HELP FOR THE HARD DRINKER
The people of the world in general, and especially the people of the
United States, are asking more questions about the cost of alcohol--not
its cost in money, but its cost in men. These are questions which
statistics cannot answer, which, indeed, can never be definitely answered;
but we know enough to be assured that if answers could be given, they
would be appalling. With increasing unanimity the thinkers of the whole
world are saying that in alcohol is found the greatest of humanity's
curses. It does no good whatever; it does incalculable harm. A dozen
substitutes may be found for it in every useful purpose which it serves in
medicine, mechanics, and the arts; its food value, of which much has
recently been said, is not needed; and it has worked greater havoc in the
aggregate than all the plagues. If not another drop of it should ever be
distilled, the world would be the gainer, not the loser, through the
circumstance. Yet the use of alcohol as a beverage is continually
increasing. The number of its victims sums up a growing total.
Sentimentalists have failed to cope with it, and the law has failed to
cope with it. In combating it, the world must now find some method more
effective than any it has yet employed.
When we consider excessive drinkers as a class, we find that a large
number of alcoholics are born with tendencies which make alcohol their
natural and almost inevitable recourse. As a rule they are naturally
highly nervous, or, through some systemic defect, crave abnormally the
excitation which alcohol confers. For these reasons, granting favorable
opportunity and no great counterbalancing check, they are foredoomed to
drink to excess. Some are predisposed to alcoholism by an unstable nervous
organism bequeathed to them by intemperate parents or other ancestors;
others are drinkers because they do not get enough to eat, or fail, for
other reasons than poverty, to be sufficiently nourished; and others,
possessing just the favorable type of physique, become alcoholics through
worry or grief. All these kinds of people are victims of a habit which,
properly speaking, they did not initiate, and of which, therefore,
censure must be very largely tempered. Yet they are generally treated as
though they had perversely brought about their own disease, a course not
more reasonable than the punishment of people for developing nephritis or
cancer.
The demand for a more effective as well as a more logical treatment of
alcoholism has even greater urgency than comes out of this injustice. Much
of our best material falls victim to this disease. By general admission
the alcoholic often possesses many qualities of mind and temperament which
the world admires and pronounces of the utmost value when rightly
developed. Even the careless weakling who drinks to excess is proverbially
likely to be generous, magnanimous, warmly impulsive, even quixotic. The
finest sensibilities, the most delicate perceptions, and the most
enthusiastic temperaments--from all of which qualities great constructive
results may be expected--are notably the most exposed to alcoholism. A far
greater number of its victims than the offhand moralist is inclined to
concede have admirable sturdiness of will and dogged persistence. With
less, perhaps, they would not have become excessive drinkers. They are
alcoholics because with the help of stimulants they have habitually forced
themselves to overwork, to bear burdens of responsibility beyond their
normal strength, or to overcome physical obstacles, like poor health,
eye-strain, and insufficient nourishment. The man who drinks is not
necessarily depraved; but under the influence of stimulant he is very
likely to drift into associations and environments which will lower his
standards until he becomes irresponsible, unadmirable, or even criminal.
ARE ALCOHOLICS GETTING A FAIR CHANCE?
It is perhaps not going too far to say that most alcoholics have not been
given a fair chance by their bodies, their temperaments, or the actual
conditions of their lives. The question is, Are they getting a fair chance
from society--society whose experience has demonstrated that it must in
some way protect itself from them?
