WHAT SHALL WE DO WITH THE INEBRIATE. • T. D. Crothkrs, M. D., Hartford, Conn. Reprint from The Alienist and Neurologist, St. Louis, April, 1881. WHAT SHALL WE DO WITH THE INEBRIATE ? T. D. Crothers, M. D., SUPERINTENDENT OF WALNUT HILL HOME, HARTFORD, CONN. ' I ''HIS was the title of a paper written by a very able physician, and published in a popular review in New England in 1858, in which inebriety was emphatically declared to be always a vice and sin, the treatment of which consisted in a more rigorous enforcement of the law, and severe punishment in every instance. A clergy- man, who reviewed this article at great length, endorsed its sentiments, and urged the additional means of conver- sion, which he claimed would cure every case. This article, and its review, passed into literature as an authoritative discussion and answer to this question. Years after, it happened that both persons met in an inebriate asylum—the doctor, to visit his inebriate son, who was an inmate of the institution; the clergyman, to receive medical treatment for both the alcoholic and opium disorder. Thus, when this question demanded a practical solution in their own family circle, all previous theories were radically changed. In 1868, a very prominent physician and medical writer refused to aid in the build- ing of an asylum, by either his influence or money, denouncing it as a humbug, and unworthy the name of 2 What shall we do with the Inebriate? science. Five years later he brought his son, a chronic inebriate, to this asylum for treatment, and warmly urged all means to sustain it. Later, his son relapsed, and reported the most extravagant stories of his freedom in the asylum to get all the alcohol he wanted. This the father believed, and became a bitter enemy of the insti- tution. The death of the son, from delirium tremens, increased his enmity, and, to-day, he condemns physical means and appliances to cure inebriety, as exploded absurdities of the past; and a large circle of medical friends accept this as a final statement of facts. This illustrates the position of many of the profession. The public have assumed that inebriety is purely a vice, and can be reached only by moral and legal appliances. The great religious movements that are sweeping over the country, with their thousands of enthusiastic reformers, are urging this view as the only one that will reach the inebriate. To-day, in all the discussions of the effects of inebriety and its presence, the same remedy is urged, and, stranger than all, is accepted by many scientific men. The failure of the medical profession to study the nature and character of inebriety has opened wide the doors for a vast army of reformed inebriates and clergymen, who, in the most extravagant and dogmatic way, are instructing the public what inebriety is and how to manage it. In 1867, Dr. Parrish asserted that inebriety must be regarded as a disease, and treated by physical means; a fact that Vnlpian had urged fifteen centuries ago, and which had been endorsed by leading men in every century from that time down; and yet the religious press sent up solemn protest against the admission of such unholy doctrines. Even the superintendents of some of the insane asylums joined in denouncing the disease theory; and, to-day, the unfortunate remark of Dr. Bucknill, regarding asylums for inebriates, “ that they failed to cure a disease which did not exist, by remedies which were not applied,” is accepted by many as authoratative. In the future, the student who examines the history of medical progress of this T. D. Crothers. century, and notes the extraordinary activity and practical character of all studies into the causes and prevention of diseases, will be amazed to find that inebriety was hardly recognized; also, that its study and treatment was left almost entirely into the hands of clergymen and inebriates themselves. The grim necessity for a practical answer to the question, “What shall we do with the inebriate?” is manifest in the great activity of temperance societies, churches and other efforts, not founded on scientific study or research. As an illustration glance at the temperance literature, filling whole libraries, and represented by hundreds of papers, all discussing and approaching inebriety from a moral standpoint; accounting for the presence of one hundred thousand inebriates, through original sin, and a vicious element in the moral nature of man ; ignoring the existence of the great natural and physical laws controlling the body and mind. While the medical literature of inebriety, could all be put on a small table, and is repre- sented by only one journal; which, nevertheless, is full of promise, and distinctly marks a new era in the field of psychological literature. Already, the disease of inebriety is clearly outlined, and the vast chains of conditions and causes stretch out into wide, unexplored fields, that are governed by laws which will be clearly understood in the future. This great army of inebriates, projected from the front line of civilization, extending back through all grades of society, are but the victims of physical causes, and the results of conditions which await further study. Such study must be thorough and exhaustive, and include all the conditions of inheritance and surroundings of mental and physical life, and of the time and circumstance of the first toxic use of alcohol. From these facts will appear some of the laws which control the development and progress of this malady. The following statement will represent the problem in its general bearings: Among all classes, and in all sections, are found men and women who persistently use alcoholic drinks to excess; suffering, both directly and indirectly, in health, character, position, also What shall we do with the Inebriate f 4 in social and pecuniary interest. This they continue to do, against all motives of self-interest, influence of others, and considerations of right and wrong, either slowly or rapidly going down to ruin and death. Through all this there is an appearance of health, and often a keen recognition of the situation, but rarely any successful effort to recover. Looking at these cases more closely* they seem to begin in some regular order, and follow a line of conditions and circumstances that are more or less uniform; that is, we may recognize a general chain of cause and effect, and note a continuous progress in each case, which is parallel. This suggests a physical origin, and if we