By W. D. Silkworth, New York, N.Y.
293 CENTRAL PARK WEST -MEDICAL RECORD MARCH 17, 1937
Alcoholism is considered by many physicians a chronic condition that gradually unfolds itself to a dismal end. They feel that it is a state of mind and advise these patients that it is up to them to discontinue their accustomed drug, which it is assumed they can do by merely making up their minds to do so. Proper attention is not given to the psychological problem as well as the physical condition of these people.
Partly as a result, the economic and social importance of alcoholism is astounding, and only those in close touch with this phase of medicine realize that the situation is a direct challenge to the physician, worthy of his best efforts. It is rendered more acute by the invasion of public bars by women and young girls, the vicious institution of the “cocktail hour” and the “new freedom” that have resulted from general demoralization during the post-war era. The subject now, concerns both sexes and all ages to a degree never before experienced, and its importance will not be fully realized until the present generation has reached middle life.
A heavy responsibility, therefore, rests upon the physician. No other condition has attained such general and widespread proportions. No other disease entails such far-reaching suffering and disaster to families and friends, nor is there any other with which the physician has been less able to cope with reasonable assurance of at least minimizing its ravages. The reason for this lies not only in the influences we have noted already, but in the fact that heretofore alcoholism has been considered a vice within the control of the relatively few individuals concerned and not as a disease entity in its more subtle and damaging aspects; and all that has been expected of the physician has been the administration of sedatives, purges and emetics to control acute stages.
It is our purpose to show that there is a type of alcoholism characterized by a definite symptomatology and a fixed diagnosis indicative of a constant and specific pathology; in short, that true alcoholism is a manifestation of allergy. If the arguments adduced appear to upset traditional ideas on the subject, it is because the major points of diagnostic importance as well as the fundamental basis of the physical and mental alterations that occur in the victims, have not heretofore been correlated or analyzed with the same interest that attaches to other conditions that are no more serious but elicit more sympathy. As the result of observations of numerous cases at Towns Hospital, New York City, over a period of years, clinical constants have been derived and data have been accumulated which indicate that the subject must be considered from the constitutional and serological point of view.
We may set it down as a fundamental proposition that alcoholism is not a habit. Second, drunkenness and alcoholism are not synonymous. Intoxication with alcohol, as commonly observed, is a purely superficial manifestation of no diagnostic importance whatever in itself; nor is the desire to take a drink, which is common to many. The majority of people who drink alcohol apparently do so with impunity. Prohibition revealed, among other things, how much people desire to use alcohol on all sorts of occasions, and that this desire, and intention, are not limited to chronic alcoholics. The judge, the senator, the preacher, all want their alcohol on occasion. The merchant or the broker closes transactions over a highball and frequently indulges several times daily for many years. The clubman and the society matron, the daily laborer, the high and the low alike may drink daily more or less liberally of any and all sorts of liquor during much of their lifetime. They may, and do, become intoxicated; but note that in the majority of such cases alcohol exhibits only the immediate effects of the drug, and recovery is prompt and uncomplicated. Copious elimination, with a cold pack on the head and a brisk shower bath on the “morning after” end the matter. Also note, for later comparison, that if, for any reason, this type of drinker decides to “swear off”, he experiences no more physical or mental pang than accompanies the abandonment of any other habitual mode of living. There is no “problem”, no struggle, no psychic complications to be met, nothing but the transient inconvenience of interruption in his usual customs. For one reason or another he has decided that the inducements to stop drinking are greater than those to continue it. He has had a one hundred percent change of mind and his will is one hundred percent free to act accordingly.
Such people drink from choice and not from necessity. They find in alcohol a pleasant stimulation, a relief from anxieties, an increased warmth of conviviality. It is not a dominant factor in their lives. They are normal people, mentally and physically, to all intents and purposes. We must keep in mind, also, the fact that the multitude of persons who exhibit misbehavior conduct through faulty upbringing or complexes, who are oppressed by a sense of humiliation or inferiority because of unfriendly or disapproving associates or because of some physical defect, and find that a few drinks enable them to consider themselves the equals of any or even superior to all others, are not to be classed as chronic alcoholics merely because they indulge in alcohol regularly. A change of environment, a new mental attitude, or the restoration of confidence in themselves may suffice to bring about a totally new policy on their part. The significant point is that under such circumstances, if they desire to stop drinking they can do it without a struggle. They have no need to lean upon anyone else or anything outside of themselves for support. Alcohol is not necessary for them.
