ALCOHOLICS
I am not specially familiar with the statistics of insanity, but I am
inclined to believe that an appreciable contribution to the total--indeed,
one of its largest parts--has arisen from the improper diagnosis of drug
and alcoholic cases, followed naturally by improper medical treatment.
Lack of definite medical help in cases of chronic alcoholism is likely to
bring about brain lesions, which eventually mean hopeless insanity.
For that special reason, the chronic alcoholic has been the chief
contributor to the army of the insane, and in the asylums his presence is
notably frequent among the violent cases. The head of one of the greatest
institutions in the United States for the care of the insane assures me
that this seems to occur among women to a greater degree than with men.
One of the most difficult problems of my work has been to discover ways by
which the medical profession can be made to understand the really serious
meaning of chronic alcoholism. Most delirium, the primary cause of which
lies in alcoholism, is amenable to treatment.
EFFECTS OF DEPRIVATION IN CHRONIC ALCOHOLISM
It is exhaustion or lack of alcohol which first produces delirium in an
alcoholic case, whether that exhaustion is due to the patient's inability
to assimilate food or alcohol or whether it is due to the fact that, being
under restraint, alcohol is denied him.
In most cases there is no form of medication which can be successfully
substituted for alcohol, and unless definite medical help is provided for
the purpose of bringing about a physical change and thus avoiding
delirium, no course remains safe except a long and very gradual process of
reduction of alcoholic poisoning. Such a measure as this cannot be
successfully applied in the wards of the general hospital, as the mere
fact that alcohol was there administered, even in slowly diminishing
doses, would make such a ward the chosen haven of innumerable "old
stagers," who, having reached that stage of worthlessness which would make
it impossible for them to obtain the narcotic elsewhere, would take the
treatment for the mere sake of getting the alcohol of which it principally
consists.
Many friends of alcoholic subjects and many physicians in private practice
have believed that they were doing the alcoholic a great service when they
put him where he could not get alcohol, and helped him over the first
acute stages of the period of deprivation by the administration of bromide
and other sedatives. This usually means delirium first and then a "wet
brain"; if the patient survives this, his next development is more than
likely to be prolonged psychosis, or, in the end, permanent insanity. It
is because of this that I consider the chronic alcoholic more clearly
entitled to prompt and intelligent medical treatment than most other sick
persons. With the alcoholic, as with the drug-taker, the first thing to be
accomplished is the unpoisoning of the body. In order to accomplish this,
it is first necessary to keep up the alcoholic medication, with ample
sedatives, using great care lest the patient drift into that extreme
nervous condition which leads to delirium. If delirium does occur, nothing
but sleep can bring about an improvement in the patient's condition. This
is the point of development at which physicians not properly informed in
regard to such cases are likely to employ large quantities of hypnotics,
and frequently this course is followed until the patient is finally
"knocked out." In many instances an accumulation of hypnotics in the
systems of persons thus under treatment has proved fatal. I am rather
proud of my ability to state that from delirium tremens I have never lost
a single case.
NECESSITY OF CLASSIFICATION OF ALCOHOLICS
The records show that to-day about forty per cent. of the insane in the
asylums of New York State have a definite alcoholic history. In this
condition lies one of the greatest opportunities ever offered to the
medical profession. Even now a proper classification of the patients thus
immured, and their appropriate treatment, would in many instances result
in the return to the normal of those affected; proper classification and
treatment at the time when the symptoms of mental disorder first appeared
would have resulted in the salvation of innumerable cases. As a matter of
fact, I earnestly believe that if this course was followed, the number of
supposedly permanent cases of insanity arising from alcoholic and drug
addictions might be decreased by seventy-five per cent.
Certain general rules may be laid down. There are no circumstances in
which it is advisable for a physician in private practice to attempt to
handle a case of chronic alcoholism in the patient's own environment.
Efforts to do this are constantly made, with the result that many
needlessly die from lack of alcohol, while an even more tragic result is
the unnecessary entrance, first into the psychopathic wards of our
hospitals and thence into our asylums for the insane, of innumerable cases
which needed intelligent treatment only for alcoholism or drug addiction.
If this treatment is neglected, the incarceration of these unfortunates in
asylums becomes necessary, for without question their insanity is real
enough.
UNSCIENTIFIC METHODS IN THE TREATMENT OF ALCOHOLISM
During the summer of 1913 I visited a large hospital in Edinburgh and
discussed alcoholism and its treatment with the visiting physician.
"We do not have many alcoholics here," said he.
"Why?" I inquired.
"All our hospital work is supported by private subscription," he answered.
"Then there is no place whatever in Scotland for the care of the acute
alcoholic case?"
