Habits that Handicap: The Menace of Opium, Alcohol, and Tobacco, and the Remedy

CHAPTER III

I have seen an astonishing number of physicians who for various physical reasons other than exhaustion and the need of stimulant considered themselves eligible to experiment with drugs. It is a curious thing that, as a class, physicians and surgeons are themselves singularly averse to submitting to surgical operation, even when symptomatic indications strongly urge it. Why surgeons, in particular, should so generally dread the application of the knife in their own cases is a puzzle, for of course no class more thoroughly understands the need of surgery. I could mention many cases of this sort, but one in particular recurs to my memory. He was one of the most careful and best-informed doctors in the country, and he was not without a certain special knowledge of the peril involved in habit-forming drugs; but he suffered from a painful rectal trouble, and although he considered himself too intelligent a man to go too far with a dangerous substance, he did go too far. He had thought that he could leave drugs off whenever he desired; he found that he could not.

THE PHYSICIAN WHO TAKES DRUGS

It is impossible to make even an approximately accurate guess at the proportion of physicians who are drug-users. Everywhere except in New York State physicians can obtain as many drugs as they desire without publicity and without laying themselves open to any penalty whatsoever, even if their purchases are brought to official attention. No medical organization takes any cognizance of drug-taking physicians or provides any medical help for them. It is highly probable that the New York State legislation may uncover some of the drug-taking doctors in that commonwealth, though this is by no means certain, since legislation in force in only one State cannot effectively put a stop to the illegal importation of habit-forming drugs from other States and countries. Proper restrictive legislation of sufficiently wide scope would very quickly disclose every drug-taking doctor in the nation, and either force him to correct his physical condition or drive him from the profession. Proper general regulation of the traffic and consumption of habit-forming drugs will aid tremendously in freeing the medical profession from drug-takers. Until this general regulation exists no general reform will be possible. An exact accounting for every grain of habit-forming drugs which he purchases, possesses, or administers, must be demanded of every physician in the United States before this evil can be entirely abated; and this accounting among physicians will be impossible until a similar accounting is demanded of every grain imported, manufactured, and dispensed by wholesale and retail druggists.

Concerning the extent of the hold which the drug habit has upon physicians I have had a rare opportunity to judge. Not only has my dealing with the drug habit been as exclusively as possible through the physician rather than through the patient, but the brevity of my treatment and the privacy that my patients are assured make it possible for many physicians who have become afflicted to come to me for relief without arousing in the mind of any one a suspicion of the real cause for their brief absence. I therefore feel that I have a firm basis for accuracy.

It is the fear of disgrace which has driven hundreds of physicians from bad to worse with the drug habit: they have become apprehensive that any effort tending to their relief will uncover their position to their families, associates, or patients, and thus bring ruin; so they have drifted on from bad to worse. Many who have not taken steps in time have reached the irresponsible and hopeless stage. To the medical profession in general, as well as to the public, these men are a dreadful menace.

ATTITUDE OF THE PROFESSION

I, a layman, have been greatly surprised that the medical world shows so little sympathy for these unfortunates. This seems to me to be specially reprehensible, since by this neglect they imperil the public. No greater service could be rendered to mankind by the medical profession than a concerted movement of the medical organizations toward the care and relief of those among their drug-taking members who are still susceptible to help, and the exclusion from medical practice of those who have already gone too far to be reclaimed. Physicians of this class who are without means are specially entitled to sympathy and help, and this service will be of double value, for it will not only give them necessary aid, but will notably safeguard the public. No physician should be permitted to practise who is addicted to the use of habit-forming drugs or who uses alcoholic stimulants to excess; but whatever is done in regard to these men should be accomplished without publicity and without any loss of pride or standing. A doctor who has used either drugs or alcohol is much more to be pitied than blamed.

