11G
Art. VIII.?STATE MEDICINE IN ITS RELATIONS TO INTEMPERANCE AND THE INEBRIATE.* By EDWARD C. Medical
MANN, H.D.,
Superintendent State Emigrant Insane Asylum, Ward's Island, New York.
past few years scientific men have been earnestly labouring to impress tlie idea upon the public that more thought and study should be expended in the direction of the dissemination of the knowledge of sanitary and hygienic laws among the ignorant masses, in order that the public health might thereby be improved and disease prevented. This study of the laws of disease as they affect communities and nations is We have now come to realise that preof very recent origin. ventive disease exists in a great measure as a result of ignorance and the violation of physical, moral, and intellectual laws, and a neglect of sanitary precautions. We have also come to realise that for the prevention of disease we must remove ignorance by a sound education of the masses, so that they may both understand and obey sanitary and hygienic laws. Then, and only then, will the preventible be converted into the prevented. We check intermittent fever by draining our land properly. We mitigate the ravages of smallpox by vaccination. We prevent consumption by avoiding a damp, wet soil for our residence. We avoid fever by taking care of the sanitary condition of our dwelling-houses and the purity of our water supply. We prevent the invasion of cholera and yellow fever by proper attention to sanitary and hygienic laws, and by quarantine; but there is a disease which tends directly to the destruction of all physical and mental health of individuals, communities, and nations, which preventive or State medicine has seemed thus far powerless to check : that widespread and universal disease?intemperance. We need more efficient and wiser legislation upon this subject; and although the Legislature undoubtedly has the right to interfere with the personal habits or private business of individuals, when these are productive of direct evil to the public, yet I think their wisdom and intelligence should be directed in During the
the channels of the
ledge
of
sanitary
and
diffusion among the laws and the
hygienic
*Read before the American Social Science
Association,
1876.1
masses of
the know-
penalties consequent
at Philadelphia, Mnv 31st.
STATE MEDICINE IN ITS RELATIONS, ETC.
117
sentiment must be enlightened upon their violation. The public and changed before prohibitory laws and statutes will avail. When the masses can be made to understand that by intemperance they are destroying not only their own physical, moral, and intellectual health, but that of their offspring, on whom this curse is inevitably entailed by the laws of hereditary transmission, then, and only then, will the disease?for disease it is? be abated. In all parts of the civilised world man seeks for some stimulus, the results of which are more or less disastrous to his physical, moral, and intellectual health, according as the liquors employed are strong and fiery, or mild and light. This tendency or appetite for stimulants varies with varying climatic law, with race, fashion, and the character of the stimulant used. The instinct or appetite for stimulants we cannot annihilate, and our efforts must consequently be directed towards its regulation, so that it may be properly restrained by education, reason, and conscience. It has been determined with comparative accuracy that the prevalence of intemperance is governed by a cosmic law, which consists essentially in the fact that the tendency to intemperance increases, and its effects on man become more disastrous, as we go from the equator, where intemperance is comparatively rare, towards the northern regions of the globe, where it is both very prevalent and its effects violent. The stimulating nature of the climate of northern regions indnces, perhaps, a desire for such stimulants, while the stimulating nature of our climate on the Atlantic coast, combined with the extremes of heat and cold, very unfavourably in the production of intemperance, tendency to which Ave inherit from our English ancestors. Before entering upon a discussion of the disastrous effects produced by intemperance, it will be interesting to note the habits and tendencies of some of the foreign countries in this respect, with the effects of indulgence in alcohol upon the physical characteristics of such nations. In Italy the inhabitants use light wines and beer; and crime resulting from intemperance is comparatively rare.* In Greece the people use universally the light wine of domestic manufacture, and consume annually about 3,800,000 bottles; yet intemperance is very rare, and in the published register of deaths in the city of Athens, for nine
operates a
the last few years, however, dipsomania has been on the increase in and there has been a decided increase of diseases of the nervous system and brain, resulting from the abuse of alcoholic liquors. This I deem to be due to the fact that the warm, humid temperature, particularly of Rome, relaxes the muscular to disease, and nervous sj'stem ; the blood circulates sluggishly, thus if alcohol be indulged in, by reason of the imperfect oxidation of the tissues. *
During
Italy,
predisposing
118
STATE
MEDICINE
IN
ITS
RELATIONS
years, only twenty-six deaths of natives are recorded as the result of intemperance, and this out of a population of about 50,000 inhabitants. In Germany wine and beer are in unlimited use, but without apparent detriment to either health or national prosperity. This is owing to climate, temperament, and mode of life. In Turkey intemperance is confined to the Christian population, as the Mohammedans abstain from drink. As the use of distilled liquors in Turkey has been found to be very detrimental to both physical and mental health, native and foreign wines are in use by the Christian population. In Spain intemperance is rare, although Spaniards drink more or less wine, Burgundy, and aquaidiente. In Denmark beer and brandy are much used, and the mental and physical constitution of the people is injuriously affected by this indulgence. Suicides are frequent from drink. The better classes use the European wines The effect of the climate and the uniform in moderation. good nourishment of the people of Denmark prevent the disastrous effects which would otherwise appear from such a consumption of alcohol. In Ireland the poorer and middle classes use whisky and porter very freely, and the rich use wines and brandies. A majority of the diseases and nearly all of the crime in Ireland is due to intemperance. In England the liquors principally used are gin, brandy, beer, wine, and cider, and intemperance is very prevalent. All the competent authorities in England concur that a large proportion of all the crime, disease, and early mortality is produced directly by intemperance. In Russia intemperance is very prevalent, the ? principal drink of the common people being vodka," which corresponds to our whisky. Wine, brandy, beer, and ale are also made in Russia, and drunk by the higher classes. In Japan the people are on the whole decidedly temperate. More or less " saki," a liquor brewed from rice, is drunk, but it is largely diluted with water, and drunk in very small glasses. Very little crime results from intemperance, owing to the division of The upper class, or the " Samonrai," the people into castes. refrain from drink, as they do not wish to endanger their chances of promotion by the Emperor, who makes his selection from the wisest or most skilful men of the upper class. Their ambition for promotion, therefore, keeps this class comparatively very temperate, while the lower classes refrain from drunkenness from a fear of offending the upper classes, their lives and property " being at the disposal of the Samonrai." In Scotland whisky is universally drunk by the lower classes, and the amount of intemperance thereby induced operates in the production of crime, and has a very unfavourable effect on the mortality of this class. An apparent exception to the law spoken of in
TO
the
INTEMPERANCE AND THE INEBRIATE.