At present the only public recognition of the alcoholic is manifested
through some form of penalization. He loses his employment, he is excluded
from respectable society, in extreme cases he is taken into court and
subjected to reprimand, fine, or imprisonment. Nothing is done to bring
about his reform except as the moral weight of the non-remedial punishment
may arouse him to his peril and set his own will at work. Instances where
this occurs are rare, because the crisis always comes when, through the
influence which alcohol has wrought upon him, his brain has been befogged
and his will weakened. Society does virtually nothing to awaken that will
or to assist its operation. The man whose drinking has so disarranged him
physically or mentally that he is obviously ill is, it is true, taken to
the alcoholic ward of some hospital, but even there no effort is made to
treat the definite disease of alcoholism. For example, Bellevue and Kings
County hospitals, where New York's two "alcoholic wards" exist, are
institutions devoted specially to the treatment of emergency cases. As a
matter of course, the alcoholics taken to them are merely "sobered up." As
soon as they are sobered and have achieved sufficient steadiness of nerve
to make their discharge possible, they are turned out again into the
liquor-ridden city, with their craving for the alcohol which has just
mastered them no weaker, with their resolution to resist its urging no
whit stronger, than they were before the crisis in their alcoholic
history engulfed them. There is as yet no public institution in New York
City where a man, either as a paying or as a charity patient, may go for
medical treatment designed to alleviate the craving for liquor; no
organized charity makes provision for the medical treatment of the
alcoholic. Only three States in the Union attempt to provide more
competently than New York State does for this class of unfortunates. The
provision they make progressively treats men convicted of drunkenness in
the courts with surveillance, threat, colonization, and finally perpetual
exclusion from society. Massachusetts has a colony for inebriates, New
York is developing one, and Iowa has had one for several years.
This, then, is at present the treatment accorded by the public to the
victims of this serious disease. There are no clinics devoted to the study
of alcoholism, although it is the ailment of probably one third of the
sick people in the world to-day. Those who feel disposed to question this
statement will be convinced that it is reasonable if they but make a count
of the private sanatoriums dealing exclusively with alcoholics in and near
New York, and, indeed, dotting and surrounding all our large cities.
Connecticut, New Jersey, and Illinois will show a startling number. And it
must also be remembered that many of the cases of disease other than
inebriety treated in all public hospitals have histories more or less
alcoholic, and that the insane asylums are crowded with those gone mad
through drink. It is the demand of common sense, not of sentiment alone,
that this situation should be altered.
Provision never has been made really to help even the man who, having lost
control, is anxious to regain it. Inquire of the United Charities in New
York and of similar organizations in other cities, and you will learn that
they are doing most intelligent work in the treatment of tuberculosis, but
that alcoholism is getting only condemnation and punishment, not curative
methods; yet there probably are forty alcoholics to every consumptive.
Neglect is almost universal, and where that charge cannot be brought,
there the errors are incredible and continual. Many are charitable toward
the drunkard, giving him their dimes when he begs for them, and thus
promoting his inebriety; but society as a whole ignores him until he
forces its attention through his helplessness or often through some sin,
which might be more rightly charged to alcohol rather than to any natural
criminal tendency in the man's nature.
ALCOHOLICS SHOULD BE TREATED AS INVALIDS
The physician, as things are, can do little with the sufferer from any
ailment if his system at the time is impregnated with alcohol, for the
alcohol may very likely prove an antidote to the medicines, or, if it does
not, may prevent the patient from taking them. An alcoholic does not keep
engagements; he cannot be expected to take doses as prescribed by his
physician. An alcoholic who is also ill of something else is doubly ill,
but he usually gets treatment only for his secondary illness. No man who
has lost control through stimulants is well, and until he has been
definitely treated, he cannot be expected to act normally. The world does
not yet know how to deal with him. Sequestration as it is usually
practised--trips round Cape Horn, weeks spent in the woods where liquor
cannot be obtained--will never do it. Not only must the physical yearning
be eliminated, but the mental willingness to drink must be destroyed
before reform can be accomplished. It is at this point that the
sentimentalists are wont to fail. A promise made by one in whom the
craving for the stimulant exists cannot properly be considered binding,
for such a one is not responsible for what he promises. If body proves
stronger than the mind in such a battle, he is merely an unfortunate, not
really a liar or a weakling. The world's loss through alcohol has been
incalculable. No community ever existed which could afford to relinquish
the services of all its citizens who drink to excess or even of those who
frequently get drunk. Yet society has continually maintained that when
encountering the alcoholic it has crime, not disease, to deal with. Hence
the crudely ineffective idea of penalization as a preventive.