make a record of the symptoms of two cases, as seen month after month, a more striking similarity will appear. Not unfrequently this is so marked that we cam predict, from some general knowledge of the patient, much of the future progress of the case. As an illustration of the uniformity of the symptoms and progress, the following study is given of two ordinary cases, which differ in no way from many others: Case 1. Case 2. A farmer, 25 years old. Began to drink suddenly. Inherited nervous diathesis. Probable active cause, obscure in- jury and overwork. Drinks steadily to excess. Delusions of strength to stop at will. Boastful and extravagant in speech. Habits became irregular. Manners changing. Morose and untruthful. Very suspicious. Melancholy and suicidal at times. Unusual violent temper. Extreme sensitiveness. Both complain of the neglect of friends to aid them by not con- cealing their true condition. Both make fitful efforts to recover and then sink back to worse conditions. A clerk, 34 years old. A long stage of moderate drinking. No special history of heredity. Active cause, general irregularities and bad living. {Drinks irregularly and at limes to excess. Same delusion. Very egotistical and self-conscious. Works spasmodically. Loosing pride in appearance. Untruthful, rude and hilarious. Alternately suspicious and credul- ous. Depressed and often exhausted. Very quarrelsome. Afraid of insults and sneers. T. D. Crothers. 5 Long distinct free intervals of so- briety. Sudden and prolongedj 11toxication. Both came under treatment in an asylum, and both relapsed after being- discharged. Later failure of mind. Religious melancholy. Death from Pneumonia. No free intervals. Intoxicated only at long intervals, but always drinking. 31ind full of delusions of wealth, and great plans for the future. In an insane asylum with general paresis. In this very general study of two cases, there is clearly a uniformity of symptoms and progression although lrcm widely different causes and circumstances. The form and character of the degeneration in inebriety will be found to be very closely related in all cases, and to follow a natural course from stage to stage. It may be stated that a careful study of every case of inebriety indicates certain conditions of body and mind, which either intensify or antagonize the development and progress of this disorder, also the special remedial means which may conduct the case to recovery. No application of means or remedies that are not based on these facts, or that do not recognize the physical changes which have taken place, will give any promise of permanency in the treatment. Here, as elsewhere, we must recognize the causes, before any intelli- gent treatment can be applied. In inebriety we have two prominent factors always present in the causation of each case. The first and most prominent to the general observer is alcohol; this may be both a primary and secondary cause, but in either case there are certain pathological changes always present during the progress of the case marked by certain fixed symptoms, that rarely vary or change. The second are the conditions of degen- eration, either inherited or acquired, that are present before alcohol is used, and break out into an inordinate desire for alcohol, or conditions of exhaustion, for which this drug seems to give relief. In the former case where alcohol appears to be the primary cause, there will be found many complex conditions; pathological changes coming from the different alcohols, that are practically unknown. 6 What shall we do with the Inebriate? Recent studies have shown that the toxical action of differ- ent alcohols depend upon the kind of alcohol, the substance from which it is made, and the process of manufacture also the natural chemical combinations which follow after its manufacture. These different alcohols when taken alone produce different physiological effects on the body. For instance, one form of alcohol will cause profound stupor, another will produce intense hvperaemia of the brain and delirum, a third is followed by musculars tremors and reduction of temperature, &c. The study of a few of these alcohols seem to indicate that each one alone, has a special physiological action over the brain and spinal cord. If we consider the almost numberless forms of alcohol, and their equally complex combinations in the various forms of drink used, and the still more uncertain physiological actions on the body, the magnitude of the subject will be partially seen. Practically, from this we may realize some of the many causes, which result in inebriety. And the only wonder is that the effects of alcohol are not more pronounced and fatal in each case. In the second factor are conditions of degeneration, either inherited or acquired, present before alcohol is used, which develop into inebriety, or produce conditions of exhaustion, for which alcohol seems to give relief. The active causation of inebriety, from inheritance, appears either in a direct or indirect form. In the former, it follows directly from father to son, or from family to family, and is manifest in childhood by a perverted brain and nerve force, and disturbed functional activities. In the latter, it is often more remotely inherited, as from the second generation back, and breaks out from the application of some peculiar, exciting causes. Next to inheritance, directly from inebriate ancestors, are degenerative conditions of the organism, following all the various forms of insanity and epilepsy; also consumption, and many of the nervous diseases noted by intense exhaustion; all these transmit a diathesis to the next generation, which often appears in inebriety. Another T. D. Crothers. series of causes will be found in the bad and imperfect nutrition of childhood. This period of life, between four and fifteen years of age, is often the starting point of inebriety. The nutrient degenerations, from both the quality, quantity and irregularities of food, also over- stimulation of the brain and nervous system, break out in inebriety, in manhood. Again, we shall find climate, occupation, education and surroundings active causation which enter into many cases, modifying and changing the progress materially. All these factors are more or less present, and enter into the causation of nearly all cases of inebriety. Up to this time, no studies have been made in this direction, and the general term of “ vice ” has been given to every obscure symptom of