This, we believe, is a fair view of the general drinking public, and constitutes a familiar background against which to contrast a very different picture. These people are not true alcoholics, but they may become so; and it is from among them that the real alcoholics are derived.
Let us now contrast with this kind of drinker an entirely different type. He is, as we have noted, a development of the class we have just described, his history may be quite like that of the average. But sooner or later there comes a time when he manifests changes that place him in a classification characterized by symptoms that were entirely lacking before, and unequivocally set him apart from the average drinker. Whereas he formerly drank for pleasure, he now has to drink from necessity in order to keep going. He cannot take his liquor or leave it, as he used to do. Yet, even if he is more or less soaked with it all day, his mind at first functions fairly well, he transacts his business with fair efficiency and keeps up with his obligations to his associates and the community. But he discovers that a change has occurred in him. He finds that he has to have a drink in the morning. Then he finds, after a little more time, that his hand shakes; when he signs his name, for example. Later, irritability and lack of concentration supervene. He is not the man temperamentally that he used to be. In order to meet these changes and increasing symptoms, he is compelled to increase the amount he consumes, and a prolonged spree replaces a short intoxication.
PHYSICAL SYMPTOMS OF ALCOHOLISM
The spree is characterized by certain definite physical symptoms in all such cases. The phenomenon of craving is prominent; there are complete loss of appetite, insomnia, dry skin and hyper-motor activity. He has a feeling of anxiety which amounts to a nameless terror. He presents the picture of a person who has just finished a race but must have more stimulation to start again at once. Alcohol in itself does not produce these symptoms in the average individual any more than the daily use of alcohol produces a chronic alcoholic in the absence of constitutional allergy. But note that, in sharp contrast to the progress of these developments, he may not, in many cases, actually be taking any more liquor on the average than one of his associates who does not get into the same state as himself, in whom the phenomenon of craving is not present. His friends and family remark the alterations occurring in him. He himself, notices them and also what is apparent to everyone else, that a very little alcohol has an effect on him altogether out of proportion to the amount taken, and different from what he used to expect. It is not at all unusual, in fact it is the rule, for such a person to say, for example: “I drank for twenty years but it never affected me this way before.” It is to be noted here that it does not take twenty years to form a habit. One case epitomized the whole clinical picture in these words: “I can make more money in a day than you can in a year. I can, and do, handle big things. I carry on transactions that keep two or three telephones on my desk busy all day. But I can’t take a drink any more. What is the difference between you and me? A psychiatrist tells me it is in here (indicating his head); that I can’t face reality.” That particular person does nothing else. He lives in and faces reality all day.
These changes mark the early stages of true alcoholism, and the beginning of a chain of symptoms that show a remarkable constancy. They occur in comparatively rapid sequence during a period of from four to six months in the course of what had been ordinary drinking habits for perhaps many years previously. At this point, even during periods of partial or complete sobriety, he develops a state of anxiety amounting to a vague fear, then depression and lack of concentration, with gradually growing indifference or complete apathy toward his former interests. Unreliability, changes in personality, loss of appetite, insomnia and tachycardia follow. He is under such tension in the effort to control himself that he has to have a drink in order to hold himself together. At the same time, and we have observed few exceptions to this, these individuals will tell you that they not only have no liking for liquor but dread to take it; and, to anyone who has watched such a person, it is obvious that this is true. But he believes he must have it, even though he realizes that, in his particular case, a single drink will plunge him into such a condition that a prolonged spree will be the inevitable result. After the first drink, and only then, does he experience the physical phenomenon of craving.
I can not emphasize too strongly the point that this man does not go on a spree from pure deviltry or desire. He often has important engagements or appointments or decisions to make the following day, to which he has given serious consideration. The situation cannot be duplicated in what we may call the “normal” or nonalcoholic drinker, who is accustomed to his few drinks a day, year in and year out, and never goes on a spree.