"No. If an intoxicated person is locked up by the police and develops
delirium, he is sent here, and we do what we can for him by the old
methods."
"You offer no definite medical help along special lines?"
"No; we have none to offer."
He showed me two cases in the general ward; one man in a strait-jacket was
in the midst of delirium tremens, his face terribly suffused. He was in a
pitiable state, and nothing was being done for him.
"What course shall we follow?" the physician inquired.
"Let me see his chart," I requested. After I examined it, it became
immediately apparent that the patient's condition was due to lack of his
usual drug. It was his third day in the ward.
"Nothing but sleep will save him," I said, and suggested medication which
was administered.
In three or four minutes the patient was relaxed and taken out of the
strait-jacket. I made certain suggestions regarding general stimulation
for the bowels and the kidneys, and diet. On the next day I found the
patient improved after twelve or fifteen hours of sleep, and wholly free
from delirium. His case had now become simply a matter of recuperation.
Another case had lived through several days of delirium tremens, which had
been followed by a "wet brain"; the visiting physician considered this
patient a fit subject for the psychopathic ward. I asked the patient
questions about himself. He was sure that he had been out the night before
and pointed out one of the internes as his companion during the hours of
dissipation. His case was regarded at the hospital as almost certain to
end in an asylum. I suggested treatment and within two days the man's mind
had entirely cleared up.
These instances of successful and prompt relief occasioned considerable
surprise among the hospital physicians, who frankly admitted that they
knew nothing to do except to keep the patients there under restraint, and,
if necessary, feed them according to existing rules, to keep their bowels
open and their bladders free, and hope for the best.
This was an institution which is supposed to represent the best medical
learning in the United Kingdom. I found similar conditions existing in the
great hospitals of London, Paris, and Berlin, so that the Scotch
institution is not an exception to the general European rule. Everywhere I
was frankly informed that the medical staff knew of nothing to be done in
alcoholic cases beyond deprivation and penalization.
Nor have we been more scientifically progressive in the United States. We
are following virtually the same unenlightened methods, and it has even
been suggested that chronic alcoholism be added to the conditions which in
the minds of some sociological thinkers justify sterilization. How
important our shortcoming is may be strikingly illustrated by the
statement that alcoholic patients comprise one third of all the cases
admitted to Bellevue Hospital in New York.
THE DIFFICULTY OF TREATMENT IN SOME ALCOHOLIC CASES
The alcoholic differs notably from the person addicted to drugs. A
drug-taker, deprived of his drug, will experience in the early stages only
acute discomfort and a natural longing for the drug of which he has been
deprived. His unfavorable symptoms can always be relieved by the
administration of the drug. The chronic alcoholic, however, deprived of
the stimulant, often drifts into a delirium which cannot be relieved by
the administration of his accustomed tipple. No more terrible spectacle
can be imagined by the human mind than that of an acute case of delirium
tremens; no patient needs more careful watching in order that unfavorable
developments may be avoided; once delirium sets in, no type of case is
medically so difficult to handle. The man who for long periods has been
saturated with alcohol, and who is suddenly deprived of it, is, I think,
more to be pitied than almost any one I know; yet relatives, friends, and
physicians frequently follow exactly this course, and think that by so
doing they are rendering the patient a kindly service.
CAUSES OF INSANITY
In mentioning the causes of insanity, it is, however, impossible to permit
the impression to be recorded that alcohol is the only offender. My
statement of the part which alcohol plays in supplying the population of
our mad-houses has never been denied; but it is also true that the use of
headache powders and other preparations commonly sold at our drug stores
and as yet slightly or not at all restricted by law, and the use of
coffee, tea, and tobacco in unrestricted quantity, also contribute their
quota to the insane. A letter from the superintendent of a certain state
asylum tells me that he has seen many improvements, sometimes even
amounting to cures, result from ten days of fasting. That fasting really
was a process of unpoisoning. In such a case the symptoms of insanity may
be attributed to auto-intoxication, coming from any one of many causes, of
which alcohol, tobacco, or even food improperly selected or unreasonably
eaten may be one. The physician can have no means of learning just what
method to pursue in any case of auto-intoxication until the patient has
been unpoisoned. If any one of the great general hospitals would secure
careful histories of one hundred of its patients and apply the proper
methods to those who are found to have been poisoned by their habits,
surprising results would be achieved. It is specially true that no
intelligent mental diagnosis can be made of any patient who has had an
unfavorable drug, alcoholic, or even tobacco, tea, or coffee history
until he has been freed from the effects of these drugs or stimulants.
The first thing that a physician must do when confronted by a case of
alcoholic or drug addiction is to learn whether it is acute or chronic. If
the case is chronic, the patient must not be suddenly deprived of his
stimulants.