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THE UPHILL FIGHT AGAINST ALCOHOLISM
by Quentin Reynolds
What
is to be done for the thousands of Americans under sentence
of death from this scourge? Here is one city that is trying
to find the answer
The United States, according to available statistics, appears
to be the alcoholic capital of the world – although
pressed closely by France and Sweden. Since 1940 the rate
of reported alcoholism in this country has risen approximately
45 percent among men and 52 percent among women. In January
the Yale University Center of Alcohol Studies reported that
there are now 4,589,000 known alcoholics in the United States.
Every major American city is faced with the problem. Boston,
Mass., although not the chief sufferer (the leader is San
Francisco, with 16,760 alcoholics per 100,000 adult population),
nevertheless has the problem in serious proportions. And
because medical, religious and communal organizations in
Boston are striving desperately and intelligently to cope
with the situation, I made a study of their program. This
is what I found.
It’s a freezing January night. Officer James Delahanty
and I are walking the Dover Street beat in Boston’s
South End, the city’s Skid Row. The saloons are emptying
now, for the law which forbids serving liquor after 1 a.m.
is strictly enforced. Men are hurrying furtively and unsteadily
along the dark street, many of them with bulges under their
coats which you know are bottles of whiskey or jugs of Sneaky
Pete (a poor grade wine, 80 cents a quart). They’re
looking for an alleyway or a friend’s room where they
can drink and blot themselves out.
Delahanty’s practiced eye sees a shapeless something
slumped against the side of a building. He goes up to it,
shakes it and says, “It’s a cold night. Better
get inside or you’ll freeze your feet off.”
A rasping, choking voice gasps, “I can’t walk.”
We try to help the man to his feet but he collapses. Delahanty
goes to the call box.
The ambulance arrives quickly, and within 11 minutes the
man is in the accident ward of Boston City Hospital, one
of the three largest municipal hospitals in the country.
Dr. Maurice Constantin, an intern, gives the man a quick
examination. He has to decide whether this is just an ordinary
drinker who has been celebrating, or a man suffering from
one of the serious mental and physical illnesses which result
from alcoholism. If he has one of these illnesses, he will
be treated with the same consideration and expert care that
he would get if he had heart trouble or double pneumonia.
For alcoholism, is a disease, and it is sternly regarded
as such by everyone at Boston City, from Dr. John F. Conlin,
superintendent, down to the newest intern.
The warmth of the accident room revives the man; he is more
responsive now; he says that his name is Dennis O’Toole.
(the names of all patients in this article are disguised)
Dr. Constantin applies a stethoscope to the patient’s
chest, takes his pulse and strips his trousers off. He frowns
when he sees that both legs are badly swollen up to the
thighs. He feels the soft flesh just below the right rib
cage, finds that the edge of the man’s liver can be
felt three finger-breaths below the last rib. This enlargement
is strongly suggestive of a fatty or badly scarred liver.
Obviously, Dennis O’Toole is not an occasional drinker;
he is a really sick man.
Constantin learns that this is O’Toole’s eight
visit to Boston City, that he had been drinking hard for
months, has eaten little during this period. O’Toole
answers all questions rationally enough, but his out-stretched
hands are tremulous, and his breath comes in labored gasps.
Constantin notes particularly his eyes: they can be made
to deviate only slightly from center. He suspects at once
that, no matter what else is wrong with O’Toole, he
is suffering from Wernicke’s disease, a disorder of
the nervous system.
Carl Wernicke brought this disease to the attention of the
medical profession in 1881. Today it is routine for a receiving
intern to examine a possible alcoholic patient for its presence.
Wernick's disease is caused chiefly by a lack of thiamine
(vitamin B1). If not caught early, irreparable damage to
the brain may occur; if not treated adequately, death may
result. Two other things about O’Toole indicate vitamin
deficiency: his tongue is smooth and red; his skin is dry
and hangs loosely.
The intern rapidly records his preliminary diagnosis to
guide the doctors on the wards: “Chronic alcoholic;
possible Laennec’s cirrhosis; rales, lower right lung
field; peripheral edema; Wernicke’s disease.”
“Get
him up to Medical Three,” he tells an orderly. “Stop
on the way for chest X ray.”
There is no alcoholic ward at Boston City. Dr. Conlin and
his staff feel that confinement in such a ward puts a psychological
burden on a sensitive patient. So Dennis O’Toole is
wheeled into Medical Three.