The worthy practitioners—and there are many—who must resort to the use of drugs in order to enable them to practise despite some physical disability which cannot be eliminated, are no less numerous in proportion to the total number of physicians than similar cases are in relation to the total number of lawyers, merchants, or journalists, but because of the nature of their work, they are far more dangerous to the general public. It seems to me that there is in this fact—the existent, non-elimination of such perilous characters from the practice of medicine, and the obvious, very real necessity for such an elimination—a suggestion for some person of philanthropic mind. If the medical profession will not care for its own, then some one else must care for them. It occurs to me that among the people whose naturally fine impulses are leading them toward the endowment of institutions for the care of the aged maiden lady, or superannuated teachers, or others to whom fate has been unkind, there are many who might well consider this great need for the establishment of a comfortable institution in this country for the care of physicians who through no fault of their own have become unable to practise their profession with profit and efficiency.

HOW THE DOCTOR BECOMES A DRUG-TAKER

The doctor’s yielding to the drug habit is a simple process, in ninety-nine cases out of a hundred unaccompanied by any unworthy tendency toward dissipation. In another part of this book I make extensive reference to the fact that nowhere in the text-books by means of which the medical students of the world receive their education is any proper attention paid to the psychology of the drug habit. We may assume that a doctor, having lost sleep because of a difficult case, is confronted on his return to his office by another that demands immediate and skilful attention. He is tired and very likely he himself is ill. He cannot yield to his worries or illness, as he would demand one of his patients to yield. He must “brace up.” He knows that in the stock of habit-forming drugs that he uses in his profession lies the material which will brace him up. He tries it; it succeeds.

This doctor has begun to nibble at the habit, and he does not know his danger. He himself does not believe that one or two or a few doses will fasten that habit upon him. He finds that a certain dosage produces the necessary desired result upon the first day; he is stimulated to new efforts in behalf of his patients, and because those new efforts are the result of stimulation, they produce abnormal weariness. This exhaustion must be overcome, and the result is another dosage of the drug; and this time the dosage must be larger than the first, for both his toleration for the drug and his weariness have increased. Only a few days of such experiences are necessary to fasten the habit upon him.

I have often endeavored to imagine the thrill of horror which must chill a doctor’s soul when he finds that this has happened. His position is a dreadful one. He has lost control. He must tell no one, for if he tells, disgrace and the loss of his means of livelihood will be but matters of a short time. He knows nothing of any means of real relief; he cannot help himself; he is familiar with the dangers attendant on the fake cures which are widely advertised. He is confronted by a stone wall. He must either continue his dosage, thus enabling him to keep on with his practice, or he must accept ruin and defeat; and to continue his dosage is the easiest thing imaginable, for the drug has been by law intrusted to his keeping and is close at hand.

Another doctor who is specially susceptible to drug addictions is the one who has been accustomed to alcoholic stimulation. Any doctor who drinks alcohol, when he finds himself beset by arduous labor involving loss of sleep, or is confronted by cases of such a complex nature that they involve a great deal of mental worry on his part, is likely to drink more than usual. Thus work and worry, the two things which make him most liable to the evil effects of any stimulation, are likely to drive him directly into over-stimulation.

Over-stimulation results in super-nervous excitation. The victim finds himself unable to sleep, he finds his hand tremulous, he finds his thoughts wool-gathering when they should be concentrating with intensity upon his work. In his pocket case there is his little morphine bottle; he knows its action, and when called to see a patient while under the influence of alcoholic stimulants he attempts to steady himself by the administration of a small dosage. The result is virtually instantaneous and at first marvelously effective. He finds himself enabled to do better work than he has done for years, and more of it. The remedy seems magical; he tries it again and again. The man is lost.

Such instances as these have produced the most utterly hopeless of the many cases of drug addictions among physicians with which I have come into contact.

TYPES OF DRUG-USERS

Specially numerous among drug victims are physicians in nose and throat work, where they make daily employment of cocaine solution. Some of the most desperate cases of drug habit that I have ever seen among physicians have come from this class, made familiar with the constant use of the drug by the necessity for continually administering it to their patients.

Another physician who is specially liable is the man who suffers severe pain from a physical cause that he knows can be removed only by resorting to surgery. The average doctor will postpone a surgical operation upon himself until his condition has long passed the stage that he would consider perilous to any of his patients. While he postpones it he is suffering, and while he suffers he may be more than likely to continue his practice through reliance upon the stimulation and pain-deadening qualities of habit-forming drugs, concerning the true and insidious nature of which he usually knows no more than the average layman.

