CLASSIFICATION OF ALCOHOLICS
Alcoholics are more easily classified than drug-takers. With few
exceptions, alcohol-users have their beginnings in social drinking. Not a
few women and boys have had their first taste of alcohol, and may even
have acquired a definite alcoholic habit, through the small quantities
administered as stimulants by physicians; but in a general way it is as
easy and just to absolve the physician from responsibility in the matter
of alcoholism as it is easy and just to put a heavy responsibility upon
him in the case of the use of drugs.
THE DEMAND FOR STIMULANTS
In these days all mankind searches for exhilaration. The instinctive
demand for it is an inevitable result of the artificial social system
which we have built up. We work beyond our strength, and naturally feel
the need of stimulants; we play beyond our strength, and as naturally
need whips for our vitiated energies. The greatest social disaster of all
the ages occurred when first alcoholic stimulation, which is only one step
in advance of alcoholic intoxication and narcotization, found its place as
an adjunct of good-fellowship. All humanity turns in one way or another to
artificial stimulants, and while alcohol and narcotics are the worst among
these, we cannot slur the fact that many who would shun these agents as
they would a pestilence, turn freely to milder, but not altogether
harmless, stimulants, such as tea, coffee, and tobacco.
I do not purpose to go into a long dissertation upon the chemical
peculiarities of alcohol; I do not purpose to discuss the value or peril
of alcohol as food; there are plenty of published chapters telling exactly
what alcohol is. I feel that it is my mission to do none of these things,
but to endeavor to reveal to the student the most effective way of dealing
with a patient who has drifted into a definite alcoholic addiction.
THE MAN WHO CANNOT BE SAVED
It seems impossible to arouse any enthusiasm or sympathy for the human
derelict whose natural weakness is inevitably such that one taste of
alcohol means a gallon, and final wreck and ruin. The human cipher, plus
alcohol or minus alcohol, it matters not which, means nothing. It may be
true that alcohol subtracted from nothing leaves nothing, but it is
certain that alcohol added to nothing may mean a peril to society and a
serious charge upon it.
A man who has achieved nothing up to the point where he has become
addicted to excessive alcoholism will rarely repay the trouble involved in
an effort to preserve him from his folly, although of course his
preservation from it might be of general social service as a means of
saving the public money that otherwise might be expended in the reparation
of the work of his destructive tendencies, besides the public expense
involved in police, court, and prison economy that prevents him from the
opportunity of indulgence. But thousands of decent men annually yield to
alcohol, and are wrecked by it. The decent and potentially valuable
citizen who through overwork, worry, sickness, sorrow, or even through a
mistaken conception of social amenities or duties, drifts into excessive
alcoholism is a victim of our imperfect social system, and repays remedial
effort. Furthermore, such a man is invariably savable if he himself
applies for salvation, assists with his own will in its application to his
case, and pays his own money for the cure.
The proportion of the cases that can be saved among the general run of
alcoholics who are sufficiently prosperous or have sufficiently prosperous
friends to make them likely to come under my direct observation amounts to
about one quarter of the whole. It will be observed that this claim for
alcoholics is far below the claim which I have made for drug-users.
Where it is found that a case of excessive alcoholism has grown out of a
lack of a normal sense of responsibility, where excessive alcoholism has
reached the point at which deterioration of the moral nature has set in,
or where social and financial entanglements already have resulted, a
problem is presented which is complicated and even very doubtful. In such
a case far more than definite medical treatment must be resorted to before
a complete restoration of the unfortunate to social usefulness can be
hoped for. The naturally irresponsible person or the person already led
into irresponsibility by alcoholism may be regarded as an almost hopeless
proposition. This is peculiarly the case where no financial obligation can
be imposed upon the patient as a part of the treatment. The very poor for
whose treatment some one else must pay, and the very rich to whom the sum
paid for treatment is a matter of no moment, are almost equally hopeless.
My long experience has taught me that the man who does not feel a
financial responsibility for that which is done for him is usually the
least promising of all the cases brought to me. I have found it necessary
to regard as a definite part of my treatment the imposition of a monetary
obligation.