inebriety. Inebriety not only appears as the result of perversions and degenerations of the brain and nervous system, following the direct use of alcohol, but it is often a symptom, and' follows other diseases as a hint of degeneration in certain cortical brain centers, notably in general paresis, epilepsy, tumors of the brain, and reflex irritations, dementia and melancholia, etc. Inebriety not unfrequently merges into acute mania and other diseases, which pass rapidly to a fatal termination. The range of causes in inebriety are very complex, involving many conditions that require careful study, from a scientific standpoint. The special question of our discussion resolves itself into two general facts: First, The special appliances and methods of treatment which are indicated by the present study of inebriety, as successful in the cure of these cases. Second, Preventive measures and hygienic means that will lessen the number of persons who suffer from inebriety. First, No matter what the real cause may be, we must recognize the presence of alcohol and remove it; for the practical fact is, that the use of this drug in toxic doses, or continuously, causes tissue degeneration and starvation, and this interferes with the process of absorption and elimination, thus breaking up all chemical changes in the body. This may go on for a 8 What shall we do with the Inebriate ? long time and without marked evidence of the real condi- tion. If the patient cannot be treated at home successfully, he must be removed to some asylum or hospital or properly quarantined, until positive seclusion from this cause can be obtained. Alcohol always masks and covers the real condition of the patient, and its with- drawal reveals the long train of causes that enter into the formation of the case, permitting more exact studies into the nature of the disorder. No case can be treated unless absolutely removed from alcohol. This can be most effectually done in a special hospital for this purpose, where legal restraint can be combined with sur- roundings to make it exceedingly difficult to procure spirits. After the removal of alcohol, the sanitary sur- roundings of the patient demands attention. From what- ever circle of life or social condition he may come, there will be found a general neglect of all healthy habits of living and exercise. All regularity of work and proper care of the body, inordinate and insufficient food, want of bath- ing, ventilation, rest and all the many conditions which enter into healthy activity of both body and mind, require careful regulation and treatment. If this cannot be done elsewhere, it must be in special hospitals, con- ducted in the most methodical and hygienic manner. Not only the location, but the building must afford every facility to bring the best conditions of health. It may be large or small, situated either in the country or suburbs of city, but it must combine seclusion from alcohol and the best sanitary conditions for restoration. Residence in such a place must be positive and exact, and not depend on the feeble will and impulse of the patient. The duration of this residence should depend on circumstances and the history of the case. The legal principle which should apply in these cases is that whenever any person by the excessive use of alcohol, not only injures himself, destroy- ing his property, but perils the rights of others, and the good order and harmony of society; he should be restrained and forced to adopt such measures as will lead to a speedy T. D. Crothers. recovery. He is for the time substantially irresponsible and incapable of exercising full liberty of choice, and should be treated the same as a small-pox case, or a suicidal mania. If he will not go voluntary into the special surroundings neccessary for health, it is the duty of his friends and society to force him to do so. The question is not of the degree of responsibility or capacity for self-restraint, or of the moral state of the patient’s mind; but the immediate means to meet the demands of the case. On the same principle that the surgeon when called to treat a fracture having first ascertained the kind of injury, uses the exact appliances to meet the case with- out regard to other causes which may have been present. In special hospitals the study of inebriety can be conducted with much accuracy, and all the many symptoms which distinguish it as a disease pointed out, and their proper treatment more positively ascertained. The application of the principle of rest in the treatment so essential, can be more thoroughly carried out here, where all the surround- ings are under the control of the physician. Nervous exhaustion is more or less present in all cases. The appli- cation of rest to both mind and body requires a nice adjustment of means and remedies based on an accurate study of the wants and history of the case. For instance, a patient accustomed to active brain labor, needs a different kind of rest from the gross lethargic case, that has but little mental exercise. The one gets rest from diversity, the other from quiet and regularity. The treatment by rest enters into all the conditions of functional and mental living. The inebriate hospital should be a rest cure in its broadest scientific sense. Turkish baths are undoubt- edly the most valuable medical means to rouse up the diseased organism; they seem to have a marked power over the vaso-motor paralysis, and increase the eliminating process of the skin, &c. Electricity and bitter barks, also arsenic and strychnia, are of great value in certain cases, while the bromide chloral and others depressants should be given guardedly, and not without positive indications 10 What shall we do with the Inebriate f of their necessity. The common practice of treating patients at home by such chemical restraints as may be obtained from chloral, bromides, opium and other drugs of this character is excessively dangerous, and always prolongs the duration of the disease, increasing the organic degeneration and making recovery more difficult. In two cases which came under my care, one for chloral, and the other opium inebriety, the origin was evidently from the use of these drugs to relieve the effects of excess of alcohol. The use of such narcotic drugs in inebriety should be contra-indicated, as a rule, from the natural tendency of this disorder to merge into diseased cravings for these substances. A physician whose son had been under treatment at Binghamton asylum for