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.

CHAPTER VII

In these days all mankind searches for exhilaration. The instinctive demand for it is an inevitable result of the artificial social system which we have built up. We work beyond our strength, and naturally feel the need of stimulants; we play beyond our strength, and as naturally need whips for our vitiated energies. The greatest social disaster of all the ages occurred when first alcoholic stimulation, which is only one step in advance of alcoholic intoxication and narcotization, found its place as an adjunct of good-fellowship. All humanity turns in one way or another to artificial stimulants, and while alcohol and narcotics are the worst among these, we cannot slur the fact that many who would shun these agents as they would a pestilence, turn freely to milder, but not altogether harmless, stimulants, such as tea, coffee, and tobacco.

I do not purpose to go into a long dissertation upon the chemical peculiarities of alcohol; I do not purpose to discuss the value or peril of alcohol as food; there are plenty of published chapters telling exactly what alcohol is. I feel that it is my mission to do none of these things, but to endeavor to reveal to the student the most effective way of dealing with a patient who has drifted into a definite alcoholic addiction.

THE MAN WHO CANNOT BE SAVED

It seems impossible to arouse any enthusiasm or sympathy for the human derelict whose natural weakness is inevitably such that one taste of alcohol means a gallon, and final wreck and ruin. The human cipher, plus alcohol or minus alcohol, it matters not which, means nothing. It may be true that alcohol subtracted from nothing leaves nothing, but it is certain that alcohol added to nothing may mean a peril to society and a serious charge upon it.

A man who has achieved nothing up to the point where he has become addicted to excessive alcoholism will rarely repay the trouble involved in an effort to preserve him from his folly, although of course his preservation from it might be of general social service as a means of saving the public money that otherwise might be expended in the reparation of the work of his destructive tendencies, besides the public expense involved in police, court, and prison economy that prevents him from the opportunity of indulgence. But thousands of decent men annually yield to alcohol, and are wrecked by it. The decent and potentially valuable citizen who through overwork, worry, sickness, sorrow, or even through a mistaken conception of social amenities or duties, drifts into excessive alcoholism is a victim of our imperfect social system, and repays remedial effort. Furthermore, such a man is invariably savable if he himself applies for salvation, assists with his own will in its application to his case, and pays his own money for the cure.

The proportion of the cases that can be saved among the general run of alcoholics who are sufficiently prosperous or have sufficiently prosperous friends to make them likely to come under my direct observation amounts to about one quarter of the whole. It will be observed that this claim for alcoholics is far below the claim which I have made for drug-users.

Where it is found that a case of excessive alcoholism has grown out of a lack of a normal sense of responsibility, where excessive alcoholism has reached the point at which deterioration of the moral nature has set in, or where social and financial entanglements already have resulted, a problem is presented which is complicated and even very doubtful. In such a case far more than definite medical treatment must be resorted to before a complete restoration of the unfortunate to social usefulness can be hoped for. The naturally irresponsible person or the person already led into irresponsibility by alcoholism may be regarded as an almost hopeless proposition. This is peculiarly the case where no financial obligation can be imposed upon the patient as a part of the treatment. The very poor for whose treatment some one else must pay, and the very rich to whom the sum paid for treatment is a matter of no moment, are almost equally hopeless. My long experience has taught me that the man who does not feel a financial responsibility for that which is done for him is usually the least promising of all the cases brought to me. I have found it necessary to regard as a definite part of my treatment the imposition of a monetary obligation.

If, for example, the employee of a person or a corporation is sent to me for relief from alcoholic tendencies by his employer or employers, I invariably refuse to accept the case unless it is agreed that the sum paid for the patient’s treatment shall be held against him as an obligation to be repaid as soon as possible to those who have advanced it. Even the man who is curable will fail in a psychological realization of the misfortune into which he has actually fallen through alcoholic indulgence unless he himself must pay the fiddler. In the case of a working-man who is brought to me for treatment by his employers, I make a minimum charge as a rule, but only on the condition that with all due speed it is deducted from his pay-envelop. In the case of men of a higher order, as professional employees, heads of departments, etc., I insist in a general way upon following the same line of procedure. I cannot too strongly emphasize my absolute conviction that it is invariably a waste of money and time for an employer or an employing company to attempt to help alcoholics by means of free medical treatments. No good will come from this in the long run, as it never will prove to be worth while. Thus we may classify very rich, utterly poor, and irresponsible inebriates as among the hopeless. From every moral, social, and economic point of view the hopeless inebriate is a liability to the world at large. Throw him in the sieve of respectability, and soon or late he will always prove small enough to slip through the meshes.

COLONIZATION OF ALCOHOLICS

Among such cases will be found fit subjects for colonization, and these are the only ones who should be treated in this way. No greater social mistake is possible than the colonization and segregation, either in sanatoriums or inebriate farms, of other than utterly hopeless alcoholic cases. The next greatest mistake undoubtedly is society’s failure to segregate those who are utterly beyond the pale of hope. These men and women will be less of a burden to their friends and the community after segregation; their segregated existence will not constitute a threat against society of the present and future generations. It is my opinion that these people, men and women, rich and poor, should be sterilized and put at work. It is possible that this plan, if properly carried out, might develop some institutional effort worth while. That at present practised means a waste of time and money.