If, for example, the employee of a person or a corporation is sent to me
for relief from alcoholic tendencies by his employer or employers, I
invariably refuse to accept the case unless it is agreed that the sum paid
for the patient's treatment shall be held against him as an obligation to
be repaid as soon as possible to those who have advanced it. Even the man
who is curable will fail in a psychological realization of the misfortune
into which he has actually fallen through alcoholic indulgence unless he
himself must pay the fiddler. In the case of a working-man who is brought
to me for treatment by his employers, I make a minimum charge as a rule,
but only on the condition that with all due speed it is deducted from his
pay-envelop. In the case of men of a higher order, as professional
employees, heads of departments, etc., I insist in a general way upon
following the same line of procedure. I cannot too strongly emphasize my
absolute conviction that it is invariably a waste of money and time for an
employer or an employing company to attempt to help alcoholics by means of
free medical treatments. No good will come from this in the long run, as
it never will prove to be worth while. Thus we may classify very rich,
utterly poor, and irresponsible inebriates as among the hopeless. From
every moral, social, and economic point of view the hopeless inebriate is
a liability to the world at large. Throw him in the sieve of
respectability, and soon or late he will always prove small enough to slip
through the meshes.
COLONIZATION OF ALCOHOLICS
Among such cases will be found fit subjects for colonization, and these
are the only ones who should be treated in this way. No greater social
mistake is possible than the colonization and segregation, either in
sanatoriums or inebriate farms, of other than utterly hopeless alcoholic
cases. The next greatest mistake undoubtedly is society's failure to
segregate those who are utterly beyond the pale of hope. These men and
women will be less of a burden to their friends and the community after
segregation; their segregated existence will not constitute a threat
against society of the present and future generations. It is my opinion
that these people, men and women, rich and poor, should be sterilized and
put at work. It is possible that this plan, if properly carried out, might
develop some institutional effort worth while. That at present practised
means a waste of time and money.
It should be borne in mind that deprivation never yet removed the
underlying cause of the desire for alcohol, no matter over how long a
period this deprivation may have extended, nor has it ever removed the
desire itself. These things can be brought about only by the elimination
of the poison from the victim's system.
All alcoholics, no matter whether they are preferred risks or hopeless
cases, whether they are to be returned to society or isolated and
sterilized, should be unpoisoned.
SUCCESS OF THE SPECIFIC TREATMENT
The first exhaustive test of this treatment for alcoholism was made at
Bellevue Hospital, and its results were announced in a pamphlet published
by Dr. Alexander Lambert. The hospital in which the work was carried on
was without ideal facilities; overcrowded wards and an insufficiency of
nurses were among the many handicaps. That the results were more hopeful
than anything theretofore accomplished is indicated by the following
extracts from articles by Dr. Lambert:
RESULTS
I am often asked as to the success of this treatment and the
percentage of patients who remain free from their addiction. This
varies enormously with the individual patients and one can only judge
from one's experience. My personal experience is that 11 per cent. of
the morphinists and 12 per cent. of the alcoholists return for
treatment. Doubling this percentage it still gives us 75 per cent. as
remaining free from addiction. Of these a very high percentage are
known to have stayed free.
SCOPE OF THE TREATMENT
This treatment is not offered as a cure of morphinism or as a cure of
delirium tremens or chronic alcoholism, as I said in the first
article. It will, however, obliterate the terrible craving that these
patients suffer when, unaided, they endeavor to get off their drugs
or are made to go through the slow withdrawal without some medication
to ease them. Compared with the old methods of either slow withdrawal
or rapid withdrawal, it is infinitely superior. Deprivation of a drug
is in no way equivalent to elimination of that drug from the body.
Deprivation causes suffering; elimination relieves it. But neither
this combination of drugs nor any other combination known to man can
prevent persons, after they are free from their addiction--be it
alcohol or morphin--from going out and repoisoning themselves by
taking again the drug which has poisoned them and led them on to
their habitual intoxication.
There are many more morphinists who have unconsciously fallen under
the spell of the habit through no fault of their own, than can be
said of alcoholists.
To any one who has ever tried to break off a patient by the old
withdrawal methods when they were taking goodly amounts of the drug,
and has struggled to keep them free from it after they have ceased
taking it, the difference in the picture when undergoing the
treatment by this new method is most striking.
