On Inebriety and the Duty of the State with Regard to Inebriates
Joseph Brajthwaite Dunedin : Princes Street.1885. page break
Much misapprehension exists as to the nature of Inebriety, which has led to mistaken treatment of the inebriate by his friends, and to his wrongful punishment by the law.
In the following paper, which was read before the Otago Branch of the N.Z. Institute, the writer has endeavoured to show that inebriety is a physical disease rather than a moral vice—an opinion held by many high authorities; and he publishes the paper in the hope that the dissemination of such views may have some effect in determining Legislation for the Care and Cure of Inebriates.page break
On + Inebriety and the Duty of the State with Regard to Inebriates.
t is now universally recoguised that one of the duties of State is to take cognisance of the diseases which may affect the people, whether with a view to promote the better treatment of disease or to its prevention. Already the most beneficial effects have resulted from legislation on sanitary matters, and it is not unreasonable to hope that in time many of the grosser and more palpable forms of disease may be completely stamped out; and medical science will be left free to occupy itself with the more obscure, and—if I may use the word—finer, diseases which affect mankind. But whatever be the form of the disease, if it appear that legislation can lessen its prevalence or diminish its effects, it is clearly the duty of the State to pass such laws as may attain that end.
To medical men, especially those who have devoted themselves to the study of the diseases of the nervous system, it is unnecessary to prove that inebriety is a disease, just as epilepsy, hysteria, &c., are diseases. But this is far from being understood by the general public, whose ignorance of its true nature is reflected in the laws passed for the punishment of habitual drunkards. I will first endeavour to show on what grounds inebriety should be regarded as a disease; and next, that it is a disease in which the State has an especial duty towards persons affected by it, for the sake of the public as well as for their own.
As regards the terms "inebriates" and "inebriety," these mean drunkards and drunkenness respectively; but the words "drunkards" and "drunkenness" are so commonly associated with the idea of a Vice, for which the drunkard merits punishment only, that there is now a tendency to substitute the Latin forms by which the disease-aspect of drunkenness will be indicated. The term "inebriety" refers more properly to the periodic form of the disease. I would define inebriety to be a disease of the nervous system, page 6 characterised by periodical fits of depression and restlessness and craving for alcohol. The restlessness and craving begin gradually, attain a certain height—a climax, and then have a tendency to decline. This is the natural course of the fit, or attack, if the patient is not treated by himself or by others with alcohol, which would have the effect of prolonging the attack indefinitely. The periodicity of the attacks alone is sufficient to mark the nervous origin of the disease. In this it resembles other nervous diseases of the so-called functional class, such as epilepsy, nervous headache or migraine, spinal irritability, neuralgia, &c.
As in the diseases just enumerated, the patient affected with inebriety is apparently in perfect health during the intervals between the attacks; all restlessness has disappeared; he is able to apply himself to business or study; and many periodical inebriates are distinguished by their energy and clear-headedness in business pursuits, while some have been eminent scholars. So free is he from all symptoms of inebriety-that no one would suspect him to be the victim of disease, and a disease which, in aggravated instances, seem like a demoniacal possession. Then he feels strong, and confident that his will is strong enough to overcome the terrible weakness and craving should it attack him again. He even believes that it never will do so. Many inebriates never touch alcohol during the interval, or would not do so did not kind friends offer them a glass, exposing them to the greatest of risks through the mistaken kindness of a vicious custom.
My attention was first strongly directed to inebriety as a nervous disease by studying the case of a professional man who was the subject of this affection. He was well read in general literature, an admirable critic of literary style, could talk with pleasure and profit to his hearers on a variety of topics, and was, except during the attacks, a delightful companion. He was not a habitual drunkard; indeed, during the intervals he was almost a total abstainer, and for weeks together entirely so. But at times the tit came on him, and then the depression and craving became so violent that I believe he would have sold his clothes to obtain alcohol. He had less will than a child, and was reduced mentally to a most pitiable condition. The fit over, he was a prey to the deepest remorse. The desire for drink was gone, and he was only sensible of the shame of having again failed to keep his resolution; and he reminded me of some lines of page 7 Schiller, which may be thus roughly rendered : " There are evil spirits who quickly work the evil thing within us, and then fleeing to hell leave Horror behind within the stained breast." When again restored to his right mind he was constantly, or frequently, occupied in studying out his disease, or whatever it was that possessed him, with the view of writing on the subject, and of finding a remedy, of which he never despaired. But the same series of events occurred again and again, and I daresay are going on still from time to time, if he is still alive. There was a strong neurotic disposition in his family.
