In recent years so much has been said about addiction to alcohol as a disease rather than as a habit that the treatment of it frankly as a disease in psychotherapeutics, even though there be not entire readiness to agree with those who emphasize exclusively the pathological interest of these cases, will not seem surprising. It is with regard to the various habits, drug and alcoholic, occurring in neurotic subjects that psychotherapy proves most effective and has secured some of its real triumphs. As a matter of fact, it has long been conceded that all of the so-called cures for alcoholism are dependent for their success upon the mental effect produced upon the patient. Most of them emphasize the necessity for building up the physical condition of the patient as a necessary preliminary to any lasting cure. There is no doubt that the powers of resistance of a man whose physical health has been seriously impaired by over-indulgence in alcohol and the lack of food and irregular sleep and exposure to the elements that so frequently accompany it, will not be sufficient to enable him to break off the alcohol habit, nor afford him the ability to inhibit the craving for stimulants, that he would have in a state of health. On the other hand, even in good health, unless his moral character is braced up, there will surely be a return to his old habit.

Historical RÉsumÉ of Cures.—We have had many different cures for alcoholism exploited during the last half century. The older method of the first inebriate asylums founded in this country was to give a man a disgust for liquor, as it was then called, by putting a small amount of alcohol into practically everything that he consumed. This did not give him enough to satisfy his craving, but it did create in him an intense distaste for it by constantly keeping the flavor before him. There was a drop or two of whiskey in his tea, there was some whiskey in his milk, there was a taste of it in the water that he drank, there was some of it mixed even in the gravy of his meat, and he always had weak brandy sauce on his dessert. The consequence was, in most cases, such a complete disgust for liquor that men were sure that they would never touch it again. Of course, in the meantime they were fed well and heartily, they were kept in an environment free from temptations to excessive indulgence in alcoholic drinks, they had brought home to them what a mess they were making of their lives and their health, they had time to reflect what ruin they were bringing on themselves and their families and usually they {695} recognized that they were the kind of men who must stay away from alcohol absolutely, for whom there could be no such thing as a moderate indulgence in stimulants. This, with the intense distaste for alcohol, amounting almost to nausea at the sight of it, acquired from the system in vogue, started them well on the road to reform.

Moral Cures.—It was the moral elements in the cure, however, that were the most important, though its inventors were sure that the physical elements played the largest role. The physical disgust for alcohol consequent upon having its taste constantly recur in everything at table passed off in a few weeks or at the most a few months. It was then that the moral uplift came in and had to be effective if the patient was to be preserved for the future from his old habit. If he was of a weak and flabby character, if, unfortunately, he was placed in circumstances where temptations were frequent, if, owing to the enforced absence in the inebriate asylum his business affairs had become involved and he was subject to many worries, then almost surely he dropped back. As a result his case was even more hopeless than before and, indeed, second cures were seldom of much benefit, for the man's confidence in himself was gone.

All in all, however, this old-time, simple method probably produced as large a proportion of "real cures" as any other method, even the much advertised and discussed scientific discoveries of modern times. All of us have heard stories of men who had seemed to be hopeless drunkards, who were thus reformed and hundreds of men who appeared to be drifting into hopeless inebriety were reformed to such an extent that they became not only useful members of society and supports to their families where they had before been a drain, but even became leaders in the work of uplifting the character of others to resist the temptation of over-indulgence in stimulants.

Modern Cures.—Of late we have had a number of "cures" for alcoholism widely exploited by well-directed advertising in the hands of men who realized what a fortune there was in this sort of thing and who actually have made immense sums of money out of them. Needless to say these "cures," though supposed to be secret, did not long remain so. Perhaps the most famous of them, the one whose institutes were found all over the country, was said to have used only two drugs, strychnin and apomorphin. The strychnin was given as a needed and well-chosen tonic for the physical condition of the patients who came to the institution usually in a rather seriously broken down condition. When patients began the treatment they were distinctly told that if they wanted whiskey at any time they could have it, but that the next injection of the "cure" after they took the whiskey would show how directly opposed to alcohol the ingredients of it were, by producing vomiting and prostration.