dipsomania, and had relapsed after being discharged, commenced active treatment by chemical restraint at home when the attack came on. By profoundly narcotising the patient on the appearance of the attack, and keeping it up until the paroxysm was over, he was prevented from using alcohol. The physician was delighted and rushed into print, in an article, to show that inebriety could be successfully treated at home by these agents. Two years after this son was sent to an insane asylum demented and idiotic, and the history indicated clearly that bromide of potassium and chloral were the active causes. The inebriate although appearing to be in possession of his mind, will always be found on the other side of that mysterious border-line of mental health. . The ego is always very active, and delusions of strength and capacity to endure and recover are present to the last moment of existence. The inebriate in the lowest chronic stages, with the adverse experience of twenty years, will talk and act confident in his ability to stop the use of alcohol abso- lutely at his pleasure. Alcohol seems to act on some cerebral centers of the brain, causing what is variously termed moral paralysis or degeneration. Marked first by false reasoning on matters of right and wrong, and T. D. Crothers. 11 timidity of character. Then a general progressive degen- eration of all the higher elements of manhood, also confused efforts to conceal his motives and character behind a mask of deception and intrigue. Prevarication, want of veracity, slandering and decline of pride with impulsive selfishness, alternating with unbounded benevolence, may be noticed in every case. These mental symptoms rarely attract attention until the case has become chronic, and even then are not observed only by his most intimate friends. In all these cases the mind needs treatment as well as the body. An asylum that will provide immunity from alcohol with good surroundings and rest, must bring mental appliances that will reach these obscure psychical condi- tions. Of these, restraint is important, not the bars of a prison or the control of an insane asylum, but a combina- tion of the two applied at times with military exactness, and alternated with freedom. Each case should be governed by conditions and circumstances which depend on the history and causes. Often restraint is injurious and the direct cause of mental irritation that may bring on a relapse; again it is a powerful stimulus rousing up the feeble will and debilitated organism into a healthy activity. It may be termed either an irritating depressent, or a stimulating tonic, and its proper application of this means is a valuable remedy. Some of the many complex conditions which enter into this question of when, and how far active restraint may be applied with benefit to the case, will be better understood in some illustrious cases. Case i.—An Irishman and farmer, who had, in all probability, inherited an insane neurosis, having drank, irregularly, from fifteen years of age. At thirty, he was a periodic inebriate, with free intervals of three months. These paroxysms came on from some unexpected condi- tion, usually intense depression from some external cause. In one of these paroxysms he was brought to the asylum, and was filled with delusions of the bad motives and purposes of his friends. For some days he suffered from muscular agitation and extreme restlessness, then recov- ered. For weeks after, he was pleased to be restrained 12 What shall we do with the Inebriate ? and watched ; said he felt more secure and confident of recovery by this means. Four months after admission, he complained of this restraint, and wanted full liberty to go and come. This was denied on general principles. He then became suspicious, and attributed this refusal to the worst motives ; was alarmed and went about in a dazed, restless manner. The watching and restraint was increased under the impression of the return of paroxysm of drink. At last he escaped, at the risk of his life, by climbing from the window of a third story, and drank very seriously. He was returned in a few hours, and recovered without any noticeable incident, submitting very cheer- fully to all the restraints of the institution. Two months later, he began to complain, as before, of the confinement and watching. As an experiment, he was given full liberty within certain limits, only required to be exact in observance of all other rules. His mind seemed at rest, and he continued a most cheerful, exemplary patient for six months, until discharged. During this time, he remained in bed for a day or more, on several occasions, giving, as a reason, a feeling of uncertainty and depres- sion—evidently a premonitory symptom of the paroxysm of drink, which yielded readily to quiet and medicine. At this time, two years later, he is in good health and active business. Here, it was clear that restraint, beyond a certain limit, was irritating and injurious. The freedom of the will acted as a tonic, giving him greater vigor and capacity. He was repeatedly watched in conditions of temptation, and always manifested strength and vigor. Case 2. Illustrates an opposite condition, demanding continuous restraint. B. was a graduate of college, and lawyer of much eminence. For some constitutional debility in childhood, he had been given wine and beer for years, daily. Epilepsy, catalepsy and consumption had appeared in various members of the family, both in present and past generations. During college life he was intoxicated frequently, and at twenty-five he drank, steadily, beer every day. At thirty-two, he was brought to the asylum an inpulsive inebriate. Drinking to intoxication every week, or oftener; depending on circumstances, and using some form of spirits every day. He was suicidal, and suffered from intense depression, with general muscular exhaustion. His mind was inpulsive and full of delusions of either extravagant hope or abject despair. He recov- ered with firm convictions, and very earnest protestations T. D. CrotJiers. 