There have been a few cases of physicians who have yielded unworthily to drugs and opiates as a means of dissipation. I have known some physicians, for example, who have been opium-smokers. In the United States the opium-smoker is invariably unworthy. Not long ago the New York police raided the apartment of a physician where were found thirty or forty opium-pipes and more than a hundred pounds of opium, either crude or prepared for smoking. I have known fewer than half a dozen physicians whose drug vice was purely social, however. The victims of drag habit who achieved it through a tendency toward dissipation are almost invariably denizens of the under-world; and if it were not for the fact that the contagion of their vice may spread, they might well be permitted by society to drug themselves to death as speedily as possible.

We shall entirely disregard the physician who becomes addicted to the use of drugs through unworthy tendencies, and consider only the dangers to the profession and the public latent in the case of the physician who becomes addicted in the less reprehensible, but more dangerous, manner that I have indicated. Not only will such a drug addiction injure the doctor’s practice and threaten his career, but it will surely constitute a threat against the welfare of his patients not included in the possibility that through it he may miss engagements, write improper prescriptions, and make mistakes of many kinds.

THE DRUG-TAKING PHYSICIAN A MENACE

A very serious danger lies in the psychology of drug addictions. The person who has taken a habit-forming drug for the purpose of relieving his own pain, and through it has found that relief which he sought, is almost certain to become abnormally sympathetic to the suffering of others. It is a curious fact that this doctor will be more than likely to administer the drug he uses to his patients, not with malicious, but with probably friendly, intent, and that he will feel no scruples whatsoever in acting as a go-between for drug-users in general who find themselves unable to obtain supplies easily. He will do what he can to help confirmed users to obtain their drugs, even if he makes no profit out of it. He will write prescriptions for them in evasion, if not in violation, of the law. It is a curious and tragic fact that the drug-taking doctor will spread the habit in his own family.

There have been many instances in my hospital when I have had a physician and his wife as patients at the same time and on the same floor. In every one of these instances the drug addiction of a wife has been the direct result of constant association with the drug-addicted husband. No more dangerous detail exists in the psychology of drug-users than their almost invariable tolerance for the habit in others and their sympathetic willingness to promote its spread among those who suffer pain. In the under-world the drug habit never travels alone. Through it the woman who is a drug-user holds the man whom she desires; through it the male drug-taker holds the woman whose companionship he finds agreeable. It is a curious fact that while in the under-world the drug habit has become a social vice, especially in the case of cocaine, and is frequently a proof of mixed sex-relations, in the upper-world it is accompanied by a secrecy of method and sequestration of administration that characterizes no other form of vice.

The difference between the psychology of the doctor’s relation to the drug habit and that of the layman to it may be summed up in the statement that while the layman does not at all know what he is getting, the doctor knows what he is taking, but thinks that he can stop taking it whenever he feels ready. It is probable, therefore, that the doctor’s primary danger is as great as the layman’s, and it is certainly true that his secondary danger—that growing out of the fact that he has drugs and the instrument for their administration always ready to his hand—is very much greater.

The unnecessary administration of habit-forming drugs to the sick must be legally prevented as far as possible. No affliction which can be added to an already existing physical trouble can compare in horror with that of a drug habit. Numbers of cases have come under my observation in which physicians have accomplished exactly this addition to the ruin of their patients’ health, to the incalculable distress of the sufferers’ families, and to the vast loss of society. In the recent legislation written upon the statute-books of New York State the first definite effort is made to provide against this catastrophe.

CHAPTER IV

The major importance of the first two groups is due to the fact that they include by far the greater number of cases, and to the pitiful fact that such victims are always innocent. Speaking generally, and happily omitting New York State from our statement, it is safe to say that the manufacturer, the druggist, and the physician are without legal restraint despite their importance as promoters of drug habits, while the comparatively unimportant drug-purveyor in the under-world is held more or less strictly in control by the police, and is subject to severe punishment by the courts in case of a conviction.

With few exceptions, the part which the doctor plays in the creation of drug habits is due to lack of knowledge; but the druggist’s part in the spread of this national curse is purely commercial, and may justly be designated as premeditated. He always has gone and always will go as far as is permissible toward creating markets for any of the wares that he sells.