When a man gets into this state, it is a remarkable and noteworthy fact that he needs only a comparatively small amount to keep him more or less interested in affairs. All he wants, and must have, is a drink every so often. It is as if these small pushes were enough, in contrast to the ordinary “drunk” who finishes the bottle at one sitting, becomes intoxicated and goes on his way again, apparently none the worse, after the drug has been eliminated. These small pushes that propel the true alcoholic through his day, are one phase of a vicious cycle, apparently, culminating in complete debauch, after which the cycle begins again.
ALCOHOLISM A TRUE ALLERGIC STATE
The inevitable conclusion is that true alcoholism is an allergic state, the result of gradually increasing sensitization by alcohol over a more or less extended period of time. The constancy of the symptoms and progress is too fixed to permit any other explanation. Some are allergic from birth, but the condition usually develops later in life. The development and course of these cases are quite comparable with the history of hay fever patients in many respects. One may enjoy absolute freedom for many years from any susceptibility to pollen. Year after year, however, there gradually develops a sensitivity to it in certain individuals, culminating at last in paroxysms of hay fever that persist indefinitely when the condition is fully established.
It is noteworthy also, that such patients may be deprived of liquor altogether for a long period, a year or longer for example, and become apparently normal. They are still allergic, however, and a single drink will develop the full symptomatology again.
There is another class of allergics who exhibit periodicity. At certain regular intervals, predictable in a given case almost to a day, varying from a few months to a year, these patients desire liquor. After a prolonged spree, they are apparently normal during the succeeding interval. These alternating cycles have a tendency to shorten the intervals between debauches, and these patients, also, deny any craving. Certainly it seems absurd to think that a man should have a craving only on certain fixed dates. Rather, we must take into consideration the fact that a manic-depressive cycle is normal to all individuals. The ordinary person “down in the dumps” cheers up on a drink or several drinks, if that mode appeals to him, gets into a merry, or mellow, mood, takes a cold shower in the morning and is done with it. The manic-depressive type who is allergic, however, goes on a spree and must carry it, willy-nilly, to a finish that may require a week or more, until a complete nerve and mental demoralization brings it to a termination through sheer exhaustion and inability to stand anymore abuse for the time being. We also have the constitutional psychopaths who become allergic to alcohol, and are emotionally unstable and inadequate. The prognosis in these cases is most unfavorable.
PHYSICAL AND PSYCHOLOGICAL TREATMENT
The physical treatment of these patients has heretofore been unsatisfactory. But if we recognize the condition as a species of anaphylaxis occurring in persons constitutionally susceptible to sensitization by alcohol, the problem resolves itself into two factors. First, the revitalizing and normalizing of cells, and second, the energizing of the normalized cells into producing their own defensive mechanism. As long ago as 1916, Professor Bechhold of Leipzig University, in his textbook on Colloids in Biology and Medicine, said: “Some day, chronic alcoholism may possibly receive a physicochemical explanation from the change in the condition of the body colloids.” On the mental side, from our point of view, the situation is a practical one and must be met through the medium of intelligence and not emotion. Nothing is to be gained by substituting one emotion for another. The patient cannot use alcohol at all for physiological reasons. He must understand and accept the situation as a law of nature operating inexorably. Once he has fully and intelligently grasped the facts of the matter he will shape his policy accordingly.
It is true, of course, that psychologically much assistance can be given. Wrong methods of thinking can be corrected. Extroversion rather than introversion can be encouraged; but fundamentally this individual must stand on his own platform, come what will – social and financial troubles, heredity, etc., notwithstanding.
In a subsequent paper, we shall discuss special therapeusis applicable to the treatment of the allergic type of case, describe some of the outstanding results that we have seen from this line of approach in this hospital and discuss moral psychology, the necessity for discriminating between those who must be hospitalized and those who can be treated at home. The complications to be met and other factors influencing treatment are so numerous and require so much space that it is not practicable to include a discussion of them in this paper.