In general the nearest approach which has been made toward physiological
treatment--beyond, of course, the mere "sobering up" in an occasional
hospital of patients made delirious by drink--has not been through
medicine, but regimen, and this regimen has invariably included sudden
enforced abstinence. This remedy is worse than the disease. It rarely
helps and sometimes kills. I have seen many men who had been pronounced
insane after they had been deprived of alcoholic beverages, without proper
treatment, but whose minds became perfectly clear as the result of the
definite medical care their cases really required. Numbers of far from
hopeless alcoholics are yearly being sent to our insane asylums, where
there is little chance of their recovery, I think. Furthermore, by merely
depriving an alcoholic of alcohol without eliminating his desire for it,
we are likely to force him into something worse. Thus the attempt to
enforce abstinence upon the man who wants to drink is not only
ineffective, but destructive. In making this statement I do not wish to be
understood as being opposed to the prohibition of the sale of alcoholic
beverages; indeed, I should favor the most drastic restrictions
prohibiting the sale of alcohol. If there was never another ounce of
alcohol manufactured, the world would be none the loser either medicinally
or commercially. My reason for making this statement is that prohibition
of the sale of alcoholic beverages has been largely defeated because there
have not been the proper safeguards thrown about the manufacture and sale
of drug-store concoctions that can be had in any quantity as substitutes
for alcoholic stimulants; and I think the most drastic legislation that
could possibly be created on this subject should be enacted and enforced
against the druggists selling over their counters such concoctions.
The late Dr. Ashbel P. Grinnell, for seventeen years dean of the Vermont
Medical College, studied this phase of the subject, gathering interesting
statistics.
After Vermont's adoption of prohibitory legislation, he sent out to
wholesale and retail drug stores, general stores, and groceries that
carried drugs as a part of their stock a letter in which were inclosed
blanks calling for specific information concerning the sale of
habit-forming drugs. Such was his personal standing in the State that he
received responses from all but two or three of those whom he addressed,
and these indicated that such sales had swelled rapidly until they
indicated a daily consumption equal to one and one half grains of opium or
its alkaloids for every man, woman, and child in the State. This vast
increase in the use of dangerous drugs he attributed solely to the
prohibition of the sale of liquor. Thus it must be argued that the attempt
to enforce abstinence upon the man who wants to drink is not only
ineffective, but destructive. Society may thus save itself from a few
drunkards, but is likely to get lunatics or "drug-fiends" in their
places.
REFORM CANNOT BE ATTAINED BY PUNISHMENT
At the foundation of the present treatment of the alcoholic is usually the
idea that threatening with punishment can be effective. Actual experience
and the slightest examination prove this to be preposterous. Many a man
who drinks when he knows he should not, does so because he cannot control
himself, and he who has lost his self-control is obviously irresponsible.
A threat, or the remembrance of a threat, cannot restrain him. A man who
had committed a crime while drunk, but whose whole career had otherwise
been reputable, was sentenced to life imprisonment. After he had served
six years his friends presented so strong a case to the governor that he
was pardoned, but with the warning that if he took one drink he might be
returned to prison to complete his sentence. An excellent illustration of
the slight influence of fear upon the alcoholic is furnished by the fact
that within a very short time he was arrested for public drunkenness.
Punishment breeds rebellion, and when you make a man rebellious you are
most unlikely to reform him. Punishment has never yet cured a disease. The
inflamed brain not only carries grudges, but is almost sure to intensify
them. If a man is discharged from his employment or arrested at a time
when he is in the abnormal alcoholic state, the effect on him cannot be
reformatory; it must be to arouse his resentment, not his repentance. The
employer who discharges a good man from his position because of
drunkenness not only fails to deal intelligently with the man or with the
subject, but may very likely be committing a crime against society by
robbing it of a useful citizen and at the same time forcing a useless one
upon it. A man taken to court for drunkenness should with great care be
properly classified. It should be determined whether he is an habitual
drunkard, an occasional drunkard, or an accidental drunkard. There may be
hope for the occasional drunkard, there is invariably hope for the
accidental drunkard. If one of these is found to have employment at the
time of his arrest, great care should be exercised not to let the fact
that he has been arrested prejudice his employer against him, and as far
as possible he should be spared humiliation. Nothing will more quickly
unfit a man for anything worth while than humiliation. To punish such a
man with a prison term will help no one.