beginning of
this paper, that
intemperance
is
119
comparatively
equator, is found in the natives, or aborigines, of Central Africa, India, West Indies, and the tropical islands of rare near
the
Ocean. It is stated that in these localities the natives rival any nations of the globe for beastly intoxication and drunken orgies. The descendants of European colonists occupying these countries are, however, uniformly temperate. If we look at the foregoing description of the drinking habits of different nations, we shall see that the greatest amount of disease and crime resulting from intemperance occurs in those countries where the climate and the nervous temperament of the inhabitants renders the effect of indulgence in alcoholic stimulants especially hurtful to the brain and nervous system. This is nowhere more noticeable than in our own country, especially on the Atlantic coast, where the peculiarly stimulating nature of the climate induces a peculiar nervous susceptibility which operates in the production of grave diseases of the nervous system if drinking habits are indulged in. The evils resulting from intemperance in our own country can hardly be over-estimated. Inebriety, insanity, epilepsy, delirium tremens, and chronic alcoholism are among the more frequent, while the laws of hereditary transmission are inexorably preparing the way for a generation of drunkards. The amount of pauperism, crime, and disease produced in this way In New York every year is something fearful to contemplate. it is estimated that 33^ per cent, of all deaths are due directly or indirectly to the abuse of alcoholic stimulants, of which it is supposed that 600,000,000 dols. worth are annually sold in this country. According to the report of the Special Commission on the Eevenue, of which Hon. David A. Wells was chairman, the amount of distilled spirits used for drinking purposes in the United States for the year ending June 30th, 1865, was thirty-nine million gallons. They also estimated the increase in the consumption of these liquors at the rate of ten per cent, per annum, which would make the consumption for the year 1870 amount to three hundred and sixty million gallons. If we add to this the imported wines and the domestic distilled spirits that are consumed we have a consumption of not far from four hundred and ten millions of gallons. Now, would the unlimited introduction of light wines and beer prevent the amount of intemperance caused by the consumption of this enormous quantity of distilled liquor? Far from endorsing the idea that the prevalence of light wines and beer diminishes intemperance in such a climate as ours, I believe it directly promotes it; as I think a person, especially one inheriting a tendency in this direction, after indulging in the Pacific
120
STATE MEDICINE IN ITS RELATIONS
wine and beer for
some time, feels a growing desire for some powerful stimulant, and soon resorts to the habitual use of distilled liquors, such as brandy or whisky. I doubt very much whether the introduction of light wines into this country, free of duty, would induce people to give up the more powerful stimulants. My own opinion, with all due deference to the opinion of others, is, that an unlimited abundance of light wines would result gradually in increased habits of intemperance, and I do not think it would result in diminishing the sale of distilled liquors. The almost universal use of light wines in France has not prevented the people from resorting to absinthe
more
and other strong stimulants. I think in our own country that intemperance begins almost universally with the use of wine and beer, which habit lays the foundation or creates a desire for a stronger stimulant, and that in this way thousands are annually prepared to become victims of inebriety. In the year 1830 a measure was introduced in England, originating, I believe, with the Duke of Wellington, establishing beerhouses, hoping that they would promote the cause of temperance and prevent the consumption of distilled spirits by the masses. Instead of exerting this benign influence, it was decided by English statesmen that it was increasing and intensifying intemperance. Lord Brougham was so much impressed by this that he introduced into the House of Lords a Bill for the repeal of the Beer Act, although he was at first very sanguine about the amount of good it was going to accomplish. The introduction of beer did not decrease the sale of ardent spirits ; and all the judicial, civil, and medical authorities united in their testimony of the increased evils arising from this measure. In the year 1872 the editor of the San Francisco Pacific wrote as follows respecting the increased use of wines, consequent upon the establishment of the vineyards of California: " The lowest, slowest, most illiterate, most unimpressible, most unimprovable, if not most vicious population outside of the great cities, is found in the oldest wine districts of this State, and that the use of the products of vineyards has been the most active cause of this condition of the population; that the increased production and consumption of wine on this coast, in the more recent years, has diminished the use of neither distilled liquors nor lager-beer, but rather inWith our national susceptible creased the demand for both." nervous temperament, the artificial habits of living, the intensity and excitement of life, and the undue predominance of the nervous temperament, which is gradually taking place in successive generations, would the dangers of intemperance be lessened by the unlimited supply of light wines and beer ? I think not. I regard inebriety as a physical disease, and I do not believe that
TO
INTEMPERANCE AND THE INEBRIATE.
121
a man whose nervous system is diseased by indulgence in alcoholic stimulants will ever voluntarily abandon distilled liquors Such a man feels, when depressed physically for light wines. or mentally, an irresistible desire, impulse, or craving to seek for the relief which he obtains temporarily from the use of alcoholic stimulants; and this relief he cannot obtain from a decidedly weaker stimulant than that he is accustomed to use. The very nature of the disease consists in the gradual development and growth of this abnormal appetite or craving, until it reaches that point where it renders its unhappy possessor blind to the dictates of reason and judgment, and the slave of this irresistible, insane impulse, by which he is impelled by a terrible vis-a-tergo, to gratify his morbid propensity. The sooner this disease theory of inebriety is acknowledged and recognised by the public, and the proper sanitary, hygienic, and medicinal remedies are applied to this disease, the sooner will it disappear and be classed under the head of pi evented diseases.
EFFECTS OF INTEMPERANCE
UPON
INDIVIDUALS AND COMMUNITIES.
