of Tables

Table 3.1 Overview of the schools and classrooms in the study 64

Table A.1 Details for the parent participants 224
Table A.2 Details for the child participants 231
Table A.3 Details for the teacher participants 233

xvii
 1
Why Study Friendships and Diversity?
Orientations and Introduction
to the Study

In brief: Introducing the sociology of friendship, the use of primary schools as

a research site and the theoretical and methodological orientations of the
research.

Introduction
I think somebody’s social class or their ethnicity is very, very irrelevant to me and
it is more about whether we can get along with each other and understand each
other and can engage with each other and you know I don’t have pre-conceived
ideas about people and it stands me in quite good stead because I make friend-
ships in unexpected places […] There is an administrator at the university
[where I work] who is on a fixed term contract ….and I always thought that
she and I got on extremely well and she was very, very efficient and she would
interrogate the data that I had requested from her to produce for me in ways
that I found quite unexpected. And I thought, “ooh here is somebody who pays
attention to detail” and so we went out for a drink, very, very kind of tenta-
tively, you know about six months ago, and I discovered that she is South
American, she is Colombian, but she spent a great deal of her life in Argentina
and she is trained as a lawyer. I used to be lawyer in a previous life and that is
how it is, I think, that Sammie and I get on really well. (Aarthi)

© The Author(s) 2018 1

C. Vincent et al., Friendship and Diversity,
https://doi.org/10.1007/978-3-319-73001-1_1
2 C. Vincent et al.

We begin with Aarthi, a middle-class, mixed South Asian heritage par-

ent who was one of the participants in the research project on which the
book is based. This is because Aarthi’s account of her approach to her
friendships and the narrative of her friendship with Sammie powerfully
captures some of the difficulties associated with the concept of friend-
ship. It is a form of social relationship that seems to be shaped by the
‘freest’ of individual choices (Blatterer 2014) and affective serendipity—as
Aarthi puts it, who she is friends with is driven by her perception of
‘whether we can get along’, ‘understand each other’, can ‘engage’. But
despite this sense of agency and an apparent absence of social formality,
friendships tend to be socially and ethnically patterned.
In Aarthi’s example of Sammie, it is the surprise of their shared past
professional identities as lawyers with which Aarthi identifies and on
which she settles, as the explanation for their ‘getting on really well’. In
this way Aarthi’s account of her relationship with Sammie would seem to
reflect the ways in which friendships can, in the words of Bunnell et al.
(2012, p. 491), ‘form a meso-scale of analysis, between dyadic relations
and broader structural categories (class, gender, ethnicity, sexuality etc.)
The latter can be reproduced and strengthened through the work of
friendship. As such friendship is not merely important in its own right
but also plays a role in broader processes of social ordering and
transformation’.
With Bunnell and colleagues’ argument in mind, this book explores
what adults’ and children’s friendships might reveal about the nature and
extent of social divisions in socially and ethnically heterogeneous geogra-
phies. How do adults conceive of and respond to their own and their
children’s friendship relations and the extent to which these are socially
and ethnically diverse? To what extent do friendship relations cross (and
thereby potentially transform) social and ethnic difference or remain
within these boundaries (and thereby reproduce/affirm them)?
We set out to respond to these questions by examining the ways in
which adults’ and children’s friendship relationships and friendship prac-
tices work, within a localised, ‘throwntogether’ (Massey 2005) urban
population who routinely experience social and ethnic difference through
geographical proximity. We develop our analysis through a focus on the
social interactions of those parents and children who live in diverse
 Why Study Friendships and Diversity? Orientations… 3

l­ocalities, but also meet through their collective use of a particular key
social resource—the primary (elementary) school. The focus on the pri-
mary school is very deliberate in that it allows us to access a particularly
affective social world that is populated by both children and adults.
Primary schools often work as what Deborah Chambers (2006) has called
the ‘hub and spoke’ of social networks; namely, they are particular social
sites within localities and communities that radiate outwards, and are
able to generate wider social connections. In this way primary schools
are, as Collins and Coleman (2008, p. 296) observe, ‘places that matter
to many people’.
Through their collective, habitual and sustained use, primary schools
are disposed to, and productive of, sociality and encounter with known
and unknown others. Indeed, hypothetically, the nature of the unknown
other is mediated by the shared use of the school so that the regular
engagement with primary school worlds means that even unknown oth-
ers become recognised strangers, with the potential for social interaction
as well as the formation of closer relationships. From that perspective,
primary schools can be understood as a form of ‘social commons’; that is,
a space within which a series of shared cultural and other resources are
available to those with access to it. The role of schools as places of
friendship-­making and the evidence that school-related friendships can
have particular longevity in people’s lives is recognised, in Savage et al.’s
(2005, p. 143) study of localised belonging and globalisation in the
Northern English city of Manchester. They report that most of their par-
ticipants described their closest friends as those that had been made in
childhood or at their children’s schools. We explore some of this same
ground in this book, considering the range of friendship formations that
can emerge through and within primary schools, both for children and
adults.
Assembling a research investigation through the simultaneous layering
of personal life and friendship relations, the routine experience of proxi-
mate (and often radical) social and cultural difference, and ‘lived in’ local-
ities and collectively used primary schools, allowed us first, to access the
multi-scale, intersecting lifeworlds of individuals, school institutions and
of place; second, to map the nature and extent of social division and
cohesion in highly diverse areas; and third, to consider the ways in which
4 C. Vincent et al.

intimate, spontaneous and micro-social interactions and networks are

structured in relationship to power (Bottero 2009, p. 407). It is all too
easy, as Sivamohan Valluvan (2016) has noted in relation to ‘the ortho-
doxies of integration’, for discussions of friendship in particular, but also
any informal, positive encounter in the context of multicultural urban
populations, to be dominated by ‘normative values’ which simply iden-
tify these optimistically, as progressive, without any acknowledgement of
the possibility of more problematic assumptions and contradictions—the
uneven power symmetries of who has to integrate, the uncertainties and
instabilities of friendships and so on (Smart et al. 2012). In focusing on
these overlapping issues as sites of attention and analysis we recognise
some of the inherent dangers of making such assumptions and fore-
ground Valluvan’s assertion (2016, p. 207) ‘that ethnic differences do not
require accommodation, remaking or respectful recognition vis-à-vis the
White majority, but should simply cease to require scrutiny and evalua-
tion in the first place.’
For these reasons, we would want to emphasise the unpredictable
and socially stratified dynamics shaping friendship relations and
exchanges across difference in the racialised contexts in which urban
multiculture can still thrive, but may be also be diminished, contained
and avoided. It is with this in mind that this chapter first considers the
concept of friendship and develops the rationale for the development
of a sociology of friendship, and begins to outline the conceptual
resources on which we draw before then describing the broad contours
of the research project and design, and outlining the structure of the
book.

An Emergent Sociology of Friendship

Friendship as a Marginalised Sociological Concept?

Throughout this book we consider how people’s dispositions to think and

act in their everyday social relations are affected by their living in a highly
diverse environment. We explore the extent to which their relationships
 Why Study Friendships and Diversity? Orientations… 5

are shaped by homophily—the idea that people’s networks and relation-

ships are based on similarity, as described by the proverb ‘birds of a feather
fit together’ (McPherson et al. 2001). Homophily is often assumed to be
the guiding principle in social relationships, both in terms of the net-
works to which people belong and their dyadic relationships. McPherson
et al. (2001) argue, in a review of research literature, that studies show an
‘extraordinary level of racial/ethnic homophily’ (p. 421) including those
of children’s friendships. They also find that possession of educational
qualifications is a key dimension for homophilous relationships, with
occupation being slightly less so (education and occupation being used as
indicators of social class). Their review emphasises the structured nature
of space, resulting in residential homogeneity as a key explanation for the
high degrees of homophily. However, most of the literature they consider
is from the USA, where residential segregation and all that that implies in
terms of opportunities for social relationships is more marked than in the
UK. Our research, in particular, takes place in highly socially and ethni-
cally diverse residential localities, which, through new migration flows
and gentrification processes, have increasingly characterised areas within
global cities such as London, New York, Singapore and Sydney.
Until relatively recently research on friendships has tended to be domi-
nated by work in the areas of social and developmental psychology and
while there have been a number of recent sociological explorations of
diverse environments, social networks and friendship homophily/het-
erophily across race, ethnicity or religion, this work has often been quan-
titative (see for example, Smith et al. 2016; Saeidibonab 2017; Leszczensky
and Pink 2017). It has tended to evidence patterns of ethnic, religious,
and national symmetry in people’s social networks, but still leaves gaps in
understanding the nature of friendship formation and everyday interac-
tions in contexts of difference—as Leszczensky and Pink (2017) conclude
in their study of adolescents and religious homophily, their data leaves
unexplained the question of ‘why religion affects friendship formation in
the first place’. Given these limits and our concern with the nature and
role of friendship relations and their social patterning, we turn now to
consider qualitative work on friendships and discuss the status of such
work within sociology.
6 C. Vincent et al.