As a rule, the patients came in perfectly confident of the effect of the remedy they had heard so much of. The strychnin injections made an excellent tonic for these nervous wrecks, bracing them up at once so that they felt better from the very beginning and this betterment was confirmed by the growing assurance from the physician and the patients around them that now, at last, they were to be relieved of their degrading habit. To those whose craving for alcohol returned in spite of the favorable condition in which they were placed and the stimulation of the strychnin, which made up so well, as a {696} rule, for the absence of their accustomed alcohol, whiskey was actually allowed. When the next time for their injection came, however, these patients who had been given whiskey on their request did not now receive an injection of strychnin but instead a small injection of apomorphin. The apomorphin acted promptly in making the stomach relieve itself and produced a complete and immediate sense of prostration. The limpness and discomfort of seasickness is as nothing compared to the state that, as a rule, develops after such treatment. Anyone who has ever had to handle, in a hospital, a wildly drunk, long-shoreman, whose brute strength in his irrational condition made him a dangerous object for patients and physicians, who has seen even large doses of morphin fail to produce quiet, and then has felt bound for the patient's sake as well as those around him, to administer a tenth of a grain of apomorphin with the result of having an eminently tractable patient in a few minutes, will have a good idea of what happened to the poor alcoholic who got apomorphin instead of strychnin.

After that the inebriate knew that any further indulgence in liquor would be followed by this extremely unpleasant result and so he had a new argument for avoiding it. After a month or six weeks of careful treatment, the preliminary rest that would restore physical health and strength being followed by a course of exercise in the open air with plenty of good food, pleasant surroundings, and hope constantly held out to them, it is no wonder that these patients went out of the sanitariums as a rule confident that their habit was conquered for good. In many cases this proved to be true. It was soon found, however, that there were many relapses. This hurt the prestige of the "cure" and the gradual diffusion of this idea spoiled its effectiveness. It still continued to do good, however, and though it has been modified in various ways, and, indeed, in various parts of the country is said to be applied quite differently, there are still many reformations worked by these cures every year and they undoubtedly do good. The secret of its success, however, is not any marvelous drug or other mode of treatment that is employed, but is because the victims of alcoholism are given an opportunity to retrieve their physical condition and then to brace up their moral characters so as to resist their craving for alcohol.

Mental Influence.—Other so-called cures and treatments have followed almost exactly similar lines. The main element in the cure has been the producing in the mind of the patient a definite idea that he can stay away from liquor if he really wishes to and then helping his run-down physical condition so that he craves stimulants less than before. Whenever such "sure cures" are used on the worst forms of alcoholic patients as we see them in the large general hospitals of our greater cities, the bums of the streets, the drunkards of a score of years or more, they have practically no effect. The man must have moral stamina, he must have some character left, besides, as a rule, he must have some good reasons in worldly interest to help him to brace up and then he may get away from alcoholism if he sincerely wills to reform. The important element, however, is the will to do so. If he is firmly convinced that he cannot stay away from liquor, if he feels in spite of all that has been done for him that he cannot resist his craving, then, of course, he will not reform. Men, however, who have sunk to the lowest depths, who, according to their own and others' testimony, have scarcely drawn a {697} sober breath for ten or even twenty years, sometimes have something happen to them, often it seems very trivial to everyone but themselves, that stiffens their relaxed moral fiber, that wakens their sense of manhood, that serves quite beyond expectation to give them a new purpose in life, and they reform and never drink again.

It is this successful phase of the cure of alcoholism, however it may be explained, that is most interesting. It represents the most encouraging aspect of the whole question. Probably nothing more harmful has ever been done than the public proclamation that alcoholism is often an hereditary disease against which it is hopeless to struggle, and that the poor victims of it are to be pitied and not blamed. Except in those of low mentality, whether of intellect or will, or in the actually insane, there never was a case of alcoholism that did not deserve at least as much blame as is usually accorded to it. This is said after making due allowances for temperament. It is quite clear that for one man alcohol has no attractions at all, while for another the craving for it is almost an insuperable temptation. It is idle to say that these two contrasted men are equally free as to whether they shall take alcohol or not. Of course they are not equally free. If the man who has no craving for alcohol prides himself on his power of resistance against the vile habit, he is simply fooling himself. He probably knows nothing about the real nature of the temptation of alcohol. The Spaniards have a proverb: "He who doesn't drink wine and doesn't smoke, the devil gets by some other way." There is probably something else with regard to which the non-alcoholic has quite as little freedom as the poor victim of alcoholism and the great law of compensation comes in to make up to both of them, for their failings. Man has the defects of his virtues.