Neither should he be sent back to his liberty without some recognition of
the fact that he has been drunk and irresponsible. Any police officer, and
more especially any police-court reporter, will testify that almost every
man who, having been arrested for drunkenness, is discharged from custody
without penalty, for one reason or another, social position, political
importance, or previous good character record, will find a saloon within
two blocks of the court and take a drink on the way home. He will probably
not get drunk,--the impression made by his arrest will remain too strong
to permit that,--but he will take a drink. And that and other drinks will
help time drive from his mind the memory of the arrest, the cell, the
court. And what is true of him who has been arrested and discharged is
also true of him who has been arrested and imprisoned. Punishment fails
utterly to "reform" the alcoholic.
Nor is colonization more effective, except for the hopeless cases. It
means segregation. A man once said to me: "I want to be helped, but not at
the cost of compulsory association with others seeking help. I know that
to be thrown into unavoidable contact with those worse than myself would
hopelessly degrade me. I should not be willing to risk that, no matter
how much good the treatment might do me." Colonization of the occasional
alcoholic stamps him only a little less deeply than his stripes are sure
to stamp the criminal who is sent to prison, and its effects upon him and
his family are not more desirable than they would be if the process made
exactly that of him. He is likely to be barred from employment after his
discharge from the colony, and thus find it impossible to reestablish
himself. Moreover, during the period of sequestration it is difficult to
devise a plan for the care of the wives and children of those sent into
seclusion. At a time when nothing in the way of betterment can be expected
of him unless he regains confidence in himself, such treatment does not
strengthen, but cripples, a man's spirit. Surveillance after his return
will work on his imagination, cowing him into morbidness, until that alone
will first weaken his will and then break it down. Too great emphasis,
therefore, cannot be placed upon the viciousness of colonization for any
but the first of the three classes into which I have said that all men
charged in court with drunkenness should be carefully separated.
Colonization of the hopeless is advisable only because such men, before
they have descended to that stage, have cost their friends and society all
that it is advisable to spend on them. If the man who is worth while is to
be saved, it must be without the application to him of the brand.
So much for the existing public methods of dealing with the alcoholic. The
most usual private method is for a man's family or friends, when he has
lost control, to send him to some place where he can "get a grip on
himself." But he often does not receive in such a place, any more than in
the hospital or prison, that specialized treatment which can make that
regained grip effective. General treatment, accompanied by a gradual
withdrawal of stimulant, will restore his bodily strength, with the
result, in nine cases out of ten, that when he emerges from the seclusion
he is able to drink more than he was before he was sequestered, and will
be sure to come to grief more quickly. In most cases his craving and need
for stimulant are in no degree decreased, and in consequence he will
frequently relapse while going to the railway station on the homeward
journey. An even graver danger is that, while still in full possession of
the alcoholic habit, he will in addition contract the hypodermic habit,
and any drug habit developed in the alcoholic is the most difficult of
cases to deal with successfully. If he does relapse, his friends will
almost surely hold him blameworthy and impatiently abandon him as
hopeless, believing everything to have been done which can be done. In
reality nothing at all useful has been done to help him. He is a sick man,
and no attack whatever has been made on his disease.
COMPLETE MENTAL CHANGE MUST PRECEDE REFORM
This brings us to the kernel of the matter. No man who has become addicted
to the use of alcohol can possibly abandon it unless he has first
undergone a complete mental change, and in ninety-nine cases out of a
hundred this alteration of the mental state will not come until he has
experienced a physical revolution. The reason for this is simple.