Regulation of the upper-world in regard to the distribution of habit-forming drugs will automatically regulate the under-world in its similar activities. The amount which will be smuggled by those of criminal tendencies always will be small as compared with the amount improperly distributed through channels now recognized as legitimate until all the States have passed restrictive legislation founded upon, modeled after, and coöperative with New York State’s legislation; and all this must be backed and buttressed by Federal legislation of a special kind before real and general good can be accomplished in the United States. Illicit drugs rarely find their way into the possession of users who have acquired drug habits through illness or pain. So it must be admitted that most of the effort that in the past has been made toward restrictive legislation has really been devoted to the interests of the unworthy rather than to those of the worthy. Save in New York State, the man or woman with a sheep-skin—the doctor, the druggist, or the nurse—remains virtually a free-lance, permitted to create the drug habit in others or in himself or herself at will.

THE DOCTOR A MEANS OF SPREADING THE DRUG HABIT

The man in severe pain is immediately exposed, by the very reason of his misfortune, to the physician with a hypodermic or the druggist with a headache powder; the man who cannot sleep may at any moment be made a victim by the physician whom in confidence he consults, or by the druggist to whom he may foolishly apply for “something” which will help him to secure the necessary rest. Save in New York State, the druggist’s shelves are crowded with jars and bottles holding dangerous compounds which he may dispense at will, his drawers are crowded with neat pasteboard boxes containing powders which are potent of great peril. The public will have made a long step toward real safety when it realizes that any drug which brings immediate relief from pain or which will artificially produce sleep is an exceedingly dangerous thing.

The sick man’s confidence in his doctor is one of the doctor’s greatest assets; it has saved innumerable lives. It is of the same general nature as the mysterious mental phenomena which frequently control physical conditions, and which have been capitalized by various bodies, such as Faith Cure and Christian Science; but if this is an asset to the physician, the general public knowledge that he carries in his case or in his pocket drugs which he can use without restraint of law for the relief of pain may become a general peril. In the old days when the doctor’s work was a mysterious process, operating by methods of which he alone was cognizant, this peril was less well defined; but now that the spread of education has made everybody a reader and periodical literature of the times has given even children a smattering of knowledge concerning medical matters, the nature of the means by which the doctor works his miracles is well known, and his unrestraint may become a public peril.

Of one thousand patients who may consult the average physician, nine hundred and ninety-nine know perfectly well that he can stop their pain if he desires to do so. Pain is unpleasant; naturally their demands that he use his power are insistent. If he refuses, they are likely to call in another and less scrupulous physician. The medical profession is overcrowded, and perhaps the doctor needs the money. Even if he is swayed by nothing but financial need, he is likely to be tempted into the administration of pain-deadening substances when his patient urges him.

There is another powerful influence which works upon the most admirable of men—the pity of the temperamental physician for the human sufferer. Most men who choose the medical profession as the avenue for their life-work have the qualities of mercy, pity, and sympathy notably developed in their psychology. This is likely to induce them to stretch points in favor of relieving suffering patients. Even when their previous experience has proved to them the danger lying in narcotics, they are likely to forget it, or to take a chance if a special emergency arises. This may be done without great peril to the patient.

DANGER OF THE KNOWLEDGE OF PAIN-RELIEVING DRUGS

The physician should exhaust every means known to medical science to prevent his patient from knowing what it is that eases pain when his practice makes it absolutely necessary that a substance of the sort should be administered, and this is very much less frequent than the average doctor realizes, as will be shown in another passage of this book. It is in this necessity for concealment that the great danger of using the hypodermic syringe as an administrating instrument principally lies. The moment the hypodermic syringe is taken from the doctor’s or the nurse’s kit, the sufferer is made aware of the means which will be used to give him ease. He remembers it, forming a respect and admiration, almost an affection, for the mere instrument, and with the most intense interest gathers such information as he may find it possible to acquire about this wonder-working little tool and the material which is its ammunition of relief. He knows absolutely that the relief which he has found is not due to medical skill, but to the potency of a special drug administered in a special way. He stops guessing as to whether he has been soothed by an opiate; he knows he has been.