Supposed Inheritance.—No man is such a slave to the habit, however, that he cannot correct it if he will. We have heard much about the inheritance of this disease. We have heard even more about its essentially morbid character, though people used to think it a moral defect. It must still be considered a moral defect, however, even though we all concede that there is an element of the pathological in it. We are getting away entirely from the ordinary idea of inheritance of disease. There is no inheritance of acquired characters. The fact that a man's father acquired the drinking habit because he was placed in circumstances where it was easy for him to indulge himself and because he did not have the moral stamina to resist, is no reason why his son should have an unconquerable or even a very strong craving for alcohol. One might as well say that because a father lost a finger when he was young his son would be born without that finger. Alcohol destroyed certain cells in the father's body and injured certain others, but produced no change deep enough to lead to hereditary influences.

Contagion More than Heredity.—Perhaps some tendency to take alcohol runs in a family, that is, perhaps there is lessened resistance to the craving for stimulants that awakens in every human being if it is once aroused. This is what is true in tuberculosis. Some people have less resistive vitality to it than others. Careful autopsies show that practically every man who lives to be over thirty has or has had living tubercle bacilli in his tissues. Seven-eighths of us are thoroughly able to resist them. The other eighth succumbs. Their lack of resistive vitality may in some degree be due to hereditary taint, {698} but that is doubtful and we know that they acquire the disease by contact with others who have it already and, as a rule, it is able to work its ravages because they are not living in conditions that would help them to resist it. If they live in the free open air and have plenty of good, simple food, the disease will not run its fatal course, but nature will cure it. If the craving for alcohol is lighted up by association, aroused by indulgence, rendered strong by environment and by exposure to temptations of all kinds with regard to it, then the resistive power of the individual is so lowered that the alcoholic habit rules him instead of his being able to command it.

Inherited Resistance.—The most curious fact that has come out in our studies of heredity in recent years has been that far from heredity working its will in causing degeneration and deterioration of mankind, immunity, for the race at least, is acquired in the course of subjection to disease and to various morbid habits. Nations, for instance, that have been subjected to diseases for long periods no longer display the susceptibility to them which they formerly possessed. After a disease has been endemic among a people for many generations that people gradually becomes quite insusceptible to its effects and suffers much less from it than before.

Just this same thing is true of alcoholism. Nations that have been the longest in a position to be subject to the temptation to use alcohol in its stronger forms suffer least from the ravages of alcoholism. The southern nations of Europe using wine daily and knowing well the process of distillation to help them to make stronger drink for many hundreds of years, now exhibit much less tendency to over-indulgence in strong drink than the northern nations whose ancestors have only in comparatively recent times been subjected to the temptation of craving for strong alcoholic liquors. The attitude of any nation toward alcohol is a function of the length of time that nation has had a chance to procure strong drink easily. Our American Indians discovered, as has every people at some time, that intoxicating liquor could be made by allowing solutions of starch and sugar to ferment. It was only with the coming of the European, however, that they were provided with "fire water"—strong drink—in quantities. Its effect on them is a matter of history. Two things the white man brought his Indian brother to which the Indians were unaccustomed and that gradually obliterated the original inhabitants of this country—infectious diseases and strong alcoholic liquors. They proved equally fatal because of Indian susceptibility to them.

From these considerations it is clear that just such an immunity to the effect of alcohol is produced in a people exposed to its effects in concentrated form for a long time as with regard to an infectious disease when they have been correspondingly exposed to it. Heredity, then, instead of playing a role that brings about deterioration in the race, on the contrary, carries on the higher qualities and gives us, as might be expected in the course of evolution, a better, that is, a more resistant, race. Most of what is commonly said as to alcoholism, and unfortunately most of the recent so-called popular scientific articles on this subject, seem to point to just the opposite conclusion to this. Men are supposed to be condemned by heredity to an inevitable craving to take alcoholic drinks that, in certain of them at least, cannot be overcome by any natural power of resistance. At this stage of our western civilization this is not true for anyone, as the more susceptible families have been long {699} since eliminated and it is a personal weakness and not a family characteristic that leads people to indulge this appetite to their own destruction.

Unfavorable Suggestion of Heredity Idea.—An alcoholic patient, or even a man with only a moderately strong tendency to take alcohol to excess, who harbors any such notion as this, has a serious impediment to the full exercise of his will in overcoming the difficulties that he encounters in any attempt at reform. In going counter to so much that has been written and still more that has been said and generally accepted on this subject I feel it necessary to quote a good recent authority on the matter and so here insert these passages from "The Principles of Heredity" by Dr. Archdall Reid. [Footnote 53] He says (p. 157):

[Footnote 53: Author of "The Present Evolution of Man," "Alcoholism," "A Study in Heredity," etc. Chapman and Hall, London, 1905.]