Excessive use of alcohol really deteriorates body and brain tissue, and
tissue degeneration transforms for the worse the entire physical and
mental make-up of a man. The confirmed alcoholic is in the state which,
save in rare instances, nothing short of specialized medical treatment can
correct. Mere general building up of bodily tone is as ineffective with
alcoholics as is enforced deprivation or punishment.
I emphasize this point particularly because many men are afraid to take
any treatment for alcoholism lest through it they lose their standing with
themselves or with their neighbors. Self-respect must be protected at
every stage of the struggle as the patient's only hope. My purpose here is
to show that the only chance of reforming most alcoholics lies in giving
them opportunity through this physiological change to reestablish
confidence in themselves.
In setting about the business of treating an alcoholic, the first step is
to realize that he is in an abnormal mental state. To moralize or to
appeal in the name of sentiment to a warped and twisted mind is, I
believe, sheer waste of time. To the man who has lost control, it must be
first restored before he can be put to thinking. You cannot expect the
distorted alcoholic brain to be honest with you or with itself.
I cannot emphasize too strongly the harm that may come out of simply
depriving the chronic alcoholic of his stimulant. I know that there are
many relatives and friends and even physicians who, out of pure
desperation, feel that they have accomplished much when they are able to
put a man where he is unable to get his drink, irrespective of the amount
which he has been accustomed to take. I consider the chronic alcoholic one
of the most important cases in medicine to deal with successfully. Strange
as it may seem to the layman,--and it is just as strange to the
physician,--to such a case there is absolutely no other form of artificial
stimulants that will take the place of alcohol, and when a patient is
deprived of his accustomed stimulant, within twenty-four hours he begins
to drift into delirium tremens, which means that the patient is a very
sick man, and unless he is properly treated, will, if he lives through the
active period of delirium, drift into a "wet brain," or, in other words,
alcoholic insanity; and even if the patient survives the latter illness, a
large percentage of such cases prove in the end to be hopelessly insane,
and about eighty per cent. of the delirium tremens cases that do not get
proper medical help die. It is a very serious matter dealing with the
chronic alcoholic. Something definite must be done for such a case;
deprivation is impossible; simple reduction is sometimes a failure;
nothing short of definite medical, hospital work will unpoison this sick
man and avoid the complications of delirium, "wet brain," or possible
hopeless insanity.
The second step is to give the patient that definite medical treatment
which will correct his physical condition. Once this change has been
effected, you have a man whose system is no longer crying out for liquor,
with every nerve a-quiver for it, every tissue thirsting for it. There
have been reforms from alcoholism which were not preceded by this
physiological change, but they have been rare.
The physiological metamorphosis may be accomplished from without, by means
of treatment, without assistance from the patient other than mere
acquiescence. The mental change can be assisted from without; it cannot be
accomplished or maintained by any one except the patient. Despite himself
a man may be successfully treated for other ailments, but not for
alcoholism. By an intelligent subsequent attitude friends or physicians
may help to restore self-confidence, but that is all they can do.
After the desire for it has once been eliminated, the patient cannot
afford to take any alcohol whatever, and after a proper change of mental
attitude he will not wish to. From alcohol he must abstain altogether,
even in illness. Let no recovered alcoholic risk relapse because alcohol
seems to his physician to be desirable as a medicine. Indeed, the most
extreme care should be exercised to avoid medicines containing alcohol
even in small percentages, and this will bar most of the proprietary
remedies. When he is hungry, let the recovered alcoholic eat; when he is
weary, let him be sure to rest; when he feels ill, let him be sure to
consult without delay a competent physician. None of these conditions
indicates a necessity for alcohol.
Thus the man who is not hopeless may be saved. Society owes every
alcoholic a fair opportunity to reform; it may be questioned if it owes
him repeated opportunities. Many alcoholics never have been and probably
never could be useful citizens. Waste of money and emotion on them is
lamentable to contemplate; the sums at present thus hopelessly thrown away
would aggregate enough really to restore every alcoholic actually curable.
Sentimentalists do not like to admit the limitations of useful help, but
those limitations do exist, and we should reckon with them. If we do, the
man really curable will have all the better chance.