There is another form of inebriety to which the term " habitual druukenness " more properly applies. It is not characterised by intervals, as in the periodic; form, or at least the intervals are so short as to be unrecognisable. The habitual drunkard of the police-court is an example. I am inclined to look upon this as the acquired form of the disease, and in the first instance at least to be regarded as a vice; but it becomes a disease nevertheless, and the treatment of both kinds is on the same principles.
The pathology of these nervous diseases, so-called functional, is still unknown. There are no constant morbid appearances; in most cases no morbid appearances at all. But it appears certain that the nerve cells are in a state of instability. In epilepsy, it is believed that there is increased nutrition of nerve centres, which is one side of high instability (Aitken's Medicine, vol. ii. p. 246). In inebriety there is, I would suggest, an opposite condition of instability, in which nutrition falls far below par. This going on gradually,. as a drain, there is not a sufficient stock of force necessary for the due performance of nerve function. Irritability and restlessness are the result. The deficiency at length reaches such a degree that the want is keenly felt by the patient, and he flies to any remedy which will supply that want. Alcohol does so for the time, or at least it renders the perception of the want temporarily less evident to the patient. Alcohol may act by accelerating the heart's action and increasing the blood supply to the nerve cells, or it may act simply as a narcotic to the nerve cells. I am inclined to believe that it both acts as a narcotic and supplies a temporary force. In either case the patient is for the moment relieved from his state of suffering, but only to feel it more acutely when the influence of the stimulant or narcotic passes off. The feeling of depression is terrible and the page 8 craving proportionately strong. An inebriate in this stage will endeavour to procure alcohol by any means—by entreaty, by threats, by stratagem; and the cunning displayed is sometimes remarkable. The moral sense frequently becomes dulled. The patient may become more violent through the refusal of his friends to supply alcohol than if he were under its influence. He speaks of those who are really nearest and dearest to him as if they were his worst enemies, and forgets all decency of language and demeanor in the height of the paroxysm; and it is well if he does not commit some act of violence. Doubtless indulgence in alcohol is responsible For some of the symptoms produced—that is, if alcohol were withheld the " attack " would only develop depression, irritability of temper, and restlessness. Too often, alas, the continued indulgence in alcohol induces an attack of delirium tremens; but delirium tremens forms no essential part of the disease inebriety, while on the other hand the active treatment necessitated by the attack of delirium tremens often cuts short the attack of inebriety. Friends of inebriates and attendants in asylums well know by the patient's restlessness when an attack is impending. "While the accessions of the inebriate condition—i.e., the craving—might, and most frequently do, come on at intervals without indulgence in alcohol, an attack may be readily induced at other times by even a moderate imbibition. So unstable is the nervous balance that a minute portion of alcohol is capable of setting up such serious disturbance as to bring on an " attack." When the crisis is past and the craving is on the wane, the inebriate is tortured with self-reproach. He bewails his want of resolution; he alternately blames his friends for having withheld alcohol and for allowing him to get it; he is in a state bordering on melancholia, and it is well if he does not again drown his cares in the bowl.
As regards treatment during the attacks, the services of a good attendant are indispensable. It should be his duty to see that no alcohol be supplied to the patient; and in private houses this is the most difficult part of the physician's prescription to get carried out. In forty-nine cases out of fifty of attacks of inebriety, whether going on to delirium tremens or not, all alcohol should be at once forbidden—there should be no " tapering off." This is, I think, the universal experience of those who of late years have had to do with the treatment of attacks of inebriety. In all the page 9 cases I have known where it has been possible to enforce the complete discontinuance of alcohol at once, the patient has made a much more rapid recovery. The general treatment during the attack should of course be left to the discretion of the physician. During the interval no medicinal treatment is followed as a rule to cure the tendency, nor is there any known specific which could do so.