With this treatment most patients do not suffer more than a bearable
amount of discomfort of hot flashes, slight pains, and the discomfort
of their cathartics. When properly administered, this is the full
extent of suffering with the majority of patients. Some do not go as
far as this, a few suffer more. But when improperly administered,
they can suffer as much by this method as by any other.
No test more exacting than the one made at Bellevue Hospital could be
devised. Most of the cases appearing for treatment in the wards of that
institution are of the most advanced type, for the nature of the New York
hospital system may be said in a general way to select for Bellevue the
least hopeful patients coming from the least hopeful classes of society.
If, therefore, anything approaching permanent relief was secured for as
many as twenty out of every one hundred cases, an extraordinary efficiency
was indicated.
Of course the intelligent reader will understand that no man with reason
can claim for any treatment the power permanently to divorce from alcohol
a man who does not wish to be divorced from it. To take a man whose system
has reached that degree of craving for alcohol that he would sign away his
right to salvation in exchange for a drink after a brief period of
deprivation, if he could not otherwise obtain the alcohol, and to unpoison
him so that he feels no necessity or even the slightest desire for a drink
or for any stimulant, is to accomplish a great deal of good. It means
that his nervous system has been restored to something nearly normal, and
that he has been given a chance. The man who has not had this help from
outside can do nothing for himself; but having been cleared of alcoholic
poison, he is brought into a mental state wherein he finds it possible to
estimate reasonably the harm which alcohol has done him. The patient is
then in a mental state that enables his relatives and friends to deal with
him without being forced to estimate and allow for alcoholic abnormalities
in his processes of thought. He is in a physical state that, although it
apparently may be worse than that in which the alcohol had placed him, is
nevertheless one that will enable his physician to work with him
intelligently.
Such an achievement seems a perfect piece of medical work of its kind.
Properly carried out, my treatment will accomplish exactly this in every
instance. It will accomplish it within five days and very likely within
three days. I have never known it to require a period of more than seven.
When this treatment is properly provided for throughout the country, it
will be found that neither large nor costly institutions will be
necessary. The stay of every patient is so brief that in the average
community a small institution containing only a few beds will be found
sufficiently large to meet all local needs.
THE HABITUAL DRUNKARD IS NOT A CRIMINAL
Legislation restrictive of the sale and use of habit-forming drugs is in
reality a dangerous experiment until other legislation that provides for
the medical help of those who would thus be deprived has first been
written upon our statute-books. I am inclined to think that many of the
failures which strew the paths of experimentalists in anti-alcohol
movements have been due to a lack of similar foresight. The man who is
penalized for drunkenness will usually get drunk again the moment he finds
himself at liberty to do so; and this will not be due to any natural
depravity upon his part, but, rather, to an almost inevitable result of
the bodily craving that thrills his every fiber and for the relief of
which nothing whatever has been provided. We shall never make any serious
progress in dealing with the most serious evils of alcoholism until we
waken to the folly of treating the hard and habitual drinker as a
criminal, exacting from him penalties and inflicting upon him disgrace.
In every instance the passage of restrictive legislation should be
accompanied by the passage of remedial legislation; for provision for the
relief of suffering caused by prohibitory laws must be provided. The
courts should carefully consider the facilities at the disposition of the
communities in which they labor, and in imposing sentences they should be
careful not to overtax them. It would be better for a community to keep a
victim upon a steady diet of alcohol for weeks while he was waiting for a
bed in a curative institution than to risk causing the man's death or
insanity by depriving him of his alcohol until the means for relieving his
system's acute demand for it were at hand. By following a similar plan, it
will be found that the evil of habit-forming drugs can be exterminated in
the United States. Whether alcoholism, which is a social vice, ever can be
similarly exterminated by like methods I do not know; but I am convinced
that an intelligent pursuit of such a policy would do more to accomplish
the desired results than ever has been done by other means.
HOW SOCIETY TREATS THE VICTIM OF ALCOHOL
The care of the inebriate who already comes under the law, and who by his
habits forces his way into the state and municipal hospitals, forms one of
the great burdens upon society of the present day. It should be regarded
as one of the most important problems of modern medicine.
No other class of the sick includes so great a number of individual cases.