In their seminal study of friendship, Liz Spencer and Ray Pahl (2006:
197) describe friends as those people in personal lives who take on the role
of ‘comforter, confidants and soulmates’. Their book sets out their argu-
ment that in the socially changing and unpredictable world in which tradi-
tional and more established points of social care—family, work,
community—are reduced and eroded from the centre of people’s lifeworlds,
it is ‘friendship [that] can act as a vital safety net providing much needed
support and intimacy’ (2006, p. 210). Given their centrality to social and
personal life there is something of a puzzle as to why, as has been widely
observed, adult friendships have tended to be one of the most neglected of
social relations (Eve 2002; Pahl 2000, 2002). Analysing sociology’s relative
lack of interest in friendship, Graham Allan (1996, p. 3) describes friend-
ships as something of a ‘Cinderella topic’ in sociology, and in doing so
captures its potential significance as a social relationship but also the extent
to which this potential has not been extensively scrutinised.
Bunnell et al. (2012, p. 490) also highlight the paradox between the
centrality of friendship relations to personal lives and the ongoing mar-
ginal status friendship has had in the social sciences when they note that
‘friendship is the means through which people across the world maintain
intimate social relations [and are] an important part of what makes us
[…] human […] although friends and friendship are more likely to be
consigned to the preface or acknowledgements of books and articles than
to feature in conceptualisation or substantive content.’ The strangeness of
this marginalisation of friendship is further underlined by the extent to
which it is a focus and preoccupation in social life outside of the social
sciences—as Louise Ryan (2015, p. 1667) observes, ‘friendship is a topic
of seemingly endless fascination in popular culture and on social media’.
How, then, to explain this sociological neglect of friendship?
For Michael Eve (2002, p. 386) the answer to this question lies in the
ways in which friendship is perceived and presented as a source of ‘emo-
tional support and small services but little else’. The spontaneous infor-
mality of one-to-one connections of the type that Aarthi, in the opening
quotation, describes as the driver of her friendships is, in Eve’s argument,
at the heart of why it is simply too inconsequential for serious sociologi-
cal engagement. In Eve’s conception friendship needs structural signifi-
cance to matter. He calls for an emphasis within sociology on rethinking
 Why Study Friendships and Diversity? Orientations… 7

friendship but through conceiving it as a structural relation, operating

beyond a dyadic arrangement, as a broader dynamic involving multiple
relations and connections through which practices operate and resources
are secured. In short, Eve’s argument is that the non-institutionalised
nature and intimacy of friendship invites its marginal status. This argu-
ment has been influential and explains the ways in which the thinking
around friendships has been subsumed into work on social networks and
social capital. The interest in social networks in social science has been
significant in the last few decades and has dominated interest in interper-
sonal relationships, social ties and social life (see, for example, Wellman
and Berkowitz 1988; Chambers 2006; Ryan 2015). The dominance of an
interest in social networks over and above friendship relations has con-
solidated—and converged—with the (different) concept of social capital
as the lens through which to situate the individual in relation to the wider
structural environment.
However, as Pahl (2002) argues in his response to Eve, the latter’s argu-
ment depends on a rather selective overemphasis on the dyadic dynamics
of friendship. Pahl highlights the ways in which sociologists such as
Adams and Allan (1998) have incorporated a more environmental and
less dyadic friendship focus into their work. And, as the later research of
Spencer and Pahl (2006) sought to illustrate, friendship relations were at
the core of social support and care in late modernity as older, more tradi-
tional social institutions such as families, communities, religion became
less central in personal lives:

We were struck by the language of suffusion used by our respondents, illus-

trating the way in which some used kin and friendship terms interchange-
ably, with very distinctive meanings. When a family member was perceived
as being ‘like a friend’ and, conversely a friend was considered as kin, the
comparison was positive and strengthened the quality of the tie, except
where a friendship was seen as a ‘duty’ and was then pejoratively described
as ‘family-like’. (Pahl 2002: 413)

And, as Pahl goes on to note, ‘in my own research with Liz Spencer, we
attempted to describe the emergence of personal communities, formed
over time in distinctive domains and fluctuating as social convoys over
8 C. Vincent et al.

the life course’ (2002, p. 421). For Pahl (2002) and for Spencer and Pahl
(2006) the emphasis is not on networks of friendships so much as the
‘personal communities’ that individuals assemble through their social
environments and lives. But perhaps most relevant to us, Pahl (2002) also
suggested in his critique of Eve that Eve underestimated the ‘importance
of friendships in social stratifications and power’. In other words, it is
both the agency of affective ties and also the multiple ways in which
structural power relations become sutured into friendship relations that
warrants sociological attention.
Aarthi’s comments on her friendships hint at how this suturing takes
place, but the process was particularly explicit in the friendship vignette
given to us by Jeanne, a parent from the pilot study we conducted prior
to our main study (Neal and Vincent 2013, see below for more details).
Jeanne is a mixed heritage, affluent, middle-class mother who had formed
what she described as a close friendship with Aiysha, a low-income Somali
refugee parent whom she met as their sons became friends. Connected
through their children, Jeanne and Ayisha have developed their own
friendship and each has offered the other significant mutual support dur-
ing difficult periods—the death of a parent, and redundancy. Jeanne
recounts the closeness they have but explains how their relationship is
always bounded by the lack of a shared private space where they can be
comfortable. As Jeanne explained, when Ayisha came to her house ‘she
didn’t ever seem at ease’. Jeanne felt this might be because of the house
presenting a very obvious middle-class material environment, a percep-
tion that was reinforced by Ayisha not ever inviting Jeanne to her house.
In his ethnography of a London street, Daniel Miller (2008, p. 287)
reminds us that home spaces and the objects within these can very power-
fully ‘speak to the nature of [social] relations’ and a similar awareness
seeped into Jeanne’s reflections as to the ways in which her affluent home
space could make Ayisha feel ‘out of place’. In response, Jeanne described
seeking alternative places for them both to go. However, going to cafes
almost inevitably involved costs, and Jeanne was very aware of the inequal-
ities in the women’s incomes. The limited material spaces where Jeanne
and Ayisha can actually be friends serves to constrain their friendship.
This means that the depth of the affective bonds between them—‘She
[Ayisha] feels like that kind of friend, that we could rely on each other
 Why Study Friendships and Diversity? Orientations… 9

in crisis’—could not counter the wider inequalities that their friendship

exposed. So as Jeanne explained, their friendship is conducted only within
the neutrality of public space—‘I have never been in her flat [and] we’ll
[have to] stand for an hour on the street corner’.
There are some echoes of Jeanne and Aiysha in Spencer and Pahl’s
(2006, p. 171) story of Terry and Doreen. Spencer and Pahl argue that
diverse ‘personal communities’ (i.e. friendship networks) do exist across
class and ethnic differences (2006, p. 89). They give the example of Terry
and Doreen, a working-class couple, who met and made friends with a
middle-class couple on holiday, and maintained this friendship over 12
years. Terry and Doreen explain how they manage the very different home
spaces in their friendship—the richer, middle-class couple do not stay at
Terry and Doreen’s house, but Terry and Doreen do stay with them.
Spencer and Pahl use this data to suggest that class differences may pro-
vide different material resources and encourage different patterns of socia-
bility and reliance, and that ‘different statuses and lifestyles may act as a
filter in the formation of friendships’ (p. 171). Similarly, in a Hungarian
study of friends with different levels of income, Lena Pellandini-Simanyi
(2017) argues that the wealthier person in the friendship may disguise or
play down their wealth, or alternatively resort to meritocratic explana-
tions that legitimise success and inequality. As Pellandini-Simanyi points
out, these strategies may ultimately result in a weakening of the friendship
bonds and suggests that growing income inequalities increase the diffi-
culty of finding activities and spaces in which affluent and non-affluent
friends can meet and interact. Thus, Pellandini-­Samanyi’s research, and
the narratives of Jeanne and Aiysha, and Terry and Doreen, all suggest
that while friendships across social difference do take place, they are mun-
danely—but profoundly—impacted by structural factors.