While inebriety cannot be said to have any pathology as far as morbid appearances post mortem are concerned, we may form a judgment from the symptoms observed as to the probable causation of the disease. This has already been been slightly referred to. The feeling of sinking and de-pression in attacks of inebriety would indicate that there is a deficiency of nerve nutrition, I look upon inebriety as an anaemic neuralgia. Other diseases in which disturbances of nerve nutrition occur temporarily are epilepsy, hysteria, and neuralgia. These are termed functional nervous diseases, as contra-distinguished from those nervous diseases in which lesions of nutrition arc advancing or permanent, and in which specific alterations can be discovered in the nerve cells. The chief cause is hereditary predisposition. Many functional derangements of the nervous system are very commonly spoken of as affections of the mind, as if the brain were one thing and the mind another, floating ethereally about the brain and pervading it in some way. But, without attempting to elucidate the respective relations of mind and matter, there seems to be no doubt that the elements composing the nervous system are capable of receiving shocks and " strains " conveyed through mental impressions. The nature of the change in the nervous elements in periodic inebriety cannot so far be demonstrated by any of the known methods of pathological investigation; but from the phenomena we may suppose that the ultimate molecules of the nerve-cells are, as if loosely held together, easily thrown into molecular vibrations setting up a violent commotion which is known as a nerve storm, and discharging currents until utterly exhausted. This condition of the nervous system may be congenital or acquired; but, once set up, the nervous system remains subject to irritation by what otherwise would be slight exciting causes. Dr. Norman Kerr says: "1 am persuaded that inebriety is mostly physical, and for the most part has a physical origin." (" Proceedings of Society for Study and Cure of Inebriety, July, 1884; p. 14.) This opinion is shared by all the most recent page 10 authorities on the subject. Persons affected with inebriety are frequently of highly-susceptible nervous organisation. They belong to the neurotic class, who, if not affected by the inebriate tendency, might be the subjects of some other form of nervous weakness—if women, they would probably suffer from hysteria and some of many forms of neuralgia; if men, they might suffer from hypochondriasis. I think frequent tipplers may, under certain circumstances, become victims of inebriate disease, but of this I am not certain, unless the constitutional tendency is there. The tippler drinks every day, and a good deal; the inebriate, or dipsomaniac, gives way to the craving only at intervals, as a rule, and exhibits other nervous peculiarities which the tippler does not. The organs of the inebriate may be healthy; those of the constant drinker show alcoholic degeneration. Inebriates are usually looked on as simply drunkards, and are treated by the general public with something like contempt. If a man does not succeed in the world, his enemies, and sometimes his friends, will say " it is his own fault," without sufficient regard to circumstances. This is inconsiderate and often cruel, and it is assuredly cruel with regard to inebriates. Certainly the inebriate is not a success, either to his forefathers or to himself. His forefathers cannot well be brought to account for his condition, and the whole brunt of it falls on himself, and keenly is he made to feel his position. I see nothing to despise in the inebriate. I look upon him as a man suffering from a disease of the nervous system, with which he may have nothing whatever to do; whose will is deficient at certain times in consequence of this disease; am) I consider that he ought to be treated with the utmost kindness, without relaxing in the slightest degree the firmness which is necessary to render true kindness effectual Without doubt a man or woman not constitutionally neurotic who, becomes a druukard, may have children who will develop inebriate disease, but it would be wrong to attribute all cases of inebriate disease to the disposition derived from drunken ancestors. The neurotic diathesis is mostly inherited from neurotic ancestors, but not necessarily from ancestors rendered neurotic by drink.
We must rather look to the conditions of society for the production of the neurotic diathesis. The fast pace at which we live, the competition which begins in the schoolroom and continues in business or professional pursuits, the necessity of making a certain income in order to keep pace with the page 11 luxurious wants of the age, the greed of speculation, so often resulting in loss, the strain of study, too often encroaching on the hours which should be devoted to sleep, to keep pace with the requirements of science; all these tend to the production of unstable equilibrium of the nervous system, and may result in hypochondriasis, insomnia, or drink-mania in the individual himself or his children.
No writer points out more clearly the causation of insanity by drink than Dr. George H. Savage, superintendent of Bethlehem Hospital. Yet he says: "Drink often gets blamed for producing insanity, whereas the intemperance was the first symptom of the disease." (" Insanity," p. 420, Cassell, London.) But it is not only intemperance which may give the first warning of the insane condition, for Dr. Savage says, in another place: " Among total abstainers we have, of course, to recognise the fact that a certain number abstain as the earliest symptom of their insanity; that is, of their perversion."
Dr. Beard, of New York, a high authority, attributes " the frequency of inebriety in America to the climate, the dryness of the air, and the extremes of heat and cold. Ine-briety and other neuralgic disorders (he says) are most common in the north and east, where there is so much total abstinence. Indeed, Dr. Beard says there is no country in the world where there is so much total abstinence from the use of stimulants, and at the same time so much inebriety as a disease. Therefore, Dr. Beard considers that the disease should be treated on the same principles as nervous diseases—first by keeping the patient from exposure to exciting causes, and second, by fortifying the system with nerve sedatives." ('British Medical Journal,' February 7th, 1880, p. 224.) There is, however, no more potent cause of insanity than alcohol. Without dwelling on the ordinary phenomena of drunkenness, which is proverbially spoken of as a short madness, the records of lunatic asylums show that melancholia, or mania, or some other form of insanity, in a large number of instances owe their origin to alcoholic excess, more especially in individuals of excitable or unstable nervous temperament.