It should be borne in mind that deprivation never yet removed the underlying cause of the desire for alcohol, no matter over how long a period this deprivation may have extended, nor has it ever removed the desire itself. These things can be brought about only by the elimination of the poison from the victim’s system.

All alcoholics, no matter whether they are preferred risks or hopeless cases, whether they are to be returned to society or isolated and sterilized, should be unpoisoned.

SUCCESS OF THE SPECIFIC TREATMENT

The first exhaustive test of this treatment for alcoholism was made at Bellevue Hospital, and its results were announced in a pamphlet published by Dr. Alexander Lambert. The hospital in which the work was carried on was without ideal facilities; overcrowded wards and an insufficiency of nurses were among the many handicaps. That the results were more hopeful than anything theretofore accomplished is indicated by the following extracts from articles by Dr. Lambert:

No test more exacting than the one made at Bellevue Hospital could be devised. Most of the cases appearing for treatment in the wards of that institution are of the most advanced type, for the nature of the New York hospital system may be said in a general way to select for Bellevue the least hopeful patients coming from the least hopeful classes of society. If, therefore, anything approaching permanent relief was secured for as many as twenty out of every one hundred cases, an extraordinary efficiency was indicated.

Of course the intelligent reader will understand that no man with reason can claim for any treatment the power permanently to divorce from alcohol a man who does not wish to be divorced from it. To take a man whose system has reached that degree of craving for alcohol that he would sign away his right to salvation in exchange for a drink after a brief period of deprivation, if he could not otherwise obtain the alcohol, and to unpoison him so that he feels no necessity or even the slightest desire for a drink or for any stimulant, is to accomplish a great deal of good. It means that his nervous system has been restored to something nearly normal, and that he has been given a chance. The man who has not had this help from outside can do nothing for himself; but having been cleared of alcoholic poison, he is brought into a mental state wherein he finds it possible to estimate reasonably the harm which alcohol has done him. The patient is then in a mental state that enables his relatives and friends to deal with him without being forced to estimate and allow for alcoholic abnormalities in his processes of thought. He is in a physical state that, although it apparently may be worse than that in which the alcohol had placed him, is nevertheless one that will enable his physician to work with him intelligently.

Such an achievement seems a perfect piece of medical work of its kind. Properly carried out, my treatment will accomplish exactly this in every instance. It will accomplish it within five days and very likely within three days. I have never known it to require a period of more than seven.

When this treatment is properly provided for throughout the country, it will be found that neither large nor costly institutions will be necessary. The stay of every patient is so brief that in the average community a small institution containing only a few beds will be found sufficiently large to meet all local needs.

THE HABITUAL DRUNKARD IS NOT A CRIMINAL

Legislation restrictive of the sale and use of habit-forming drugs is in reality a dangerous experiment until other legislation that provides for the medical help of those who would thus be deprived has first been written upon our statute-books. I am inclined to think that many of the failures which strew the paths of experimentalists in anti-alcohol movements have been due to a lack of similar foresight. The man who is penalized for drunkenness will usually get drunk again the moment he finds himself at liberty to do so; and this will not be due to any natural depravity upon his part, but, rather, to an almost inevitable result of the bodily craving that thrills his every fiber and for the relief of which nothing whatever has been provided. We shall never make any serious progress in dealing with the most serious evils of alcoholism until we waken to the folly of treating the hard and habitual drinker as a criminal, exacting from him penalties and inflicting upon him disgrace.

In every instance the passage of restrictive legislation should be accompanied by the passage of remedial legislation; for provision for the relief of suffering caused by prohibitory laws must be provided. The courts should carefully consider the facilities at the disposition of the communities in which they labor, and in imposing sentences they should be careful not to overtax them. It would be better for a community to keep a victim upon a steady diet of alcohol for weeks while he was waiting for a bed in a curative institution than to risk causing the man’s death or insanity by depriving him of his alcohol until the means for relieving his system’s acute demand for it were at hand. By following a similar plan, it will be found that the evil of habit-forming drugs can be exterminated in the United States. Whether alcoholism, which is a social vice, ever can be similarly exterminated by like methods I do not know; but I am convinced that an intelligent pursuit of such a policy would do more to accomplish the desired results than ever has been done by other means.

HOW SOCIETY TREATS THE VICTIM OF ALCOHOL

The care of the inebriate who already comes under the law, and who by his habits forces his way into the state and municipal hospitals, forms one of the great burdens upon society of the present day. It should be regarded as one of the most important problems of modern medicine.

No other class of the sick includes so great a number of individual cases. We find, for example, the almost incredible fact staring us in the face that more than one third of all the patients admitted to Bellevue Hospital in New York City are sent there by alcohol, while less than two per cent. are sent there by habit-forming drugs.

I am casting no reflection upon this or any other institution when I say that there and elsewhere little understanding is shown in dealing with these cases. As a matter of fact, no intelligence is anywhere shown in this matter. The policeman who finds a drunken man or woman on his beat arrests the unfortunate with as much wrath and probably as much brutality as he would show a burglar or a murderer; the committing magistrate before whom the victim is taken treats him or her precisely as he would treat a criminal; in the various penal institutions to which this man or woman is committed the idea upon which their whole treatment is based is that of punishment.