We find, for example, the almost incredible fact staring us in the face
that more than one third of all the patients admitted to Bellevue Hospital
in New York City are sent there by alcohol, while less than two per cent.
are sent there by habit-forming drugs.
I am casting no reflection upon this or any other institution when I say
that there and elsewhere little understanding is shown in dealing with
these cases. As a matter of fact, no intelligence is anywhere shown in
this matter. The policeman who finds a drunken man or woman on his beat
arrests the unfortunate with as much wrath and probably as much brutality
as he would show a burglar or a murderer; the committing magistrate before
whom the victim is taken treats him or her precisely as he would treat a
criminal; in the various penal institutions to which this man or woman is
committed the idea upon which their whole treatment is based is that of
punishment.
It seems to me that the imperfections of this system might most easily be
corrected by the committing magistrates. It is the largest problem which
confronts these officials; therefore they might very well afford the time
necessary to study it carefully. Concerted action by this group of the
judiciary might accomplish worthy results almost immediately. As matters
are at present organized, the committing magistrate may do any one of four
things with an inebriate who has been brought before him: he can release
him without penalty, he can put him on probation, he can fine him, he can
imprison him. I have yet to discover any one capable of telling me why
measures of this sort can possibly be expected to have a beneficial effect
upon a person who through over-indulgence has set up in his system a
demand for alcohol.
I have no wish to appear publicly as the critic of our petit judiciary,
but no class of men is less informed upon this subject--the one subject
upon which they should be best informed--than the committing magistrates
not only of the United States, but of every other country in the world. A
year or two ago I made a somewhat comprehensive European tour, and studied
carefully the methods of dealing with inebriety. Nowhere did I find the
faintest indication of a tendency for real intelligence in regard to the
matter. We insist upon special education for the professors of our
colleges; yet the influence of a committing magistrate upon the human life
that is brought under his direct sphere of influence may be greater even
than that of a college professor or a college student, and of our
committing magistrate we make no educational demand whatsoever, and have
never established even a minimum standard of intelligent information for
our petit bench. It is my belief that expert sociological knowledge should
be required of every man considered for the important post of committing
magistrate.
RESPONSIBILITY OF THE MAGISTRATE
The fact that in New York State a colony for inebriates has been
established by law makes this special knowledge more necessary there than
it was before. Wherever such institutions have been founded, and the
courts may contribute to their population by commitment, an unintelligent
magistrate finds it within his power not rarely, but every day, to do more
harm during one session of his court than he is likely to find it within
the scope of his intelligence to do good during the course of a year's
sitting. I find it impossible to be otherwise than bitterly pessimistic in
regard to the work our courts are doing with alcoholics.
Under the New York law, a man taken for the first time before a magistrate
and charged with alcoholism must either be fined or told that if he again
appears charged with that offense, he will be subject to commitment to the
inebriate farm for a period of not less than three months. By this
procedure not one thing has been accomplished toward the salvation of the
man. If he is not committed, but is only threatened and ordered to report
weekly or oftener to the probation officer or the court itself, the
greatest of all damage has been done, since the man's pride has been
depreciated. After definite medical treatment has been administered to an
inebriate, the only other thing that can be done is to make an intelligent
appeal to his pride. In this appeal is included at least one half the
possibilities of his salvation. Nowhere save in a few instances in New
York City is the alcoholic case treated with medical intelligence, and
nowhere in the world is the balance of the necessary treatment--the right
appeal to pride--carried out with any degree of common sense.
I find one system of special horror in this treatment of
inebriates--committing a man for three months, then for six months, and
then for twelve. No more certain means could be devised to increase the
harm done by alcohol to the community. Not only does this course fail to
help the man in any measure whatsoever, but it increases the unspeakable
harm which his misfortune must inflict upon his family. In most instances
such a commitment not only means the man's separation from his means of
livelihood for the period of its duration, but his discharge from it as
the result of this utterly inefficient and legally inflicted disgrace.
The whole effort of society in dealing with the alcoholic should be to
prevent those things which at present are the very ones which it
accomplishes--mental depression, loss of pride, disgrace, and loss of
social position. I am inclined to think that as the world grows older it
will be more and more convinced of the inefficiency of punishment, and
more and more aware of the necessity of reform through helpfulness.
