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are certain relatively rare forms of madness such as alcohol-paranoia, etc.
The position of alcohol as the cause of the other mental diseases is still more doubtful. In the case of the so-called dipsomania, the abuse of alcohol is not the cause of the disease, but rather a symptom. The disease is rare. In general, the abuse of alcohol manifests itself symptomatically in a majority of different psychoses; for instance, in maniac and paralytic conditions of exaltation, dementia praecox and others.
The mental diseases which occur in individuals given to drunkenness are then, partly, some of those specifically mentioned above, and, partly, those in which alcohol is less a cause than an expression of an abnormal physical constitution which reveals itself more clearly through the mental ailment.
Concerning the extent to which an immoderate use of alcohol works injury by occasioning physical and mental diseases and by lowering the general condition of health, it is exceedingly difficult to gain any knowledge that can be expressed in figures. But that most important excessive mortality, by which the unmarried men of the cities are distinguished from those of the married, especially those of the rural districts, is held by some to indicate the deleterious effect of alcohol upon health and length of life. Having knowledge of the prevalence of alcoholism, particularly among the unmarried men of the larger cities, one cannot doubt that it has this consequence, both by a direct effect upon the organism and indirectly by affecting the social standing of the individual and exposing him to accidents and all other kinds of harm. But to attribute the whole of this excessive mortality to alcohol is not justifiable. Numbers of weak and sickly men, who since early youth have suffered from chronic diseases, do not get married on this very account, and others, both men and women who in different ways are less qualified for life, are for various reasons drawn to the cities. Besides married men are probably, regardless of alcohol, better protected against bad influences-for instance, sexual diseases-than their unmarried comrades.
It is especially difficult to judge in what degree and to what extent alcohol is actually a cause of physical diseases, because one and the same disease is in most cases due not to one but to many The value of statistical material gathered from hospitals, for instance, in shedding light on this question depends in the last
analysis upon the care of the physician concerned in searching out the etiology of the disease, his position toward the question of how far in general it is possible by abuse of alcohol to occasion this or that ailment, as well as upon his subjective conception of the extent to which the abuse is conspicuous among other contributing causes. Indeed, one who has practical experience with the difficulties of determining in a given case the etiology of a condition of disease, which from an etiological point of view is not known to be specific, must feel doubt about the usefulness of gathering such data.
Relative to nervous and mental diseases, the preponderant number of those which are caused by alcohol may for the greater part easily be distinguished. However, some probably less known conditions should be pointed out in this connection, which indicate beyond peradventure that the role of alcohol in causing mental diseases is by no means of the importance which the modern abstinence literature would give it.
(After an examination of certain official statistics dealing with the proportion of insane supposed to have become such through drink, the following conclusion is reached: Alcohol is thus in the larger cities certainly the cause of a large number of cases of mental disease, but only exceptionally of those popularly designated as such. And since cases of mental diseases arising from alcohol as a rule are of short duration, and since they are generated by definite external and not insuperable causes, they do not have the serious consequences either for the individual stricken by them, or for society, which commonly 'belong to other forms of mental disease.
Chapters VIII. to X.
(Although these chapters from a medical and scientific standpoint are among the most significant and suggestive in the whole book, they do not readily lend themselves to a popular résumé and only their general trend will be indicated in the following):
Chapter VIII., under the heading "Alcoholismus Chronicus," asserts that the weight of the alcohol question lies in the study of the alcoholic individual. If the study of the alcoholic person yielded no other results than a knowledge of the best means of restoring him to a normal position in society, we should not be justified, no matter how important in itself such knowledge may be, in regarding such a study as the beginning or end of the alcohol
question. But the study under consideration does not only include the condition in which the alcoholic finds himself and what should be done about it, but first and foremost the circumstances that brought him to it. By a deeper penetration of this question one would surely gain a valuable insight into the general occurrence of the abuse of alcohol. Such a study is the starting point both of preventive and curative measures against the injury wrought society by alcohol. On this account there is ample reason for holding the study of the alcoholic individual to be the most important source of knowledge in the study of the alcohol question as a whole.
Chapter IX. treats of different categories of persons who abuse alcohol, and attempts to classify them accordingly. It emphasizes the importance of distinguishing the symptoms of the social evil to be cured.
