The drug habits and their treatment : a clinical summary of some of the general facts recorded in practice

Preface

The Disease of Inebriety is now passing through the empiric and squatter stage of development, which meets every new truth of science. The partial recognition of the Disease of Inebriety has attracted the empirics, who, like squatters in a new country, rush in and occupy the land with great noise and pretension. They never build towns or cities, or develop the country, but disappear when permanent settlers arrive. This little work comes in the capacity of a permanent settler, and aims to point out some of the general facts and conditions of Inebriety, and to indicate the great possibilities awaiting further research and more exact study. The curability of this form of neurosis is established beyond question, from the limted studies and experience of the present. Evidently we are on the threshold of a new realm of practical science, in the study and cure of the Disease of Inebriety, and the results may exceed any present expectation.

The Journal of Inebriety, which was established in 1876 to promote the study of spirit and drug neuroses, has published nearly all the literature on the subject for the past quarter of a century. The

D DRUG HABITS AND THEIR TREATMENT.

student of this topic has to do pioneer work with little or no aid from others, and this volume comes as an assistant to suggest lines of study and point out the direction for future inquiries.

These neuroses are rapidly increasing, and their study and treatment is becoming more and more imperative. The colleges will have to add to their curriculum this new field of study; already a New York college has taken up this subject and lectures are given on the topic. This work is only a general discussion of a topic which will be treated by the author more exhaustively in a larger work now preparing. If this work brings new interest to the subject and increases the number of scientic workers, its object will be accomplished.

T. D. CKOTHERS, M. D.

Chapter I. Habit, And The Damages Of Alcohol

The popular and common meaning of the word habit is some state or condition of the body, voluntarily acquired and continued at the will of the person. Conduct and acts which can be changed or checked by the will, and are apparently under the control of the person, are called habits. In its broader, scientific sense, there is a physiological and psychological tendency to repeat the same acts apparently outside of the control of the will. It is this meaning of the word habit which will be used in the present study.

Of all the drugs used either medicinally or as beverages, alcohol seems to be the most destructive. In recent times this fact is becoming more and more apparent in science studies. All the recent text-books on the practice of medicine recognize the dangers from the use of alcohol, and its influence as a contributory cause in many of the organic diseases of the body and brain. The modern clinician inquires into the history of the use of alcohol, either moderately or immoderately, and this fact is important in a knowledge and treatment of the cause. Next to syphilis, alcohol is one of the most potent poisons in the causation of disease. In the neuroses, alcohol is very prominent as an active or contributory cause. The various palsies, mental derangements, and disturbances of nutrition, circulation and obscure organic affections, are always better understood when all alcoholic causation is eliminated. In pneumonia, the prognosis is very different where there is no history of the use of alcohol. In surgical treatment the fact of the use of alcohol complicates the results. While alcohol is still used as a medicine in many instances, its influence as a cause of disease, both active, predisposing and contributory, is becoming more and more prominent. Recent researches show that alcohol has a peculiar, corroding action on the cell and tissue. It is not only a toxin but produces toxins which are chemical and physical poisons. Every new advance in the chemic, physiologic, pathologic and psychologic fields brings out this fact of the danger of alcohol either in moderation or in excess. The increasing number of cases which become disabled and degenerate in almost every community from the use of alcohol suggests something more than moral lapses and sinful weakness.

HISTOKY AND ASSOCIATION WITH OTHEE DISEASE.

A clinical study of accurately grouped histories of a large number of cases brings ample confirmation of the fact that inebriety or alcoholism is a disease. A closer study of these causes indicates a distinct and clearly traceable causation, also a uniform development and progress, and a uniform symptomatology and termination. The physical conditions apparently resulting from the poisonings of alcohol on the nerve centers and organic activities appear to follow a definite, organized line of degeneration whose progress and termination can be traced with much certainty.