It seems obvious that penalization, probationary influences, or
colonization must be utterly useless in removing from a man's physical
system the craving for alcohol. Therefore it is equally obvious that their
only successful mission must be to remove the victim of drink from contact
with society for the length of time during which his sentence is
operative. The man who is in all probability incurable is not put
permanently out of harm's way by these means, or placed where he can do no
harm; the man who has good stuff in him but who has through chance used
drugs to excess upon one or more occasion is offered by these methods
nothing in the nature of a fair show toward regaining his usefulness.
I see the possibility of many serious results in New York's board of
inebriety plan. These, I think, have their beginning principally in the
fact that nothing along the line of classification has been devised or, as
far as I know, has been even suggested. If its work were made efficient by
means of the adoption of a plan of classification, this board really might
become a great boon to society. Suppose that instead of penalizing the man
who has been taken before it for inebriety, the board, after intelligent
and detailed investigation has shown that the man is probably curable,
should provide for him the necessary definite medical treatment to relieve
his system from the ill effects of alcohol, and then should bring him into
contact with psychological and analytical minds capable of enforcing upon
him a realization of the terrible meaning of alcoholism. Without having
affected the man's pride it would send him back to his family and his task
with a cool brain and a new point of view. Would not this be a vastly
better way of dealing with him than those which are at present followed?
There is no reason why some small charge should not be enforced against
such beneficiaries of an enlightened public intelligence who might be
found able to meet it. This would accomplish two things: it would reduce
the public expense of the system and it would add very greatly to the
mental impression left upon the mind of the person for whose benefits the
State was working. Furthermore, if a magistrate had once formed the habit
of feeling personal interest in individual cases probably his first act
after a man had appeared before him would be to send for the accused's
employer and make the truth of the situation clear to him. The mere fact
that a man has once been intoxicated should not justify his discharge from
employment in which at normal times he is useful and efficient. Both for
his sake and for his employer's, efforts should be made toward reform; for
it is not infrequently the case that the man who has lost control through
drink is in normal conditions the best man in the office, factory, or
workshop. That is one of the chief tragedies of the problem of alcohol.
There is no subject upon which society more sadly needs enlightenment. In
this educational process it is probable that the magistrate will be the
largest factor. He must realize that he is not society's instrument of
vengeance, but society's instrument of helpfulness. It should be his aim
not to punish, but to protect and preserve. He must realize that
scientific knowledge of the problems which confront him is as necessary to
his real efficiency as scientific knowledge is to the analytical chemist.
The heart of a conscientious magistrate should thrill with a special
sympathy, should be aware of a great responsibility, whenever there
appears for judgment in his court a man who for the first time has lost
control of himself through drink. To mar this man forever is an easy
task; to make him may be difficult, but it is certainly not beyond the
bounds of possibility.
The hard drinker who for the first time is haled into court as the
consequence of intoxication never is willing to concede either to himself
or to others that he needs help. His soul revolts before the mere thought
that he has more than temporarily, even momentarily, lost control. He is
likely to deny that he has developed a craving for alcohol, and
emphatically and indignantly to assert that his drunkenness has been
merely incidental to the social spirit, an accident, and in general a
thing of no primary importance. The thought that without help there is
even a possibility that he may drift from bad to worse is abhorrent to
him, and is indignantly repudiated. He will cheerfully admit that many
other men of his acquaintance have fallen victims to the effects of
alcohol, but he will vehemently deny the possibility of a similar fall on
his own part. The magistrate who thoroughly understands all the details of
the alcoholic's psychology, and who is sufficiently adroit of mind and
speech to take advantage of this understanding, giving the culprit who has
been brought before him every benefit of a carefully and intelligently
organized knowledge of alcoholism, could not fail to be one of the most
useful of society's servants and safeguards.