It seems to me that the imperfections of this system might most easily be corrected by the committing magistrates. It is the largest problem which confronts these officials; therefore they might very well afford the time necessary to study it carefully. Concerted action by this group of the judiciary might accomplish worthy results almost immediately. As matters are at present organized, the committing magistrate may do any one of four things with an inebriate who has been brought before him: he can release him without penalty, he can put him on probation, he can fine him, he can imprison him. I have yet to discover any one capable of telling me why measures of this sort can possibly be expected to have a beneficial effect upon a person who through over-indulgence has set up in his system a demand for alcohol.

I have no wish to appear publicly as the critic of our petit judiciary, but no class of men is less informed upon this subject—the one subject upon which they should be best informed—than the committing magistrates not only of the United States, but of every other country in the world. A year or two ago I made a somewhat comprehensive European tour, and studied carefully the methods of dealing with inebriety. Nowhere did I find the faintest indication of a tendency for real intelligence in regard to the matter. We insist upon special education for the professors of our colleges; yet the influence of a committing magistrate upon the human life that is brought under his direct sphere of influence may be greater even than that of a college professor or a college student, and of our committing magistrate we make no educational demand whatsoever, and have never established even a minimum standard of intelligent information for our petit bench. It is my belief that expert sociological knowledge should be required of every man considered for the important post of committing magistrate.

RESPONSIBILITY OF THE MAGISTRATE

The fact that in New York State a colony for inebriates has been established by law makes this special knowledge more necessary there than it was before. Wherever such institutions have been founded, and the courts may contribute to their population by commitment, an unintelligent magistrate finds it within his power not rarely, but every day, to do more harm during one session of his court than he is likely to find it within the scope of his intelligence to do good during the course of a year’s sitting. I find it impossible to be otherwise than bitterly pessimistic in regard to the work our courts are doing with alcoholics.

Under the New York law, a man taken for the first time before a magistrate and charged with alcoholism must either be fined or told that if he again appears charged with that offense, he will be subject to commitment to the inebriate farm for a period of not less than three months. By this procedure not one thing has been accomplished toward the salvation of the man. If he is not committed, but is only threatened and ordered to report weekly or oftener to the probation officer or the court itself, the greatest of all damage has been done, since the man’s pride has been depreciated. After definite medical treatment has been administered to an inebriate, the only other thing that can be done is to make an intelligent appeal to his pride. In this appeal is included at least one half the possibilities of his salvation. Nowhere save in a few instances in New York City is the alcoholic case treated with medical intelligence, and nowhere in the world is the balance of the necessary treatment—the right appeal to pride—carried out with any degree of common sense.

I find one system of special horror in this treatment of inebriates—committing a man for three months, then for six months, and then for twelve. No more certain means could be devised to increase the harm done by alcohol to the community. Not only does this course fail to help the man in any measure whatsoever, but it increases the unspeakable harm which his misfortune must inflict upon his family. In most instances such a commitment not only means the man’s separation from his means of livelihood for the period of its duration, but his discharge from it as the result of this utterly inefficient and legally inflicted disgrace.

The whole effort of society in dealing with the alcoholic should be to prevent those things which at present are the very ones which it accomplishes—mental depression, loss of pride, disgrace, and loss of social position. I am inclined to think that as the world grows older it will be more and more convinced of the inefficiency of punishment, and more and more aware of the necessity of reform through helpfulness.

It seems obvious that penalization, probationary influences, or colonization must be utterly useless in removing from a man’s physical system the craving for alcohol. Therefore it is equally obvious that their only successful mission must be to remove the victim of drink from contact with society for the length of time during which his sentence is operative. The man who is in all probability incurable is not put permanently out of harm’s way by these means, or placed where he can do no harm; the man who has good stuff in him but who has through chance used drugs to excess upon one or more occasion is offered by these methods nothing in the nature of a fair show toward regaining his usefulness.

I see the possibility of many serious results in New York’s board of inebriety plan. These, I think, have their beginning principally in the fact that nothing along the line of classification has been devised or, as far as I know, has been even suggested. If its work were made efficient by means of the adoption of a plan of classification, this board really might become a great boon to society. Suppose that instead of penalizing the man who has been taken before it for inebriety, the board, after intelligent and detailed investigation has shown that the man is probably curable, should provide for him the necessary definite medical treatment to relieve his system from the ill effects of alcohol, and then should bring him into contact with psychological and analytical minds capable of enforcing upon him a realization of the terrible meaning of alcoholism. Without having affected the man’s pride it would send him back to his family and his task with a cool brain and a new point of view. Would not this be a vastly better way of dealing with him than those which are at present followed?