The idea of disease is very old, and dates back to the early ages of the world. The fathers of medicine asserted that drunkenness was a disease, and curable as other diseases. Hippocrates, Galen, and many of the old worthies gave strong opinions on this subject but these facts were not formulated into theories until the beginning of this century when Dr. Eush in this country, and Salvator of Russia, and Cabanis of France, formulated and put into active service these facts. The disease of inebriety and its pathology and treatment has been studied more accurately in America than elsewhere. The first inebriate asylum organized in 1864, took up' this subject as a medical one in advance of all others. From that time the growth of the subject has extended all over the world, and researches and literature 'have been very largely the result of the efforts of Americans. The Journal of Inebriety, the organ of this new study, has been published since 1876, giving researches and facts along this line exclusively.

When the drink symptoms of alcohol are examined with more care, they are found to be closely related to a great variety of neurotic diseases. In many cases they appear to be phases or types of epilepsy, hysteria, neuralgia, also closely allied to consumption, and intimately connected with heart disease. Many of the degenerations of the nerve centers, such as the palsies, the paretic states, have alcoholic stages and symptoms. Neurasthenia in all its types and forms is often manifest in this way. Nerve storms, such as headache, neuralgias of the stomach, and various parts of the body often precede and follow alcoholic excess. The various organic and functional affections of the heart often exhibit this drink symptom. Tuberculosis alternates with drink excesses. At one time acute symptoms of breaking down of nerve structure is checked by the advent of a drink craze. When this subsides, the acute symptoms reappear. Not unfrequently they are associated, and it is difficult to decide which is cause and which is effect. The epilepsies seem to have drink symptoms more commonly than other diseases, the drink craze taking the form of paroxysm and subsiding after a time in much the same way as the epilepsies. The periodical drinkers are very largely of the class of explosive epilepsies in which nerve energy gathers and bursts at stated intervals. The frequent use of alcohol in these neurotic cases suggests the disease character and the action of physiological laws which are at present largely unknown.

FORMS OF INEBRIETY AND DRINK HABITS.

The various forms of alcoholic drinking may be grouped into three classes, namely, the continuous, the periodical, and the regular. Beyond this there is a class which may be called the contagious or neurotic cases which seem not to drink except from peculiarly exciting conditions. These various classes are well-known and often merge into each other.

The continuous drinker seems to possess the power of using alcohol in uniform doses at short intervals without exhibiting any marked derangements of character and conduct. He belongs to those who pride themselves on being able to drink without any serious damage. They are the moderate drinkers in every community whose masked condition is misleading to all except to physicians. They die suddenly from congestion of the brain, hemorrhage or pneumonia. Often they are found dead in bed or die from heat or sun-stroke. Some of these persons become insane, usually of the type of dementia. Others have palsies from which they never recover. Such persons suffer first in the community from the presence of epidemic diseases, and seem to have no resisting power to concussions, injuries or shocks. The spirit and beer-drinking longshoremen at Liverpool have a frightful mortality. Yet they are types of physical strength and vigor and seldom appear to surfer from intoxication. They are unable to resist the slightest attack of disease, and die from the simplest injuries. In this county few moderate drinkers attain the average longevity of the race unless they are muscle workers and live in the open air. As brain workers, living indoors, their length of life is greatly diminished.

Most of the drinkers after a variable time merge into periodical or impulsive drunkards, and drink to stupor or maniacal conditions. It rarely happens that men can drink in moderation in this country where the condition of mental strain is intense and exhaustive. The periodical drinker is always a neurotic. The excessive use of spirits after a free interval is of the nature of a nerve storm. The morbid gathering of the energies of the system explodes in this impulsive, unreasoning demand for relief which alcohol most quickly overcomes. There will be perfect freedom from desire, and even distrust for spirits up to a certain point ; then an overpowering impulse to drink will follow. Nothing short of complete saturation from alcohol and profound and repeated narcotism, which seems to exhaust the nerve energies, will satisfy this morbid demand. The abrupt beginning and sudden termination of the drink paroxysm indicates its neurotic nature.