Dr. Brendan M. Fox, the intern on duty, takes blood, urine
and sputum specimens, and verifies Dr. Constantin’s
findings. Now he tests O’Toole for the serious and
tragically common mental component of Wernicke’s disease:
Korsakoff’s psychosis, named for Sergei Korsakoff,
one of Russia’s most brilliant psychiatrists, who
discovered it in 1889.
The disease takes the form, mainly, of loss of memory, particularly
for recent events. Seen almost exclusively in alcoholics,
its primary cause is likewise nutritional deficiency. Often,
by the time it manifests itself, damage to the brain is
so great that the patient is committed to a mental institution
as incurable.
O’Toole is fortunate. Unlike nine out of ten patients
with Wernicke’s disease, he is lucid.
Now Dr. Fox helps O’Toole to his feet and asks him
to walk across the room. O’Toole walks like a man
on stilts, his feet far apart. Fox notes the word “ataxia”
– inability to coordinate voluntary muscular movements
– on the chart. Then he gives his patient as injection
of chlorpromazine, a tranquilizing drug, and puts him to
bed.
O’Toole falls into a deep sleep. Fox orders intravenous
feeding of thiamine, plus liquids low in salt content (in
case of any serious heart ailment).
Dennis O’Toole, 42, unemployed, was getting the kind
of attention that many could not afford. To the staff of
Boston City he was not a drunken derelict but a very ill
patient whom it was their duty to help.
Eight days later I sat with Dennis O’Toole in a ten-bed
ward. He proudly showed me his completely normal legs. I
told him how a number of doctors had studied his case, and
of the various (and expensive) drugs which had kept him
alive.
“They
take pretty good care of you at that,” he said complacently.
I asked O’Toole how much he drank. He evaded the question
by saying he was just a social drinker – which is
the stock answer I received from dozens of alcoholics. Sure,
he drank every day, he said, but you couldn’t really
call him an alcoholic.
How much whiskey did he drink each day? A pint?
“A
pint!” he exploded. “Mister, when I’m
drinkin’, I spill more than a pint a day.”
Now that O’Toole is in fairly good physical condition,
the staff concerns itself with his rehabilitation. A psychiatrist
visits him daily and tries to gain his confidence. But O’Toole
has talked with psychiatrists before; he listens with apparent
sympathy but with little understanding.
Father Laurence M. Brock, S.J., for ten years chaplain of
Boston City, visits O’Toole every day, and the patient
obviously likes the big, rugged priest. O’Toole even
drops in to the beautiful little chapel on the ground floor
to hear Mass. But when you ask the priest if he has made
any progress, he shakes his head sadly.
“I
never ask a man to sign the pledge that he will never drink
or even that he won’t take a drink for six months
or a year,” he says. “I find that the pledge
works only when the patient asks to take it. Very, very
few of the Dennis O’Tooles ever make it. I phoned
Alcoholics Anonymous and they sent a man to see him. He
promised to attend a few of their meetings. I doubt he will.
The rehabilitation of an alcoholic has to come from within.
“We
have about 2000 beds here at the hospital. If it weren’t
for alcohol, we could get along with a lot fewer. Go over
the accident cases; a great many are the result of drinking.
And far too many other patients are here because alcohol
made them susceptible to disease.”
Before Dennis O’Toole is discharged, Resident Dr.
Stanley M. Silverberg has a long talk with him. He pleads
with him to return to visit Dr. Iver Ravin’s out-patient
clinic for alcoholics. He tells O’Toole of the drug
called Antabuse, designed to help him overcome his alcoholic
habits. A pill is taken each morning, and if the patient
then takes a drink, he is overcome by violent nausea.
“Doc,
I don’t need any of them gimmicks to stay sober,”
O’Toole says earnestly. “I don’t need
no head doctor nor no priest or A.A. guy holding my hand.
I got will power!”
And so Dennis O’Toole leaves Boston City Hospital.
The institution has done everything humanly possible to
help him. But it can’t make him help himself. Even
the most skilled experts in medical, psychiatric and spiritual
counseling cannot make O’Toole admit that he has no
control over alcohol. He is a chronic alcoholic who refuses
to believe that he is slowly committing suicide.
One cannot say that Dennis O’Toole is a typical alcoholic,
for there is no typical victim of this disease. Nor does
the scourge stalk only the Skid Rows of the big cities.
Less than 15 per cent of our four and a half million alcoholics
dwell in the Dover Streets and Boweries of the land.