13 that he would never use alcohol again. At times he complained of the restraint as being unnecessary, but submitted quietly, although very emphatic in his thorough recovery. After three months treatment, he relapsed from the most trifling temptation, and from this, during his entire residence of a year and a-half in the institution, he could not be trusted a moment, but would procure spirits under all circumstances, and at all times, although seemingly the soul of honor and honesty. He would apparently regret having fallen at the time, and seemed anxious to avoid any temptations in the future, but soon after display intrigue and cunning to procure spirits with every opportunity. He drank on being discharged, and continued up to his death, a year later. This case needed the restraint of a military asylum, controlling all the little events of every-day life, and the more exact and complete, the better he would be. A third case is given as combining many of the characteristics of both : Case 3. Was a merchant, forty-six years old, who was an accidental inebriate. That is, he used alcohol only to relieve conditions of exhaustion and excitement that came on suddently. After a few weeks residence in the asylum he became impatient of restraint and was allowed to have a certain amount of liberty, which he soon abused and relapsed. Four months of careful restraint followed, and he was given liberty again ; two days after he was so much agitated that he was again restrained. From this time and during six months treatment, alternate restraint and freedom were given him, depending upon his mental and physical condition. If he was restless, irritable and nervous, careful watching was instituted, but if he was cool and quiet, he could go about with safety. Great care was given to have him under observation, in the afternoon and at night, as these were considered dangerous periods. This patient is now doing well, and is a good example of the indications of treatment from a thorough study of the case. Continuous restraint and unlimited freedom were both contra-indicated from a clinical study, but the wise applica- tion of each was found to be absolutely essential in the treatment. This is undoubtedly a means of treatment which should be used with the same discretion and judgment as medicines. In the practical application of the treatment What shall zve do with the Inebriate ? of these cases in an asylum, three distinct classes will be found. The first class is probably most prominent of all others, and are found to be deficient by inheritance. They have an exceedingly low sense of duty, and conceptions of right and wrong. Very frequently they display distinct criminal tendencies, associated with weak will and low passionate impulses. As inebriates they need sharp, active discipline and exact military surroundings, regulating every duty and act of life. This continued for a long time in an asylum with medical treatment, gives much promise of permanent cure. After two or more years in an asylum, if they can be placed in some position removed from all general temptation, and actively employed for a long time, their restoration is assured. For a long time these cases have been regarded as types of all inebriates, when, literally, they are simply strongly marked cases of defective brain and nerve force, alternately criminals, insane and inebriates, from accident and circumstance. They are freighted with a peculiar diathesis, which breaks out into either criminality, insanity inebriety or trampism, or one or more together, depending on circumstances, and are always more or less incurable. Superintendents of insane asylums, and judges, have based all their conclusions of inebriety from observations of this class. In the insane asylum they are the most trouble- some of all cases; in the courts they are the repeaters, that are sent to jail regularly* for intoxication; and, in all circles, they are the pests of society, continually drinking, committing petty crime, and outraging society by all kinds of excess. In inebriate asylums they abuse all the privileges, and bring every effort to help them into discredit. Injuring the other patients, and continually keeping up an atmosphere of insubordination and irregularity. When discharged, are full of slanderous stories about the asylum, and stand around the corners of streets advertising the failure of the institution to effect a cure in themselves. The State of Connecticut has char- T. D. Crothers. tered a company to organize and conduct an asylum work-house for this class, which will provide active work, sharp restraint, with medical care, and educational influ- ences ; not with the idea of permanently curing these men, but to relieve community of their presence, and make them self-sustaining. The law provides that such cases may be sentenced to inebriate asylums for a period of three years. After the first year they may be released on parole at the option of the managers. The building is not erected, only a farm has been bought for this purpose, but the plans and much of the preliminary work has begun. On simple, economical reasons, the value of such an asylum is apparent. Some, of these cases are permanently restored in the imperfect asylums of to-day. Inebriates of this character are reported cured from long confinement in many of the English prisons, under adverse conditions, and without anything but absolute control and regularity of surroundings. In a military work-house* can be combined all the means and methods of treatment which are especially applicable to such cases. This class of inebriates are universally misunderstood, and never studied clinically; yet they will be found to have a distinct cause, development, symptomatology and termin- ation. Nothing is more erroneous than the very common expression of the incurability of inebriety, based on empiric efforts to cure the criminal or insane inebriate, by means that are not only inadequate, but unfounded on any knowledge of the nature of the disorder. I protest against all deductions as to what inebriety is, and how it may be treated, founded on a limited obser- vation of such cases, which are always exaggerated types. The second class of inebriates, who come for treatment, are less prominent, and are the victims of circumsta ices, and some accidental causes *not understood. They come from the middle classes, and represent the hard working, active brain-labor of the country. Heredity is always more or less obscure, and usually the history of nervous and constitutional disease is not in the direct 16 What shall zve do zuith the Inebriate ? line of inebriety, but in some collateral branch. They are particularly noticeable from the prominence of delu- sions of strength to stop all use of spirits at their pleasure. Yet they never do, notwithstanding all their past fail- ures, insist, with earnestness, that they have the full power and capacity to recover. In