The effects of intemperance upon the sanitary condition of individuals and communities is very disastrous. This naturally results from the pauperism and crime, and the moral and social degradation of the masses, consequent upon this indulgence in alcohol, which culminates in the ruin of their ph}7sical, moral, and intellectual health. This is seen most clearly when countries are visited by epidemics, when it is observed that temperate communities resist disease far better than intemperate ones. Intemperance weakens the constitution, so that it cannot resist the poison of cholera, yellow fever, &c. The desire for alcoholic stimulants is often the result of an abnormal constitutional organisation. It also appears as the result of ill health, sunstroke, blows on the head or spine, and severe mental shock, in the same way as do other nervous diseases. Alcohol is not either respiratory or accessory food, as it has been claimed to be. Liebig and others maintained that when alcohol was taken into the system it united with oxygen, and that combustion or oxidation ensued, by which it was converted into carbonic acid and water; hence it was termed by him "Respiratory Food." This theory of Liebig was destroyed by the researches of Dr. Prout, of London, who proved by direct experiment that the presence of alcohol in the body directly diminished the amount of carbonic acid gas exhaled from the lungs. These experiments of Dr. Prout were confirmed by Sandras and Bouchardet, of France, who repeated them with like results, and also by scientists in our own country. The
122
STATE
MEDICINE IN ITS RELATIONS
chemico-physiologists then maintained that alcohol, being a hydro-carbon, must necessarily be used for maintaining temperature and respiration, and that its use increased temperature and strength. Dr. Boker, of Germany, then instituted a series of experiments, proving that the use of alcohol retarded tissue metamorphosis, and thereby decreased the excretion or elimination of effete matter, so that from the accumulation of hydrocarbonaceous material the individual increased in weight. This
latter fact led certain persons to claim that alcohol was an accessory food?an erroneous idea, which they would have recognised as such, had they observed such individuals carefully ; for they would have seen that such persons always exhibit a corresponding decrease in nervous and muscular stamina. It was proved in 1869 by the experiments of Dr. N. S. Davis that, after taking alcohol, either in a fermented or distilled state, the temperature began to fall within an hour, and continued to fall for two
or
three hours.
A few
years
later, Lallemand, Perin,
and Duroy proved, by a series of experiments, that alcohol was absorbed and carried with the circulation throughout the whole body; and also a very important point, that it was eliminated as Others alcohol, unchanged, from the lungs, skin, and kidneys. claim that only a part of the alcohol taken is eliminated. We see, therefore, that alcohol has no claim to be regarded as food, as it is not used to build up the tissues of the body, or repair or It merely diminishes restore lost nervous or muscular force. the nervous sensibility of the individual, so that it lessens his consciousness of impressions, and acts as a sedative by retarding tissue The nervous sensibility is diminished by metamorphosis. virtue of a paralysis of the vaso-motor and cerebro-spinal system of nerves, which the alcohol causes as it circulates through the body. The use of alcohol, therefore, to recapitulate, diminishes the temperature, the strength and the power of endurance of the individual who takes it habitually, and increases his predisposition to disease. It impresses a peculiarly morbid influence upon the brain and nervous system, which, if the habit be indulged in, becomes a permanent pathological impression, and results in the formation of an irresistible or insane impulse to seek for the relief obtained from alcoholic stimulants. In this state of moral insanity, the control which the intellect normally exercises over the moral senses is overborne by the superior force This permanently diseased state, or dipderived from disease. somania, is markedly hereditary, and, like insanity, appearing under other forms, it often disappears in the second generation It manifests to break out with renewed intensity in the third. itself in predisposition or simple aptitude; in a latent state; or in the actually developed disease. In the second or latent state,
TO
INTEMPERANCE
AND
THE
INEBRIATE.
the germ of the disease, which has been inherited
by
123 the indi-
for years, and starts into life in advanced age ; as the result of ill health or mental shock, resulting in mental inebriety in a previously healthy and temperate person. This permanently diseased state of the brain is due probably to the interference in the nutrition, growth, and renovation of the brain-cells, which, by the use of alcohol, are
vidual,
lies
dormant, perhaps,
unduly stimulated, so that a process of waste and decay is induced, beyond the powers of reparation and renovation. Owing to this impression of a pathological state on the braincells, there results a change of healthy function, and disease is induced. The effect of the alcohol is to cause a change in the chemical composition of the cerebral cells from the standard of health, which is the foundation and the starting-point for organic disease. Owing to long-continued use of alcohol, we have resulting: Cerebral hyperemia, with symptoms of irritation, due to increased excitability of the nerve filaments and ganglion-cells of the brain. At a later stage, we have symptoms of exhaustion, due to lost excitability of the nervefilaments and ganglion-cells, owing to a want of the proper supply of arterial oxygenated blood to them. Alcohol not only weakens and impairs the functions of the body, but it causes grave nervous diseases, such as insanity, epilepsy, and chorea, and also influences the offspring of intemperate parents in the most unfavourable manner. The offspring of such parents inherit a predisposition or aptitude for some form of nervous disease, the particular form being often determined by causes subsequent to birth. It may be inebriety, insanity, epilepsy, chorea, or a proclivity to crime. These children, offspring of intemperate parents, are generally cursed with a defective, illbalanced organisation, and a weakened, if not actually diseased, nervous system ; as a result of which they are predisposed to seek for the relief obtained from alcohol, when depressed mentally or physically. They soon degenerate, become victims to the irresistible impulse, and die inebriates. Insanity from intemperance is on the increase, especially in England, where it shows an alarming increase, judging from the last reports of one of the largest asylums, the Crichton Royal Institution, where in the last five years the admissions due to intemperance have risen from 8 per cent, to 35 per cent. The Medical Superin" tendent, Dr. Gilchrist, remarks, that doubtless a more minute analysis would largely increase the proportion of those in which the excessive use of stimulants, by the patients themselves, or by their parents, constitutes an important, if not the primary, factor in the production of mental disturbance." In order to successfully combat all these manifold evils which we have seen
124
STATE MEDICINE IN ITS RELATIONS
result from intemperance, we need to educate the public up to the universal acceptance of and belief in the fact that alcohol, instead of being a tonic and restorative to the system, is a narcotico-irritant poison; that it has no analogue in the human system; and that its continued use will inevitably result, not only in the impairment of the mental and physical health of the individual himself, but also that of his offspring. When the public come to take this view of the subject, and come to believe that mind and body are debilitated, instead of nourished and renovated, by the habitual use of alcoholic liquors, public sentiment will then be adequate, without the necessity of prohibitory laws, to the prevention of intemperance. INEBRIATE
ASYLUMS AND CARE OF TIIE INEBRIATE.