Formerly all the world believed in the transmission of acquirements, and consequently all the world was constantly finding conclusive evidence of its constant occurrence. To-day there is hardly a rag of that evidence left, and, with rare exceptions, only certain French medical observers are able to discover fresh evidence. It is a remarkable fact, however, that the problem of evolution—of adaptation—has excited singularly little interest in France, and it is equally curious that these French observations relate almost entirely to laboratory work which it is not easy to repeat. In Great Britain or Germany, you may cut off the tails of a thousand dogs, or amputate the limbs of a thousand men, or observe the non-infected offspring of a thousand tuberculous patients, and get no evidence of transmission.

With regard to alcohol Dr. Reid in the same volume insists on the proposition that alcohol does not cause degeneration of a race, creating, as is claimed, ever more and more a tendency for people to take it because their immediate ancestors have taken it, but, on the contrary, there is a distinct evolution against it, and that what is hereditary, not by acquisition, but by family trait, is an immunity against the disease which eventually protects the nations that have been longest exposed to the effects of alcohol from the evil consequences of the substance. He says (p. 196):

How, then, has alcohol affected the races that have used it? Are the Jews and the races inhabiting the South of Europe the most degenerate on earth? Are North Europeans only less degenerate? Are the races that have never used alcohol, the Terra del Fuegians, the Esquimaux, and the Australian blacks, for instance, mentally and physically the finest in the world? We have only to state the proposition to see its absurdity. There is no evidence that the hereditary tendencies of any race have been altered by alcohol circulating in the blood and acting directly on the germ plasm. Once again the sufferings of the peoples have produced no effect, but the deaths among the peoples have produced an immense effect. Every race that has had experience of alcohol is temperate in the presence of an abundant supply in proportion to the length and severity of its past experience of the poison. The South Europeans and the Jews are the most temperate peoples in the world. West Africans also are very temperate. North Europeans are not drunken. Those savages, and those only, who have had little or no experience of alcohol—Esquimaux, Red Indians, Patagonians, Terra del Fuegians, Australian blacks—are beyond all the peoples the most drunken on earth.

Lest it should be thought that this discussion of the subject is only of significance with regard to nations and does not touch the individual, and, therefore, has but little significance for the problem that we are treating here. Dr. Reid's succeeding paragraph deserves attention:{700}

Stated in this brief and direct way, the thesis is apt to excite incredulity. It is sharply opposed to popular beliefs, though that need not trouble us. Popular notions on abstruse points of science are occasionally erroneous. Of more importance is the fact that a mass of statistics purporting to prove that the children of drunkards tend to be degenerate has been compiled, especially by medical men in charge of lunatic asylums. But no "control" observations appear to have been made. We know that many drunken parents have normal children; certainly, therefore, parental drunkenness is not invariably a cause of filial degeneration. We know also that many temperate parents have defective children. There is nothing to show that the proportion is greater in the one case than in the other. Even were it established that the proportion of defective children is higher in the case of drunken parents, it would still have to be proved that the relation is one of cause and effect. People who have an inborn tendency to mental defect, who are abnormally depressed, nervous, restless or irritable, are often so constituted as to find solace in drink. Their children are liable to inherit their inborn mental defects with spontaneous variations—that is, to inherit the defect to a greater or lesser extent. The unborn child of a drunken and pregnant mother is practically another drunken person, as liable, or more liable to suffer from the effects of drink; but in such a case the resulting defect, though a mere acquirement, is tolerably certain to be regarded as a congenital (i. e. inborn) defect by the medical man who sees it. Mere acquirements, also, are the defects due to the ill-treatment, want and neglect to which the children of drunken parents are particularly exposed. Indeed, were it fully established that drunken parents, other than pregnant mothers, tend to have an excessive number of their children "congenitally defective," it would still be a question whether the filial defects were not mere acquirements. Prof. Cossar Ewart's observations on diseased pigeons renders this not unlikely. All these sources of error render the success of a statistical inquiry peculiarly difficult, if not impossible, but there is no indication that they ever occurred to the minds of the compilers.