An Established Sociology of Friendship?

It is in the context of gathering narratives such as those of Aarthi and

Jeanne, that we follow Eve and Pahl in their push for a sociology of
friendship. However, we also suggest that this sociology of friendship is,
in fact, more advanced than either Eve or Pahl indicate. As further
10 C. Vincent et al.

explored in Chap. 4, there is a relatively well-established focus on chil-

dren and young people’s friendships and what social and ethnic difference
means in terms of formations of interpersonal relationships (e.g. Hewitt
1986; Jones 1988; Back 1996; Bruegel 2006; Reay 2007; Hollingworth
and Mansaray 2012; Harris 2013). For example, Roger Hewitt focussed
specifically on adolescent interethnic friendships on a social housing
estate in South London, examining how racism and cultural difference
were continually negotiated and manipulated by the teenage participants
in his study through invariably complicated practices, with attention also
being paid to their parents’ opinions on particular ‘mixed’ friendships.
Irene Bruegel (2006), studying friendships in primary schools, concludes
that these can and do cross ethnic divides, when children are in multi-­
ethnic schools. Bruegel argues that it is the sharing of daily routines that
leads to such relationships, rather than more artificial cohesion initiatives
such as twinning schools. Her report concludes by noting that some par-
ents in the study became more positive about those of different back-
grounds as a result of their children’s friendships, and agrees with Putnam
(2000) that ‘more communal schools’ can foster ‘civic re-engagement’.
Bruegel’s later work (Weller and Bruegel 2009) also emphasises the role
children play in the generation of neighbourhood social capital, directly
through their own local relationships, and indirectly, as parents come to
form new networks around their children (also Byrne 2006).
Adult friendship experiences and the changing roles and forms of
friendships in personal lives and contemporary social relations have been
the focus of the work of a range of scholars such as Roseneil and
Budgeon (2004), Savage et al. (2005), Savage et al. (2013), Smart et al.
(2012), Bunnell et al. (2012), Kathiravelu (2013), and Ryan (2015). This
body of work variously engages with gender, ethnicity, sexuality and social
class and their effects on social relationships. For example, in their study of
localities, globalisations and belonging, Savage et al. (2005) demonstrate
the relevance of spatial and social stratifications to adult friendship prac-
tices. They found that most of their participants identified as having a ‘best
friend’, but that this relationship was largely abstract and geographically
distant. The best friend was not someone with whom p ­ articipants had
routine and regular contact but was usually someone met in child/young
adulthood rather than someone who lived near to them in the present
 Why Study Friendships and Diversity? Orientations… 11

day. In their ‘most working class’ area (defined using a range of criteria),
Savage et al. found that the friendship ties were mostly local, but this was
also the area in which the lowest number of participants reported having
a best friend. For Savage et al., then, the dispersed geography of ‘best
friends’ and infrequent face-to-face contact reinforced the concept of
elective belonging (i.e. an articulated commitment to particular places,
rather than an attachment that arose through embedded historical social
ties to a locality) because participants demonstrated that they were deeply
connected to ‘people living elsewhere […] belonging to social groups
scattered in space’ (2005, p. 151). The variety and complexities of what
defines friendship relations for children and for adults— longevity, emo-
tional closeness, trust, care giving, shared beliefs, life stage, the situa-
tional moment, and so on—have also emerged as key features in our
work and these variations all tend to involve a spatial dimension (see
Chaps. 4 and 6).
More recently, in their Bourdieusian redefining of class categories in
the UK, Savage et al. (2013) include friendship networks as part of the
social capital that shapes and reinforces people’s class location. The role of
social capital in friendship networks also informs Ryan’s (2015) study of
the friendship-making practices of professional Irish migrants in the
UK. Ryan concludes that rather than co-ethnic ties formed though shared
Irish identities (ethnic homophily), her participants’ networks were more
accurately defined by multiple, cross-ethnic and complementary friend-
ship formations and practices, with friendship relations being established
and maintained through a variety of professional and other immediate
social environments: ‘far from simple linear progression from mainly co-­
ethnic to mainly ethnically diverse friendships over time, I have shown
how networks may bring together a mix of friends reflecting the com-
plexity and multidimensionality of identities—including professional
identity’ (2015, p. 1680).
Extending this argument about the complexities of identities in friend-
ship formation, Pellandini-Simanyi emphasises how some of her partici-
pants in income-difference friendships used their sense of social justice to
mobilise strategies in their attempt to manage and flatten the impact of
the income differences. These had limited success because as Pellandini-­
Simanyi observes they are trying ‘to resolve structural contradictions at a
12 C. Vincent et al.

micro, everyday level, and therefore they are only able to reach limited
solutions. Even if they are aware and acknowledge structural and unjust
causes of inequalities, it is impossible to resolve these injustices within the
context of a friendship, which by definition is based on principles of reci-
procity and equality’ (2017, p. 604).
However, the extent to which, like Ryan’s more granular social net-
works, Pellandini-Simanyi’s participants were aware of and committed to
attempts to counter the inequalities in their friendships remains signifi-
cant. That people have a lay awareness of difference and sense of injustice
and that this may filter into their affective practices and everyday interac-
tions is an argument that resonates with other work in the field of the
lived experiences of multiculture (Amin 2012; Wise 2005, 2009; Wise
and Noble 2016; Valluvan 2016; Neal et al. 2016, 2018). A core puzzle
that we explore in the book is this tension between the drift in friendship
relations towards homophily on the one hand, and on the other, friend-
ship practices that are shaped and enacted by individuals whose values
and attitudes to ethnic diversity and inclusion are more open—even if, as
Pellandini-Simanyi suggests, it is not fully possible to counter wider social
inequalities within the limits of the friendship relation.
However, while these developments in the study of friendship evidence
the establishment of a sociology of friendship, what is more absent in the
study of friendship is a sustained focus on the effects of social and ethnic
difference on friendship relations, and this is seems a particular lacuna
given the context of rapidly changing contemporary urban environments.
Following Eve (2002), we emphasise the importance of the context in
which friendships are formed and maintained, and from Pahl (2002), we
take the need to approach the friendship relation as personal but also
socially situated. We suggest that it is the strangely simultaneous, non-­
institutionalised and institutionalised affective and social content of
friendship that makes it a relevant (and necessary) focus of sociological
attention. And, in the context of exploring the experiential dimensions of
contemporary urban diversity, the friendship relation, with its ability to
condense (and converge) affective and personal lives and social divisions
and structural forces means it has escaped its marginal status and increas-
ingly moved towards the mainstream of sociological agendas.
 Why Study Friendships and Diversity? Orientations… 13

 onviviality, Heterogeneity, Encounter and Proximity:

C
The Timeliness of Developing a Sociology of Friendship

Thus, we understand friendship as having both an interior- and exterior-­

world duality. As Kathirvelu notes, ‘friendship can then work dually – as
a lens through which we can understand how diverse cities work, but also
as an example of a site for plural and pleasurable interactions’ (2013,
p. 8). This makes it a pertinent and timely lens through which to reflect
on, connect with and inform current debates about everyday multicul-
ture and social mixing practices (and avoidances) in urban environments.
While Chaps. 2 and 6 explore these debates in fuller detail, we note here
the growing interest in research, policy, and political circles in friend-
ships, everyday encounters and social interactions of communities in the
increasing number of localities which are characterised by significant
social and ethnic difference (Cantle 2001; Amin 2002, 2012; Gilroy
2004; Commission for Integration and Cohesion 2007; Putnam 2007;
Wise and Velayuthum 2009; Noble 2009; Hemming 2011; Neal et al.
2018). While very differently inflected, this body of work shares an
emphasis on informal social interactions. In the more policy-oriented
social cohesion literature, friendships are particularly apparent, and of
interest, because of the assumed informal ‘social glue’ qualities of social
interaction. This means that friendship relations—and particularly affec-
tive social connections—do tend to feature in social capital, capacity and
cohesion debates (Pahl 2002; Cantle 2001; Commission for Integration
and Cohesion 2007; Casey 2016).
The former UK governments’ various policy concerns for building
community cohesion in England (New Labour government 1997–2010),
developing ‘stronger families and stronger communities’ in the Coalition
(2010–15) government’s Big Society initiative, and the more recent inte-
gration and securitisation agenda (Conservative government 2015
onwards) each illustrate forms of ongoing policy and political engage-
ment with micro interactions, social responsibility and local capacity. For
example, both the Cantle report (2001) with its concerns about ethnic
segregation and the report of the Commission on Cohesion and
Integration (2007) with its focus on locality and place, stress the
14 C. Vincent et al.

importance of contact, civic exchange, neighbourliness, capacity and

community for achieving social cohesion and stability (for a local exam-
ple see Hackney Council’s 2013 Corporate Equality and Cohesion
Policy).
In particular it is in relation to race and ethnicity, where friendship has
been presented as having the potential (i) to be a socially transformative
relationship, (ii) offer evidence of quotidian multiculture practices and
competencies (Neal and Vincent 2013; Neal et al. 2018; Wise 2009), and
(iii) to work as an evidential marker of social cohesion. Over the last ten
years, three pieces of research—from the Commission for Racial Equality
(Finney and Simpson 2009, p. 96), the Citizenship Survey (Kitchen et al.
2006, p. 20) and Cantle’s 2017 report focusing on understanding school
segregation (Cantle 2017)—argued that friendship patterns between dif-
ferent ethnic groups were a key barometer of levels of ethnic integration/
segregation. In these reports, especially the first two, there was a focus on
different religious as well as ethnic groups. Here, it is the intimate, micro-­
social processes of friendship that are being interpreted as an evidential
measure of social cohesion and integration.
While an emphasis on the presence, or absence, of cross-ethnic friend-
ship patterns is part of a response to wider anxieties that regularly circu-
late about ethnic and religious segregation, social class-based segregation
is a more unspoken and, to some extent, an assumed division. This con-
trasts with the ‘noise’ around the claims of increasing ethnic segregation
(Neal et al. 2013). In other words, cross-ethnic friendships are explicitly
identified as evidence of integration and cohesion while cross-class friend-
ships lack a particular policy focus. Class separations can be complicated,
especially in socially diverse urban localities where gentrification pro-
cesses deliver socially mixed geographies (see Chaps. 2 and 6). As research
into education in heterogeneous urban areas has shown, interac-
tions across social class can be directly and indirectly contained and man-
aged by a series of parental strategies and practices (Butler and Hamnett
2011; Byrne 2006; Reay et al. 2011).
The tensions between the possibilities and constraints afforded by the
convergence of gentrification and migration that shapes the profiles of
particular urban localities, is further discussed in the following chapter
and we would only want to note here that there has been a focus in much
Another random document with
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hypochondriasis, intellectual feebleness, and insanity. Two forms of
hereditary alcoholism have been recognized: First, that in which the
disease or defect of the parent is transmitted to the offspring; and
second, that in which the disease or defect is not directly transmitted
to the offspring, but a morbid tendency which manifests itself in
diseases or defects of a different kind.49
49 1. Heredite de similitude, Alcoolisme hereditaire homotype; 2. Heredite de
transformation, Alcoolisme hereditaire heterotype.

1. The appetite for strong drink is frequently transmitted from parents

to the children, just as other traits of the mind or body. Sometimes it
develops early, sometimes late in life; as a rule, however, this
hereditary propensity shows itself at an early age, and is apt to be
intensified at the time of puberty and the menopause. Objections
have been urged against the theory of hereditary alcoholism. Among
these the strongest is perhaps that the taste for drink in the offspring
of alcoholic subjects is the result rather of opportunity and example
than of heredity. The frequency with which alcoholic tendencies
develop themselves in children reared and educated away from their
parents, and the number of cases in which these tendencies show
themselves only at an advanced period of life, long after the
influence of example in childhood has ceased, sufficiently disprove
this assumption. The hereditary influence does not, however,
invariably manifest itself in the desire for drink. On the contrary, not
rarely it consists in feebleness of nervous constitution, characterized
by irritability, want of mental repose, or a restless or vicious
disposition which demands constant excitement. Hence such
individuals, although intellectually well developed, are often scarcely
more than moral imbeciles, in whom the passion for drink may be
replaced by the opium habit, addiction to gaming and to other vices,
and whose career is shaped largely by an inordinate and insatiable
craving for excitement of all kinds. Hereditary alcoholism follows the
laws of heredity in general. The tendency may be transmitted directly
from one generation to another, or may skip one or more
generations, taking in the intermediate periods some different form.
2. The second variety is that in which the symptoms of chronic
alcoholism are manifested in the offspring in the absence of the
direct action of alcohol; that is to say, not the taste for alcohol, but
the results of the gratification of that taste are transmitted, just as
epileptic or hysterical patients may transmit to their offspring epilepsy
or hysteria; thus it is not rare to encounter in the descendants of
alcoholic parents perverted sensation, both general and special,
hyperæsthesia, anæsthesia, flying neuralgias which do not always
follow the course of particular nerves, but frequently affect in a
general way the head or the members or manifest themselves as
visceral neuralgias. These persons are much troubled with headache
from slight causes and with migraine. Nor are disturbances of vision
rare, nor vertigo. Insomnia is also frequent in such individuals, and
augments the other symptoms. Digestive troubles also frequently
occur, notwithstanding a regular and perfectly temperate life. Such
persons are often subject to hallucinations of sight and hearing, and
are liable to have delirium in trifling illnesses.

The second form of hereditary alcoholism manifests itself in a wholly

different manner. The descendants, without a special appetite for
strong drink, and in the absence of the special morbid manifestations
above described, are singularly liable to mental and nervous
diseases of various kinds. Among these convulsions and epilepsy
are especially frequent; hysteria and various forms of insanity also
occur. In this group of cases we find every degree of arrest of
intellectual development, from mere feeble-mindedness to complete
idiocy. As manifestations of the influence of alcoholism upon the
offspring may be cited certain moral peculiarities otherwise
inexplicable, such as are seen in children who at a very tender age
show themselves vindictive, passionate, and cruel, to whom the
sufferings of others afford pleasure, who torment their companions
and torture their pets, and show precocious vicious tendencies of all
kinds. Later in life these persons become lazy, intolerant of
discipline, vagabonds, unstable of character, without the power of
application and without moral sense. Given to drink, defiant of law,
they constitute the great body of tramps, paupers, and criminals. The
children of alcoholic subjects are often feeble and puny, pale, badly
nourished, and curiously subject to morbid influences.

IV. Dipsomania.

Dipsomania, which has also been described under the term

oinomania, is rather a form of insanity than of alcoholic disease. The
characteristic symptoms are, however, in the greater number of
instances, due to indulgence in alcohol. The subjects of this affection
usually belong to families in which insanity, and especially this
particular form of insanity, is hereditary.