these cases there are general conditions of ill health present, such as general exhaustion, anaemia, neuralgia and functional disorder of the heart and stomach. Injuries of the brain and spinal cord, profound shocks from both mental and physical causes,’ sunstroke, and exhausting diseases can be often traced as the active causes in many cases. Dr. L. D. Mason has recently published some very significant studies into the causes of inebriety, which indicates how much of this subject is almost entirely unknown. This class will be found to represent an average physical and mental capacity, with, not unfre- quently, great activity and ambition to attain either wealth or distinction in life. From various circumstances, depending on ill health, irregularities of living, bad sur- roundings, over-work, mental worry, and many other causes, the use of alcohol commences as a temporary relief, and culminates in a toxic condition or intoxica- tion, From this time, pathological changes begin, and alcohol is demanded ever after. After a period of con- stant use of alcohol, they frequently merge into periodic inebriates, with a free interval of more or less uncer- tain length. Many of these persons are strong tem- perance workers in the free intervals, and appear to be in good health and in full possession of their will-power. To their friends they are enigmas, and seem to be under control of an evil spirit, and are never able to understand why or when they will drink. These are literally very hopeful cases, even in the chronic stages, and when they remain a long time in the asylum, recover. I think that a very large per cent, of these cases can be permanently cured. They need, most of all things, seclusion from alcohol, and physical rest, also T. D. Crothers. 17 change of life and activities, with long continued hygienic and medical treatment to build up the system. These are the cases which get well all unexpectedly ; from no special means other tfyan the will to do so. They are often the shining examples of prayer-meetings and temperance societies, and seem to relapse and recover in the most mysterious, uncertain manner. In the asylum treatment of these cases great care is necessary in the matter of restraint and effort to keep the mind occupied all the time. Each case demands special conditions and methods of treatment, which shall educate the patient’s mind, and teach him to observe the utmost regularity in all habits and duties of life. After treat- ment in an asylum, such cases need a change of labor and living, also freedom from excitement or long continued, exhausting work. If the mind can be kept active and buoyant, the vigor of the body is sustained. Such cases cannot be treated at home, under any circumstances, but must have both change of life and surroundings. A third class of inebriates differing from both of the others mentioned and equally prominent are always seen in the asylum. They are noted for the exhibitions of great extremes of strength and weakness. The patient will stop the use of alcohol at home suddenly, and under the most adverse conditions come to the asylum, either alone or with his friends, and give strong evidence of great earnestness and honesty of purpose. On the way to the asylum he will pass through great temptations and never touch spirits; but in one hour after arrival, he will plan and execute the most cunning schemes to get spirits. He will exhibit at times a kind of a malicious mania for alcohol, and then be bowed down with the greatest contrition and sorrow, and do all that is possible to repair the injury. Unlike the class last mentioned, there will be found a certain method in both his relapses and recoveries, that to many will seem exceedingly sus- picious. This class always inherit an uncertain nerve and brain condition, and come very often from intellectual and \ What shall zve do with the Inebriate ? hard brain workers. Politicians, lawyers, editors, brokers, railroad men, and over-worked clergymen contribute the largest number of descendents to this class. They usually possess a degree of talent that borders on genius or madness, and seem to have no fixed principle or purpose in anything. They often come from wealthy, luxurious surroundings, suffering in childhood from bad food and no training, and general imperfect physical growth, ner- vous excitement in early life, wine on the table, surfeit of food and many other causes which break up natural healthy growth. I have traced the early causes of many of these cases to nervous shock and exhaustion at pu- berty from the first sexual act. A condition of feeble reaction from any kind of exhaustion is always present, and wine and spirits are used to counteract this effect. They are always filled with the delusion that the mod- erate use of alcohol is a normal healthy state, and all their ideals of life center on this condition. In the early stages they are constant drinkers, but later when more debilitated, are impulsive, irregular inebriates. In some cases a wonderful power of self-control is seen, which seems to be of the nature of paralysis, by which the patient will unexpectedly stop all use of alcohol and go about in the worst conditions of temptation for a long time; and the only explanation which he gives is, that he has made up his mind to drink no more. A remarkable example of this was seen in the history of Judge Ray- mond. When thirty he was a confirmed inebriate, and given up by his friends. All unexpectedly he resolved not to use alcohol again until he was seventy years old. From this time on he was a strict temperance man, and finally became a judge, and was a very eminent and exemplary man. On the morning of the seventieth birth- day he became very much intoxicated, and died two years later of delirium tremens, having drank in the meantime almost constantly, These cases are frequently marked in the later stages by delusions or suspicions of injustice from their nearest friends. Extreme degrees of T. D. Crothers. 