AMOS J. GIVENS, M.D., LL.D., STAMFORD, CONN.
There are many varieties of dipsomania, that is, of the ungovernable periodic lust for drink, with, in the interim, no desire for alcoholic beverages, in fact, often a feeling of abhorrence at the mere thought of such indulgence.
A very clever man in the profession has acutely remarked in connection with this disorder, that it is an unfortunate thing that so many scientific persons are so prone to try for one explanation, and to hit upon the explanation by the most unknown quantity that we have, so far as the interpretation is concerned. This comment is made in connection with the effort to "explain everything concerning epilepsy according to Lombroso," or after the manner of Kraeplin, who refuses to see anything else in dipsomania than one of the manifold manifestations of epilepsy. Nevertheless, Kraeplin discusses dipsomania under the general heading of "Chronic Alcoholism," and uses as an illustration a case presenting few of the distinctive earmarks of epilepsy.
That dipsomania in many of its characteristics often resembles epilepsy, no one will deny, yet these cases not infrequently present no typical epileptic disturbances, the excessive periodic drinking impulse being the only sign of the disease. When the latter is the case, the individual, without warning or noticeable premonitory symptoms, will commence inordinate drinking, many times consuming almost unbelievable quantities of beer, wine, or liquor, before the attack expends itself.
In other instances, prodromal symptoms of irritability, anxiety and uneasiness, restlessness, despondency or fear, capricious appetite, and sleeplessness are observable. These are characteristic of the epileptic, but so are they also of many nervous affections, indicating departures from the normal.
Again, Cutten, of Yale, in his interesting work, "The Psychology of Alcoholism," disposes of the status of the dipsomaniac by ranking him insane. "Clearly to be classed as a form of insanity," he says, "yet seldom found in an insane retreat, are cases of dipsomania." Yet, as if desirous of somewhat modifying his own statement, he adds, some pages further on:
"No other class of partakers of alcohol is composed of such bright and intelligent men, or men who, by nature and education, are better equipped morally."
The truth is, the taint of epilepsy is discoverable in many instances, and a sufficiently large number of cases present such other symptoms as to perhaps justify the description "periodic insanity." Periodic they certainly are, and, for the time being at least, within the boundaries of that elastic term "insanity," although one is excusably reminded of that eminent English jurist, who, before the House of Commons, remarked: "I have read every definition (of insanity) which I could meet with, and never was satisfied with one of them, and have endeavored in vain to make one satisfactory to myself. I verily believe it is not in human power to do it."
"Experience teaches," says the old adage sagely, and as we grow wiser through an extended and enlarged professional experience, we become more averse to making unqualified statements like Berkeley, for instance, of Johns Hopkins, who, in his "Treatise on Mental Diseases," chapter on the "Periodic Insanities," does not omit a foreword pointing out the relation of these disorders to that borderland of insanity whose inhabitants are sometimes neither fish, nor fowl, nor good red herring.
Dipsomania may, of course, be associated with manic-depressive insanity, with general paresis, with paranoid conditions which sometimes renders diagnosis difficult; with cases, in a word, well adapted to the ministrations of hospitals for the insane, and frequently found there.
It is a mistake, however, to assume that the more usual examples of the periodic drinker can be most greatly benefited in such institutions. Their mission is primarily to treat another class also, in the majority of cases, directly or indirectly the victims of alcoholism, for there is a vicious circle of alcoholism and insanity, insanity and alcoholism, with affectional offshoots too familiar to the neurologist and alienist to require comment.
The ordinary dipsomaniac is assuredly the product of the past; he is, in other words, an inheritor. It is not without reason that the term "delirium tremens," coined by Sutton, in 1813, preceded by full thirty years that of dipsomania, first used by Swaine Taylor, in 1843.
The almost universal daily use of liquor, and the incidental frequent drinking bouts of the eighteenth century, are matters of history. These habits of general, and often immoderate drinking, persisted in the first half of the nineteenth century, while the excessive use of alcohol, even as a medicine, is yet within the memory of men of middle age.