Dr. W. B. Carpenter says: " The closeness of the affinity between the states of insanity and alcoholic intoxication is further made apparent by the extreme readiness with which the balance of reason is disturbed by a small quantity of liquor. In those unfortunate individuals in whom there page 12 exists a predisposition to mental derangement, the power of volitional control being already feeble, it is easily overcome, and the propensities and passions, which are always unduly excitable, are readily aroused into morbid activity by this provocation, so that a very few glasses of wine or a small quantity of spirits is sufficient to induce what may be regarded either as a fit of drunkenness or a paroxysm of insanity—the two influences concurring to produce the mental disturbance which neither of them alone would haw sufficed to bring about. [The italics are mine.] ('Principles of Mental Physiology," p. 651, 1874.; Even patients say it is like a madness, not only while the fit is on them, hut during the interval, when there are no disordered ideas. The beginning of the inebriate disease is often determined by some nervous shock or strain. A man of neurotic temperament experiences a sudden loss in his business, by which the work of years is undone and his prospects are shattered. Soon afterwards one hears that he has " taken to drink." All pity for him ceases when he does so; but the taking to drink is after all only a symptom of the shock to the nervous system. Prolonged mental strain may have a like effect in an individual predisposed, also injuries to the head.
On the foregoing grounds I think we are justified in regarding inebriety as a disease, depending on a lesion of nerve-nutrition. It will be noted that in order to carry out the treatment the patient should be perfectly under control. He should for the time be deprived of liberty of action, and should he so circumstanced as not to be able to obtain a a drop of alcohol. These conditions it is almost impossible to obtain in private houses.
First as to control. Frequently the patient will not allow a strange nurse to come near him, even if an attendant could keep him obedient to orders. He is under the care of his wife, or some member of his family, but insists on going out, or in getting spirits or beer, and becomes violent unless it is supplied. Often a wife has said to me: "I had to give him a glass now and then, just to keep him quiet." I had an inebriate patient who held a situation of great responsibility, and was during the interval exceedingly clear-headed in business matters. He used to get the inebriate fit every two or three months, and it was important that he should be got well as soon as possible. When an attack occurred a man was engaged to be with him, and page 13 watch him, and prevent his getting liquor. For a time all went well. He recovered from two or three attacks within three days after treatment was commenced; but at length he grew intolerant of being watched, said he would have no gaoler about him, and peremptorily ordered the attendant away, and me also. After this all treatment was futile. There was no check on the fatal craving for alcohol; he had an apoplectic stroke, and died a few days afterwards. Had he been under proper control in a hospital, he might, I believe, have been alive now. The friends of such patients have often said: " There ought to be some place where he could be locked up until he is better; some hospital or asylum; we cannot look after him." And the cases are numerous in which patients have voluntarily given themselves up for treatment in an asylum or retreat, where they knew they would be deprived of liberty for a certain period. In the hospital where I was house-surgeon there was a temporary asylum, where, besides other cases, inebriates were received. I well remember a man who used to come from time to time and beg to be taken in until the fit should pass over. He used to remain for a few days, and go out cured for the time. And from a paper by Dr. Norman Kerr I learn that upwards of a dozen inebriates have voluntarily placed themselves in the Dalrymple Home, under the compulsory clauses of the Habitual Drunkards Act, 1879. But not only is it of importance that inebriates should be treated in some special hospital during the inebriate state, but also that they should remain for a sufficient time. The only hope of cure for the inebriate lies in total abstinence, and this it is impossible to procure without the control of a special hospital or asylum.
The prospects of cure will depend on (1) the nervous temperament; (2) the degree to which the nervous system has been implicated; (3) the time which has elapsed since the actual attacks of inebriety began; and (4) on the system of treatment pursued in the special hospital or retreat where the patient may be under care. In any confirmed case less than a year's seclusion in a special institution or retreat would be useless. Even then the prospects of cure in confirmed long-standing cases may be small, I admit, for the tendency is still there. It may be dormant for a time, but easily aroused by the immediately exciting cause—alcohol. Yet no case should be deemed hopeless. There are many instances where moral force has prevailed, and in others page 14 sudden mental emotion; it may be through some religious agency, or due to the powerful representations of a temperance lecturer. The mental paralysis is removed, just as functional paralysis of the limbs is sometimes cured by a visit to a holy shrine or by an alarm of fire. I borrow from Dr. Carpenter's book (p. 371) a quotation from Kobert Coll yer: " I heard a man say that for eight and twenty years the soul within him had to stand like an unsleeping sentinel, guarding his appetite for strong drink." These cases, alas! are too few in this matter-of-fact age, and practically nothing but placing the inebriate under such conditions that he cannot by any possibility procure alcohol, is the only method of treatment deserving confidence. Only in an asylum or retreat can such conditions be obtained.