If
nature exacts its usual inexorable toll, a tall, good-looking
man of about 50 who is registered at Boston City under the
name of Peter Slocum will be either dead or buried alive
in a mental hospital within a short time. Slocum was found
stumbling across Boston Common talking incoherently. Reasonably
well-dressed with money in his pocket, he might just have
had one too many. But the intern on duty at Boston City
needed only a few minutes to make the diagnosis: Korsakoff’s
psychosis, in an advanced stage.
A few days after Slocum was admitted, a man came to the
hospital in search of a missing brother. He found that the
man registered as Peter Slocum was indeed his brother. He
told me his alcoholic history and allowed me to visit with
him.
Slocum had been an alcoholic for 20 years, and had taken
a dozen “cures” at private institutions. During
most of this time he had held a good job as a sales director,
but now he had come to the end of the road. I spent considerable
time with him but he never remembered me from one visit
to the next. One time the doctor with me asked, “Do
you know where you are Peter?”
“At
my sister’s home in Malden,” Slocum said in
a soft, gentle voice. (Contrary to general opinion, few
alcoholics are violent. Chaplain Brock refers to them as
“the gentle people.”)
“He
has no sister, nor any relatives in Malden,” the doctor
said to me. We talked with Slocum for an hour, but it was
impossible to establish any real communication.
Dr. Kermit H. Katz, visiting physician who is chief of the
5th and 6th Medical Services at the hospital, had investigated
Slocum’s history thoroughly. “He was always
good at his job,” Dr. Katz explained. “He was
the man who took clients out when they came to Boston. He’d
drink with them at lunch and then drink with another group
at dinner. He did this for years, until finally there came
a time when he didn’t merely want a drink –
he needed a drink. He never really liked the taste of alcohol,
but to keep going he had to have a few eye-openers in the
morning. Then came the final step: he had to drink constantly.
“He’d
go away and get straightened out temporarily, but he always
had to return to the bottle. Now? We’ve tried everything
science has taught us. But I can’t see any hope. There
is too much organic damage. I wish that those who could
still rehabilitate themselves could see Peter Slocum today.”
Certainly the example of Slocum is a sobering one. Even
more sobering is the experience of listening to a patient
in the grip of delirium tremens, the final stage of prolonged
alcoholism. Come with me to a private room in the 5th Medical
Service at Boston City.
Mrs. Rogers, age 36, once an attractive brunette, is the
patient. When I saw her she had been in delirium tremens
for five days. Usually the symptoms abate within 72 hours.
She lay in bed “in restraint” – her wrists
and legs attached by cuffs to the side of the bed, but loosely
enough to permit some movement.
Her husband had brought her to the hospital in a state of
coma after she had suffered an alcoholic epileptic seizure.
She made a partial recovery from the seizure and then had
slipped into delirium tremens. She had been a heavy drinker
for 12 years. Her husband said that she drank beer steadily
each morning and then shifted to wine in the afternoon.
He himself was a moderate drinker. Their home? The husband
had finally sent their two children to relatives. He had
only a deep and gentle pity for the woman who had been his
wife for 17 years. She was being given oxygen through a
nasal tube. Glucose, water and vitamins were being injected
intravenously.
Her eyes were wide open, and she was carrying on an animated
conversation, all of it meaningless. When the doctor pointed
to me and asked, “Mrs. Rogers, do you know this man?”
she said in what appeared to be a normal voice, “Yes,
that’s my brother Steve. Where is Anne? Oh, here she
is”-a white clad nurse had entered the room. ”I
like your brown hat, Anne, but it doesn’t go with
that plaid skirt…Steve, the water is running. Turn
it off, Steve. Make him turn it off, Anne – it’s
up to your ankles. Now it’s up to your waist. You
stay here if you want – I’m going to the kitchen….”
The doctor said, “I’ve turned it off, Mrs. Rogers.
It’s all right.” The patient seemed reassured.
But in a few moments she was babbling something equally
fantastic. When we left, she was talking animatedly about
a little dog she believed to be in bed with her. Twenty-four
hours later Mrs. Rogers stopped talking forever.
SOMEWHERE
in Boston today there is a girl named Therese, working as
a waitress. She came to Boston City in an alcoholic coma,
more dead than alive; the whole resources of the hospital
were regimented in an effort to save her. She was in such
grave condition that she was given a private room, and during
her first two weeks a nurse was with her 24 hours a day.
Some of the drugs given Therese during the three months
of her hospitalization were: penicillin, paraldehyde, chloral
hydrate, an extract of rauwolfia, chlorpromazine, thiamine,
codeine, sulfisoxazole (a sulfa drug) and tetracycline (an
antibiotic). She had two electro-cardiograms, two chest
and kidney X- rays, ten urinalyses, 11 blood counts, a Papanicolaou
smear test (for vaginal cancer) and several blood cultures.