We have already spoken of the necessity of wise legislation to the prevention of intemperance ; but what shall we It becomes a grave question relating to do with the Inebriate ? the political economy of the commonwealth as to the annual
tending
the State by the loss of the labour of inebriates. longevity of a man at 20 years of age, if temperate, has been estimated at 44*2 years; while if intemperate, his average life is reduced to 15*6 years. If an inebriate at 20 years of age is not reformed or cured, the State loses his earnings for the 44*2 years which he would have made if temperate ; and there is also an expense entailed, for his care, on his family or the State, for the 15*6 years remaining as his average life. When we reflect upon the extent of intemperance throughout the commonwealth, we see what an immense loss is suffered by the State by such a waste of productive power, and what a grave financial problem this subject becomes when viewed in this light. We need, in every State of our country, to establish State inebriate hospitals, adapted in construction, location, and surroundings to the special needs of this class of unfortunates, so as to enable them, with the assistance of wise superintendence, to regain the lost self-control and manhood, and have their weakened and diseased minds and bodies properly strengthIn this way a great annual expense would ened and cured. be saved to every State, by materially lessening the number of paupers, idiots, and criminals, to say nothing of the destitute children, and that percentage of the insane who have been rendered so by the abuse of alcohol. If one-tenth part of the sum annually appropriated in each State to almshouses, hospitals, prisons and asylums, should be appropriated to the reform and cure of inebriates, the expenses of the above-named institutions in a short time would be very much lessened, by the decrease in loss entailed
The average
on
INTEMPERANCE
TO
admissions, which would
AND
THE
INEBRIATE.
be the natural result of
pauperism, crime, and disease. inebriate hospitals in every State, building the
causes of
such States would pass such laws
a
125 decrease in
in addition to the Legislature of
If,
as would enable the public operation remedial restraint, so that inebriates should be committed in precisely the same manner as are the insane, and held for treatment until the superintendent deemed them fit to take their place in society, we should then soon have accomplished great good in the permanent reforma-
guardians
to
put
into active
of men who are admitted with broken-down To do this, miliand shattered constitutions. systems tary discipline, good hygienic influences, cheerful, tranquil, and pleasant surroundings, and regular exercise, both bodily and mental, are among the indispensable indications for treatment, while the superintendent will be best able to judge of the special needs of individual cases. There should be no half-way or sentimental measures adopted in the confinement and treatment of inebriates. The public must understand that inebriation is a type of insanity, and that in all cases prompt and effective measures will be taken to prevent such individuals from ruining themselves and injuring society. That in all cases prompt measures will be taken to confine such persons in an institution for the cure of inebriates, by law; and that, when there, they will be under strict discipline, which will require and enforce both physical and mental labour, as they are a class of patients, tion
and
cure
nervous
for whom, in my estimation, not less than the insane, physical and mental labour is absolutely necessary for restoration to An inebriate who is allowed to idle away his time will health. never acquire the mental and physical stamina which is requisite for his reformation and cure. He will only degenerate, and on his discharge will relapse into his former habits. An inebriate asylum where the patients cannot be detained by law until cured, loses much of its efficacy. It must be understood that the inebriate is suffering from a physical disease, and that he is committed to an inebriate hospital to stay until cured,
whether that cure takes for its completion six weeks or six years ; and that when in such an institution he is to submit to the discipline of the house. If the question be raised, How can you tell whether your patient is cured ? I reply, that when reasonable hopes are entertained of the cure of a patient,-when we think that we have given our patient new blood, bone, muscle, and mind enough to take care of himself, his family, and his property, then, I would do as I am in the habit of doing with my insane patients, send them on pass?on trial?still maintaining a legal control over them, and, when it is clear that they are going to do well, discharge them. With the insane I
126
STATE
have found this
MEDICINE
IX
ITS
RELATIONS,
ETC.
to work well; why not with the inebriate in like manner legally committed upon admission ? For the successful treatment of inebriety, as with insanity, it is necessary to send the patient for treatment in the early and curable stage of the disease. Like insanity, inebriety, if treated in the early and curable stage, ought to give a much larger percentage of cures than it now does ; while if the patients are sent for treatment after years of disease, they present small chances for recovery. Yet people do not wish to send their friends for treatment to such an institution until they have become confirmed sots, and beyond all hope of reformation Such cases should be sent to an asylum, and should and cure. not be allowed to cumber up the wards of an inebriate hospital where we send patients, not to keep, but to cure and return to society. Finally, the Legislature should, in dealing with this question, in addition to legislating in the direction of the dissemination of knowledge among the masses, as to the nature and effects of alcohol, deal with its indiscriminate sale, just exactly as it does with the sale of arsenic or prussic acid, for it is just as surely a deadly poison. Arsenic is sometimes used as food to increase flesh and impart brilliancy to the eye and complexion, but is it not a deadly poison ? Opium and haschish are also used, for their effects, in the same manner, but is The not their sale restricted, as with all other poisons ? Legislature must appreciate the fact that the use of alcohol is a form of suicide, and must legislate in this direction. No other form of prohibitory statutes will ever accomplish the desired result. I have already alluded to the fact that it becomes at times a very difficult task to convince a man's family that he is a proper subject for an inebriate asylum. I deem it a sacred duty that in such cases devolves upon the governmental authority, to protect society, as in the case of other insanities, against danger, either existing or being apprehended, such as can be avoided by precautionary and preventive of person and property measures, and to protect in his rights whatever from citizen the individual cause, is unfortunately who, so far impaired in his physical, mental, or moral faculties, as to render his uncontrolled movements alike prejudicial to his own interests and those of society.