But it will be asked, What are the prospects of cure in these retreats ? Mr. Alford states that " In America such institutions show 60 per cent, of cures. Convicts after years' enforced abstinence seldom lapse into drunken habits." Out of twenty-two cases in a private asylum at Balham, Mr. Carsten reports six as cured. In several cases where patients were uncured, the failure was owing to the existing laws (1875-76). Dr. Norman Kerr estimated the cures in American retreats at 30 per cent, of male drunkards, and 3 per cent, of female drunkards (" British Medical Journal," September 2nd, 1876, pp. 304, 305); and yet Mr. S. S. Alford says that he was disappointed with the retreats for inebriates in America, owing to their want of definite system in the management or treatment of the patients. The inference is that had there been a good system the percentage of cures might have been higher. Now, one of the chief objects of this paper is to urge that it is the duty of the State to provide or license such Retreats, which should not be in any way connected with a lunatic asylum. It is true, as I have said, that inebriate disease is not far removed from insanity; but our chief hope in the success of treatment is to enlist the patient in his own cause, to encourage the exercise of his will in the right direction, and such means are frequently successful. By placing him in an asylum he finds himself at once classed with lunatics. " What hope is there for me ?" he might say. " I am looked on as only fit for a lunatic asylum." And it is well if he does not give way to utter despair. Such patients seldom forgive their friends, and constantly speak of their unkindness in having them placed in an asylum. Since writing page 15 the foregoing, I find Dr. Savage refers to the question as to whether persons suffering from alcoholic insanity should be sent to asylums. He says : " If suffering from simple acute alcoholism, or if suffering from delirium tremens, it is best not to send them to lunatic asylums. The great danger of admitting such cases is, that they rarely appreciate the intention of their friends, and are commonly vindictive. Such cases are too frequently morally perverse and sly; trumped-up accusations and vexatious law-suits are constant sources of worry as a result of their admission " (p. 421). Now, the friends ought to be relieved of any odium which the patient might throw on them, by the necessity which the law would impose on them to report to the proper authorities all cases of ungovernable intoxication, which would thus be taken out of their hands.
It may be asked : " Is there any necessity for the establishment of special hospitals for inebriate patients ?" The best answer to this is to enquire what is usually done with inebriates, that is, persons who are found drunk, whether in consequence of inebriate disease or from over-conviviality. By the Police Offences Act, 1884, section 19 (New Zealand), " Every person found drunk in any public place, on a first conviction, shall be liable to a penalty not exceeding 20s, and in default of payment thereof may be imprisoned for any period not exceeding forty-eight hours. On a second conviction within six months shall be liable to a penalty not exceeding £3, and in default may be imprisoned for any period not exceeding seven days. On a third conviction within such period of six months shall be liable to be imprisoned for any period not exceeding fourteen days, or, at tne discretion of the convicting Justice, to a penalty not exceeding £5, and fourteen days' imprisonment in case of default; and on any subsequent conviction within such period of six months shall be deemed to be a habitual drunkard, and shall be liable to be imprisoned for any period not exceeding three months." Any of these convictions may carry hard labour with them. (See Justices of the Peace Act, 1882, section 102.) Again and again this process may be repeated, with no change for the better in the condition of the inebriate; and amongst the poorer classes as many as sixty or eighty convictions have been obtained in one case. Indeed, 1 have been informed by one of our Magistrates that some of these poor wretches only enjoy twenty-four or forty-eight hours' liberty at a time, page 16 before they are again convicted and sent to prison. In gaol the associations are certainly not such as tend to promote a cure by moral agencies. The inebriate—the man suffering from a nervous disease for which he may be in no way responsible—finds himself associated with forgers, thieves, and it may be, with criminals worse than these. There is no classification. He is clad in the gaol dress, and the letters H.M.G. are printed in very legible characters on the back of his prison jacket. In the case of women inebriates the effect of the evil associations may be infinitely worse. Truly " to be weak is miserable." The wretched sufferer from this nervous disease has good reason to complain of the means adopted by society to deter him from committing an offence which no power on earth can keep him from committing if alcohol can be procured. As far as the public is concerned, the gaol can only be looked upon as a place where the inebriate is in safe keeping, and where his relatives and the public will not be troubled by him. No one expects that inebriates will be reformed in gaol.