There is no reason why some small charge should not be enforced against such beneficiaries of an enlightened public intelligence who might be found able to meet it. This would accomplish two things: it would reduce the public expense of the system and it would add very greatly to the mental impression left upon the mind of the person for whose benefits the State was working. Furthermore, if a magistrate had once formed the habit of feeling personal interest in individual cases probably his first act after a man had appeared before him would be to send for the accused’s employer and make the truth of the situation clear to him. The mere fact that a man has once been intoxicated should not justify his discharge from employment in which at normal times he is useful and efficient. Both for his sake and for his employer’s, efforts should be made toward reform; for it is not infrequently the case that the man who has lost control through drink is in normal conditions the best man in the office, factory, or workshop. That is one of the chief tragedies of the problem of alcohol.

There is no subject upon which society more sadly needs enlightenment. In this educational process it is probable that the magistrate will be the largest factor. He must realize that he is not society’s instrument of vengeance, but society’s instrument of helpfulness. It should be his aim not to punish, but to protect and preserve. He must realize that scientific knowledge of the problems which confront him is as necessary to his real efficiency as scientific knowledge is to the analytical chemist.

The heart of a conscientious magistrate should thrill with a special sympathy, should be aware of a great responsibility, whenever there appears for judgment in his court a man who for the first time has lost control of himself through drink. To mar this man forever is an easy task; to make him may be difficult, but it is certainly not beyond the bounds of possibility.

The hard drinker who for the first time is haled into court as the consequence of intoxication never is willing to concede either to himself or to others that he needs help. His soul revolts before the mere thought that he has more than temporarily, even momentarily, lost control. He is likely to deny that he has developed a craving for alcohol, and emphatically and indignantly to assert that his drunkenness has been merely incidental to the social spirit, an accident, and in general a thing of no primary importance. The thought that without help there is even a possibility that he may drift from bad to worse is abhorrent to him, and is indignantly repudiated. He will cheerfully admit that many other men of his acquaintance have fallen victims to the effects of alcohol, but he will vehemently deny the possibility of a similar fall on his own part. The magistrate who thoroughly understands all the details of the alcoholic’s psychology, and who is sufficiently adroit of mind and speech to take advantage of this understanding, giving the culprit who has been brought before him every benefit of a carefully and intelligently organized knowledge of alcoholism, could not fail to be one of the most useful of society’s servants and safeguards.

The man or woman taken before a magistrate as the result of alcoholic over-indulgence offers a peculiarly perplexing problem. Society has placed itself in a highly inconsistent position as regards its relation to alcohol. It permits a man to pay it for the privilege to sell alcohol to any one who asks for it, the only restriction being that he may not sell it to a person who already has “had too much.” This leaves the decision as to a customer’s needs and capacity, as well as perils, to be rendered by the man behind the bar. Thus to an extent we intrust daily the destinies of an appreciable proportion of our public to a class of men who certainly have done little to earn general confidence. In nearly every State, if not in all, laws exist imposing penalties upon the dealer in alcohol who sells drink to a person who is already in a state of intoxication; but a careful study of the records of our courts would fail to reveal any large number of liquor dealers who have been charged with this offense, while it is obvious that most persons found upon the public streets or elsewhere in a state of intoxication must have had alcohol served to them at a time when they had already “had enough.” As a matter of fact, the intelligent mind cannot fail to realize that the man who has “had enough” invariably has had too much.

This is only one of many reflections which must occur to the inquiring mind occupying itself with this problem. We have made innumerable laws dealing with, and fondly supposed to control, the sale of alcoholic beverages, but as a matter of fact only one sort of law has ever been devised which possibly could control it, and that law provides for absolute prohibition.

THE NEED OF AN ORGANIZED EFFORT TO HELP THE ALCOHOLIC

If the world wishes to be relieved in any measure from the human waste attributable to alcohol, the time must speedily arrive when municipalities will recognize it as their duty to provide definite medical help for every man who wishes to be freed from the craving for alcohol, and who cannot afford to pay for treatment. It must be recognized that it is society’s duty to hold out this helping hand to every man who has a job and is in danger of losing it through the trap which society itself has set for his feet by authorizing, and thereby encouraging, the sale of alcoholic intoxicants.

Notwithstanding the presence in our social fabric of innumerable charitable bodies, churches, religious societies, and other groups of people who mean well and work hard to aid the unfortunates, it is a fact that nowhere in the United States or, as far as I know, anywhere else is there a single organization which is effectually working along definite and intelligent lines for the preservation of the endangered man who is still curable.

No mother, wife, employer, or magistrate can effectively reason with a man whose brain is befogged by alcohol, for that man cannot reason with himself. Tears, threats of imprisonment, and loss of position do not have upon him their normal reaction. He is a sick man whose mental and physical condition is abnormal; it must be made normal before anything real can be done toward his assistance.

There is but one way out of the sad muddle in which alcohol has plunged certain branches of our judiciary. In every city must be established emergency hospital wards to which committing magistrates may send persons with excessive alcoholic or drug histories. Treatment in these emergency wards will be neither difficult nor costly.

Once this has been done, the patient may be returned to court, where his clarified brain will greatly assist the magistrate in deciding upon the proper course for his assistance and the protection of society.