19 mental and physical exhaustion characterize the case in its later stage. In treatment, the necessity for absolute quiet and rest with extreme regularity of surroundings and varied restraint are apparent. This class are for a long time irritable and fault-finding, but seldom are un- managable. They enter heartily into all plans of treat- ment for themselves, and although they will sympathize and plan to get alcohol for the newly arrived patient, yet never touch any themselves. They are often very emotional and deeply religious, and recover readily in ordinary aslyum treatment, but seem to be influenced by circumstances and health more than the other classes. Their ultimate recovery depends on complex conditions, which are largely unknown, and are always questions which the intimate study of each case will determine. In this class I have seen less complicating diseases, and been able to trace a range of connected symptoms from the beginning to the end in many instances. The study and successful treatment of these cases can only be assured in well-ordered asylums. In this very general description of three classes of inebriates, which appear in every study of this subject, the varied complexity of the causes requiring special means are apparent. No question of treatment or means to lessen the number of inebriates can be determined except from a clinical study. Inebriety is curable to a large degree, and if taken in the early stages, recovery would be the rule, and failure the exception. Even now many chronic cases, under adverse circumstances, recover permanently, and nearly all are largely benefited by asylum restraint and medical care. Inebriety will be no mystery when we shall understand its nature and causes, and its treat- ment will be no doubtful matter when we can classify and treat each case according to its special demands. We have indicated that inebriety can be reached most successfully: First.—By isolating the patient in a special home or hospital, where all his surroundings can be under the care and control of a physician. Second.—Here a 20 What shall we do with the hiebriatef special study of the case will reveal the minute chain of causes which have increased or directly brought on the the disorder. Third.—From this study will be marked out the particular treatment essential to the cure in each case. The second general fact covers all those preventive measures and hygienic means that will lessen the numbers of persons who suffer from inebriety. Inebriety is both endemic and epidemic. In the former it is incident to our times and civilization, following the intensity of American life and the revolutions of society, which spring from new inventions, with new and constantly changing conditions of living. The type is also different, notable in the precipitation and rapidity of process of degeneration and exaggerated emotional symptoms always present. Very many forms of mania and delusions in inebriety seem almost peculiar to this country. Inebriety is also epidemic, and moves in cycles and waves, appearing in certain towns and cities, and for a few years raging with great intensity, then dying away only to re-appear after a certain interval. In a New England village of a few hundred inhabitants, twice within eighty years inebriety has been noted for its prevalence. Following these were distinct seasons of great freedom from its presence. Records of police courts show this fact quite distinctly. In frontier towns this epidemic character of inebriety is also apparent. Further studies of the social progress of the age will point out some of the many causes which gather and break out into inebriety, de- veloping through different stages, then declining to almost extinction. The rise and fall of great temper- ance movements are but ripples on the surface of these tidal currents of inebriety. Inebriety will follow certain conditions of living in society, and in the in- dividual, with the same certainty that the plant comes from the seed. It is always epidemic when the causes are in the surroundings and social conditions, and clearly follows a certain course to extinction. In the individual or family it may remain long years, or T. D. Crothers. 21 one or two generations but through the wise limi- tation of nature, change and extinction always fol- lows. In the almost unknown field of prevention, the study of heredity meets us at the outset. Already we have found certain inherited conditions extremely favor- able to the development of inebriety, and in such cases may expect, with much certainty, the appearance of this disorder. Applying these and other facts, we shall be able to prevent it, and not only antagonize, but remove many of the active causes. From this study we shall learn what special appliances to use and how to conduct the treatment, so that restoration will be permanent; also, to be able to distinguish between the incurable and curable conditions. My studies into the causation of inebriety has pointed to childhood as a period of extreme susceptibility to this disorder, which may break out in manhood, or later, from the application of peculiar exciting conditions. I am convinced that, at this period, perversions of nutrition, defects of digestion begin, which become the starting point of inebriety. Children that are over-fed, using food far in excess of the wants of the body, or food that is defective in some quality, always have a starved, defective organism, whose functional activity is perverted and irregular. Over-stimu- lation of the digestive organs, during this period of growth, is followed by exhaustion and demands for relief, which alcohol seems to meet most readily. The children of the the very poor, and very wealthy, are subject to constant irregularities of hunger and satiety, and inebriety is often but an expression of the injury which follows. The prevention of inebriety should begin with a study of the diet, and nutrition of the tissues in childhood, and the removal of every .obstacle to the healthy growth of the body. Every condition that per- verts or prevents this healthy growth favors the develop- ment of both functional and organic disease, of which inebriety is prominent. Want of education and general training, which shall extend to purposes and objects of What shall zve do zvith the Inebriate ? 