HABIT, AND THE DAMAGES OR ALCOHOL. 15

Then follows a long free interval. In some instances the return of the drink paroxysm is uniform as to time, rarely varying more than an hour. This periodicity is so absolute and positive that it can be traced, and even anticipated. In other cases it is irregular, and depends upon unknown conditions or on some special exciting cause, which when removed, is followed by a cessation of the paroxysms. Many of these cases are literally epileptoid, and frequently merge into convulsive spasms which are called alcoholic epilepsy. The palsies after the cessation of the drink craze and the convulsive activity of the muscles indicate central brain lesions of grave character. The symptomatology of these cases is a very interesting study, and while each case differs widely there is often a uniform movement which can be readily traced.

SYMPTOMATOLOGY AND CLASSES OF DRINKING MEN.

Many of these cases appear among the active brain workers of the country, and their addiction is concealed. The sudden disappearance of energetic, active men, and their return in a week or two a little paler are the general indications of these alcoholic attacks. Some of these cases use spirits only at midnight and alone. Others never drink except at the club and in certain company; and then only at stated intervals. Many of these persons frankly confess that they go off to indulge in this alcoholic narcotism, that it is an irresistible charm which they are powerless to control. Others conceal these attacks or explain them as due to other causes.

Not unfrequently these attacks end in acute mania from which recovery is very slow, and in many cases does not follow. After the subsidence of the drink storm, the mind often retains its exalted and delusional state, and permanent mental troubles begin. Some of the most dangerous homicidal cases have followed the drink excess of periodical drinkers. General paralysis is often a sequel of this form of drinking. Paranoia, and many of the obscure mental disorders come from this cause.

The third class of irregular or impulsive drinkers are very numerous, and drink or abstain from causes and conditions very obscure. Sometimes a period of abstinence extending over years will occur, then they will drink to excess and continue at irregular intervals for an indefinite time. Such persons drink when excited or from overwork or underwork or any other causes which seem to break up the uniformity of their life and surroundings. Many of these persons explain the drink craze by the most trifling, childish theories. Often they appear in temperance meetings, and describe with great minuteness their sin of drinking, giving great prominence to the struggles which they claim to have undergone in the effort to abstain trom drink. They are also prominent at prayer-meetings, and pose as types of the power of conversion. There is in this class a mixture of imbecility and delusional cunning which is not well understood. At times they appear like dipsomaniacs overwhelmed with a mad craze for spirits but unlike this class, when forced by adverse circumstances and with apparent objects to gain, they show remarkable power of abstinence. Others of this class drink in favorable circumstances only, and abstain when their interests are in peril. The drinking seems to be of a mental as well as a physical type. The mind recurring to alcohol as a help when the conditions are favorable. They alternate between extreme condemnation of persons who use it, and childish theories and explanations of their own addiction. They are filled with buoyant and most extravagant theories of the" methods of relief and means of escape, and are the most devoted advocates of all new remedies and means of treatment. Among these persons the mental element will often develop into fixed delusions of the necessity of alcohol as a medicine, and many of the most devoted advocates of the tonic and stimulant powers of alcohol belong to this class. Some of these persons use wines continuously, and only resort to alcohols at long intervals. Such cases become demented after a time, and are noted as cranks, paranoiacs and persons with twisted brains. They belong to the eccentric class, and those who are uncertain, unreliable, unstable, and likely to develop into more pronounced forms of mental disease.

A study of the causes of these different classes reveals varied and complex conditions. When the histories of a large number are carefully gathered and compiled, it is found that over sixty per cent have inherited from their parents a predisposition

to seek for some relief for states of depression and ill-feeling.

HEREDITY AND FORMS OF PREDISPOSITION.

These causes are divided into two classes, one called direct and the other indirect. The direct heredities are those where the parents have been moderate or excessive drinkers. The indirect heredities are cases where grandparents drank or used drugs.

In the first class, there is often a direct transmission from parent to child of the drink impulse appearing at about the same time as in the parent, following a uniform course, and ending in the same way.

Example. One family for three generations had several sons in each branch who began to drink at puberty, and either died or became total abstainers at about thirty years. The daughters in these families were drug-takers and alcoholics, hysterical, and epileptoid. Some of them died in early life but all showed marked defects of brain and nervous system.