The commitment of the alcoholic to an ordinary penal institution is a perilous expedient. The experiences which various authorities connected with the Department of Correction in the City of New York have had with drug and alcohol smugglers indicate a condition that exists more or less generally in penal institutions throughout the country. The drug-user or alcoholic who has been locked up in a prison is in no way relieved of his craving for the substance which is harming him, and his efforts to obtain it will be desperate. The class of men who surround him as prison guards is not of a high type. If he has money, they will get it from him if they can; and if he has friends outside, especially if they themselves be drug or liquor addicts, they will attempt to smuggle to him what he craves. Inasmuch as it is much easier to smuggle drugs into a prison than it is alcohol, many alcoholics have been changed in prison to drug-takers, and after this change the metamorphosis for the mere drunkard into an actual criminal has often occurred. The administration of a definite medical treatment should therefore be regarded as imperative in all cases of drug addiction, and in most cases of alcoholic addiction that appear in our prisons. In the cases of alcoholic addictions, imprisonment should end, in the case of first offenders, with the completion of the treatment and the restoration of the subject’s mind to normal.

I cannot too strongly or too frequently reiterate the statement that there is no more desperate illness than chronic alcoholism.

Purification from the physical demand for alcohol at the place of commitment of men taken before the courts upon the charge of intoxication might save the public from a greater burden than any other available medical process. Drunkenness cannot rightfully be considered as a crime as long as society sanctions the sale of alcohol and profits by it; therefore the punishment of alcoholics as criminals is an intolerable injustice. That it is also an economic waste is as clearly apparent.

CHAPTER VIII

Nothing more strikingly illustrates how addicted people may become to a habit than the smoking and chewing of the traditional Southern gentleman of the old school, whom any other personal uncleanliness would have horrified. Young men most fastidious about their apparel seem quite unaware that it is saturated with the smell of tobacco. The odor of a cigarette is probably as offensive to some of those who do not smoke as any other smell under heaven. Yet such is the power of habit that we tolerate all these things.

If we could begin all over again, we should find the same general objection to smoking that existed in Europe when the habit first began. Our chief need, then, is a new mind on the subject. How can we get it?

The circumstance of my giving up smoking eighteen years ago may have some slight significance in this connection. I was smoking hard, and began to have a vague feeling that it was hurting me. I had been playing whist at a late hour in my room at a hotel, and when I finally went to bed I could not sleep for a long while. I awoke with a bad taste and a parched mouth in a room heavy with stale smoke and unsightly with cigar-butts lying everywhere. Suddenly a disgust for the whole habit seized me, and I broke off at once and completely. After a week or so, when the first feeling of seediness and uneasiness and depression had worn away, I found my appetite and concentration and initiative increasing. You will observe that it was not until I began to regard smoking as harmful that I saw it was also filthy. I had a new mind on the subject.

I am trying to give my readers a new mind on the subject, and if they have not come to suspect the evil of smoking, they will naturally ask me to prove that it is harmful.

Let us begin at the bottom.

Does it do any one any physical good? Arguments in favor of tobacco for any physical reason are baseless. It does not aid digestion, preserve the teeth, or disinfect, and it is not a remedy for anything. The good it does—and no habit can become general, of course, unless it does apparent good—can only be mental. Let me admit at once that smoking confers mental satisfaction. It seems to give one companionship when one has none, something to do when one is bored, keeps one from feeling hungry when one is hungry, and blunts the edge of hardship and worry. This sums up the agreeable results of tobacco. There are one or two more specialized agreeable results which I exclude at this moment because they are only temporary. The results I mention—let me admit at once—are real, and both immediate and apparent. On the other hand, the injurious results, after one has become inured to tobacco poison, are both unapparent and delayed.

THE PHYSIOLOGICAL ACTION OF TOBACCO

As to the physiological and toxic effects of tobacco there is much difference of opinion. Everybody knows that the first chew or the first smoke is apt to create nausea; and that no matter how long a man has been smoking, a little lump of the tar which has collected in his pipe will sicken him. Nicotine is in itself highly toxic, but is very volatile and is absorbed only from the portion of the cigar or cigarette held in the mouth. The products of combustion of tobacco are chemical substances which are also toxic, and nausea naturally stops the smoker before symptoms of acute poisoning result. One must look, then, for symptoms of slow poisoning. The popular belief that tobacco stunts growth is supported by the fact that non-smokers observed for four years at Yale and Amherst increased more in weight, height, chest-girth, and lung capacity than smokers did in the same period.

Every athlete knows that it hurts the wind; that is, injures the ability of the heart to respond quickly to extra work. It also affects the precision of eye and hand. A great billiard-player who does not smoke once assured me that he felt sure of winning when his opponent was a smoker. A tennis-player began to smoke at the age of twenty-one, and found that men whom he had before beaten with ease could now beat him. Sharp-shooters and riflemen know that their shooting is more accurate when they do not smoke. But you may say: “The athletes and billiard-players and the rest are experts. I am an average man, making average use of my faculties. Besides, I am not contending that excessive smoking isn’t injurious, and I will even concede that the limit of excess varies with the man. But is it not true that harmful results of average smoking for the average man are rare?”

In answer, let me on my side admit that they are—the apparent harmful results.

We are, however, very ignorant of the effect of small, continued doses of the various tobacco poisons. All drugs comparatively harmless, such as lead, mercury, and arsenic, produce a highly injurious effect when taken in repeated small doses. Just what effect the use of tobacco engenders we cannot absolutely know, but no physician doubts that smoking may be a factor in almost any disease from which his patient is suffering.