22 life, very commonly develops inebriety. The child grows up with all its faculties undisciplined, every emotion and appetite indulged in, with no motive except the gratifi- cation of every physical want, all the passions constantly stimulated, and in an atmosphere of unhealthy excite- ment, inebriety is a natural sequence. I have no doubt that the present system of education, particularly over-stimulating the brain and nervous system in bad sanitary surroundings, to the neglect of the physical growth of the body, which ends in both physical and mental dyspepsia often lays the foundation for inebriety. This is verified in any general study of the health and mental condition of college and high-school graduates. The unnatural and perverted tastes, and feeble will power, with ignorant eccentricities, often seen in this class, are the fertile fields which need only the exciting cause to break out into this malady. Certain seasons of the year, marked by sudden climatic changes, and certain kinds of labor noted by extremes of excitement, muscular activity and exhaustion, also all bad physical and social surround- ings, are among the predisposing causes which must be removed and studied in both the treatment and prevention of inebriety. The early treatment of inebriety will be practically the most active source of prevention. Remove the patient from his dangerous surroundings, and effect- ually quarantine him, with the first intimation of the disorder, and his cure is assured. Neglect this until he has become chronic, and the difficulties are increased, also the pos- sibilities of cure diminished. No other disorder is more difficult to cure in its chronic stages. The public mind must outgrow the crude notion that inebriety implies vicious weakness on the part of the patient. They must realize that he is but the victim of physical laws, whose violation must be paid with great exactness. Dyspeptic persons should never use alcohol as a medicine, or any form of bitters which contains spirits Epileptics, hyster- ical persons and those who suffer from nervous injury of any kind, such as shock to the brain from sunstroke, violent concussions of the system, followed by symp- toms of headache and any disorder of the spinal cord, should never use alcohol in any form. Exhausting diseases and conditions of extreme anaemia, and all the forms of inflammation of the mucous membrane of the stomach and bowels also contra-indicate the use of this drug. In many cases the free use of ice-water has pro- duced an acute attack of dipsomania. From a careful study of the sanitary and psychological conditions which surround us, there will be found many special exciting and predisposing causes which can be removed, that are almost unknown to-day. The mortality from inebriety exceeds all other maladies which affect the race, and when we shall study it as a physical disease and understand the causes, its prevention and cure, will mark a new era in the civilization of the world. The question, What can we do with the inebriates? can and will be practically answered in the future, by these methods which I have merely outlined. The frontier lines of this subject have been hardly crossed by scientific investigation. Standing on the borders we can discern faint outlines of hills and valleys, and vast stretches of unexplored lands full of mystery that will be found under the domain of law, rich in physiological fact and principle. A knowledge of this unexplored land will vanish the fog and traditional superstition which hangs over it and all the conflict of opinion and theory will be solved, and inebriety will be known and studied as a physical disease, both preventable and curable to a large degree; some of the facts which I have made prominent in this paper may be stated thus : 1. Inebriety is a physical disease with a distinct origin, development and progress. Its symptomology is contin- uous and can be traced from stage to stage. 2. In the causation the desire for alcohol is both a symptom and a disease. Different effects come from different alcohols, and different degrees of functional and organic perversions complicate and enter into the causa- T. D. Crothers. 23 24 What shall we do with the Inebriate ? tion. Inebriates are divided into classes which require special methods and means of treatment. 3. When inebriety is studied as a special disease in hospitals for this purpose, its curability will be found equal to any other disease, and the answer to the question, What can be done for the inebriate ? will be understood and practically carried out. Every intelligent Physician and Medical Student should subscribe for “ The Alienist and Neurologist.” PROSPECTUS FOR 1881 ■SHANKFUL for the encouragement and generous judgments it l has received in the past, the Alienist and Neurologist enters j upon another year with a hopeful, and, it is believed, useful fit- before it. Its subscription list and the number of its j % contributors and pages have steadily increased since the day of a ®P4 its inception, till it now counts ils friends and collaborators in all \ ie states at home and in many Countries abroad. It will con- ixjpt i tinue its endeavors to promulgate sound teaching respecting the gjjjh nature and treatment of the Neuro-Psychic and Nervous dis- t eases. It will continue to maintain that psychiatry and neurology, like the study of the vascular system, are essential parts of the trunk, rather than special branches of medicine, and will endeavor to bring these departments concisely, prominently and satisfactorily before the General Profession. ! Due prominence will be given to electrology, alcoholism, meconism, chloralism, and the pathology, management and treatment of inebriety, as within its legitimate province. Though the writings of savants will often find place in its pages, their contributions will he mainly such as the practicing physician cannot well ignore. No effort or necessary outlay in the conduct of the Alienist and Neurologist will be spared to deserve and retain its present degree of professional confidence, and to merit still greater approbation and support. ! It will be the chief aim of this journal to so present the clinical aspects of neurology, that the medical student and the physician just starting out in his career, may intelligently comprehend them. The Alienist and Neurologist is not so much a journal for specialists, as it is a special journal for general practitioners and advanced students of medicine, in which ; may be found more that pertains to morbid psychology and neurology, than may be found in any general medical journal, and so presented as to be of special value to every physician who aspires to the highest attainable practical advancment. The Medico-Legal aspects of such subjects as come within its scope ! will receive full consideration. Its columns will continue open to the candid and impersonal discus- sion of all unsettled questions in psychological and neurological science. Contributions of merit from competent sources of experience invited. C. H. HUGHES, M. D., Editor. EY. E. CARRERAS, Publisher, . 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