It is not only those of weak psychology or mental characteristics who are affected by this knowledge and who through it become drug-takers, though it is the general impression that this is the case. No impression was ever more inaccurate. The mentally strong and the morally lofty are as much averse to suffering physical pain as the mentally weak and the morally degenerate. All are in the same class when the drug has been administered until that point of tolerance is reached where its administration cannot be neglected without the indignant protest of the physical body. That this fact should be impressed upon the medical profession as a whole is one of the most needful things I know.

Another hazard which the doctor runs, if he passes the point of extreme caution in the administration of drugs to patients, is the possibility, even the probability, that through such an administration he will lose control of his patients. From the moment the patient becomes cognizant of the means which the doctor has successfully used to alleviate his pain, he begins to dictate to the doctor rather than to accept dictation from him. No doctor can control a case successfully unless his judgment is accepted as the supreme law of treatment. A patient who is not susceptible to the doctor’s dictation cannot be expected to get the full advantage of the doctor’s skill or knowledge. If diagnosis shows that a patient requires some operation, as in certain uterine troubles, or more especially in the case of bladder affections or gall-stones,—cases in which frequently only an operation can give relief,—and if that patient is aware that even if the operation is not performed, the doctor can still ease all suffering, that patient, loath to run the risk of the surgeon’s knife, horrified by the thought of hospitals and operating theaters, is likely to demand the relief which opiates offer, and refuse to risk the cure which surgical procedure alone would certainly afford.

The conscientious doctor who insists upon the proper course in such a case is seriously handicapped by the presence in the medical profession of many men who are less conscientious, and who may yield more readily to the urgings of the patient. Thus the possibility of unrestricted use of habit-forming drugs by the medical profession becomes a handicap to the conscientious man and a commercial advantage to the unscrupulous practitioner.

UNCONSCIOUS VICTIMS OF THE DRUG HABIT

Episodes occurring continually in the course of my work add to the strength of my conviction of the physician’s responsibility. For years not a week has passed which has not brought me patients with stories of the manner in which they have become victims of drug addiction through the treatment of their physicians. Lying before me as I write is a communication from a young man in Pennsylvania. He had been hurt, and through improper surgical attention a healing fracture had been left intensely painful. The attending doctor, unable to correct his imperfect work, had left with him a box of tablets to be taken when the pain became severe. Promptly and inevitably the youth achieved the drug habit. He felt disgraced, he would not tell his father, his wife, or his sister. His doctor could give him no relief. By some accident he saw an article of mine which was published in the “Century Magazine,” and made a pitiful appeal to me. I have received many such communications.

A pathetic letter comes to me from a woman suffering with fistula. Having achieved the morphine habit as the direct and inevitable result of taking pain-killing drugs given to her by her family physician, she now feels herself disgraced. Like many sensitive women who in this or some other way become victims of the drug habit, she is obsessed, as her letter clearly shows, with the conviction that her achievement of the habit has been a personal sin, and that her continued yielding to it puts her beyond the pale of righteousness. She writes that she finds herself incapable of going to her church for Sunday services or to prayer meetings because she feels ashamed when in the imminent presence of her Maker. Another woman, evidently animated by a similar psychological phenomenon, writes that having acquired the drug habit, although blamelessly, since it was through the administration of narcotics by her doctor, she finds it a psychological impossibility to kneel at her bedside and offer that prayer to God which it had been her nightly practice to deliver.

I could multiply such instances indefinitely. It is impossible to conceive any episodes more pitiful than the cases of this sort which have been detailed to me by drug victims, doctor-made. That feeling of disgrace, that unjustified conviction of sin on the part of absolutely innocent women victims of the drug habit, is apparently among the most terrible of humanity’s psychological experiences. If I had the pen of a Zola and the imagination of a Maupassant, I might properly impress the medical world with a sense of its responsibility in this matter. Without it I fear that I may fail to do so; but could I accomplish only this one thing, I should feel that my life had been of use to that humanity which I desire above all things to serve.

No work could be of more importance to the world of sufferers than one which would put the use of these potentially beneficent, but, alas! often injurious, drugs upon a respectable basis, so that the man who must be given the relief which they alone can offer may no more hesitate to tell his neighbor that he is taking morphine than he now will hesitate to tell his neighbor that he is taking blue mass pills or citrate of magnesia.