There can be, for instance, no question that smoke simply as smoke irritates the mucous membrane of the bronchial tubes and renders them more susceptible to infections; by irritating the mucous membrane of the nose and throat it tends to produce catarrh and therefore catarrhal deafness. It would therefore seem fair to state that the man who does not use tobacco is less susceptible to disease and contagion, and recovers more quickly from a serious illness or operation. From this we should expect to find that tobacco shows most in later life, when vitality is ebbing and the machinery of the body is beginning to wear. It is in his middle age that a man begins to feel the harm. In short, though we know only the precise or immediate effect of nicotine and only some of the morbid processes which excessive smoking may produce, it is likely that the worst aspect of tobacco is something that we do not know very much about—its tendency to reduce a man’s general vigor.

The dominant characteristic of tobacco is the fact that it heightens blood-pressure. The irritant action by which it does this sometimes leads to still more harmful results. Its second action is narcotic: it lessens the connection between nerve-centers and the outside world. These two actions account for all the good and all the bad effects of tobacco. As a narcotic, it temporarily abolishes anxiety and discomfort by making the smoker care less about what is happening to him. But it is a well-known law of medicine that all the drugs which in the beginning lessen nerve-action increase it in the end. Thus smoking finally causes apprehension, hyper-excitability, and muscular unrest. Here this inevitable law seems to give contradictory results. Every physician knows that an enormous amount of insomnia is relieved by smoking, even if it is at the expense of laziness the next day; at the same time every physician knows that most excessive smokers are troubled with insomnia.

CIGARETTES

In using tobacco we take the poison into the tissues. The chewer and the snuffer get the effect through the tissue with which the tobacco comes in contact. The cigarette-smoker almost invariably inhales, and he gets the most harm merely because the bronchial mucous membrane absorbs the poison most rapidly. The tobacco itself is no more harmful than it is in a pipe or a cigar. Indeed, it is often less so in the cheaper grades, for, being less pure, it contains less nicotine. Furthermore, the tobacco is generally drier in a cigarette, and for that reason the combustion is better, for the products of the combustion of dry and damp tobacco are not the same. But since it is a little difficult to inhale a pipe or a cigar without choking, the smoke products of a pipe or cigar are usually absorbed only by the mouth, nose, and throat, whereas the inhaled smoke of the cigarette is absorbed by the entire area of windpipe and bronchial tubes. If you wish to see how much poison you inhale, try the old experiment of puffing cigarette smoke through a handkerchief, and then, having inhaled the same amount of smoke, blow it out again through another portion of the same handkerchief. The difference in the discoloration will be found to be very marked. You will note that in the second case there is hardly any stain on the handkerchief: the stain is on your windpipe and bronchial tubes.

If a man inhales a pipe or a cigar, he gets more injury simply because he gets stronger tobacco; but a man never inhales a pipe or a cigar unless he is a smoker of long standing or unless he has begun with cigarettes. Besides allowing one to inhale, a cigarette engenders more muscular unrest than any other kind of smoke. Because of its shortness, cheapness, and convenience, one lights a cigarette, throws it away, and then lights another. This spasmodic process, constantly repeated, increases the smoker’s restlessness while at the same time satisfying it with a feeling that he is doing something. Yet despite the fact that cigarette-smoking is the worst form of tobacco addiction, virtually all boys who smoke start with cigarettes.

It is generally believed that in the immature the moderate use of tobacco stunts the normal growth of the body and mind, and causes various nervous disturbances, especially of the heart—disturbances which it causes in later life only when smoking has become excessive. That is to say, though a boy’s stomach grows tolerant of nicotine to the extent of taking it without protest, the rest of the body keeps on protesting. Furthermore, many business men will tell you that tobacco damages a boy’s usefulness in his work. This is necessarily so, since anything which lowers vitality creates some kind of incompetence. For the same reason the boy who smokes excessively not only is unable to work vigorously, but he does not wish to work at all. This result, apparent during growth, is only less apparent after growth, when other causes may step in to neutralize it. Tobacco, in bringing about a depreciation of the nerve-cells, brings, together with physical results like insomnia, lowered vitality, and restlessness, their moral counterparts, like irritability, lack of concentration, desire to avoid responsibility and to travel the road of least resistance. If there were some instrument to determine it, in my opinion there would be seen a difference of fifteen per cent. in the general efficiency of smokers and non-smokers. The time is already at hand when smokers will be barred out of positions which demand quick thought and action. Already tobacco is forbidden during working hours in the United States Steel Corporation.