There are two forms of dipsomania—the essential and the

symptomatic. Of these, the latter is the more frequent. Its
consideration requires in this connection very few words. It manifests
itself by an irresistible desire on the part of many insane people for
alcohol. It occurs both in the prodromic and in the fully-established
periods of insanity. It is especially common in various forms of mania
and in the prodromic periods of general paralysis. The dominating
influence in essential dipsomania is heredity. Occasional causes
may bring on particular attacks, but their influence is secondary.
Dipsomania cannot be looked upon as a distinct recurrent affection
in an otherwise healthy person. At some period in their lives, and
often long before the occurrence of characteristic paroxysms,
dipsomaniacs show peculiarities indicating defects of mental
organization. Certain symptoms of dipsomania are often mistaken for
its cause. Thus, dyspepsia is more frequently an effect than a cause
of the alcoholic excesses. The despondency, irritability, restlessness,
hysterical manifestations, and insomnia which precede the attack are
not the cause of it: they are its earliest symptoms.

The affection usually begins insidiously and is progressive. As a rule,

although not always, it begins in early adult life. The manifestations
of this disease are essentially intermittent and paroxysmal, but the
impulse to drink must be regarded as a symptom which may be
replaced by other irresistible desires of an impulsive kind, such as
lead to the commission and repetition of various crimes, as the
gratification of other depraved appetites, robbery, or even homicide.
The paroxysms are at first of short duration, and are followed by
return to the previous regular and decent manner of life. They
become, however, by degrees, more violent and more prolonged. At
first lasting for a few days or a week, by and by they extend to
periods of a month or six weeks, the attack wearing itself out, and
recurring with a periodicity sometimes variable and sometimes
constant. In the intervals of these attacks for a considerable time the
patients very often lead sober, chaste, and useful lives. At length,
however, evidences of permanent mental trouble are manifested,
and the case settles into confirmed insanity. The attack is usually
preceded by evidences of mental derangement; the patient becomes
restless and irritable; sleep is irregular and unrefreshing; he
complains of general malaise, and is anxious, troubled by vague
apprehensions. He presently abandons his usual occupations and
gives himself up to disordered impulses, among which alcoholic
excesses are the most frequent and the most easily gratified.
Sometimes the patient passes his time at taverns drinking with all
comers; at others he shuts himself up in a chamber and gratifies his
desire for drink to the most extreme degree alone. Dipsomaniacs not
rarely leave their homes and associates without warning or
explanation, and pass the period of the paroxysm among associates
of the most disreputable character. The desire for drink is gratified at
all costs, and not infrequently they return to their friends without
money and without sufficient clothing, most of it having been sold or
pawned in order to purchase drink. The paroxysm is succeeded by a
period of more or less marked mental depression, during which the
patient not rarely voluntarily seeks admission to some asylum.

The true nature of dipsomania is frequently overlooked. As a

symptom of hereditary insanity it is in striking contrast with the
habitual propensity to drink which occurs in the ordinary alcoholic
subject. The latter seeks occasions to drink. He renews his excesses
not intermittently, but habitually. If in consequence of disgrace or
misfortune or under strong moral suasion he is for a time
abstemious, it is only to renew and to continue his indulgence upon
the first favorable occasion. On the contrary, the true dipsomaniac
recognizes his malady and struggles against it. Even more: for a
time he shows much skill in concealing it. He avoids occasions to
drink, and, reproaching himself for his mad and unreasonable desire,
seeks by every means to overcome his impulse to it. The ordinary
drunkard may become insane because he drinks; the dipsomaniac
drinks because he is insane.50
50 Magnan, Le Progrès médical, 1884.

Dipsomaniacs are apt to manifest precocious or retarded intellectual

development. They are from infancy or childhood especially prone to
convulsive or other paroxysmal nervous phenomena. They are often
choreic, often hysterical. This association with instability of the
nervous system is related to the fact that dipsomania is more
common in women than in men.

DIAGNOSIS.—1. Acute Alcoholism.—The diagnosis of the ordinary

form of acute alcoholism, with the exception of alcoholic coma,
requires no consideration. The diagnosis of alcoholic coma from
profound coma due to other conditions is, in the absence of the
previous history of the case, always attended with difficulty, and is in
certain cases quite impossible. It is therefore of great practical
importance to obtain the history where it is possible to do so. The
odor of alcohol upon the breath is of less positive diagnostic value
than would at first thought appear. In the first place, sympathetic
bystanders may have poured alcoholic drinks down the throat of one
found unconscious, or, in the second place, individuals who have
taken a certain amount of drink may be, and not unfrequently are,
seized with apoplexy in consequence of the excitement thereby
induced. The more common conditions with which alcoholic coma is
confounded are apoplexy from cerebral hemorrhage and narcotic
poisoning, especially opium-poisoning. To these may also be added
uræmic coma and, under exceptional circumstances, sunstroke. In
all these cases the circumstances under which the individual has
been found are of diagnostic importance.

In alcoholic coma the pupils are more commonly dilated than

contracted, the heart's action feeble, the respiration shallow, the
muscular relaxation symmetrical, and the temperature low. There is
a strong odor of alcohol upon the breath.

In apoplexy from cerebral hemorrhage the condition of the pupils will

depend upon the location of the clot. They may be moderately
dilated, firmly contracted, or unequal. The enfeeblement of the
heart's action is, as a rule, less marked than in profound alcoholic
coma. The pulse may be small or full and slow or irregular. It is
usually slow and full. The respiration is often, although not invariably,
slow and stertorous. Not uncommonly, the eyes and also the head
deviate from the paralyzed side. If the coma be not absolute, the
muscular relaxation is unilateral. The temperature is at first slightly
below the normal, but less, as a rule, than in alcoholic coma; after
several hours it rises to or above the normal.

In complete opium narcosis the insensibility is profound; the heart's

action is slow or rapid, but feeble; the respirations slow and shallow
or quiet or stertorous; the face at first flushed, afterward pallid and
cyanosed; the pupils minutely contracted or dilated as death
approaches; and the muscular relaxation complete, with abolition of
reflex movements. In cases of doubt it is important to use the
stomach-pump.

Uræmic coma is apt to be preceded by or alternate with convulsions.

The pupils are more commonly slightly contracted than dilated, but
are without diagnostic significance. The temperature is not elevated;
it may even be low. The face may be pallid, pasty, and puffy, and
there may be general anasarca if the nephritis be parenchymatous.
On the other hand, in interstitial nephritis there is hypertrophy of the
heart, without evidence of valvular disease, and some degree of
puffiness of the lower extremities. In doubtful cases the urine should
be drawn by a catheter and subjected to chemical and microscopical
examination.51 Diabetic coma occurs suddenly without convulsions.
This condition may be suspected when the emaciation is extreme or
upon the recognition of sugar in the urine.
51 The following is the method recommended by Green (Medical Chemistry,
Philadelphia, 1880) for the detection of alcohol in the urine: If its reaction be acid, the
urine is exactly neutralized by potassium acid carbonate. It is then distilled on a water-
bath in a flask or retort connected with a condensing apparatus. When about one-
sixth of the liquid has passed over the distillate will, if alcohol be present, present the
following characteristics: first, the peculiar alcoholic odor; second, a specific gravity
lower than water; third, upon being mixed with dilute sulphuric acid and treated with a
few drops of potassium bichromate solution the liquid becomes green, owing to the
separation of chromic oxide; the odor of aldehyde may at the same time be observed.
This reaction is not characteristic, but may serve to confirm other tests. Fourth, if
dilute alcohol be shaken with an excess of solid and dry potassium carbonate in a
test-tube, the greater part of the water will be appropriated by the potassium
carbonate, and two layers of liquid will be formed. The alcohol constitutes the upper
layer, and if sufficiently concentrated will burn upon the application of a flame. Finally,
a small trace of alcohol may be separated from the urine without difficulty after the
ingestion of alcoholic liquids by means of a good fractionating apparatus. Less than 1
per cent. of alcohol cannot be detected.

Sunstroke is characterized by dyspnœa, gasping respiration,

jactitation, and intense heat of the skin. The pulse varies. It may be
full and labored or feeble and frequent. The face is usually flushed.
The pupils, at first contracted, are afterward dilated. The coma is apt
to be interrupted by transient local or general convulsions.