Dr. Alfred Carpenter, speaking at the meeting of the British Medical Association in August, 1876, said :—"As a Magistiate is the south of London he had to commit these poor drunkards over and over again, knowing that as soon as ever they came out of prison they would be before the Bench again. He had no hesitation in saying that in such cases short terms of imprisonment were worse than useless, and that to treat habitual drunkards in that way was a great mistake. He never sent a person to prison in that way without feeling that he was doing an injustice in punishing as a crime that which in reality was a disease. They had no more right to send these poor people to the treadmill for a fortnight for getting drunk than they had to send them to a lunatic asylum. The treatment required was not penal but curative." (" British Medical Journal," August 12, 1876, p. 218).
The report of the Committee of the British Medical Association on legislative restriction for habitual drunkards says:—"That the merely penal treatment for drunkenness, by commital to prison for short periods, far from influencing far the better the habitual drunkard, is shown by the evidence taken before the Select Committee of the House of Commons to be ' worse than useless;' confirms him in his evil ways by utterly destroying his self-respect, and rendering him reckless of consequences; and thus runs counter to the page 17 whole tendency of recent legislation, which aims at the reformation as well as the correction of the offender." (" British Medical Journal;" August 12, 1870, p. 214). But there is some provision made by law in New Zealand other than sending inebriates to gaol, at least, those who have friends. As already mentioned, they may be committed to an asylum, on the application of their friends, by an order of a Judge of the Supreme Court, if it appear that they have shown symptoms of delirium tremens or other evidence of habitual over-indulgence in alcohol, or that they have threatened violence, or wasted their means. It is provided that they are to be placed in a ward where lunatics are not kept, and that they shall do such work as may be beneficial to health and assist in cure.
The last regulation is an excellent one, for nothing tends to restore healthy nerve-nutrition so much as healthy occupation. The man who is healthily occupied has no time for brooding. The disease-aspect of inebriety and the possibility of cure are thus officially acknowledged by the Act, for such work as may assist in the cure of the habitual drunkard is enjoined. Still, the connection of these means of cure with the name of the asylum is frequently quite sufficient to deter the friends of patients from availing themselves of the provisions of this Act; and the appearance in person of the habitual drunkard before the Judge I have known to be objected to by a patient—a woman—who was otherwise willing even to seclude herself in an asylum as a means of cure. Why not, therefore, have some retreat to which no objection could be offered except that it deprives the patient of his liberty, and which will afford him a period of rest from alcohol and from unhealthy influences that may give him a new start towards recovery ? At once I see the objection which starts to the lips of many who would say: "Is it right to deprive a man of his liberty for, it may be, six months or a year because he chooses to indulge in the free privilege of drinking? What an interference with the liberty of the subject!" These objectors ought to consider that there is no subject whose liberty is more violently and more unpleasantly interfered with than the inebriate. His liberty is interfered with by police constables and by magistrates, and he may find himself almost a permanent inmate of the gaol. When he is at large he interferes very seriously during his outbreaks with the liberty of those about him, and may endanger their lives. I would merely substitute page 18 a not disagreeable residence in a Home for Inebriates for a most disagreeable seclusion in prison; and the object of this would be not to punish but to cure.
The necessity for providing some means of treatmeut for inebriates has naturally made itself felt in Great Britain, and,. maiuJy through the efforts of Dr. Cameron, M.P., the late Dr. Stephen S. Alford, Dr. Alfred Carpenter, and others, the Habitual Drunkards Act was passed in 1871), after the matter had been agitated for over twenty years. It was founded on a Bill introduced by the late Dr. Dalrymple, M.P., but which failed to pass, I presume, because public opinion was not ripe enough on the subject. The British Medical Association took up the matter in 1871, and its Committee worked assiduously to accumulate facts and arguments in favour of the measure. It obtained the co-operation of the Social Science Association, I think in 1875. In 1877 the Society for the Control and Cure of Habitual Drunkards was formed. These societies did much to educate the public mind as to the disease-aspect of inebriety, and at length their efforts were successful by the introduction of the Habitual Drunkards Act, 1879. The Earl of Shaftesbury advocated the Bill in the House of Lords. The Act was passed not in the original form projected by its promote, but was the best that could be obtained. The Act is only tentative, and is to be in force ten years from the date of its being passed. It defines the habitual drunkard to be "a person who, not being amenable to any jurisdiction of lunacy, is, notwithstanding, by reason of habitual intemperate drinking of intoxicating liquors, at times dangerous to himself, or herself, or to others, and incapable of managing himself, or his or her affairs. The habitual drunkard may, by declaring himself to be such before two Justices, bind himself legally to remain an inmate of a house specially licensed during not less than three months nor more than twelve months." ('British Medical Journal,' August 17, 1878, p. 250).