Many men were prejudiced against smoking until they went to college. There they found themselves “out of it” because they did not smoke. More than that, they found that the smoke of social gatherings irritated their eyes and throat, and they thought that smoking might keep them from finding other people’s smoke annoying. A man who had left off smoking told me that at the first “smoker” he attended afterward he found the air offensive and his eyes smarting intolerably, although when he had been helping to create the clouds in which they were sitting he had not noticed it at all. These two experiences are common. For this reason, the social inducements to smoking are considerably greater than those to drinking. The man who refuses to drink may feel as much “out of it” as the man who refuses to smoke, but he has ordinarily, and in the presence of gentlemen, no other penalty to pay. He undergoes no discomfort in spending the evening in a roomful of drinkers, and he can manage to find things to drink that will have for them the semblance of good-fellowship. It is the social features that attend the acquiring and the leaving-off the habit which make smoking difficult to attack. In its present state, even if a boy were thoroughly familiarized in school with the harm tobacco would do him, he would still be seduced by the social side of it.[1]

When a habit fosters or traditionally accompanies social intercourse, it is all the harder to uproot.

What grounded opium so strongly in China was its social side. The Chinese lacked social occupation, and it was not the custom of the country for a man to find it with his friends and family, though no people are more socially inclined. Smoking opium became their chief social activity; they gathered together in the one heated room of the house to gossip over their pipes. We smoke tobacco as the Chinese smoke opium, “for company” and in company. Thus one must provide strong reasons to make a man give it up. He will not do so because it costs him something; he expects to pay for his pleasures. When a man has actually gone to pieces, it is comparatively easy to convince him that he ought to give up what is hurting him; but the average man has not been excessive enough for that, and has never brought himself to the point of serious conscious injury. Even a physician cannot with any certainty tell the average moderate smoker whether tobacco is hurting him. Consequently, if one would make this man stop smoking, especially when he sees that leaving off has caused some people more apparent discomfort than all their smoking did, one’s only chance is to make him change his mental attitude. I hope to assist in doing this by calling attention to the fact that tobacco not only prepares the way for physical diseases of all kinds, as any physician will tell you, but also, as long investigation has shown me, for alcoholism and for drug-taking.

TOBACCO, ALCOHOL, AND OPIUM

The relation of tobacco, especially in the form of cigarettes, and alcohol and opium is a very close one. For years I have been dealing with alcoholism and morphinism, have gone into their every phase and aspect, have kept careful and minute details of between six and seven thousand cases, and I have never seen a case, except occasionally with women, which did not have a history of excessive tobacco. It is true that my observations are restricted to cases which need medical help,—the neurotic temperaments,—but I am prepared to say that for the phlegmatic man, for the man temperamentally moderate, for the outdoor laborer, whose physical exercise tends to counteract the effect of the tobacco and the alcohol he uses—in short, for all men, tobacco is an unfavorable factor which predisposes to worse habits. A boy always starts smoking before he starts drinking. If he is disposed to drink, that disposition will be increased by smoking, because the action of tobacco makes it normal for him to feel the need of stimulation. He is likely to go to alcohol to soothe the muscular unrest, to blunt the irritation, he has received from tobacco. From alcohol he goes to morphine for the same reason. The nervous condition due to excessive drinking is allayed by morphine, just as the nervous condition due to excessive smoking is allayed by alcohol. Morphine is the legitimate consequence of alcohol, and alcohol is the legitimate consequence of tobacco. Cigarettes, drink, opium, is the logical and regular series.

The man predisposed to alcohol by the inheritance of a nervous temperament will, if he uses tobacco at all, almost invariably use it to excess; and this excess creates a restlessness for which alcohol is the natural antidote. The experience of any type of man is that if he takes a drink when he feels he has smoked too much, he finds he can at once begin smoking all over again. For that reason, the two go together, and the neurotic type of man too often combines the two. Tobacco thus develops the necessity for alcohol.

It is very significant that in dealing with alcoholism no real reform can be expected if the patient does not give up tobacco. Again, most men who have ever used alcohol to excess, if restricted voluntarily or involuntarily, will use tobacco to excess. This excess in tobacco produces a narcotic effect which temporarily blunts the craving for alcohol. Another way of saying the same thing is that when smokers are drunk they no longer care to smoke, a fact that is a matter of common observation. This means that there is a nervous condition produced alike by alcohol and tobacco. When a man gets it from drinking, he does not keep on trying to get it from smoking. As well as reacting upon each other, the two habits keep each other going. It is not altogether by haphazard association that saloons also sell cigars; they sell them for the same reason that they give away pretzels—to make a man buy more drinks.

This relationship between tobacco and alcoholism is not understood by the public. It has been absolutely demonstrated that the continued use of tobacco is a tremendous handicap upon the man who is endeavoring to free himself from the habit of alcoholic indulgence. Only a man of the strongest character will persist in abstaining from alcohol unless he also abstains from tobacco, even after he has undergone the most intelligent medical treatment. In the system of a man already disposed toward alcoholic stimulation, no one thing will prove so positive a factor toward creating the sense of need as the use of tobacco. Physiological action of tobacco is to create muscular (motor) unrest. Most habitual smokers consume every day more than enough tobacco to carry them far beyond the point where its stimulating effect ends and its narcotic effect begins. Where this habitually occurs, the definitely toxic effect is notable, and this results in a demand for that stimulation which the tobacco itself once furnished, but now does not. Here is an evil effect of tobacco that is rarely understood and almost never admitted.

OPIUM AND CIGARETTES IN CHINA

Current history affords us a striking proof of the closeness of the relation between tobacco and opium.