It is impossible to lay down any rules by which the maniacal form of

acute alcoholism may be at once diagnosticated from acute mania
from other causes. For the characteristics of the convulsive form of
acute alcoholism and those forms which occur in persons of
unsound mind the reader is referred to the descriptions of those
conditions. The diagnosis of acute poisoning by alcohol in lethal
doses can only be established during life by investigation of the
history of the case.

II. Chronic Alcoholism.—The lesions of chronic alcoholism, as has

already been pointed out, are not in themselves peculiar to that
condition. Many of them occur with more or less frequency in morbid
states not induced by alcohol. It is their association and progressive
character which gives to chronic alcoholism its individuality. The
occasional prominence of certain symptoms or groups of symptoms
may thus in particular cases lead to some confusion of diagnosis,
especially where the history is unknown or the habits of the
individual are concealed. In the greater number of cases, however,
the association of symptoms is such as to render the diagnosis, even
in the absence of a direct history, a comparatively easy one.

Chronic alcoholism is a condition rather than a disease—a condition

characterized by varying lesions of the viscera and nervous system,
by profound disturbances of nutrition, and by grave mental and moral
derangements. This fact being recognized, the cardinal error of
diagnosis to be guarded against is that of overlooking the condition
upon which the disease itself with which we have to do depends or is
associated. Congestion, inflammation, sclerosis, and steatosis affect
the various organs of the body and produce their characteristic
symptoms. Profound and lasting disturbances of nutrition demand
our attention. Psychical derangements of all grades, from mere
moodiness to confirmed and hopeless insanity, take place. These
affections must be diagnosticated for themselves here as elsewhere
in clinical medicine. The recognition of the underlying condition can,
however, alone supply the key to their true pathology.

Delirium tremens is occasionally diagnosticated with difficulty from

some forms of insanity not caused by drink. Here transitory and fixed
delusions, not mere terrors and hallucinations, are of importance, not
less than the absence of the varied and complex associations of
symptoms which are characteristic of alcoholism. The delirium of the
acute infectious diseases may be mistaken for delirium tremens.
Pneumonia, typhoid fever, and the exanthemata occasionally begin
with delirium resembling in some respects delirium tremens. Here
the history of the case, the pyrexia, and the general condition of the
patient are sufficient to establish the diagnosis if the danger of error
be borne in mind.
III. Hereditary Alcoholism.—The diagnosis of this condition can only
be established by careful investigation of the family history and
systematic study of the stages of progression by which the morbid
condition presented by the patient has been reached.

IV. Dipsomania.—The diagnostic points are the hereditary

transmission of this or other forms of insanity—the mental instability
of the patient in early life and in the intervals of the paroxysms, the
intermittent or cyclical recurrence of the attack, the morbid impulses
of a different kind associated with the impulse to drink, and the
struggle of the patient against his recurring impulses to
uncontrollable excesses.

PROGNOSIS.—The prognosis in acute alcoholism of the ordinary form

is favorable, so far as the immediate attack is in question. The
prognosis in rapidly-developing, overwhelming coma from enormous
doses of alcohol is in the highest degree unfavorable. Acute coma
from moderate doses usually passes off in the course of some
hours. It occasionally, however, terminates in fatal pneumonia.

The prognosis in delirium tremens of the ordinary form is favorable. It

becomes, however, more and more grave with each recurring attack.
Delirium tremens in patients suffering from advanced disease of the
heart, lungs, liver, or kidneys, or complicated by acute diseases of
these organs, is apt to prove fatal.

The prognosis of chronic alcoholism is gloomy. If the lesions be not

advanced, permanent discontinuance of alcoholic habits may be
followed by restoration of health, but, unfortunately, the
discontinuance is too often merely temporary, the habit being too
strong to be permanently broken off.

The prognosis in hereditary alcoholism is unfavorable, both as

regards the alcoholic habit and as regards the development of
serious diseases of the nervous system under adverse
circumstances, even in the absence of the direct action of alcohol.
The prognosis in dipsomania is unfavorable. The paroxysm may
recur many times without apparent serious result; the patient in the
course of some days or weeks recovers, abandons his evil courses,
and resumes his usual occupations. After a time, however, the
insanity of which the dipsomania is the recurring manifestation
declares itself as a more or less permanent state. The outbreaks
become more frequent and more prolonged, the mental condition in
the intervals progressively more morbid, until the patient lapses by
degrees into confirmed insanity.

The prognosis in all forms of alcoholism, both acute and chronic, is

rendered in a high degree uncertain by the psychical disorders which
characterize so many of its phases. In consequence of some of
these conditions the patient loses at once his appreciation of bodily
dangers and his power to avoid them; by reason of others, to escape
imaginary evils he plunges into real ones; and finally some of them
are of such a nature that they impel him to the blind and unreasoning
commission of the most grievous crimes, including suicide and
homicide.52
52 “I believe that more suicides and combined suicides and homicides result in this
country from alcoholism in its early stages than from any other cause whatsoever” (T.
S. Clouston, Clinical Lectures on Mental Diseases, Am. ed., 1884).

TREATMENT.—The prophylaxis of alcoholism has regard to

communities at large and to individuals. The prevention of the evils
of excess by the control of the sale of drink constitutes one of the
more important objects of state medicine. At the same time, the
traffic in alcohol is curiously evasive of legal enactments. The
difficulties attending the enforcement of sumptuary laws are well
known. Restrictive laws concerning the making and sale of alcoholic
drinks, while partaking of the nature of sumptuary laws are of more
comprehensive character, being obnoxious to powerful commercial
interests and to the sense of personal liberty of large numbers of
persons of all classes. As a result of organized opposition and
individual violation they are to a great extent inoperative as regards
the prevention of alcoholism.
Aside from the question of revenue from taxation, the practical
influence of law is in this matter somewhat limited, being confined
chiefly to the prevention of the sale of liquors to minors and persons
already intoxicated, and to ineffectual attempts in certain countries to
regulate the quality of the drink sold. The penalties for personal
drunkenness which does not lead to overt acts are, as a rule, wholly
inadequate to restrain it. The best results upon anything like an
extended scale have been obtained by the co-operative action of
philanthropic individuals in endeavoring to influence the moral tone,
especially among workingmen, to diminish temptations, and to
provide for leisure hours, in the absence of drink, reasonable
amusements and occupation to occupy the time ordinarily spent in
taverns and similar places.

The decrease in the consumption of alcoholic drinks in the United

States within recent years is doubtless due in part to increasing
popular knowledge concerning the dangers of alcoholic excess and
to the growth of a more wholesome public sentiment. It is, however,
in part also due to poor wages among workingmen.

As regards the individual, prophylaxis against alcoholism consists

either in total abstinence from, or in the most guarded indulgence in,
alcoholic beverages. It is unfortunate that individuals whose moral
and physical organization is such as renders them most liable to
suffer from the consequences of alcohol are by that very fact most
prone to its temptations, and hence contribute largely to the subjects
of alcoholism. These individuals are found among the ignorant, the
very poor, and especially among neurotic subjects of all classes of
society. Due consideration of this fact cannot fail to establish the
responsibility of those fortunately not belonging to these classes, in
two respects: first, that of example; and second, that of personal
restraint from the standpoint of heredity. The influence of heredity
among races addicted to alcohol has not yet attracted the attention it
deserves. It is probable that much of the tolerance for alcohol
exhibited by individuals, families, or even nations, is to be accounted
for by heredity. Still more probable is it that most of the evils and
crimes that befall alcohol-drinking communities and individuals are
due directly or indirectly to the abuse of this agent. No argument
against the indulgence in narcotics can be more potent than that
derived from a consideration of the laws of heredity.