The man or woman taken before a magistrate as the result of alcoholic
over-indulgence offers a peculiarly perplexing problem. Society has placed
itself in a highly inconsistent position as regards its relation to
alcohol. It permits a man to pay it for the privilege to sell alcohol to
any one who asks for it, the only restriction being that he may not sell
it to a person who already has "had too much." This leaves the decision as
to a customer's needs and capacity, as well as perils, to be rendered by
the man behind the bar. Thus to an extent we intrust daily the destinies
of an appreciable proportion of our public to a class of men who certainly
have done little to earn general confidence. In nearly every State, if not
in all, laws exist imposing penalties upon the dealer in alcohol who sells
drink to a person who is already in a state of intoxication; but a careful
study of the records of our courts would fail to reveal any large number
of liquor dealers who have been charged with this offense, while it is
obvious that most persons found upon the public streets or elsewhere in a
state of intoxication must have had alcohol served to them at a time when
they had already "had enough." As a matter of fact, the intelligent mind
cannot fail to realize that the man who has "had enough" invariably has
had too much.
This is only one of many reflections which must occur to the inquiring
mind occupying itself with this problem. We have made innumerable laws
dealing with, and fondly supposed to control, the sale of alcoholic
beverages, but as a matter of fact only one sort of law has ever been
devised which possibly could control it, and that law provides for
absolute prohibition.
THE NEED OF AN ORGANIZED EFFORT TO HELP THE ALCOHOLIC
If the world wishes to be relieved in any measure from the human waste
attributable to alcohol, the time must speedily arrive when municipalities
will recognize it as their duty to provide definite medical help for every
man who wishes to be freed from the craving for alcohol, and who cannot
afford to pay for treatment. It must be recognized that it is society's
duty to hold out this helping hand to every man who has a job and is in
danger of losing it through the trap which society itself has set for his
feet by authorizing, and thereby encouraging, the sale of alcoholic
intoxicants.
Notwithstanding the presence in our social fabric of innumerable
charitable bodies, churches, religious societies, and other groups of
people who mean well and work hard to aid the unfortunates, it is a fact
that nowhere in the United States or, as far as I know, anywhere else is
there a single organization which is effectually working along definite
and intelligent lines for the preservation of the endangered man who is
still curable.
No mother, wife, employer, or magistrate can effectively reason with a man
whose brain is befogged by alcohol, for that man cannot reason with
himself. Tears, threats of imprisonment, and loss of position do not have
upon him their normal reaction. He is a sick man whose mental and physical
condition is abnormal; it must be made normal before anything real can be
done toward his assistance.
There is but one way out of the sad muddle in which alcohol has plunged
certain branches of our judiciary. In every city must be established
emergency hospital wards to which committing magistrates may send persons
with excessive alcoholic or drug histories. Treatment in these emergency
wards will be neither difficult nor costly.
Once this has been done, the patient may be returned to court, where his
clarified brain will greatly assist the magistrate in deciding upon the
proper course for his assistance and the protection of society.
The commitment of the alcoholic to an ordinary penal institution is a
perilous expedient. The experiences which various authorities connected
with the Department of Correction in the City of New York have had with
drug and alcohol smugglers indicate a condition that exists more or less
generally in penal institutions throughout the country. The drug-user or
alcoholic who has been locked up in a prison is in no way relieved of his
craving for the substance which is harming him, and his efforts to obtain
it will be desperate. The class of men who surround him as prison guards
is not of a high type. If he has money, they will get it from him if they
can; and if he has friends outside, especially if they themselves be drug
or liquor addicts, they will attempt to smuggle to him what he craves.
Inasmuch as it is much easier to smuggle drugs into a prison than it is
alcohol, many alcoholics have been changed in prison to drug-takers, and
after this change the metamorphosis for the mere drunkard into an actual
criminal has often occurred. The administration of a definite medical
treatment should therefore be regarded as imperative in all cases of drug
addiction, and in most cases of alcoholic addiction that appear in our
prisons. In the cases of alcoholic addictions, imprisonment should end, in
the case of first offenders, with the completion of the treatment and the
restoration of the subject's mind to normal.
I cannot too strongly or too frequently reiterate the statement that there
is no more desperate illness than chronic alcoholism.
Purification from the physical demand for alcohol at the place of
commitment of men taken before the courts upon the charge of intoxication
might save the public from a greater burden than any other available
medical process. Drunkenness cannot rightfully be considered as a crime as
long as society sanctions the sale of alcohol and profits by it; therefore
the punishment of alcoholics as criminals is an intolerable injustice.
That it is also an economic waste is as clearly apparent.