Delirium tremens, as the result of excessive indulgence, was soon considered by itself, while advancing knowledge of the pathology and psychology of drunkenness, made differentiation of other types imperative. So also a constantly increasing identification went on of the results which the use of alcohol entailed upon descendents, and especially of that inheritance which may be termed the alcoholic diathesis.
It is to this diathesis that the periodic drinker is heir. "Practically all dipsomaniacs," says Carroll, "are the descendents of alcohol-using parents." In addition to this we frequently find, in the immediate ancestry, histories of hysteria, epilepsy, migraine and insanity contributing, as does alcohol, that legacy of insecure equilibrium we call instability of the nervous system.
What form the neurotic taint passed on through inheritance will take seems oftentimes to the observer largely a matter of chance plus the pressure of environment; but let the unrest, the craving for he knows not what of the unstable individual, supplemented by physical and psychical conditions which lower vitality, and tend to bring to the surface all inherent weaknesses, once resolve itself into a periodic thirst for drink, and, like the breaking of a dam and the irresistible onrush of water, his will will go down before his raging and almost unquenchable thirst. At such times, neither regard for himself nor his family, his social standing or his means of livelihood, will restrain him. Drink he must and will have, though he pawn the clothes from off his back.
The correct statement of two dipsomaniacs, recorded by Prof. William James, well illustrate this state of mind. "Were a keg of rum in one corner of a room," said one, "and were a cannon constantly discharging balls between me and it, I could not refrain from passing before that cannon in order to get that rum." "If a bottle of brandy stood on one hand," testified the second, "and the pit of hell yawned on the other, and I were convinced that I should be pushed in as sure as I took one glass, I could not refrain."
The dipsomaniac is far removed from the ordinary sot who befuddles himself day after day with beer and whiskey. Too often, unfortunately, the former may represent the most useful and gifted classes of society. The case of the individual who secretly hid stores or brandy, gin, etc., in his boots, bookcases, sleeves of his coat, and elsewhere, against the time of his temptation when his downfall was complete, the expert in inebriety can easily duplicate. Likewise the dentist in a New Hampshire city, who, gentlemanly in manner and skillful, in his work while himself, yet when overtaken by the drink mania at intervals of several months, became another being, highly irritable and vicious, invariably putting all his wife's clothes in the stove before indulging in his orgy.
Even the moderate drinker may become the dipsomaniac. A specialist before the New York Psychiatric Society, in May, 1909, reported the case of a young lawyer, who, ceasing constant indulgence, became periodically, and in certain environments, obsessed by the desire for alcohol. By the exercise of his will and appropriate treatment, he escaped the usual outcome. Here the psychogenetic factor was the alcohol first resorted to as a social factor.
In some instances the dipsomaniacal periods recur with astronomical exactness. A certain number of days, weeks, or months regularly elapse. In other cases, equally free during the interim from the desire for alcoholic stimulants, the outbursts are variable, and dependent upon exciting circumstances, such as the strain of some important business deal, domestic difficulties, sexual furore, etc. The attacks may occur at increasingly shorter intervals, or remain constant; may be self-limited, or limited only by capacity of the means of getting liquor; may be characterized by complete intoxication or but clouded consciousness; may end in anorexia, nausea, gastric catarrh, headache and tremors, and gradual convalescence, or lead to a nervous collapse, severe and protracted. Delirium tremens is one of the possibilities and chronic alcoholism in inadequately treated cases.
Adequate treatment, however, offers to the average dipsomaniac a chance which is well worth his while to avail himself of, for the percentage of cures or marked amelioration is not small, considering the nature of the difficulty. Above all else, however, the ministering physician must have the patient under his entire control and for a sufficient length of time to insure results, for the treatment of the dipsomaniac is the treatment of the neuropathic basis, the reconstruction of the physical man, the re-education of his will, the readjustment of his viewpoints. These things require time, and this is recognized not only by neurologists and alienists, but also by jurists and intelligent lay students of these problems. The isolation of the dipsomaniac, the gaining his co-operation, the application of therapeutic measures can best be secured in some institution where special attention is given to this class of cases. Both voluntary and compulsory commitment must be provided for. Connecticut, following the example of England, has wisely enacted laws meeting this need, and provided for a three years' detention if necessary.