There is a good provision for those habitual drunkards who, except during the outbursts of drink-mania, are rational enough and able to earn enough to support themselves and families, by which an inebriate can have himself formally committed to a retreat, and at once released on a license, which places him under the control of some suitable person, such as father, brother, or wife. If he drinks he breaks his license, and can be sent back to the retreat.page 19
The Act is detective, inasmuch as it rests entirely with the inebriate patient himself whether he will place himself in a retreat, notwithstanding that the will of the inebriate is weak and vacillating. Still Mr. S. S. Alford found that in America, where the State may compel an inebriate to enter an asylum, that 94 per cent, of the occupants of American homes are voluntary inmates ('British Medical Journal,' February 7, 1880, p. 224, and in previous numbers,) so that there were great hopes of good from the Act. These hopes have been realised to some extent by the success of the Dalrymple Home for Inebriates; but the Society for the Study and Care of Inebriety is endeavouring to promote further legislation, by which a permanent Act may be passed rendering it compulsory under certain conditions, on an inebriate to enter a retreat for a given time.
I cannot find any provision for a State Retreat for Inebriates in Great Britain, and this is a serious defect in the Act, and that the want is felt is evident from the following resolution passed by the Board of Poor Law Guardians of Newcastle-on-Tyne:—"That this Board, being deeply impressed with the necessity of provision being made for more stringent dealing with habitual drunkards, do memorialise the Local Government Board to take such steps as will lead to the law being so amended as to give power to local authorities or boards of guardians to maintain retreats, either in connection with existing workhouses or asylums, or in separate establishments, as may be thought most desirable; and further, that power be given to magistrates to commit habitual drunkards to such retreats with or without their consent, provision being made for the recovery of the cost of their maintenance when it is ascertained that persons restrained have means for their own support, etc. . . . And it should also be pointed out to the Local Government Board that, to prevent the Habitual Drunkards Act from becoming inoperative, the restriction as to its time of duration should be removed." Other boards of guardians have passed similar resolutions. ('British Medical Journal,' December 1, 1883, p. 1085; and November 10, 1883, p. 930).
I am indebted to a paper by Mr. A. Oakey Hall, of London, ex-Mayor of New York, for information regarding American legislation for inebriates. As long ago as 1857 the New York State Inebriate Asylum was incorporated. The charter sets forth that—Section 4: The object of this page 20 institution shall be the medical treatment and control of the inebriate. Section 5 : Said Institution shall have power to receive and retain all inebriates who enter said asylum, either voluntarily or by the order of the Committee, of any habitual drunkard. All poor and destitute inebriates who are received into said Asylum shall be employed in some useful occupation in or about the Asylum. Said inebriates shall have all moneys accruing from their labour, after the expense of their support in said Asylum shall have been paid, which shall be sent to their families monthly. If said inebriates have no families, it shall be paid to him or her on his or her discharge from said Institution. Inebriates' Home, King's County (N.Y.)—Section 6: Said Justice shall have power in his discretion to issue his warrant committing the person so found to be a habitual drunkard to the custody of the said " Home," to be detained for such period, not exceeding one year, etc., etc. Section 8: The estate of any person committed to such "Home," and the person committed, shall be liable for the support of such person therein, etc. In Pennsylvania, Massachusetts, Maryland, California, and other States, institutions are incorporated having similar powers. (Proceedings of Society for Study and Cure of Inebriety, October, 1884, London.)
In 1877 the Mayor of Boston (U.S.) appointed a committee of three (Rev. Dr. A. A. Miner, Dr. George C. Shattuck, and Dr. John E. Tyler) to report on the treatment of drunkenness in the city institutions and suggest measures of reform. They condemn the method of dealing with drunkards, by which, when arrested and convicted of intoxication, they are fined or sent to a workhouse or penitentiary for some short period, commonly thirty days. If the fine be paid the burden falls upon the family or friends of the drunkard, who are innocent of all fault, and are sufficiently punished by the mere fact of his drunkenness. If he be sent to prison, the term of his confinement is long enough for him to get sober, but not long enough for him to acquire habits of sobriety. The consequence is, they say, that a restoration to liberty is followed by a new outbreak and anocher commitment. The worst defect, however, of this method of punishment is its failure to make any distinction between drunkards and criminals. The Commissioners suggest that the institution at Deer Island be converted into a sort of reformatory, where all kinds of agricultural and mechanical labour can be carried on. Thither drunkards page 21 should be sent for terms long enough to enable their constitutions to recover thoroughly from the effects of alcohol, and to give them an opportunity to acquire habits of industry. In some cases a year would be sufficient for this purpose; in others three years might be required. The 'British Medical Journal,' from which the foregoing is taken, adds:—"The present system of tines and imprisonment serves to manufacture drunkards, instead of reforming them." (British Medical Journal,' January 19, 1878, p. 98.)