RESPONSIBILITY OF THE TRAINED NURSE

That the medical world should ever have been so lax in its realization of its proper responsibility as to allow trained nurses to carry hypodermic syringes and to administer habit-forming drugs seems to me to be one of the most amazing things in the world. No physician who has had an extensive experience with drug addiction and who has any conscientious scruples whatsoever will fail to make sure before he leaves a nurse in charge of a patient that the attendant possesses no habit-forming drugs and is without any instrument with which they may be hypodermically administered. If such drugs are to be used, they should be kept in the physician’s possession until they are used, and should be administered by means of an instrument which he carries with him. When such drugs are left, the nurse should give an accounting for every fraction of a grain.

I have no desire to convey the impression that in my opinion all nurses are untrustworthy or unscrupulous, but it must be remembered of them, as it must be remembered of the doctor, that they are in the employ of the patient, that their income depends upon giving satisfaction to their employer, and that they are likely to make almost any kind of concession and resort to almost any practice in order to make comfortable and profitable assignments last as long as possible. It is impossible not to admit the truth of this statement, and it must be recognized that if it is true, a nurse is under too great a responsibility when she is in possession of a hypodermic kit, particularly if the patient knows that it is her kit, her hypodermic, her drug, and that she will not be called to account by the physician for such drugs as she may administer. It must be rather disconcerting for a physician to reflect upon the fact that a nurse whom he has left in charge of a critical case, through greed or even through the general and admirable quality of mercy, is equipped for, and ignorantly may yield to the temptation of, resorting to a practice that may not only undo all the good his treatment has accomplished, but, in addition, may afflict the patient with suffering more terrible than any which disease could give. This element of mercy, soft-heartedness, and readiness to pity must specially be remembered in considering the relation of the trained nurse to the patient. If men are often induced to enter the medical profession because of its presence in their soul, even more frequently are women led by it to become trained nurses. The sympathetic woman is even more likely to yield to the pleadings of suffering patients than is the sympathetic male doctor.

It must also be remembered that, like the doctor, the nurse is human, and neither iron-nerved nor iron-muscled. She is frequently under terrific strain, which makes her tend toward the use of stimulants of any kind. That which she can administer to herself by means of the hypodermic is closest to her hand, is easiest to take, and is least likely to be discovered. Again, too, it must be remembered that the nurse is as susceptible to pain as are the rest of us. Suffering, with the means of alleviation at her hand, and, like the doctor, ignorant of its true peril, what is more natural than that she herself should use the hypodermic for her own relief? Thus it comes about that probably a larger proportion of trained nurses than of doctors are habitual drug-users. This is not a statement which is critical of the profession, for if all mankind knew of drugs, had hypodermics, and knew how to use them, a very large proportion of the human race would resort to this quick and effective, if inevitably perilous, means of finding comfort when agony assailed them.

The world does not, the world cannot, understand that while to the normal human being the worst that can come is pain, the worst pain is vastly less terrible than the horrors which at intervals inevitably afflict the habitual drug-user. Not one human being who has become a victim of a drug habit through its use for the alleviation of pain but will voluntarily cry after he has come to realization of the new affliction which possesses him, “save me from this drug habit, and I will cheerfully endure the pain which will ensue.” The horror of pain is not so great as the horror of the drug habit.

Another very serious reason for extreme caution on the part of the medical profession in regard to the use of habit-forming drugs is that the effect of such drugs upon a patient must almost certainly make accurate diagnosis of his case difficult or even impossible. A patient whose consciousness of pain is dulled or eliminated by the use of drugs cannot accurately describe to a physician the most important symptoms of his ailment. Without the assistance of such a description the physician is so handicapped that all the skill which he has acquired in practice and all the knowledge he has gained from study are apt to be of no avail. Indeed, in the case of habitual drug-users accurate diagnosis of any physical ailment is impossible until the effect of the drug has been so completely eliminated that not one vestige of it remains.

CHAPTER V

One of the most difficult problems of my work has been to discover ways by which the medical profession can be made to understand the really serious meaning of chronic alcoholism. Most delirium, the primary cause of which lies in alcoholism, is amenable to treatment.