A TEST OF THE WORTHY
It is possible to discriminate between the curable and the incurable by
the simplest of expedients. Usually the question, What is this man willing
to do in return for help? will, with its answer, also supply the answer to
the inquiry as to his future. No man of sufficient mental fiber to make
helping him of any actual value is willing to accept charity. Even if he
finds himself at the moment unable to repay the debt involved, he will be
anxious to make it a future obligation. My fifteen years of experience
have proved to me that the sense of personal obligation is of great moment
in this matter. Even when it becomes necessary for a relative, employer,
or friend to assist a patient by the payment of his bills, it should be
regarded a part of the treatment to consider this a loan, which must be
repaid, and not a gift. It follows, sadly enough, that the most hopeless
alcoholic is the rich young man to whom financial obligations incurred for
treatment mean nothing whatsoever, and to whom responsible employment is
unknown. Indeed, it seems well-nigh impossible to reform the vagrant rich.
The man who thinks that giving up his alcohol is primarily a privation,
although he may admit the definite necessity of this privation, is not
likely to reform permanently; but there is hope for that one who declares
without apology that drinking is a bad business and that he wishes to be
helped to stop it. I cannot say with too great emphasis that
self-respecting pride is the main hope of the alcoholic.
It must not be overlooked, however, that it is the pride of the curable
alcoholic which makes him difficult to reach. To try to help such a man
when it is too late is a pitiably usual experience, for not until it is
too late does the pride of such a man allow him to apply for help. The man
who says, "I will not drink to-day," and finds himself compelled to; who
promises himself, but cannot keep his promise, is the man who most
deserves help, and is most likely to yield some sort of good return on an
investment made in him. Indeed, it is the rare alcoholic, curable or
incurable, who of his own initiative submits himself to treatment. Friends
must assist; but while the importance of such friendly service cannot be
overestimated, it must be of the right kind or it will be worse than
useless. Friends of alcoholics too often either sentimentalize or bully
when they go about the task of helping, or they allow too little time for
the accomplishment of the reform. Successful business men are specially
likely to act childishly when dealing with the mighty problem of assisting
alcoholics to their feet. They are likely to affirm that there is no
excuse for any man who yields to drink. If they have given help before,
they are prone to call attention to the fact that their beneficiary has
not recompensed their kindness by reforming, and declare, for instance,
that they will pay his board another week, but that will be the end of
their endeavor. This spirit--and it is the usual spirit--can accomplish
nothing; and the money spent in this and other ill-considered and
half-hearted efforts to save men has not decreased, but has increased, the
dissipation it has sought to stop. Even relatives and intimate friends are
likely to become weary of a case which shipment to some private
institution, deportation to a ranch, or embarkation on a sailing-vessel
for a long voyage has failed permanently to help.
Such treatment works no reforms, or almost none. Until the cause of
drinking is removed, travel from one place to another in an effort to
obtain reform by breaking up old associations will be of no avail, but
will, instead, repeat the experience of the old woman in the fairy-tale
who was bothered by a goblin. When she uprooted herself from her old home
and sought another, the goblin, hidden in a churn, went with her. It was
the old woman, not the cottage, he was haunting; it is the man, not his
environment, in which the alcoholic habit finds its stronghold. When a
patient by intelligent treatment has been put into a receptive state of
mind, he should be told to look up his old associates and to them declare
himself upon the liquor question. If they are friends, they will
congratulate him; if they are not, he will have gained by making certain
of it. And there is very little danger that, after he has seen them, he
will wish again to make intimates of them; that after, in his sober
senses, he has examined the surroundings which they frequent, he will be
willing to return to them. Being himself normal, he will wish for normal
men as friends; being far more fastidious than he was when he was
alcoholic, the old haunts will fill him with disgust. This declaration of
himself the man must himself make. Good friends may help him otherwise,
and chiefly by refraining from the slightest thing which may by any
chance tend to decrease his self-respect and his confidence in his own
power to stay reclaimed. What a man needs is a new mind on the subject.