insane, if they
plan
are
Art. VIII.?STATE MEDICINE IN ITS RELATIONS TO INTEMPERANCE AND THE INEBRIATE.* By EDWARD C. Medical
MANN, H.D.,
Superintendent State Emigrant Insane Asylum, Ward's Island, New York.
past few years scientific men have been earnestly labouring to impress tlie idea upon the public that more thought and study should be expended in the direction of the dissemination of the knowledge of sanitary and hygienic laws among the ignorant masses, in order that the public health might thereby be improved and disease prevented. This study of the laws of disease as they affect communities and nations is We have now come to realise that preof very recent origin. ventive disease exists in a great measure as a result of ignorance and the violation of physical, moral, and intellectual laws, and a neglect of sanitary precautions. We have also come to realise that for the prevention of disease we must remove ignorance by a sound education of the masses, so that they may both understand and obey sanitary and hygienic laws. Then, and only then, will the preventible be converted into the prevented. We check intermittent fever by draining our land properly. We mitigate the ravages of smallpox by vaccination. We prevent consumption by avoiding a damp, wet soil for our residence. We avoid fever by taking care of the sanitary condition of our dwelling-houses and the purity of our water supply. We prevent the invasion of cholera and yellow fever by proper attention to sanitary and hygienic laws, and by quarantine; but there is a disease which tends directly to the destruction of all physical and mental health of individuals, communities, and nations, which preventive or State medicine has seemed thus far powerless to check : that widespread and universal disease?intemperance. We need more efficient and wiser legislation upon this subject; and although the Legislature undoubtedly has the right to interfere with the personal habits or private business of individuals, when these are productive of direct evil to the public, yet I think their wisdom and intelligence should be directed in During the
the channels of the
ledge
of
sanitary
and
diffusion among the laws and the
hygienic
*Read before the American Social Science
Association,
1876.1
masses of
the know-
penalties consequent
at Philadelphia, Mnv 31st.
STATE MEDICINE IN ITS RELATIONS, ETC.
117
sentiment must be enlightened upon their violation. The public and changed before prohibitory laws and statutes will avail. When the masses can be made to understand that by intemperance they are destroying not only their own physical, moral, and intellectual health, but that of their offspring, on whom this curse is inevitably entailed by the laws of hereditary transmission, then, and only then, will the disease?for disease it is? be abated. In all parts of the civilised world man seeks for some stimulus, the results of which are more or less disastrous to his physical, moral, and intellectual health, according as the liquors employed are strong and fiery, or mild and light. This tendency or appetite for stimulants varies with varying climatic law, with race, fashion, and the character of the stimulant used. The instinct or appetite for stimulants we cannot annihilate, and our efforts must consequently be directed towards its regulation, so that it may be properly restrained by education, reason, and conscience. It has been determined with comparative accuracy that the prevalence of intemperance is governed by a cosmic law, which consists essentially in the fact that the tendency to intemperance increases, and its effects on man become more disastrous, as we go from the equator, where intemperance is comparatively rare, towards the northern regions of the globe, where it is both very prevalent and its effects violent. The stimulating nature of the climate of northern regions indnces, perhaps, a desire for such stimulants, while the stimulating nature of our climate on the Atlantic coast, combined with the extremes of heat and cold, very unfavourably in the production of intemperance, tendency to which Ave inherit from our English ancestors. Before entering upon a discussion of the disastrous effects produced by intemperance, it will be interesting to note the habits and tendencies of some of the foreign countries in this respect, with the effects of indulgence in alcohol upon the physical characteristics of such nations. In Italy the inhabitants use light wines and beer; and crime resulting from intemperance is comparatively rare.* In Greece the people use universally the light wine of domestic manufacture, and consume annually about 3,800,000 bottles; yet intemperance is very rare, and in the published register of deaths in the city of Athens, for nine
operates a
the last few years, however, dipsomania has been on the increase in and there has been a decided increase of diseases of the nervous system and brain, resulting from the abuse of alcoholic liquors. This I deem to be due to the fact that the warm, humid temperature, particularly of Rome, relaxes the muscular to disease, and nervous sj'stem ; the blood circulates sluggishly, thus if alcohol be indulged in, by reason of the imperfect oxidation of the tissues. *
During
Italy,
predisposing
118
STATE
MEDICINE
IN
ITS
RELATIONS
years, only twenty-six deaths of natives are recorded as the result of intemperance, and this out of a population of about 50,000 inhabitants. In Germany wine and beer are in unlimited use, but without apparent detriment to either health or national prosperity. This is owing to climate, temperament, and mode of life. In Turkey intemperance is confined to the Christian population, as the Mohammedans abstain from drink. As the use of distilled liquors in Turkey has been found to be very detrimental to both physical and mental health, native and foreign wines are in use by the Christian population. In Spain intemperance is rare, although Spaniards drink more or less wine, Burgundy, and aquaidiente. In Denmark beer and brandy are much used, and the mental and physical constitution of the people is injuriously affected by this indulgence. Suicides are frequent from drink. The better classes use the European wines The effect of the climate and the uniform in moderation. good nourishment of the people of Denmark prevent the disastrous effects which would otherwise appear from such a consumption of alcohol. In Ireland the poorer and middle classes use whisky and porter very freely, and the rich use wines and brandies. A majority of the diseases and nearly all of the crime in Ireland is due to intemperance. In England the liquors principally used are gin, brandy, beer, wine, and cider, and intemperance is very prevalent. All the competent authorities in England concur that a large proportion of all the crime, disease, and early mortality is produced directly by intemperance. In Russia intemperance is very prevalent, the ? principal drink of the common people being vodka," which corresponds to our whisky. Wine, brandy, beer, and ale are also made in Russia, and drunk by the higher classes. In Japan the people are on the whole decidedly temperate. More or less " saki," a liquor brewed from rice, is drunk, but it is largely diluted with water, and drunk in very small glasses. Very little crime results from intemperance, owing to the division of The upper class, or the " Samonrai," the people into castes. refrain from drink, as they do not wish to endanger their chances of promotion by the Emperor, who makes his selection from the wisest or most skilful men of the upper class. Their ambition for promotion, therefore, keeps this class comparatively very temperate, while the lower classes refrain from drunkenness from a fear of offending the upper classes, their lives and property " being at the disposal of the Samonrai." In Scotland whisky is universally drunk by the lower classes, and the amount of intemperance thereby induced operates in the production of crime, and has a very unfavourable effect on the mortality of this class. An apparent exception to the law spoken of in
TO
the
INTEMPERANCE AND THE INEBRIATE.