I have spent a good deal of time in the Orient in the interest of those who were trying to subdue the opium evil, and I may add that there is in China to-day a flourishing American tobacco concern which has grown rich out of the sale of cigarettes. With the extremely cheap Chinese labor, the concern was able to sell twenty cigarettes for a cent of our money. Up to the beginning of this enterprise (about 1900), the Chinese had never used tobacco except in pipes, and in very minute quantities in rolling their own crude cigarettes. The concern was sending salesmen and demonstrators throughout the country to show the people how to smoke cigarettes. Now it is estimated that one half of the cigarette consumption of the world is in China. In trying to lessen the opium evil, in which they have to a considerable extent succeeded, the Chinese are merely substituting the cigarette evil. It is well known to the confirmed opium-smoker that he needs less opium if he smokes cigarettes. The Chinese to-day are spending twice as much money for tobacco as for opium.

I once said to a Chinese public man: “I can help you to get rid of the opium habit because you have found that you must get rid of it, but I cannot help you to get rid of the evil you are substituting for it, for not even America has yet found out that she must get rid of it. Your cure, I fear, is worse than your disease; and our disease has no cure—until we change our mental attitude.”

If any one thinks that China is the gainer by substituting the one drug habit for the other, I beg leave to differ with him. The opium-smoker smokes in private with other smokers, and is thus not offensive to other people. He is not injuring non-smokers, or arousing the curiosity of boys, or polluting the atmosphere, or creating a craving in others. In the West the opium habit is generally condemned because the West is able to look with a new and unbiased mind on a drug habit that is not its own.

I consider that cigarette-smoking is the greatest vice devastating humanity to-day, because it is doing more than any other vice to deteriorate the race.

LIKE ACTION OF THE THREE HABITS

The more you compare smoking and drinking and drugging, the more resemblances you see. Opium, like tobacco and alcohol, ceases to stimulate the moment the effect of it is felt: it then becomes a narcotic. The history of the three as a resort in an emergency is precisely the same. At the time when the average man feels that he needs his faculties most, he will, if addicted to any of the three, deliberately seek stimulation from it. He does not intend to go on long enough to get the narcotic effect, since that would be clearly defeating his own aims; he means to stop with the stimulant and sedative effect, but that he is unable to do. The inhaler of tobacco gets his effect in precisely the same way that the opium-smoker gets his—the rapid absorption by the tissues of the bronchial tubes. It may be news to the average man to hear that the man who smokes opium moderately suffers no more physical deterioration than the man who inhales tobacco moderately. The excessive smoker of cigarettes experiences the same mental and physical disturbance when deprived of them that the opium-smoker experiences when deprived of opium. The medical treatment necessary to bring about a physiological change in order to destroy the craving is the same. The effect of giving up the habit is the same—cessation of similar physical and nervous and mental disturbances, gain in bodily weight and energy, and a desire for physical exercise. A like comparison, item for item, may be made with alcohol, but it is the similarity with opium which I wish particularly to emphasize here.

TOBACCO AND MORAL SENSITIVENESS

Morphine, as is very well known, will distort the moral sense of the best person on earth; it is part of the action of the drug. Since the way morphine gets its narcotic effect is very similar to the way tobacco gets its effect, one would naturally suppose that tobacco would produce in a milder degree something of the same moral distortion. This may seem a startling conclusion, but change your mental attitude and observe. Have not smokers undergone a noticeable moral deterioration in at least one particular? They have a callous indifference to the rights of others. This happens with all habitual indulgence, of course, but is it not carried more generally to an extreme with tobacco than with anything else? Few men quarrel with a hostess who does not offer them drinks, but all habitual smokers expect that, regardless of her own desires, she will let them smoke after dinner.

“We gave up the fight against tobacco in our drawing-rooms long ago,” said a famous London hostess. “We found it was a case of no smoke, no men.”

Respectable men in New York City who would not dream of deliberately breaking any other law carry cigars and cigarettes into the subway despite the fact that it is forbidden and that it is vitally necessary to keep the air there as pure as possible. A gentleman is more annoyed at being forced to consult another’s preference about not smoking than about anything else that could arise in social intercourse, and is often at small pains to conceal his impatience with old-fashioned people who believe they have rights which should be respected.

On all sides the attitude seems to be, “What right has any one to object to my smoking?” The matter is really on just the opposite basis, “What right has any one to smoke when other people object to it?”

If a man must get drunk, we say he shall get drunk where he is a nuisance only to himself and to others of the same mind. If a man feels the need of interlarding his conversation with obscenity and grossness, we say he may not compel us to listen to him. But a smoker may with impunity pollute the air, offend the nostrils, and generally make himself a nuisance to everybody in his neighborhood who does not practise his particular vice. Is this not a kind of moral obtuseness? Change your mental attitude and consider.

The action of a narcotic produces a peculiar cunning and resource in concealment; it develops, when occasion arises, the desire to deceive and, whether occasion arises or not, the desire to shift obligation and evade direct responsibility. Tobacco does this more mildly than opium, and it does so more appreciably with boys than with men; but, as with opium, it is part of the narcotic effect in all cases.

Let it always be remembered that if a man smokes and inhales tobacco excessively he is narcotizing himself more than when he smokes opium moderately.