EFFECTS OF DEPRIVATION IN CHRONIC ALCOHOLISM

It is exhaustion or lack of alcohol which first produces delirium in an alcoholic case, whether that exhaustion is due to the patient’s inability to assimilate food or alcohol or whether it is due to the fact that, being under restraint, alcohol is denied him.

In most cases there is no form of medication which can be successfully substituted for alcohol, and unless definite medical help is provided for the purpose of bringing about a physical change and thus avoiding delirium, no course remains safe except a long and very gradual process of reduction of alcoholic poisoning. Such a measure as this cannot be successfully applied in the wards of the general hospital, as the mere fact that alcohol was there administered, even in slowly diminishing doses, would make such a ward the chosen haven of innumerable “old stagers,” who, having reached that stage of worthlessness which would make it impossible for them to obtain the narcotic elsewhere, would take the treatment for the mere sake of getting the alcohol of which it principally consists.

Many friends of alcoholic subjects and many physicians in private practice have believed that they were doing the alcoholic a great service when they put him where he could not get alcohol, and helped him over the first acute stages of the period of deprivation by the administration of bromide and other sedatives. This usually means delirium first and then a “wet brain”; if the patient survives this, his next development is more than likely to be prolonged psychosis, or, in the end, permanent insanity. It is because of this that I consider the chronic alcoholic more clearly entitled to prompt and intelligent medical treatment than most other sick persons. With the alcoholic, as with the drug-taker, the first thing to be accomplished is the unpoisoning of the body. In order to accomplish this, it is first necessary to keep up the alcoholic medication, with ample sedatives, using great care lest the patient drift into that extreme nervous condition which leads to delirium. If delirium does occur, nothing but sleep can bring about an improvement in the patient’s condition. This is the point of development at which physicians not properly informed in regard to such cases are likely to employ large quantities of hypnotics, and frequently this course is followed until the patient is finally “knocked out.” In many instances an accumulation of hypnotics in the systems of persons thus under treatment has proved fatal. I am rather proud of my ability to state that from delirium tremens I have never lost a single case.

NECESSITY OF CLASSIFICATION OF ALCOHOLICS

The records show that to-day about forty per cent. of the insane in the asylums of New York State have a definite alcoholic history. In this condition lies one of the greatest opportunities ever offered to the medical profession. Even now a proper classification of the patients thus immured, and their appropriate treatment, would in many instances result in the return to the normal of those affected; proper classification and treatment at the time when the symptoms of mental disorder first appeared would have resulted in the salvation of innumerable cases. As a matter of fact, I earnestly believe that if this course was followed, the number of supposedly permanent cases of insanity arising from alcoholic and drug addictions might be decreased by seventy-five per cent.

Certain general rules may be laid down. There are no circumstances in which it is advisable for a physician in private practice to attempt to handle a case of chronic alcoholism in the patient’s own environment. Efforts to do this are constantly made, with the result that many needlessly die from lack of alcohol, while an even more tragic result is the unnecessary entrance, first into the psychopathic wards of our hospitals and thence into our asylums for the insane, of innumerable cases which needed intelligent treatment only for alcoholism or drug addiction. If this treatment is neglected, the incarceration of these unfortunates in asylums becomes necessary, for without question their insanity is real enough.

UNSCIENTIFIC METHODS IN THE TREATMENT OF ALCOHOLISM

During the summer of 1913 I visited a large hospital in Edinburgh and discussed alcoholism and its treatment with the visiting physician.

“We do not have many alcoholics here,” said he.

“Why?” I inquired.

“All our hospital work is supported by private subscription,” he answered.

“Then there is no place whatever in Scotland for the care of the acute alcoholic case?”

“No. If an intoxicated person is locked up by the police and develops delirium, he is sent here, and we do what we can for him by the old methods.”

“You offer no definite medical help along special lines?”

“No; we have none to offer.”

He showed me two cases in the general ward; one man in a strait-jacket was in the midst of delirium tremens, his face terribly suffused. He was in a pitiable state, and nothing was being done for him.

“What course shall we follow?” the physician inquired.