Warnings as Suggestions.—I have a case in my notes in which a rather prominent professional man insists that he is quite sure that the alcoholism from which he suffered during the ten years between twenty-five and thirty-five was entirely due to suggestion. As a boy of sixteen he had gone off to boarding school, but not until his mother had taken him aside, told him that his father had drunk himself to death, had done it by secret tippling, and that they had found that for many years he had been accustomed to have whiskey near him in his office and take it rather frequently. He had never tasted spirituous liquor at this time and his mother begged him not to, for she felt sure that if he did his father's craving would awaken in him and would become uncontrollable. The day that he went away his father's eldest brother took him aside and said practically the same thing to him. A maiden aunt was not quite so emphatic, but she, too, pleaded with him to understand all the dangers. For his first year at school he did not touch liquor, but in his second year he tasted it once or twice but had no particular craving aroused in him. By chance when he was home at Christmas time some college mates who were visiting him gave his mother the impression that he belonged to a rather jovial set. Once more he was warned by mother and uncle. Above all they told him never to keep strong drink near him because that was what his father used to do. During his college years the fear of this hung over him. He resented it and probably took more liquor than he would have so far as actual craving went. After getting out into active life once more he suggested himself into the habit of taking an occasional glass of whiskey by himself. After a time he was constantly taking too much. For {701} ten years he hurt all of his prospects, broke his mothers heart, and was looked upon as a hopeless alcoholic. Then one day the thought came to him that it was not that he craved alcohol so much, but that his thoughts turned on it constantly and at first he dreaded it overmuch, then wondered what attraction there could be and then acquired a habit by suggestion. Once this train of thought worked itself out in his mind, he quit spirituous liquors for good. For ten years he has not touched them, he does not care for them, they do not constitute a temptation.

It must not be forgotten that many warnings may so preoccupy the mind with regard to a danger as to constitute temptations by suggestion. This is eminently true of alcoholism, the drug habits, sex habits and the like, in spite of the foolish present-day notion that information and warning must necessarily be helpful. In all these, teaching may be suggestively harmful.

Prophylaxis.—The most important part of the treatment of alcoholism through mental influence is by prophylaxis, and that, to be effective, must begin very early. Just as with regard to overeating, as I have pointed out in the chapter on Obesity, it is extremely important not to permit children to acquire habits with regard to alcohol when they are young. During the growing years the system, indeed one may say all the systems of the body—the nervous, the muscular, the digestive and the mental systems—are all more or less unstable. Deep impressions may be produced on them then, and if children are allowed, much less encouraged, during their growing years (and this includes practically all the years up to twenty-five) to indulge in alcohol, then one can look for the development of a craving very hard to eradicate later in life. Many of them will be able to conquer the desire thus awakened, but a great many of them will not. We have some very definite evidence on this point and some of it collected here in America is very valuable. Dr. Alexander Lambert of New York made a study of over 250 cases of alcoholism seen in the wards at Bellevue Hospital, paying special attention to the age at which the patients remembered they had begun the use of alcoholic liquors. If anyone doubts the influence of youth in this matter, then his statistics should be read:

Of 259 instances where the age of beginning to drink was known, four began before six years of age; thirteen between 6 and 12 years; sixty between 12 and 16; one hundred and two between 16 and 21; seventy-one between 21 and 30; and eight only after 30 years of age. Thus nearly seven per cent. began before 12 years of age, or the seventh school year; thirty per cent. began before the age of 16; and over two-thirds—that is, sixty-eight per cent.—began before 21 years of age.

Dr. Henry Smith Williams, commenting on Dr. Lambert's study of this subject in his article on "The Scientific Solution of the Liquor Problem," [Footnote 54] states emphatically the conclusion so inevitable from these statistics that more than anything else alcoholism is the result of habits and occasions created in early years. He adds some remarks that are worth noting for those who are interested in the prevention and cure of alcoholism, not only in particular cases, but also for the community:

[Footnote 54: McClure's Magazine, February. 1909.]{702}

In the light of such facts, it is clear that the drink problem is essentially a problem of adolescence. The cumulative effects of alcoholic poisoning frequently fail to declare themselves fully until later in life; but the youth who does not taste liquor till his majority minimizes the danger of acquiring the habit in its most insistent form; and the man who does not drink until he is thirty is in no great danger of ever becoming a drunkard. As to the man who has passed forty—well, according to the old saw, he must be either a fool or his own physician. His habits of mind and body are formed, and if he becomes a drinker now he can at most curtail by a few years a life that is already entering upon the reminiscent stage. As factors in racial evolution, the youth of each successive generation, not its quadragenarians, are of interest and importance.