beginning of
this paper, that
intemperance
is
119
comparatively
equator, is found in the natives, or aborigines, of Central Africa, India, West Indies, and the tropical islands of rare near
the
Ocean. It is stated that in these localities the natives rival any nations of the globe for beastly intoxication and drunken orgies. The descendants of European colonists occupying these countries are, however, uniformly temperate. If we look at the foregoing description of the drinking habits of different nations, we shall see that the greatest amount of disease and crime resulting from intemperance occurs in those countries where the climate and the nervous temperament of the inhabitants renders the effect of indulgence in alcoholic stimulants especially hurtful to the brain and nervous system. This is nowhere more noticeable than in our own country, especially on the Atlantic coast, where the peculiarly stimulating nature of the climate induces a peculiar nervous susceptibility which operates in the production of grave diseases of the nervous system if drinking habits are indulged in. The evils resulting from intemperance in our own country can hardly be over-estimated. Inebriety, insanity, epilepsy, delirium tremens, and chronic alcoholism are among the more frequent, while the laws of hereditary transmission are inexorably preparing the way for a generation of drunkards. The amount of pauperism, crime, and disease produced in this way In New York every year is something fearful to contemplate. it is estimated that 33^ per cent, of all deaths are due directly or indirectly to the abuse of alcoholic stimulants, of which it is supposed that 600,000,000 dols. worth are annually sold in this country. According to the report of the Special Commission on the Eevenue, of which Hon. David A. Wells was chairman, the amount of distilled spirits used for drinking purposes in the United States for the year ending June 30th, 1865, was thirty-nine million gallons. They also estimated the increase in the consumption of these liquors at the rate of ten per cent, per annum, which would make the consumption for the year 1870 amount to three hundred and sixty million gallons. If we add to this the imported wines and the domestic distilled spirits that are consumed we have a consumption of not far from four hundred and ten millions of gallons. Now, would the unlimited introduction of light wines and beer prevent the amount of intemperance caused by the consumption of this enormous quantity of distilled liquor? Far from endorsing the idea that the prevalence of light wines and beer diminishes intemperance in such a climate as ours, I believe it directly promotes it; as I think a person, especially one inheriting a tendency in this direction, after indulging in the Pacific
120
STATE MEDICINE IN ITS RELATIONS
wine and beer for
some time, feels a growing desire for some powerful stimulant, and soon resorts to the habitual use of distilled liquors, such as brandy or whisky. I doubt very much whether the introduction of light wines into this country, free of duty, would induce people to give up the more powerful stimulants. My own opinion, with all due deference to the opinion of others, is, that an unlimited abundance of light wines would result gradually in increased habits of intemperance, and I do not think it would result in diminishing the sale of distilled liquors. The almost universal use of light wines in France has not prevented the people from resorting to absinthe
more
and other strong stimulants. I think in our own country that intemperance begins almost universally with the use of wine and beer, which habit lays the foundation or creates a desire for a stronger stimulant, and that in this way thousands are annually prepared to become victims of inebriety. In the year 1830 a measure was introduced in England, originating, I believe, with the Duke of Wellington, establishing beerhouses, hoping that they would promote the cause of temperance and prevent the consumption of distilled spirits by the masses. Instead of exerting this benign influence, it was decided by English statesmen that it was increasing and intensifying intemperance. Lord Brougham was so much impressed by this that he introduced into the House of Lords a Bill for the repeal of the Beer Act, although he was at first very sanguine about the amount of good it was going to accomplish. The introduction of beer did not decrease the sale of ardent spirits ; and all the judicial, civil, and medical authorities united in their testimony of the increased evils arising from this measure. In the year 1872 the editor of the San Francisco Pacific wrote as follows respecting the increased use of wines, consequent upon the establishment of the vineyards of California: " The lowest, slowest, most illiterate, most unimpressible, most unimprovable, if not most vicious population outside of the great cities, is found in the oldest wine districts of this State, and that the use of the products of vineyards has been the most active cause of this condition of the population; that the increased production and consumption of wine on this coast, in the more recent years, has diminished the use of neither distilled liquors nor lager-beer, but rather inWith our national susceptible creased the demand for both." nervous temperament, the artificial habits of living, the intensity and excitement of life, and the undue predominance of the nervous temperament, which is gradually taking place in successive generations, would the dangers of intemperance be lessened by the unlimited supply of light wines and beer ? I think not. I regard inebriety as a physical disease, and I do not believe that
TO
INTEMPERANCE AND THE INEBRIATE.
121
a man whose nervous system is diseased by indulgence in alcoholic stimulants will ever voluntarily abandon distilled liquors Such a man feels, when depressed physically for light wines. or mentally, an irresistible desire, impulse, or craving to seek for the relief which he obtains temporarily from the use of alcoholic stimulants; and this relief he cannot obtain from a decidedly weaker stimulant than that he is accustomed to use. The very nature of the disease consists in the gradual development and growth of this abnormal appetite or craving, until it reaches that point where it renders its unhappy possessor blind to the dictates of reason and judgment, and the slave of this irresistible, insane impulse, by which he is impelled by a terrible vis-a-tergo, to gratify his morbid propensity. The sooner this disease theory of inebriety is acknowledged and recognised by the public, and the proper sanitary, hygienic, and medicinal remedies are applied to this disease, the sooner will it disappear and be classed under the head of pi evented diseases.
EFFECTS OF INTEMPERANCE
UPON
INDIVIDUALS AND COMMUNITIES.