Chapter X. is a dissertation on the necessity of understanding the causes leading to an abuse of alcohol. About this the publications concerned with temperance matters have very little to say. The early temperance movement was of a religio-ethical character to which this point of view was foreign. Latterly attention has been directed solely to the cause of abuse lying closest at hand, namely, the alcohol itself and in its very nature has been found a sufficient explanation of the conditions to be done away with. In full harmony with this, the temperance movement has centered its effort to the absolute prohibition of all alcoholic beverages. That some persons use intoxicants without harm to themselves or to society, but others with most lamentable results, is a condition that does not seem to arouse much interest. Alcohol has been pictured as one of the most dangerous and seductive poisons, against which no one who uses it may be safe. Persons who consume alcoholic drinks in moderation have been stigmatized as those who by hindering the adoption of general prohibition have the heaviest responsibility for the misfortunes others call down upon themselves and upon society by abuse. An inevitable consequence has been, partly, a lack of interest or plain indifference for a study of the social and individual back of the abuse of liquor, and, partly, too little concern about awakening a sense of responsibility in the individual for his use of intoxicants.
Another reason why the study has been neglected is its extraordinary difficulty. A purely statistical inquiry to demonstrate
the socially operating causes of acts regulated by the human will, invite to the most palpable mistakes. Only one who has immersed himself in the study of many individual cases, who tries to understand their acts from their point of view, who has an eye open to the individual circumstances leading to a departure from social obligations, is in position to determine statistically the cause of such acts among natural groups of society.
In the special matter of investigating the causes of the socially injurious abuse of alcohol on the part of so many, the method of procedure should be to select a number of alcoholic persons commensurate with the limitation of the inquiry, and then try to penetrate their lives. Through conversation with them, their parents and other relatives, their whole development should be traced and an insight gained into their actual ways of living, their habits, point of view, associations and the like. The study should not be too closely confined to their alcoholic habits.
As it is gradually being realized how inevitably their development under given conditions brought them to a notorious abuse of alcohol, it will usually remain to ascertain a great many circumstances which may have been contributory. The "causes" sought for are of course, in turn, conditioned by many other circumstances.
The study in question should serve a practical aim, which often necessitates taking cognizance of negative causes. It is not only the existence of evil conditions but the absence of powers working for good that pave the way to an abuse of drink. It follows that in order to reduce the ills resulting from alcohol, a fight should be made not only against bad conditions but for the creation of new ones, so that the vacuum may be filled which a decidedly limited use of alcohol would make particularly notable in exceedingly many cases.
In each effort to trace the psychologic explanation of why the individual is given to abuse alcohol, one difficulty must not be left out of sight. It is usually necessary to seek an answer to the question: Are the present injurious drink habits wholly or partly an indication of outward circumstances impressions during childhood or youth, the actual social environment, occupation, associations, prevailing regulations of drink selling, etc. or do they express inherent peculiarities of character; that is, the inherited. psychic constitution? . . .
In order properly to lay bare the rôle alcohol plays as an enemy of humanity in different ways, it is imperative to strike out in other
paths than those hitherto followed. Especially must the inherent causes of the abuse of alcohol be made clear, for it stands out not only as a cause of misery but often as a consequence of misery, a sign of grave defects both in individuals and in social conditions.
In order to ascertain the causes of the abuse of alcohol, two lines of inquiry must be followed, one social and the other individual. In the one instance, the problem is to investigate society with special regard to its prevailing drink habits; that is, to plot out the conditions of life in which all individuals coming into view are found within certain natural boundaries, such as smaller communities, one or more quarters of a large community, different occupations, etc. In the second instance, certain individuals must be selected according to varying standards. By aid of the data obtained, eventually even by observing the same individual for a certain time, their past can be reconstructed and made to show what their present life is. The first may be designated as making a social cross-section of a naturally limited portion of society and the second as making a longitudinal section of the life of individuals distinguished by certain characteristics.
(This chapter deals with the general causes of the abuses of alcohol with special reference to conditions in Sweden). The principal causes both of the use and abuse of alcohol lie in its very nature. Consumed at a suitable time, place and in moderate quantities, alcoholic beverages bring about a physical condition which, in a majority of persons, make it easily understood why such drinks are highly prized throughout wide circles of respectable citizens. If the only results were to produce a happier, more communicative frame of mind, to make one forget even for a while the drawbacks and irritations of the workaday life, to soften one's moods, etc., the only question would be of economic ability to indulge in such beverages. But a large number of persons, and perhaps chiefly those less fortunately placed, use intoxicants to such an extent and under such conditions that their influence is quite another and positively injurious. How widespread a social misfortune may occur can be understood by realizing that the psychic effect of over-indulgence in alcohol is to diminish the power of judgement, vitiate the moral strength of resistance, and also increase impulsivness. As, in addition, habits and point of view no less than