The rule is that where alcohol takers have large families, the tendency is to an early extinction. The defects transmitted seriously impair longevity under the most favorable conditions. Many children of drinking parents are total abstainers until some serious change or physical revolution takes place in their organism; then, if alcohol is used, they become impulsive drinkers of the most imbecile type, drinking usually to death. Other descendants of alcoholic ancestors are delusional fanatics in their conceptions of the drink disease and their theories of its remedies.

It may be stated as a rule that the children of alcoholic parents are defectives, and will often use alcohol with or without any particular exposure. The exceptions to this only indicates a change in the type of degeneration. For instance, daughters of alcoholized parents show great feebleness of moral faculties and become prostitutes, hysterics and degenerates. If they fortunately escape this, they may develop in later life some of the manias which indicate their unsoundness.

In the third generation from the alcoholized parents extreme types of weakness with mental incapacity and physical defects appear. Statistics of the criminal and degenerate classes show a large percentage of alcoholized parents. Morel, of France, has made a table of this decline which can be stated with great certainty as showing the line of degeneration. First generation, alcoholic excesses with immoralities and degradation. Second generation, early drunkenness, manias, and general palsies, with criminality and pauperism. Third generation, sobriety, hypochondria, great feebleness and paralysis. Fourth generation, mental feebleness, idiocy and extinction.

In the examination of a large number of cases, these direct heredities of persons in this country seem not to pass beyond the second generation. The vitality becomes exhausted and early death from acute and chronic disease follows.

The general principles that obtain in these cases may be stated as follows : 'All children of inebriate parents inherit a defective vitality with feeble power of resistance and inability to adjust themselves to the surroundings. These conditions of weakness and degeneration diminish the power of resistance to all inflammatory disease and make narcotism from alcohol fascinating because it brings with it a feeling of strength and relief from physical and mental pain.

Often the higher moral faculties of the person are undeveloped, and the children of alcoholized

HABIT, AND THE DAMAGES OF ALCOHOL.

persons are born criminals without consciousness of right and wrong, and with a feeble sense of duty and obligation.

Another curious fact is that the children of alcoholized persons often show great fecundity and have large families, suggesting the oft-noted fact that just before the extinction of the race Nature makes a supreme effort to perpetuate the seed and to save it from obliteration. While these inebriates' families are often large, they rarely live through childhood, and carry into maturity defects which soon cause their extinction. Families of this kind are by no means uncommon. The general history clearly indicates degeneration, both in appearance and conduct. Tuberculosis, hysteria, eccentricity, rheumatism, and an almost endless variety of neuroses appear. Occasionally some member of these dying families will be brilliant and precocious, and start far away above his age and generation in intellectual development and achievement but die suddenly. The vast majority comprise the dying masses or as it is popularly termed "the driven-out, or crowded-out remnants of the race."

The indirect heredities are equally startling.

s. Why one generation of sober people should inter-

^5 ^ vene, and only in the third generation the defects

v ^ of the grandparent appear is difficult to under-

' ru stand. In the figures we have mentioned the indirect heredities will be from a third to a half of the sixty or seventy per cent of cases. In all probability some form of defects has laid dormant through one generation and breaks out in the third from the application of some exciting causes or possibly in the second generation there was an absence of these causes. Nearly all these persons who develop alcoholism in the third generation also exhibit various neurotic troubles, both of nervous system and nutrition, also a tendency to rapid exhaustion.

The following is an example : An inebriate ancestor had four children who were temperate and well. Of their children, eight out of eleven drank at different times, four of them dying from this cause, the others becoming demented or dying from intercurrent diseases. Other members of the family were neurotics and died of consumption or broke down in early life and were invalids.

In three cases under my care, there was no inebriety in the ancestors but in the grandparents on both sides there had been excessive drinking. Each of these cases had a very careful training and the inebriety did not break out until middle life. The conditions in which it developed pointed out clearly the neurotic inheritance. There is no more mystery in this than the transmission of physical defects from one generation to another or the skipping of one generation and the develop-

HABIT, AND THE DAMAGES OF ALCOHOL.

ment of the same peculiarity in the second or third generation.

