FORMS OF INEBRIETY
| Men | Women | |
| Steady drinkers | 130 | 2 |
| Periodical drinkers | 76 | 8 |
| Morphinism | 3 | 11 |
| Alcohol-morphine | 5 | 2 |
| Alcohol-cocaine | 3 | .. |
| Alcohol-heroin | 3 | .. |
| Alcohol-morphine-cocaine | 3 | 1 |
| Alcohol-morphine-cocaine-heroin | 1 | .. |
| Alcohol-morphine-veronal | 1 | .. |
| Morphine-cocaine | .. | 1 |
| Morphine-cocaine-heroin | 2 | .. |
| —— | —— | |
| Total | 227 | 35 |
The treatment of the inebriate naturally divides itself into two stages: the treatment, first, of the immediate effects of indulgence, and, second, such treatment as will tend to prevent a repetition of the indulgence. The treatment of the immediate effect of alcoholic indulgence is regarded as the easiest part of the work. While patients are at times received under the influence of intoxicants, in no case have they been unruly. For an obstreperous intoxicated person the quickest soberer is apomorphine judiciously used; but we have never yet resorted to it. Generally, a fairly rapid reduction in the amount of alcohol consumed is made, instead of immediate withdrawal. Only in the most exceptional cases is alcohol given over three or four days. As a rule, during the first day it is given fairly freely. The treatment received during this period depends entirely upon the individual; and the treatment of one may be entirely different from that of another. Many receive baths at a temperature of 98° to 100° F. for thirty or sixty minutes for nervousness and sleeplessness. Some receive the coal-tar hypnotics, veronal or sulphonal; the more restless, hyoscine; and for others paraldehyde is used,—and occasionally chloral is used in combination with hyoscine and cannabis indica.
As long as he receives alcohol, the patient remains in bed and receives only liquid diet. In cases of considerable digestive disturbance, capsicum is freely used, but we have seldom found it necessary.
All receive preliminary catharsis, but no attempt is made at prolonged elimination in that way.
For about a month tonic treatment with strychnine nitrate is used in doses of 1-20 to 1-40 gr. three times a day. Any other medication depends entirely upon the physical condition of the patient as revealed on examination. Only under the most exceptional circumstances are drugs given in alcoholic vehicle.
In morphine or cocaine users, the reduction is usually made more gradually, requiring a week to ten days. Generally, we find a patient comfortable with one-half the drug he has been accustomed to taking. In some cases we find it best to reduce the quantity to about one-half grain, and then abruptly cease.
Under this plan, diarrhea, cramps, restlessness, and insomnia are much less marked. We regard the free use of the prolonged warm bath as more advantageous to those addicted to drugs than to alcohol. Generally, it is the only measure that seems to offer relief. We particularly do not use hypodermic medication in any drug users.
Heroin users, who seemingly are more numerous, receive their drug only once in twenty-four hours. The withdrawal of the drug does not cause the discomfort that the withdrawal of morphine causes. Vague sensations of discomfort, some perspiration, and insomnia are met with in such cases.
No users of cocaine only have been met with, but in mixed forms this drug is at once withdrawn.
The removal of alcohol or drugs is the easiest part of the work. Under the regular discipline of the institution, and the absence of temptation, the great majority of patients get along without any trouble because of abstinence. But there is the future to fear. The patient must go out into the world again, and engage in the daily struggle for his livelihood. One must aim to put him in such condition that he may be able to resist the temptations that will surround him on every hand. Our work, then, is to build up and re-educate, to strive to form a new character, to encourage a habit of sobriety, instead of drunkenness, to teach the man to work, to occupy himself, to obtain for him a new outlook on life, and to teach him his duty to himself, to his family, and to his neighbor. Here is where our difficulty begins. Nearly every inebriate has a firm belief in his ability to abstain from alcohol or drugs at any time and under any condition, because he thinks he is not really responsible for the condition into which he has fallen, and that, had not certain things happened, he would not have been drinking.
He is insistent in iterating and reiterating that he has now made up his mind to stop drinking, and that is all that is necessary. Though admitting that, for five, ten, or fifteen years, he has been going steadily downward, he has full confidence in himself, and he believes injustice is being done him when his parole is refused and he learns that he is expected to remain until he has strength to resist temptation.
In this upbuilding of body and character the following are essential: regularity of habits, discipline, work, food, and recreation, together with the personal influence of the physician and those coming into close and personal contact with the patient.