Treatment.—The conclusions that naturally flow from the historical introduction to this chapter which show mental influence as the basis of all cures, simplify very much the treatment of alcoholism on psychotherapeutic principles. There is no doubt that moral means are the only really effective remedies in this matter. They fail often, not because of any lack of power, but because of lack of co-operation on the part of the patient. There are men whose mentality and responsibility is breaking down, and who are on the way to the insane asylum for various causes, who cannot be thus influenced. They are, however, not alcoholics, but incipient insane patients likely to go to excess in any line. There is no pretense that psychotherapy will cure mental disorder that rises to the height of real insanity. On the other hand, just as after several relapses of tuberculosis due to the foolishness of the patient, further improvement by sanatorium treatment is usually out of the question, so each relapse of the alcoholic patient makes it increasingly difficult to bring about noteworthy improvement. There are examples, however, which demonstrate that even after seventy times seven relapses men may still encounter something that rouses their dormant wills to real activity and then their alcoholism is a thing of the past, for good and all.

Sanitarium Question.—There always comes the question whether these cases need to be sent to a sanitarium or can be treated at home. The answer to this question is the same for alcoholism as it is for tuberculosis or, indeed, for any of the exhaustive diseases. It all depends on the individual's physical condition and his circumstances. If tuberculosis is discovered, as it should be, at a very early stage in the disease—not when the patient is coughing up bacilli in large numbers and already has many physical signs in his lungs, but when he has a slight unproductive cough and over-rapid pulse and some prolongation of expiration at one apex—then he may be cared for at home, if the physician is confident that he can make his patient feel the absolute necessity for following instructions and can make him realize the seriousness of his condition in spite of the few symptoms that are present. If his environment is unfavorable, in a crowded tenement house or where an abundance of fresh air cannot be readily obtained, the patient may have to go to a sanitarium for proper treatment even at this early stage, or at least he will have to change his living conditions.

This question has received a very different answer in recent years from what used to be given to it. Formerly the physician hesitated to say "tuberculosis" to his patient until the disease was well advanced and then he advised the distant West or some other change of climate, though, as a rule, this brought only a palliation of symptoms, the case being too far advanced, and {703} the fatal termination came in the course of two or three years. Now the careful physician diagnoses tuberculosis much earlier, detects the disease in its incipiency, and is able to treat the patient at home quite successfully, if conditions are at all favorable. It is true he has to make him give up fatiguing occupations, and especially those in dusty places; he has to insist on his living out of doors a good part of the day, even though there should be no better means of securing this than the roof or a fire-escape, and on keeping his windows open all night. He has to watch his nutrition carefully and see that he gains in weight. If all this can be accomplished, however, there is no reason why a tuberculosis patient in the incipient state should not get better at home almost as well as he would at a sanitarium. The only difference between the two methods of treatment is that in a sanitarium the patient realizes that his one duty in life is to care for his health and he does not bother about other things, as he is likely to do if he remains at home.

If this precious development of teaching with regard to tuberculosis, which is founded on such thorough-going common sense and the application of good therapeutic principles to the treatment of the disease, be transferred to the sphere of alcoholism, then the answer to the question whether there shall be sanitarium treatment or not is practically arrived at. If the patient is in an early stage of his alcoholism, if the pathological character of his tendency to take intoxicants has been recognized and made clear to him early, then there is little difficulty in treating him at home. The crux of the problem is just that which occurred with regard to tuberculosis years ago. The physician does not take the early symptoms of the affection seriously enough. He does not want to disturb his patient's equanimity by the suggestion that he is in the incipient stage of alcoholism any more than a few years ago the family physician cared to suggest the awful thought of tuberculosis until the condition had reached a serious stage. But this is the essential preliminary to the successful treatment of alcoholism just as it is to the successful treatment of tuberculosis.

It is almost useless to send advanced cases of tuberculosis, in which cavity formation has already occurred, to a sanitarium. The course of their disease may be delayed for a while, but scarcely more than that. Their resistive vitality has been so overcome by the ravages of the disease that their ultimate cure seems beyond hope, yet not infrequently wonderful results are obtained even in these cases. Just this same thing is true with advanced cases of alcoholism. No one can do anything with them, though careful treatment in a sanitarium may, on a number of occasions, afford them opportunity to brace up and be themselves, i.e., their better selves, for several months. Just as with tuberculosis, however, even the quite advanced cases will sometimes be so much bettered by sanitarium treatment that, though their prognosis seemed absolutely hopeless and was so pronounced by good authorities, all the symptoms are relieved and the patients get a new lease of life that may last for many years.