The effects of intemperance upon the sanitary condition of individuals and communities is very disastrous. This naturally results from the pauperism and crime, and the moral and social degradation of the masses, consequent upon this indulgence in alcohol, which culminates in the ruin of their ph}7sical, moral, and intellectual health. This is seen most clearly when countries are visited by epidemics, when it is observed that temperate communities resist disease far better than intemperate ones. Intemperance weakens the constitution, so that it cannot resist the poison of cholera, yellow fever, &c. The desire for alcoholic stimulants is often the result of an abnormal constitutional organisation. It also appears as the result of ill health, sunstroke, blows on the head or spine, and severe mental shock, in the same way as do other nervous diseases. Alcohol is not either respiratory or accessory food, as it has been claimed to be. Liebig and others maintained that when alcohol was taken into the system it united with oxygen, and that combustion or oxidation ensued, by which it was converted into carbonic acid and water; hence it was termed by him "Respiratory Food." This theory of Liebig was destroyed by the researches of Dr. Prout, of London, who proved by direct experiment that the presence of alcohol in the body directly diminished the amount of carbonic acid gas exhaled from the lungs. These experiments of Dr. Prout were confirmed by Sandras and Bouchardet, of France, who repeated them with like results, and also by scientists in our own country. The
122
STATE
MEDICINE IN ITS RELATIONS
chemico-physiologists then maintained that alcohol, being a hydro-carbon, must necessarily be used for maintaining temperature and respiration, and that its use increased temperature and strength. Dr. Boker, of Germany, then instituted a series of experiments, proving that the use of alcohol retarded tissue metamorphosis, and thereby decreased the excretion or elimination of effete matter, so that from the accumulation of hydrocarbonaceous material the individual increased in weight. This
latter fact led certain persons to claim that alcohol was an accessory food?an erroneous idea, which they would have recognised as such, had they observed such individuals carefully ; for they would have seen that such persons always exhibit a corresponding decrease in nervous and muscular stamina. It was proved in 1869 by the experiments of Dr. N. S. Davis that, after taking alcohol, either in a fermented or distilled state, the temperature began to fall within an hour, and continued to fall for two
or
three hours.
A few
years
later, Lallemand, Perin,
and Duroy proved, by a series of experiments, that alcohol was absorbed and carried with the circulation throughout the whole body; and also a very important point, that it was eliminated as Others alcohol, unchanged, from the lungs, skin, and kidneys. claim that only a part of the alcohol taken is eliminated. We see, therefore, that alcohol has no claim to be regarded as food, as it is not used to build up the tissues of the body, or repair or It merely diminishes restore lost nervous or muscular force. the nervous sensibility of the individual, so that it lessens his consciousness of impressions, and acts as a sedative by retarding tissue The nervous sensibility is diminished by metamorphosis. virtue of a paralysis of the vaso-motor and cerebro-spinal system of nerves, which the alcohol causes as it circulates through the body. The use of alcohol, therefore, to recapitulate, diminishes the temperature, the strength and the power of endurance of the individual who takes it habitually, and increases his predisposition to disease. It impresses a peculiarly morbid influence upon the brain and nervous system, which, if the habit be indulged in, becomes a permanent pathological impression, and results in the formation of an irresistible or insane impulse to seek for the relief obtained from alcoholic stimulants. In this state of moral insanity, the control which the intellect normally exercises over the moral senses is overborne by the superior force This permanently diseased state, or dipderived from disease. somania, is markedly hereditary, and, like insanity, appearing under other forms, it often disappears in the second generation It manifests to break out with renewed intensity in the third. itself in predisposition or simple aptitude; in a latent state; or in the actually developed disease. In the second or latent state,
TO
INTEMPERANCE
AND
THE
INEBRIATE.
the germ of the disease, which has been inherited
by
123 the indi-
for years, and starts into life in advanced age ; as the result of ill health or mental shock, resulting in mental inebriety in a previously healthy and temperate person. This permanently diseased state of the brain is due probably to the interference in the nutrition, growth, and renovation of the brain-cells, which, by the use of alcohol, are
vidual,
lies
dormant, perhaps,
unduly stimulated, so that a process of waste and decay is induced, beyond the powers of reparation and renovation. Owing to this impression of a pathological state on the braincells, there results a change of healthy function, and disease is induced. The effect of the alcohol is to cause a change in the chemical composition of the cerebral cells from the standard of health, which is the foundation and the starting-point for organic disease. Owing to long-continued use of alcohol, we have resulting: Cerebral hyperemia, with symptoms of irritation, due to increased excitability of the nerve filaments and ganglion-cells of the brain. At a later stage, we have symptoms of exhaustion, due to lost excitability of the nervefilaments and ganglion-cells, owing to a want of the proper supply of arterial oxygenated blood to them. Alcohol not only weakens and impairs the functions of the body, but it causes grave nervous diseases, such as insanity, epilepsy, and chorea, and also influences the offspring of intemperate parents in the most unfavourable manner. The offspring of such parents inherit a predisposition or aptitude for some form of nervous disease, the particular form being often determined by causes subsequent to birth. It may be inebriety, insanity, epilepsy, chorea, or a proclivity to crime. These children, offspring of intemperate parents, are generally cursed with a defective, illbalanced organisation, and a weakened, if not actually diseased, nervous system ; as a result of which they are predisposed to seek for the relief obtained from alcohol, when depressed mentally or physically. They soon degenerate, become victims to the irresistible impulse, and die inebriates. Insanity from intemperance is on the increase, especially in England, where it shows an alarming increase, judging from the last reports of one of the largest asylums, the Crichton Royal Institution, where in the last five years the admissions due to intemperance have risen from 8 per cent, to 35 per cent. The Medical Superin" tendent, Dr. Gilchrist, remarks, that doubtless a more minute analysis would largely increase the proportion of those in which the excessive use of stimulants, by the patients themselves, or by their parents, constitutes an important, if not the primary, factor in the production of mental disturbance." In order to successfully combat all these manifold evils which we have seen
124
STATE MEDICINE IN ITS RELATIONS
result from intemperance, we need to educate the public up to the universal acceptance of and belief in the fact that alcohol, instead of being a tonic and restorative to the system, is a narcotico-irritant poison; that it has no analogue in the human system; and that its continued use will inevitably result, not only in the impairment of the mental and physical health of the individual himself, but also that of his offspring. When the public come to take this view of the subject, and come to believe that mind and body are debilitated, instead of nourished and renovated, by the habitual use of alcoholic liquors, public sentiment will then be adequate, without the necessity of prohibitory laws, to the prevention of intemperance. INEBRIATE
ASYLUMS AND CARE OF TIIE INEBRIATE.