In these drug diseases there is probably transmitted some special tendency to seek relief in some way from psychical and physical pain. Alcohol gives the most positive relief of all other drugs. There is also transmitted a low degree of vitality with feeble resisting powers to pain, and defective control. The person suffering from nerve or mental pain is unable to bear discomfort and becomes possessed with the impulse to secure relief at all peril. There is also, no doubt, transmitted some latent predisposition to hyperesthesia and exhaustion of the nerve centers which provoke morbid impulses to overcome them.

NEURASTHENIA AND OTHER CAUSES.

Next to heredity as an active cause in inebriety, states of exhaustion and neurasthenia are most prominent. The use of drugs, particularly alcohol, is far more impulsive and precipitate in this country than elsewhere. No doubt this is due to the intensity of living, the continuous excitement and rapid change in life and living occupying nearly every moment of the time, drawing constantly on the energies of the brain and body without healthy periods of rest. To this is added the consequent neglect of the healthy normal functions of the body. As a result neurasthenia, cerebrasthenia, and other profound neuroses lower the vitality of the body and produce a condition of mental pain and suffering for which narcotic drugs are most grateful. Often these conditions of exhaustion begin in early life and are intensified by educational training and bad conditions of living. The overworked and those who have a large burden of cares and exacting duties, and who neglect to live in accord with the requirements of their life, soon exhaust their vitalities and become early victims. They become drug-takers, finding most ready relief in "bitters" and remedies containing alcohols, and soon abandon these for the various compounds of strong liquors.

There are others who become neurotic from bad surroundings, suffer from shocks, both physical and mental, and have stages of extreme depression in which alcohol is a grateful remedy.

The perturbations and changes of puberty are often fatal periods for the development of this predisposition. The disasters and storms of later life have the same effect.

The failures of nutrition, conditions of starvation, with anemia and insomnia, are all active causes.

There are a number of persons in every community who are constitutionally sensitive to their surroundings. They seem to reflect the company they are associated with as well as the hygienic conditions they live in, and are subject to every fluctuation of both mental and physical conditions of life. Such persons are intemperate or temperate according to the presence of temptation or absence of it.

Inebriates of this class are called contagious inebriates.

Where the causations are clearly physical, they early become chronic and develop serious disease. Such persons are usually neurotics of the hyperesthetic, emotional class. They often possess genius but are impulsive, unreasoning and credulous, accepting the conclusions of the present without doubt or question, and also seem to be governed entirely by present impressions. In company with drinking men they imitate them. With abstainers, they are abstinent, and never seem to realize that they cannot do as others do without suffering. Many of this class are wanting in culture and training. Often they come from indulgent family circles where every wish has been gratified. In other circles where they have been isolated, and seldom come in contact with new persons and conditions of life, they become mere imitators, and do not seem to be able to adapt themselves to any new conditions but are molded by the surroundings entirely. Such persons are often described as "sowing wild oats" at this time, and from bitter experience acquire certain predispositions which are fatal through all after life.

Parents and guardians are more responsible for this condition than the victims themselves. Young men and women with this pliable contagious mentality require more than school and home training. They need to be under the control and direction of robust and controlling minds for a long time.

As inebriates such persons early become demented and fall into pauperism and petty crimes, rarely becoming criminals except of the lowest type.

As patients, nothing but a revolution of surroundings and conditions of living will be of any advantage. They are subject to every new method of treatment, and become restored and pose as examples of cure from every condition and method of treatment. Then they relapse as quickly, and seem so thoroughly identified with the surroundings that it is difficult to classify them.

Types of the two classes are apparent in the following examples:

A , the only son of an excellent clergyman,

was brought up without the slightest control, and every whim was gratified. In college he fell in with drinking companions, and drank to great excess. Later, as a merchant, he drank in company, and wherever he went seemed to follow the habits and practices of those he was associated with. He was converted frequently, signed the pledge on many occasions, went to several asylums, came away restored — only to relapse when brought in contact with drinking company. Finally, at thirty years of age, he was sentenced to prison as an accessory to murder. He is there at present, and is a most reputable prisoner, allowed great liberties, and is an active man in his place.

The exact surroundings and prison discipline have brought him to a higher standard of living than he has had before. When his sentence is finished he will be employed in the prison, and probably will live a useful, temperate life.