In the same way some apparently hopeless cases of alcoholism will brace up after sanitarium treatment and have many years of useful sober life without a break. In alcoholism, as in tuberculosis, the will of the individual is the all-important consideration. Someone has said that tuberculosis takes away mainly the quitters. Those who have the courage to insist that they {704} will live in spite of everything being apparently against them, pull through crises that seem absolutely hopeless and survive for years. Robert Louis Stevenson bravely doing his work, living on in spite of fate and disease, is the typical example. Alcoholism completely overcomes only the quitters. If a man wants to give up drinking even when he seems practically a hopeless wreck from the effects of alcohol, he can do so if he has a physician in whom he has confidence, who will relieve him from depressing symptoms due to previous excess, who will lift him up and strengthen him by food and stimulation, and, above all, by faithful, unending, never discouraged assurance that he can conquer the craving which has such a hold of him, if he only persists a little and does not give up the struggle. The victory is worth while and it is not hard to lift a man up if he has any remnants of character left.

Confidence.—In the treatment of alcoholism, then, just two things are necessary. One of these is that the patient has confidence in himself, the other that he has confidence that his physician can help him over the hard spots on the road. There is no doubt that many drugs can be used that will lessen the patient's irritability, increase his nerve force, stimulate organs which are depressed by the reaction against over-stimulation, arouse appetite and correct disturbed functions. All these things must be done. It is no use laying down any set of rules as to how they shall be done, for they must be done differently in individual patients. It is not alcoholism that is treated nor the effects of alcoholism, but an individual alcoholic patient, and a set of symptoms that are very different in every individual. The more physiological disturbance can be relieved by proper drug, dietetic, hydropathic and remedial measures, the more chance is there for the patient to get over his habit without trouble. Every ill feeling that he has tempts him to think of alcohol. Above all, he must be made to sleep, his bowels must be thoroughly regulated, and he must be made to eat heartily. For stimulation full doses of nux vomica, not less than thirty drops three or four times a day or even oftener, are probably best.

For cases of alcoholism in the earlier stages there is but little difficulty. Those who try the effect of favorable suggestion, of confident assurance, of constantly repeated encouragement on individuals who have begun to be afraid that they cannot break the habit, will frequently have the most gratifying results. The important point to remember is that men are suffering from alcoholism who are indulging in alcohol every day and to whom it has become more or less of a necessity, though even as yet its effect upon their business is not marked and they are not known, even among their acquaintances, as drunkards. Whenever a man must have three or four whiskeys a day or he cannot do his business and his appetite fails him and he does not sleep well, he is an alcoholist. He has the cellular craving that later may become an absolute tyrant. If we can educate the community generally to realize this as we are gradually educating them to the knowledge that tuberculosis must be caught in its incipient stage and that pulmonary consumption begins in very mild symptoms after a person has been exposed to it, we shall have little difficulty in curing tuberculosis or in treating alcoholism successfully by suggestion.

For alcoholism, as for the drug habits and also the sex habits, moral influences are all-important. Hence the necessity for exercising them {705} frequently. It is probable that the best way to break any of these habits is to have the patient come regularly to the physician's office, at least once, and at the beginning twice a day. In cases of alcoholism the method of giving for the first week, at least, the dose of the stimulant drug which replaces the alcoholic stimulation directly to the patient is often of great service. It seems a good deal to ask the patient to come three times a day just to get a drug (tonic), but it is comparatively easy to resist the craving for liquor for four or five hours, that is, until the doctor is seen again, while sometimes twenty-four hours will seem a long while. The personal element in this matter is extremely valuable. It is this that has made the efficiency of all forms of cures, and it is only this that can be successfully used.

How much can be accomplished for even the worst forms of drunkenness and under extremely unfavorable circumstances once a really strong impression is made on the individual's mind and his will is aroused to help himself seriously may be readily learned from the lives of any of the great temperance advocates. Their experience is illuminating. It shows clearly that strong personal influence will do more than anything else for these sufferers. Sometimes their efforts are supposed to affect only certain classes of individuals who have character but who, for some reason, have fallen into an unfortunate habit. A little investigation will show, however, that they affect all classes and kinds of individuals and, indeed, may reform a whole community. The story of Father Matthew is very interesting in this regard because there is some striking testimony as to his reformation of whole neighborhoods that had been given over to drink before and that among a people especially emotional and susceptible. The movement that he initiated still lives in the temperance societies of the English-speaking peoples everywhere which help by prophylaxis in youth and the moral force of association in later life.