We have already spoken of the necessity of wise legislation to the prevention of intemperance ; but what shall we It becomes a grave question relating to do with the Inebriate ? the political economy of the commonwealth as to the annual
tending
the State by the loss of the labour of inebriates. longevity of a man at 20 years of age, if temperate, has been estimated at 44*2 years; while if intemperate, his average life is reduced to 15*6 years. If an inebriate at 20 years of age is not reformed or cured, the State loses his earnings for the 44*2 years which he would have made if temperate ; and there is also an expense entailed, for his care, on his family or the State, for the 15*6 years remaining as his average life. When we reflect upon the extent of intemperance throughout the commonwealth, we see what an immense loss is suffered by the State by such a waste of productive power, and what a grave financial problem this subject becomes when viewed in this light. We need, in every State of our country, to establish State inebriate hospitals, adapted in construction, location, and surroundings to the special needs of this class of unfortunates, so as to enable them, with the assistance of wise superintendence, to regain the lost self-control and manhood, and have their weakened and diseased minds and bodies properly strengthIn this way a great annual expense would ened and cured. be saved to every State, by materially lessening the number of paupers, idiots, and criminals, to say nothing of the destitute children, and that percentage of the insane who have been rendered so by the abuse of alcohol. If one-tenth part of the sum annually appropriated in each State to almshouses, hospitals, prisons and asylums, should be appropriated to the reform and cure of inebriates, the expenses of the above-named institutions in a short time would be very much lessened, by the decrease in loss entailed
The average
on
INTEMPERANCE
TO
admissions, which would
AND
THE
INEBRIATE.
be the natural result of
pauperism, crime, and disease. inebriate hospitals in every State, building the
causes of
such States would pass such laws
a
125 decrease in
in addition to the Legislature of
If,
as would enable the public operation remedial restraint, so that inebriates should be committed in precisely the same manner as are the insane, and held for treatment until the superintendent deemed them fit to take their place in society, we should then soon have accomplished great good in the permanent reforma-
guardians
to
put
into active
of men who are admitted with broken-down To do this, miliand shattered constitutions. systems tary discipline, good hygienic influences, cheerful, tranquil, and pleasant surroundings, and regular exercise, both bodily and mental, are among the indispensable indications for treatment, while the superintendent will be best able to judge of the special needs of individual cases. There should be no half-way or sentimental measures adopted in the confinement and treatment of inebriates. The public must understand that inebriation is a type of insanity, and that in all cases prompt and effective measures will be taken to prevent such individuals from ruining themselves and injuring society. That in all cases prompt measures will be taken to confine such persons in an institution for the cure of inebriates, by law; and that, when there, they will be under strict discipline, which will require and enforce both physical and mental labour, as they are a class of patients, tion
and
cure
nervous
for whom, in my estimation, not less than the insane, physical and mental labour is absolutely necessary for restoration to An inebriate who is allowed to idle away his time will health. never acquire the mental and physical stamina which is requisite for his reformation and cure. He will only degenerate, and on his discharge will relapse into his former habits. An inebriate asylum where the patients cannot be detained by law until cured, loses much of its efficacy. It must be understood that the inebriate is suffering from a physical disease, and that he is committed to an inebriate hospital to stay until cured,
whether that cure takes for its completion six weeks or six years ; and that when in such an institution he is to submit to the discipline of the house. If the question be raised, How can you tell whether your patient is cured ? I reply, that when reasonable hopes are entertained of the cure of a patient,-when we think that we have given our patient new blood, bone, muscle, and mind enough to take care of himself, his family, and his property, then, I would do as I am in the habit of doing with my insane patients, send them on pass?on trial?still maintaining a legal control over them, and, when it is clear that they are going to do well, discharge them. With the insane I
126
STATE
have found this
MEDICINE
IX
ITS
RELATIONS,
ETC.
to work well; why not with the inebriate in like manner legally committed upon admission ? For the successful treatment of inebriety, as with insanity, it is necessary to send the patient for treatment in the early and curable stage of the disease. Like insanity, inebriety, if treated in the early and curable stage, ought to give a much larger percentage of cures than it now does ; while if the patients are sent for treatment after years of disease, they present small chances for recovery. Yet people do not wish to send their friends for treatment to such an institution until they have become confirmed sots, and beyond all hope of reformation Such cases should be sent to an asylum, and should and cure. not be allowed to cumber up the wards of an inebriate hospital where we send patients, not to keep, but to cure and return to society. Finally, the Legislature should, in dealing with this question, in addition to legislating in the direction of the dissemination of knowledge among the masses, as to the nature and effects of alcohol, deal with its indiscriminate sale, just exactly as it does with the sale of arsenic or prussic acid, for it is just as surely a deadly poison. Arsenic is sometimes used as food to increase flesh and impart brilliancy to the eye and complexion, but is it not a deadly poison ? Opium and haschish are also used, for their effects, in the same manner, but is The not their sale restricted, as with all other poisons ? Legislature must appreciate the fact that the use of alcohol is a form of suicide, and must legislate in this direction. No other form of prohibitory statutes will ever accomplish the desired result. I have already alluded to the fact that it becomes at times a very difficult task to convince a man's family that he is a proper subject for an inebriate asylum. I deem it a sacred duty that in such cases devolves upon the governmental authority, to protect society, as in the case of other insanities, against danger, either existing or being apprehended, such as can be avoided by precautionary and preventive of person and property measures, and to protect in his rights whatever from citizen the individual cause, is unfortunately who, so far impaired in his physical, mental, or moral faculties, as to render his uncontrolled movements alike prejudicial to his own interests and those of society.
insane, if they
plan
are