Example No. 2 is that of a farmer's son, brought up in the interior, isolated, and seldom coming in contact with other persons. At twenty he procured a situation in a large city, and soon became an inebriate, and drifted from place to place, having no individuality — simply following every influence which is brought to bear on him. Finally, ten years later, he became a servant of a vigorous man who realized his flaccid character, and treated him with great severity, forcing him to live in correct surroundings and away from bad company. He remained here many years and was a temperate, valuable man. Then his employer died, and in another situation he became a drinker and soon relapsed and died.

Both of these cases are types of a class of persons who in certain surroundings could be made useful citizens, and, acting under the control and dictation of others, might be free from all use of drink.

Chapter II. Dipsomania

Dipsomania, as its name implies, is an insane thirst or craze for alcohol. This disease is not very common, and frequently appears without premonition. Such persons have used spirits in moderation or at intervals, rarely to stupor, and are considered temperate. Suddenly, without apparent cause, they will be possessed of an insane desire to procure spirits and drink to stupor. On recovery after an interval the mania comes on again, and another period of narcotism follows. This continues several days until complete exhaustion, gastritis, and delirium supervenes. Then a long, irregular period of rigid abstinence follows.

This differs widely from the periodical drinker in coming on suddenly and possessing the body like a veritable mania in which no other thought or motive exists except to procure spirits.

It is an insanity of the impulsive type, and has a distinct beginning, progress, and termination; and is certain to end in recovery. Such persons are dangerous when opposed but harmless when permitted to use spirits. Delirium tremens is not often associated with this although some cases have been called delirium tremens. The impetuosity of the impulse and its overmastery of the mind and body is illustrated in many striking cases.

In one instance a man chopped off his hand for the purpose of procuring spirits as a medicine for the shock.

During the Civil War, a sutler's wagon with a barrel of whiskey was broken down between the lines within easy range of the sharpshooters on both sides. The certainty of instant death did not deter men on both sides from attempting to reach the barrel to procure spirits. After a number of men had been killed a cannon was brought up to destroy the barrel.

Men have been known to deed away their property for spirits under this impulse. Some famous trials have followed from acts committed during this period. A noted statesman had dipsomaniac impulses which were controlled by placing him in a cell for forty-eight hours. Others have been given spirits to stupor until the impulse died away. Many of these cases become opium-eaters or have died from the effects of narcotic drugs given to check the impulse. When the craze subsides a period of extreme exhaustion follows, without delusions or hallucinations; the mind seems to be clear again. Some authors think that this condition is more common among women than men. In my experience it is of shorter duration and more easily checked in women. In some of these cases where the impulse is forcibly restrained by drugs it breaks out again with greater force than ever. Active treatment should be continued for some time after the subsidence of the impulse. There is associated with this, loss of appetite, excessive perspiration, increased heart's action and slightly raised temperature of the body. Insomnia and intense muscular and mental activity are also common symptoms.

These attacks usually follow each other at irregular intervals, depending upon unknown causes, but no doubt due to some central irritation and exhaustion. All periodic drinkers are not dipsomaniacs, and very few inebriates can be classed under this head. Many of these persons go to the insane asylums before the paroxysm subsides, and afterward are very clamorous to be released, claiming that they have been unjustly confined. The following is an example : A lawyer supposed to be temperate, though he had occasionally used spirits in company and at banquets, suddenly developed this impulse following a period of intense excitement. He wandered about the streets, drinking at all times and places in the most maniacal way, giving no reason for his conduct, simply saying that he must drink. He was forcibly restrained, and developed maniacal violence, and was taken to an insane asylum. He recovered, was discharged, and commenced action for false imprisonment. Two years after, following a political campaign during which he was abstinent, the same impulse came on, lasting about a week, during which time he was continually stupid or wildly delirious, having no other thought on his mind but drink continuously. He eventually became insane, and died in an asylum. Physicians who treat cases in prisons notice the outbreak of this impulse among the inmates, often manifest in a dazed, delirious condition, with continuous talk of drink and effort to procure it in some form.