After-Treatment.—In alcoholism the most important feature of the treatment is what has come to be known in our time as the after-treatment. This department of therapeutics has taken on great importance in recent years in every form of disease. For early and middle life most diseases have a definite tendency to get better, though many of them leave distinct pathological tendencies. The after-treatment, then, has become much more important than the cure for the patient during the existence of the acute or sub-acute stage. Even in children's diseases it is now generally recognized that while measles and whooping cough are not dangerous affections as a rule, they may prove the forerunners of tuberculosis, because of the weakened pulmonary resistance consequent upon their invasion. For scarlet fever, the possibilities of injury to the kidneys after the great irritation to which they have been subjected, is now recognized and convalescence is prolonged. In typhoid fever we realize that not weeks but many months of convalescence are needed to put the patient beyond the risk of various degenerative processes that may be serious. There is even question in the minds of many observant physicians whether the weakness incident to typhoid fever may not, if a premature return to work is allowed, prove a potent cause of precocious arterio-sclerosis.

In a word, after-treatment has become one of the most interesting subjects of modern therapeutics. It will not be surprising, then, if we insist that the after-treatment of the alcoholic is the most important part of the remedial methods to be employed. If a man who has suffered from tuberculosis because {706} he was working in one of the many dusty trades and living in a badly ventilated tenement house is restored to health or at least has all his symptoms disappear as a consequence of sanitarium treatment, it is almost needless to say that he must not be allowed to return to the conditions in which his disease originally developed. If he does, he is absolutely certain to have a relapse. This phase of tuberculosis has been much discussed in recent years. It is often said that it is impossible to keep working people from a return to their occupations. Just so far as that is impossible, so far will any real hope of keeping their tuberculosis in abeyance be reduced. They are much more likely to suffer from the disease, as a rule, after their return from the sanitarium than they were before they originally contracted it, because apparently some of their immunity has been destroyed by the invasion of the bacillus.

It is only recently that we have thus planned for the after-treatment of tuberculosis. If we are to be successful in the after-treatment of alcoholism, at least some of this same thoughtfulness must be exercised. The victims must be discouraged from going back into the conditions in which their habit developed. It is comparatively easy, especially at the beginning of his alcoholism, to stimulate a man back to normal physical condition, to reduce his craving for intoxicants, give him back his appetite and set him on his feet again. The affection is quite curable. If a man returns to the conditions in which it originally developed, however, it will develop again quite as inevitably as tuberculosis does under similar conditions. We do not blame the sanitarium if, after having given a man a new lease of life in spite of tuberculosis, he resumes the unsanitary life in which his disease originally developed and has a relapse. It is not the fault of the system of treatment for alcoholism if men relapse, but the blame is upon them that they do not take their danger of relapse seriously enough, permit themselves to get into an unfavorable environment, and, as a consequence, suffer once again from their affection.

Religious Motives.—More and more we are realizing the place of the higher motives of life in the reform of alcoholic patients. Religious motives probably form the best possible source of suggestions that enable a patient to lift himself out of the slough of despond of chronic alcoholism. Many of the best workers for the reform of the drunkard were themselves drunkards for many years. The motive of helping others is particularly important in its effects upon any alcoholic. Some motive apart from himself is more helpful than any appeal to his selfishness or even to what he can do for his children and his wife. It is the newer motive that appeals most strikingly. In recent years certain church movements have done much for alcoholic patients. In this they are only repeating the effect of other great church movements and the effect of the lives of apostles of temperance in recent generations. Without these higher motives cure is probably impossible in many cases. With them it not only becomes possible but even comparatively easy in the most hopeless-looking cases.

In the light of what we have heard recently of the success of the Emanuel movement in the treatment of alcoholism, it is interesting to recur to what was said in this relation by Prof. Forel of Zurich on the treatment of alcoholism, in a communication read to the South German Neurologists and Psychiatrists at its meeting in Freiburg over twenty years ago. Prof. Forel, who is not what {707} would be called a particularly religious-minded man, insisted that "an inebriate asylum can only with great difficulty be successful without religious auxiliaries, since most inebriates, and especially at the beginning of their reformation, are entirely too weak to get along without religious consolation. To secure this, however, the nicest tact is required in order to permit the practice of all the different nuances of faith that men have, in peace and comfort. This can only be secured if in practice faith is subjected to charity for one's neighbor as the basis for religion."

Many such expressions have been used before and since in practically every country in Europe. The assertion that physicians have failed to recognize the part that religion plays in such cases is entirely without foundation and can only be made by those who are quite ignorant of our medical literature.