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