I. The Treatment of Acute Alcoholism.—The medical treatment of

mere drunkenness requires no consideration. The rapid elimination
of alcohol, and the transient nature of its pathological effects in
excesses which are not repeated or prolonged, explain the
spontaneous recovery, which is usually sufficiently prompt and
permanent. The physical suffering and mental distress following
unaccustomed excesses are of salutary influence. Under certain
circumstances a powerful effort of the will is sufficient to control, at all
events for a time, the more moderate effects of alcohol. A similar
result follows the use of cold douches, the Turkish bath, and full
doses of certain preparations of ammonium, particularly the officinal
solution of the acetate of ammonium. In alcoholic stupor of an acute
kind the patient may be left to himself, care being taken that the
clothing is loosened and that the position is such as to prevent local
paralysis from the nerve-pressure. Alcoholic coma, if of moderate
intensity, may be managed in the same way. Profound alcoholic
coma requires, however, more energetic measures. Frictions,
artificial warmth, stimulating enemata, as of turpentine or of hot salt
and water, an ounce to the pint, hypodermic injections of strychnia or
atrophia in minute doses and occasionally repeated, inhalations of
ammonia, and occasional cold affusions, followed by brisk frictions
with warm flannel and faradism of the respiratory muscles, may be
needed to tide over the threatened fatal collapse. The stomach
should be at once washed out with hot coffee.

In the convulsive form of acute alcoholism chloral in twenty-grain

doses, repeated at intervals until sixty grains have been given,
usually serves to arrest, or at all events to moderate, the paroxysm.
It may be administered by the mouth or in double doses by the
rectum. If chloral be inadmissible by reason of weakness of the
circulation, paraldehyde may be substituted in doses of from half a
drachm to one drachm, repeated at intervals of from one to two
hours until quietude is produced. Where the convulsive paroxysms
are of great violence it may be necessary to control them by the
cautious administration of ether by inhalation.

The mania of acute alcoholism calls for energetic management. To

avert injury to the patient himself or to those about him he must be
confined, if practicable, in a suitable apartment in a hospital; if not, in
his own house and carefully watched. Here, as a rule, paraldehyde,
chloral, or large doses of the bromides constitute our most efficient
means of medication.

In all forms of acute alcoholism it is a rule admitting of no exception

to at once withhold alcohol in every form and all doses. If, under
exceptional circumstances, great nervous depression or flagging
circulation seems to call for the use of alcohol in small amounts, it is
far better to substitute other drugs. The frequently repeated
administration of hot beef-tea or rich broths in small doses, with
capsicum and the use of the various preparations of ammonia, or
small doses of opium with or without quinia and digitalis, proves
useful in proportion to the skill and discrimination with which they are
selected and repeated. It is a good plan to commence the treatment
with an active purge.

In the acute collapse following excessive doses—lethal doses—the

stomach is to be immediately emptied by the tube or pump and
washed out with warm coffee. In the absence of the stomach-tube
emesis may be provoked by the use of mustard or sulphate of zinc
or by hypodermic injection of apomorphia. The patient must be
placed in the recumbent posture and surrounded with hot blankets.
The cold douche may be occasionally applied to the head and face,
and the muscles of respiration may be excited to action by faradism.
Artificial respiration and friction of the extremities may also be
required. Inhalations of ammonia may be used. The flagging heart
may be stimulated by occasionally tapping the præcordia with a hot
spoon—Corrgan's hammer. Hypodermic injections of digitalis may
also be employed. Overwhelming doses of alcohol, leading promptly
to collapse, usually prove fatal despite all treatment.
II. The Treatment of Chronic Alcoholism.—Whatever may be the
prominence of particular symptoms or groups of symptoms, whether
they indicate derangement of the viscera, of the nervous system, or
of the mind, whatever their combination, the fundamental therapeutic
indication in chronic alcoholism is the withdrawal of the poison. The
condition is directly due to the continuous action of a single toxic
principle: its relief when practicable, its cure when possible, are only
to be obtained by the discontinuance of that poison. This is a matter
of great, often of insurmountable, difficulty. The obstacles are always
rather moral than physical. Occasional or constant temptation, the
iron force of habit, the malaise, the faintness, the craving of the
nervous system, and, worse than all, the enfeebled intellectual and
moral tone of the confirmed drunkard, stand in the way. Even after
success seems to have been attained, and the patient, rejoicing in
improved physical health and in the regained companionship and
consideration of his family and friends, feels that he is safe, it too
often happens that in an unguarded moment he yields to temptation
and relapses into his old habits. A patient of the writer, after seven
years' abstinence from drink, again became its victim in
consequence of the incautious suggestion of a young medical man,
met at a summer hotel, to take brandy for some transient disorder,
and died after eight months of uncontrollable excesses. It is
necessary to guard the patient against the temptation to drink. To
secure this he may he sent as a voluntary patient for a length of time
to a suitable institution, or, still better, he may place himself under the
care of a conscientious, clear-headed country doctor in a sparsely-
settled region, preferably in the mountains or at the seaside. The
malaise, depression, insomnia, and other nervous symptoms when
of moderate degree are best treated by abundance of nutritious and
easily-assimilable food, taken often and in moderate amounts. To
this end gastro-intestinal disturbances may be practically
disregarded, except in so far as they regulate the selection of a
highly nutritious diet. As a matter of fact, in the early periods of
chronic alcoholism, while visceral lesions of a grave character are
yet absent, appetite and digestion alike improve in the majority of
cases upon the withdrawal of alcohol, provided a sufficiently
abundant and easily assimilable dietary is insisted upon. Grave
visceral lesions characterize a more advanced alcoholic cachexia
and necessarily complicate the treatment. Nevertheless, even here
the indication is the withdrawal of the poison. The nervous symptoms
require special medication. The whole group of tonics, from simple
bitters to quinia and strychnia, is here available. It is impossible to
lay down rules for the treatment of particular cases except in the
most general manner. In the absence of conditions calling for special
treatment, such as gastritis, hepatic or pulmonary congestion, fatty
heart, etc., good results follow the frequent administration of small
doses of quinia and strychnia; thus, the patient may take one grain of
quinia six or eight times a day, or a little gelatin-coated pill containing
1/200–1/100 of a grain of strychnia every hour during the waking day,

amounting in all to one-twentieth, one-tenth, or one-fifth of a grain in

the course of twenty-four hours. This treatment is often followed by
the relief of tremor, the quieting of nervous irritability, and the
production of good general results. The malaise, the general
depression, and especially the sinking feeling at the pit of the
stomach so often complained of by patients, are best relieved by
food. Fluid extract of coca is also useful in these conditions. The
value of cocaine in the management of the nervous symptoms of
chronic alcoholism, and in particular as a temporary substitute for
alcohol, is doubtful. The writer, having used it in a number of cases
by the mouth and hypodermically in doses of ¼–1 grain, has had
variable results. In some cases it temporarily relieved the craving
and concomitant symptoms; in others it failed wholly: in one instance
one-fourth of a grain was followed by great nervous depression. It is
desirable not to inform the patient of the nature of the remedy,
especially if its use be followed by good results, lest the cocaine
itself supplant alcohol as an habitual narcotic. Cold or tepid
sponging, the occasional hot bath at bedtime, and the Turkish bath
are useful adjuvants to the treatment. As a rule, opium is
contraindicated. Sleep often follows the administration of a cupful of
hot broth or milk at bedtime. Lupulin is here useful, and the writer
has come to regard an ethereal extract of lupulin in doses of from
one to three grains as a valuable and harmless hypnotic. If
necessary, hypnotic doses of chloral or paraldehyde may be used,
but care is required in their administration, and their early
discontinuance is advisable. If anæmia be profound, chalybeate
tonics do good, and among the preparations of iron pills of the dried
sulphate with carbonate of potassium (Blaud's pills) are especially
useful.

The obesity of drunkards, as a rule, diminishes on the withdrawal of

alcohol. Under circumstances of partial or complete abstinence from
drink measures to reduce the weight of such patients are wholly
inadmissible.

In conditions characterized by failure of mental power, in beginning

dementia or threatened insanity, the syrup of the hypophosphites,
the compound syrup of the phosphates, or cod-liver oil should be
administered. These remedies are likewise useful in various forms of
alcoholic paralysis, as are also faradism and galvanism employed
secundum artem. The various forms of alcoholic insanity require
special treatment, only to be had in institutions designed for the care
of patients suffering from mental diseases in general.

