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.