Regular work is one of the most valuable of the remedial agents at our command. It should be suited to the individual, and, as a rule, should not be that to which the man has been accustomed. Particularly is this true of the man who is used to mental labor only,—the clerk, the physician, the pharmacist, the merchant, etc. For them out-of-door work on the farm, lawn, or in the garden, is the very best, and next comes indoor shop-work. We must provide something that engages time and attention, that provides some new outlook upon life, and enlarges some field of endeavor in which the patient has labored before coming to the Hospital. Thus far the work has been on the farm or the improvement of the grounds, or has been carpenter, cement, or some construction work. The women do all the mending, and make all needed articles, such as bedding, towels, etc. They also work in the laundry. At present we are teaching embroidery of various kinds, no one of our patients having ever learned any such work.
The future must see us provided with shops, especially for winter work. With a capacity of ninety-nine men we are able to keep them fairly well occupied during the winter months, but any increase will have to be cared for under special conditions.
A very important factor is the length of time, as mentioned above under prognosis, that a patient remains under care. As a general thing, it is expected that the average patient will remain, approximately, six months. The period of detention is determined only after a study of the individual. An endeavor is made to consider all factors that may influence the future life of the patient,—the length of time and the amount he has been drinking, the effect on his character and physical health, the surroundings and occupation to which he must return. Some patients are paroled at the end of six months, some remain seven months. Drug users require treatment for a much longer period of time than users of liquor; and they remain from nine months to a year. The law provides that a patient shall not be paroled in less than two months, nor shall he be detained longer than two years without parole. This, of course, introduces the disagreeable aspect of the work. The detention is compulsory; and in some patients antagonism possibly over-balances the benefit of detention.
“One of the most pronounced features of inebriety is, however, the inability of many inebriates to appreciate the necessity for treatment; and the more severe the inebriety, the less easy it is first to get the patient under treatment at all, and, secondly, to get him to remain long enough for any treatment to have a permanent curative effect. One has only to work among inebriates, no matter to what class of society they belong, to know that fear of interfering with the liberty of a subject who has no real liberty, in that he is a slave habitually or periodically to the drink craze, results in the interference with the liberty of all those who have to put up with his irresponsible behavior under the influence of alcohol and other narcotic drugs.
“Were the treatment of the inebriate only possible in a free sanatorium, only a small minority of inebriates would come under treatment at all, and these would be of the less severe type.” (Pathological Inebriety, by J. W. Ashley Cooper, 1913.)
Discipline is of great importance, but great care must be taken in its enforcement. It is of more value for one to perform a certain duty because one regards it either as the proper thing or as likely to benefit one’s self or others.
The personal influence of those who come into close contact with the inebriate can hardly be overestimated. He is easily influenced, often easily led, and a few thoughtless words or careless actions can undo the result of patient work.
All factors that may influence the future life of the patient must be taken into consideration,—the length of time and amount he has been drinking, the effect on his physical health and character, and the surroundings and occupation to which he must return. Very often the cause of the commencement of the patient’s excessive drinking may be removed or may have disappeared. Such would favorably influence the prognosis.
The presence or absence of irremediable disease is important. For instance, a woman recently committed to our care suffered from what was supposed to be, or was, neuralgia. She still has occasional twinges of pain; but we believe when the dentist has finished his work these will disappear, and her prospect be reasonably bright. A man, 56 years of age, four years ago, suffering from stone in the bladder, was given morphine, following an operation. The bladder condition was permanently relieved, but he became a morphine user. Such a case is a promising one. In him the destruction of character is but little marked.
A boy, chasing around the city, acquired the cocaine habit, and became a loafer, drinker, and follower of loose women. For him the future offers practically no prospect. Were he a little younger, and had the attempt to rescue him been made earlier, there would have been much more promise. But I doubt whether he can withstand the lure of his former life. With a few drinks, his judgment becomes paralyzed, and he is back to cocaine again.
Another man, an alcoholic, a printer, became nervous and exhausted after six months of linotype work. He probably will not get over his drinking permanently unless he changes his occupation.
One of the most important factors as regards recovery is the length of time a patient remains at the Hospital. It is sheer folly to expect that in a few short weeks a man shall have entirely recovered from the effect of excesses extending over a period of years, to expect him to regain a lost will power in that time.
Another important factor is the insight a patient obtains into his own condition. We cannot claim to make a man stop drinking. All we can do, is to place him in such mental and physical health that it is unnecessary for him to resort to stimulants.