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 reëstablish 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 reëstablish 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.