“Let me see his chart,” I requested. After I examined it, it became immediately apparent that the patient’s condition was due to lack of his usual drug. It was his third day in the ward.

“Nothing but sleep will save him,” I said, and suggested medication which was administered.

In three or four minutes the patient was relaxed and taken out of the strait-jacket. I made certain suggestions regarding general stimulation for the bowels and the kidneys, and diet. On the next day I found the patient improved after twelve or fifteen hours of sleep, and wholly free from delirium. His case had now become simply a matter of recuperation.

Another case had lived through several days of delirium tremens, which had been followed by a “wet brain”; the visiting physician considered this patient a fit subject for the psychopathic ward. I asked the patient questions about himself. He was sure that he had been out the night before and pointed out one of the internes as his companion during the hours of dissipation. His case was regarded at the hospital as almost certain to end in an asylum. I suggested treatment and within two days the man’s mind had entirely cleared up.

These instances of successful and prompt relief occasioned considerable surprise among the hospital physicians, who frankly admitted that they knew nothing to do except to keep the patients there under restraint, and, if necessary, feed them according to existing rules, to keep their bowels open and their bladders free, and hope for the best.

This was an institution which is supposed to represent the best medical learning in the United Kingdom. I found similar conditions existing in the great hospitals of London, Paris, and Berlin, so that the Scotch institution is not an exception to the general European rule. Everywhere I was frankly informed that the medical staff knew of nothing to be done in alcoholic cases beyond deprivation and penalization.

Nor have we been more scientifically progressive in the United States. We are following virtually the same unenlightened methods, and it has even been suggested that chronic alcoholism be added to the conditions which in the minds of some sociological thinkers justify sterilization. How important our shortcoming is may be strikingly illustrated by the statement that alcoholic patients comprise one third of all the cases admitted to Bellevue Hospital in New York.

THE DIFFICULTY OF TREATMENT IN SOME ALCOHOLIC CASES

The alcoholic differs notably from the person addicted to drugs. A drug-taker, deprived of his drug, will experience in the early stages only acute discomfort and a natural longing for the drug of which he has been deprived. His unfavorable symptoms can always be relieved by the administration of the drug. The chronic alcoholic, however, deprived of the stimulant, often drifts into a delirium which cannot be relieved by the administration of his accustomed tipple. No more terrible spectacle can be imagined by the human mind than that of an acute case of delirium tremens; no patient needs more careful watching in order that unfavorable developments may be avoided; once delirium sets in, no type of case is medically so difficult to handle. The man who for long periods has been saturated with alcohol, and who is suddenly deprived of it, is, I think, more to be pitied than almost any one I know; yet relatives, friends, and physicians frequently follow exactly this course, and think that by so doing they are rendering the patient a kindly service.

CAUSES OF INSANITY

In mentioning the causes of insanity, it is, however, impossible to permit the impression to be recorded that alcohol is the only offender. My statement of the part which alcohol plays in supplying the population of our mad-houses has never been denied; but it is also true that the use of headache powders and other preparations commonly sold at our drug stores and as yet slightly or not at all restricted by law, and the use of coffee, tea, and tobacco in unrestricted quantity, also contribute their quota to the insane. A letter from the superintendent of a certain state asylum tells me that he has seen many improvements, sometimes even amounting to cures, result from ten days of fasting. That fasting really was a process of unpoisoning. In such a case the symptoms of insanity may be attributed to auto-intoxication, coming from any one of many causes, of which alcohol, tobacco, or even food improperly selected or unreasonably eaten may be one. The physician can have no means of learning just what method to pursue in any case of auto-intoxication until the patient has been unpoisoned. If any one of the great general hospitals would secure careful histories of one hundred of its patients and apply the proper methods to those who are found to have been poisoned by their habits, surprising results would be achieved. It is specially true that no intelligent mental diagnosis can be made of any patient who has had an unfavorable drug, alcoholic, or even tobacco, tea, or coffee history until he has been freed from the effects of these drugs or stimulants. The first thing that a physician must do when confronted by a case of alcoholic or drug addiction is to learn whether it is acute or chronic. If the case is chronic, the patient must not be suddenly deprived of his stimulants.

CHAPTER VI

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.