Whilst it is desirable in the treatment of all forms of chronic

alcoholism to secure the permanent discontinuance of the alcoholic
habit, the skill, judgment, and experience of the physician must
determine the degree of rapidity with which this, when practicable, is
to be done. The number of cases in which alcohol can be
discontinued at once and finally is limited; those in which it can be
wholly given up in the course of a few days constitute the largest
proportion of the cases; finally, in a small number of cases alcohol
can only be withdrawn cautiously and by degrees.53 Whilst it is in
most cases essential to remove the patient from his customary
surroundings and companionships, it is in the highest degree
important to provide for him mental occupation and amusement. To
this end a wholesome open-air life, with sufficient daily exercise to
induce fatigue, is highly desirable, as indeed is the companionship of
interested and judicious friends.
53 It must be borne in mind that in chronic alcoholism acute maladies of all kinds,
including traumatism, both accidental and surgical, act as exciting causes of delirium
tremens. The part played by the abrupt diminution or withdrawal of alcohol under such
 circumstances is often an important one. It is the opinion of the writer that a certain
amount of alcohol should be administered for a time at least in the accidental injuries
and acute sicknesses of alcoholic subjects, and that the reduction should be gradually
made.

The Treatment of Delirium Tremens.—The patient should be

confined in a large, well-aired apartment, without furniture except his
bed, and when practicable he should have a constant attendant. The
favorable influence of a skilful nurse in tranquillizing these patients is
very great. The custom of strapping them to the bed by the wrists
and ankles is to be deprecated. If the case be a mild one, and
especially during convalescence, open-air exercise in the sunshine
with an attendant is of benefit; care must, however, be taken to
guard against the danger of escape.

Under no circumstances should visitors be permitted to see the

patient. In young persons the treatment may be preceded by an
active saline or mercurial purge. In elderly persons, those suffering
from cachectic conditions, or in cases characterized by marked
debility and feeble circulation—conditions frequent in persons who
have had repeated attacks—it is not desirable to purge. Alcohol
should be either wholly withdrawn or more or less rapidly diminished.
It must be replaced by abundant food in the form of concentrated
broths or meat-extracts. In cases of vomiting these must be given
hot and in small doses frequently repeated. Bitter infusions may also
be given, or milk or equal parts of milk and Vichy water. If there be
thirst, the effervescent waters may be given freely. Patients often
drink with satisfaction and apparent benefit hop tea, which may be
made simply with water or with equal parts of water and porter.

The medicinal treatment will depend to a large extent upon the

peculiarities of the case. In mild cases a combination of the watery
extract of opium in small doses, not exceeding a quarter of a grain,
with quinia and digitalis, repeated every four or six hours, is often
useful. Although the view once entertained that the graver symptoms
were the result of prolonged sleeplessness is no longer tenable, the
induction of sleep, or at all events of mental and physical repose, is
among the more important therapeutical indications. For this purpose
hypnotic doses of opium are not only not desirable, but are even, in
the majority of instances, attended with danger. The sleep which
follows repeated and increasing doses of opium in delirium tremens
has too often terminated in coma deepening into death. As
calmatives, extract of cannabis indica, hyoscyamus, or the fluid
extract of piscidia are useful. As hypnotics, the bromides, chloral,
and paraldehyde yield, in the order here given, the best results. The
bromides are better in large single doses than in small doses often
repeated, better in combination than singly. Chloral, either by the
mouth or by the rectum, in doses of from twenty to forty grains, is
often followed by beneficial sleep. It is contraindicated where the
heart's action is much enfeebled. Paraldehyde, in doses of half a
drachm to one drachm, repeated at intervals of two or three hours
until sleep is induced, is still more efficient. This drug may be
administered without the fear of its exerting a depressing influence
upon the heart. The depression characteristic of grave delirium
tremens may be combated by repeated small doses of champagne
or by carbonate of ammonium in five- or ten-grain doses; the
vomiting, by withholding food and medication by the mouth, and
giving them for some hours wholly by the rectum or hypodermically.
Excessive restlessness is sometimes favorably influenced by cold
affusion, followed by brisk friction and warm blankets with continuous
artificial heat. The cold pack has proved useful.

Digitalis may be employed, ex indicatione symptomatica, but the

enormous doses of tincture of digitalis used by the late Jones of
Jersey and others are here mentioned only to be condemned.

To sum up, the chief indications for treatment are complete isolation,
the withdrawal of alcohol, abundant, readily assimilable, nutritious
food, and control of the reflex excitability of the nervous system.

III. Hereditary Alcoholism.—The treatment of the vicious propensities

of the descendants of alcoholic parents does not fall directly within
the province of the physician. It is among the most difficult problems
of education. The recognition of the cause of evil traits manifested in
childhood and youth may do something to avert dangers commonly
unsuspected. All things considered, the outlook is not hopeful. The
recognition, on the part of the physician, of the influence of
hereditary alcoholism in cases of arrested development, feeble
organization, or declared disease of the nervous system will perhaps
do less to aid his treatment in many cases than to reconcile him to its
want of full success. The cry of warning is to those who are eating
sour grapes that the teeth of their children will be set on edge.

IV. Dipsomania.—The general indications for the treatment of

dipsomania are two: first, the management of the paroxysm; second,
the control of the general condition itself.

First, then, during the paroxysm the patient must be saved, in so far
as is possible, from the danger of injuring himself or others and from
squandering his property. If the excesses are of such a degree as to
render it practicable, the same treatment must be carried out as in
cases of acute alcoholic mania and delirium tremens—namely,
confinement in a suitable apartment under the care of an
experienced nurse and the control of the doctor. Unfortunately, this
plan is not always practicable in the early days of the outbreak. Here
tonics, coca, and repeated small doses of quinia and strychnia are of
advantage. Courses of arsenic at the conclusion of, and in the
intervals between, the paroxysms are of use, on account of the
excellent influence they exert on the general nutrition. These may be
advantageously alternated with iron, cod-liver oil, and the compound
syrup of the phosphates or of the hypophosphites. Hydrotherapy
may also be used with advantage, and the influences of a well-
regulated hydropathic establishment are much more favorable than
those of institutions specially devoted to the treatment of alcoholic
subjects. In the latter the moral atmosphere is apt to be bad; the
patients support each other, and too often conspire to obtain in
secret that which is denied them openly, or, if the discipline be too
strict for this, they sympathize with each other in their restraint, react
unfavorably upon each other in the matter of shame and loss of self-
respect, and plot together to secure their liberty.
Few dipsomaniacs in the earlier periods are proper subjects for
treatment in hospitals for the insane. If cerebral excitement or
sleeplessness persist after the paroxysms, chloral, paraldehyde, or
the bromides in large doses may be used to secure sleep. Various
combinations of the bromides are often of use where the single salts
fail. It must not be forgotten that during the paroxysm there is great
danger lest the patient do himself or others harm. When there are
indications of an impending attack, and during the period of
depression following the attacks, benefit is derived from the daily use
of bitter infusions. As a matter of fact, however, the management of
these cases is among the most unsatisfactory of medical
undertakings. The difficulty is increased by the latent character of the
mental disorder in the intervals between the attacks. Even when
such patients voluntarily enter hospitals for the insane, they cannot
be retained there sufficiently long to derive any permanent benefit.
What we want is, in the words of Clouston, “an island where whiskey
is unknown; guardianship, combined with authority, firmness,
attractiveness, and high, bracing moral tone; work in the open air, a
simple natural life, a return to mother Earth and to Nature, a diet of
fruits, vegetables, bread, milk, eggs, and fish, no opportunity for one
case to corrupt another, and suitable punishments and deprivations
for offences against the rules of life laid down. All these continued for
several years in each case, and the legal power to send patients to
this Utopia for as long a period as medical authority determines, with
or without their consent.”

THE OPIUM HABIT AND KINDRED AFFECTIONS.