In Victoria, if any person addicted to the habitual excessive use of intoxicating drinks shall apply to the Master in Lunacy, and shall declare in writing attested by a Justice of the Peace that he is desirous to submit himself to curative treatment, in order to be cured of such habit, etc., the Master in Lunacy may authorise the detention and curative treatment of such person in any licensed house for a period not exceeding twelve months, or in any public asylum, for a sum to be fixed by the master for the maintenance of such person. In other respects the Victorian Act resembles that of New Zealand. There is no provision for poor inebriates; otherwise there is much to commend in this statute. (Acts of Parliament of Victoria; Lunacy Statute, 1867.)
In New South Wales persons having no lawful means of support and habitual drunkards may be committed to a workhouse. Any person so committed may be discharged at any time by order of the Governor, with the advice of the Executive Council. The Act says that the Justices may commit a person brought before them if they shall be satisfied that such person is an irreclaimable drunkard. (Public Statutes of New South Wales; an Act to establish Workhouses, 27th September, 1866). The word workhouse, savoring of poor law, is very objectionable.
But apart from the view that special retreats are necessary for the sake of inebriate patients, I would urge their establishment in order to relieve the families of such patients of the burden of maintaining them. I know of many instances where the wife could provide for herself and children, but an attack of inebriety in the husband throws all back. He must be watched day and night while the attack lasts, medical attendance and medicines must be procured, the shop or the sewing which would otherwise bring in enough to keep them is necessarily neglected, and she is obliged again and again to appeal to friends, who begin to get weary of giving assistance. The poor wife says : " Some- page 22 thing must be done; he must be put somewhere; " but the-prospect of prison or of the lunatic asylum deters her from taking any action, and she says: " Well, I will give him another trial." These poor women have bitter lives, and many of them make noble sacrifices for the sake of their families. The State ought to afford them a ready means of relief from the consequences of a physical and mental disease in their husbands for which they are in no way responsible.
I would then propose the establishment of Hospitals for the Care and Cure of Inebriates, such hospitals to be either supported by the State, or else under State inspection and control. That persons suffering from inebriate disease should, if the outbreak of the disease be recent, on the representation of their friends to a magistrate and after due examination by medical men and proper certificates being signed by them, be committed to one of the hospitals for nervous diseases for a year. That the period of detention in such hospital might be lessened on the recommendation of the medical officers. That during the patient's residence in such institution he should be obliged to do sufficient work to pay the expenses of his living, and the surplus to be handed to his friends for his support on his discharge. The object of the work would not be merely to pay expenses, but to give healthy mental and bodily occupation; to substitute healthy nerve-work for unhealthy impulses, and thus to act curatively. In cases where such seclusion and abstinence from alcohol for a year had been tried without effect—that is, in cases of presumed incorrigible drink-mania—the patient should on each outbreak, if not under proper care and control, be admitted for treatment until the attack should be over, and he should be detained as long as the medical officers thought fit with regard to his safety.
I have explained what proper care and control means, but will do so again. It means such care as will prevent the patient getting alcohol during the attack—an exceedingly difficult measure to carry out in private houses. I would avoid the use of the word " asylum," and name an institution for the treatment of inebriates " Hospital for Disease of the Nervous system," It could easily be specified in the rules of the hospital for which particular nervous disease it was intended. Such a name would be less repugnant to the patient than the word " asylum," and would serve to educate public opinion. The establishment of such page 23 State Hospitals might be objected to on the score of cost, but it must be evident that the community pays far more heavily by the present system, or want of system, than it would do if special hospitals were established. We should then be saved the expense of maintaining such patients in prison; and such special hospitals could be made self-supporting to a very great extent, rendering the estates of those who were able to pay liable for their maintenance, while the others should work for their support. It might be a considerable time before private retreats would remunerate the promoters in New Zealand, but I am sure there are inebriates enough in New Zealand to justify the establishment of a State retreat for the Northern Island and another for the Middle Island. Inebriates, who might be allowed to live out of the retreat on parole, could, if they broke their parole, be treated in the nearest public hospital and discharged when the fit was over; but if they again broke out they could be committed to the retreat for the full time on the recommendation of the medical officers without option of leaving until their time should have expired.
Conclusions : (1) That inebriety is, in the great majority of cases, a physical disease. (2) That inebriety is curable in a large number of cases. (3) That the committal of inebriate patients to prison is unjust, and morally and physically injurious to them. (4) That patients affected with inebriety can only be treated with any measure of success in special hospitals or retreats, where precautions against their obtaining alcohol could be thoroughly carried out. (5) That it is the duty of the State either to establish or license retreats for inebriates, or to do both.
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