She was taken to the operating room on two occasions, at
which time she received the most modern (and expensive)
anesthesia, and had a complete gynecological survey. A sternal
puncture was done, and the marrow was cultured for bacteria.
The state of her liver was assessed by performing a liver
biopsy (removal of a small portion or the organ for microscopic
examination). Visiting physicians held half a dozen conferences
to determine the best way to treat her various physical
and mental ills.
I studied the complete medical and surgical record of Therese’s
three-month stay in the hospital. Included were reports
from eight internists, one gynecologist, two pathologists,
one general surgeon, five laboratory and X-ray technicians,
one heart specialist, two neurolog-ists and a specialist
in lung disease. Therese finally walked out of the hospital
in fairly good health.
What did her treatment cost the taxpayers of Boston?
Dr. Katz looked puzzled when I asked him that question,
for at Boston City great importance is placed upon the life
of a patient but much less on the cost of preserving that
life. However, Dr. Katz went through the file and estimated
that the cost to a paying patient in a private hospital
for the drugs, laboratory tests, medical, surgical and nursing
attention that Therese had received would have been at least
$5000. (It might be noted that Katz and 500 other visiting
doctors and psychiatrists give their skill and time to Boston
City patients with no recompense at all.)
The budget at Boston City is 16 million dollars a year.
When you ask Dr. Conlin how much of that is consumed in
the care of alcoholics, he smiles, “Does it matter?
They are just as sick as men and women who come here with
meningitis or cancer and, as you’ve seen, they are
treated the same. Happily, both the profession and the public
are finally beginning to realize that alcoholism is a disease
and not a form of adult delinquency.”
What
can be done for the advanced alcoholic?
Alcoholics Anonymous, which has an active membership of
about 150,000, is still, doctors believe, the most impotent
of all forces for rehabilitating the alcoholic. But Boston
keeps trying to find other, even better answers. It is an
uphill fight.
Far out in Boston Harbor is a small island connected with
the mainland by a causeway. This is the home of the Long
Island Hospital (part of Boston City), an institution for
sufferers of chronic diseases. Chronic alcoholics, of course,
make up only a portion of the hospital’s patients,
but it is a discouraging portion. For despite the heroic
efforts being put forth, the number who can be classified
as “cured” is so low as to be frightening.
Dr. David Myerson, the hospital’s psychiatrist, recently
completed a three-year study of 101 alcoholics here. Fifty
percent had attended high school. And some of these had
once held good jobs in business or industry. Virtually all
had lost all family relationships, and for them had substituted
the illusionary companionship found in local taverns.
Each patient had entered Long Island voluntarily, with an
avowed desire to be rehabilitated. Each to a great degree
lost his sense of isolation, because at Long Island he was
a member of a group. (Once a week the dedicated members
of Alcoholics Anonymous hold meetings here.) The hospital
soon became a home for the patients, and when they improved,
jobs were found for them in Boston. Each night they returned
to the hospital in buses.
What is the result of Dr. Myerson’s treatment and
study?
For 47 of the 101, complete failure. For 22, partial recovery.
(They still went on prolonged drinking bouts two or three
times a year.) Twenty other patients remained sober for
the three years of the study, but each admitted that he
could maintain this immunity from alcohol only if he continued
to live at the hospital under medical and psychiatric supervision.
The remaining 12 abstained from liquor, did satisfactory
work in their jobs, and finally decided that they could
face life in the city independently, without reliance upon
the hospital.
“I
try to keep in constant touch with these 12 men,”
Meyerson says. “Are they cured? We can never use that
word in discussing an alcoholic patient. But they have apparently
learned to live with their affliction. They all continue
to attend AA meetings and to engage in therapy we suggest.
But if any of these men ever takes one drink, he will have
failed to overcome his problem. Alcohol to them is a destructive
force against which they must carry on an endless struggle.”
Of course, the alcoholic cases Dr. Myerson deals with are
in the most advanced stage. As in other illnesses, the chances
of cure are better if detection is earlier. Psychiatrist
David Landu believes that at least a partial solution to
the problem lies in reaching the “unrecognized alcoholic,”
who has not yet arrived at the point of no return. If such
men and women could be made to realize that it is merely
a question of time before their minds and bodies become
scarred and, eventually, destroyed, they might escape the
sentence of death which can pass upon them.
(Source:
Reader’s Digest, April 1956)
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