The compulsory commitment of inebriates is an advantage secured by law in some other States, notably in Kansas, Louisiana, Pennsylvania, Vermont and Massachusetts. Among the few States providing special hospitals are Massachusetts, Iowa and Minnesota, while inebriates are sent by a number of States to their hospitals for the insane, a very inadequate and unsatisfactory solution of the problem.
Charpentier and Ley, in their papers on "Alcoholism and Criminality," presented at the Twentieth Congress of Alienists and Neurologists of France and French-speaking countries, in Paris, August, 1910, said: "All those who have had any considerable experience with asylums for inebriates, agree in saying that only a course of total abstinence, lasting from six months to two years or more, is capable of effecting cures.... Under favorable conditions of time and treatment, 30 to 50 per cent. of cures are recorded."
The dipsomaniac is no exception to this rule of essentials or to the possibility of redemption. Rather is he a conspicuous illustration, and, as a class, perhaps better worth saving for the community than the chronic alcoholic, both because the former often represents a gifted element, and because the alcoholic deterioration of the whole man is usually less. So Kraeplin maintains, adding that for this reason he presents, on the whole, a more favorable prospect of overcoming the alcoholism than ordinary drunkenness.
The treatment of these cases has been indicated by generalizations, and will not be particularized here, being, in many respects, classic, and above all else, requiring to be individualized. Hardly a month goes by, however, but what new indications are perceived that in all countries the preventive phase of the question is commanding greater attention. Great Britain is making a valiant struggle and with reason. Thirty-three years ago, Kirton, in his little volume, "Intoxicating Drinks: Their History and Mystery," said, "There are in the Old and New Testaments together, 3,566,480 letters. The money spent yearly in the United Kingdom on strong drinks would enable us to place forty-one sovereigns upon every one of the letters in the Bible." Great Britain recognizes that crime, insanity, feeblemindedness, form the harvest of such investments, and, by issuing fewer licenses, shortening the hours during which intoxicating drinks can be had, ensuring their greater purity, forbidding, when practicable, Sunday sales, and by temperance teaching, has secured a decline of spirits consumed from 37,000,000 of proof gallons in 1900, to 24,000,000, in 1910.
The Imperial Statistical Bureau in Germany has made exhaustive investigations of the consumption of alcohol by workingmen, and is discouraging successfully its use, and the same policy is being actively pursued in the German army. France is following suit. Switzerland has long been a conspicuous leader in this warfare for sane minds in sound bodies, and reported as long ago as 1893 a reduction of at least 25 per cent. in the use of spirituous liquors since the legislation of 1887, when, by expropriation, 1,400 large and small distilleries were suppressed. The recognition by the different foreign governments of the advisability of restrictive or prohibitive measures in relation to the consumption of alcoholic beverages since the war began, is a well known fact. Only in the United States do we find a formidable increase from 14.6 gallons of intoxicants consumed for every person in the country in 1889, to 21.85 gallons per capita in 1909. Also, our importations of intoxicating liquors have more than doubled in twenty years.
The problem of the dipsomaniac, as of all inebriates, is and always must be primarily the problem of the underlying causes producing him, and no other single cause assumes such menacing and formidable proportions as the enormous and widespread consumption of alcoholic beverages.
- Meyer: Journal Nervous and Mental Diseases, November, 1909.
- Kraeplin: Clinical Psychiatry, p. 182.
- Cutten: The Psychology of Alcoholism, p. 251.
- Ibid. p. 257.
- Church and Peterson: Nervous and Mental Diseases, p. 653.
- Kelynack, Editor: The Drink Problem, p. 116.
- Carroll: Charlotte Medical Journal, 1908.
- Jamea: Text-Book of Psychology, pp. 439, 440.
- This case I know of: The other is Cutten's.
- Publication No. 1390, Mass. House of Representatives, 1910.
National Eclectic Medical Association Quarterly, Vol. 7, 1915-16, was edited by William Nelson Mundy, M.D.