Doctor William D. Silkworth, called, “the little doctor who loved drunks”, began an indispensable contribution to Alcoholics Anonymous during the early 1930’s from his position as medical director of Charles B. Towns Hospital, 293 Central Park West (89th street), New York, N.Y. Towns, founded in 1901, was well known then as a rich man’s drying-out place; a rehab for the wealthy, and it served a worldwide clientele. American millionaires, European royalty and oil sheiks from the middle east walked its halls, side by side: brothers in humiliation in bathrobes and slippers.

It was Dr. Silkworth who told Bill Wilson, during the summer of 1933, of the nature of alcoholism: that, in his opinion, the problem had nothing to do with vice or habit or lack of character. It was, he said, an illness with both mental and physical components. Silkworth is quoted widely as calling the illness a combination of “—an obsession of the mind that condemns one to drink and an allergy of the body that condemns one to die” or go mad if one continues to ingest alcohol.

Dr. Silkworth was not the first highly respected authority to write about alcoholism. Solomon, considered the wise man of his era, wrote about it in Proverbs, Chapter 23, and Verses 29 through 35. Solomon’s Biblical words seem an accurate description of the alcoholic of today.

Dr. Benjamin Rush, one of the signers of The Declaration of Independence, was the first member of the medical community to write about alcoholism and suggest it might be an illness. In a medical paper he wrote in 1784, Dr. Rush said he thought alcoholism was “-a disease process.” He offered no further clinical evidence. So: Dr. Silkworth, it appears, was the first medical person to detail alcoholism, in writing, as an illness.

Silkworth, thus, disagreed with his employer, Charles B. Towns. Towns, who had once claimed to have a “cure” for alcoholism, believed firmly in a physiological, medical model of addiction. But, he denied that alcoholism, per se, was a disease. Silkworth argued that certain individuals were “constitutionally susceptible to sensitization by alcohol” and that drinking sparked an allergic reaction. This, he insisted, made it physically impossible for an alcoholic ever to tolerate alcohol. Moreover, he said, that problem drinkers would have to learn and accept this fact as part of their treatment.

Silkworth played a major role in many of the early recoveries from active alcoholism, particularly those in New York. It’s estimated that he treated forty thousand alcoholics during his career. The introduction to his writings in the book, “Alcoholics Anonymous” says early AA members considered the Brooklyn-born Silkworth no less than a medical saint.

Dr. Silkworth advised Bill Wilson to stop preaching at the drunks he was trying to help by telling them about his powerful spiritual experience. Silkworth urged Wilson to begin, instead, by telling each of the alcoholics that his condition was hopeless, a matter of life-or-death. Only then, Silkworth believed, would the drunks be willing to listen to a story about a spiritual remedy.

Through no fault of the doctor’s, there is disagreement about parts of his professional history and about his birth year. In Silkworth’s biography in the book, “Dictionary of American Temperance Biography: From Temperance Reform to Alcohol Research, the 1600s to the 1980s,” the historian Mark Edward Lender lists Silkworth’s date of birth as July 22, 1877. All other sources used in this compilation, which contain a date of birth for Silkworth, including his New York Times obituary, agree that Silkworth’s birth year was 1873.

It’s agreed, generally, that Silkworth graduated from Princeton University (A.B. 1896) and that he took his M.D. degree from New York University-Bellevue Medical School (1899). But, two principal sources, “Pass It On,” published by Alcoholics Anonymous, and, “Not-God,” researched and written by the widely respected historian Ernest Kurtz, Ph.D and published by Hazleden, offer differing versions of his career path thereafter.

“Pass It On,” (p. 101) reports Silkworth became a specialist in neurology, a domain that sometimes overlaps psychiatry, and entered private practice in the 1920’s. It says Silkworth invested his savings in a stock subscription for a new, private hospital. “Pass It On” says Silkworth’s investment came with the promise of a staff position when the hospital was built. But, the report says Silkworth lost everything in the stock market collapse of 1929. And,”Pass It On” quotes Bill Wilson as saying that Silkworth, in desperation, went to Towns in 1930 for compensation of about forty dollars a week, plus board.

“Not-God,” (p. 22) reports that after he received his medical degree from NYU, Silkworth began a coveted internship during 1900 at Bellevue Hospital, 462 First Avenue (27th. Street), in Manhattan. It says that in 1924-after completing specialty training as a neuro-psychiatrist—Silkworth became medical director of Towns. “Not-God” notes that Dr. Silkworth estimated his patients’ rate of recovery, until Bill Wilson came along, at “approximately only two percent.”

So: “Pass It On” and “Not-God” show a six-year difference in Silkworth’s arrival date at Towns.

A third source offers a wider time differential but more information about Silkworth. The respected Journal of Studies on Alcohol, published monthly by The Center of Alcohol Studies at Rutgers University, New Brunswick, New Jersey reports Silkworth arrived at Towns in 1932. An article by Leonard Blumberg, (Professor of Sociology, Temple University, Philadelphia Vol. 38. No. 11, 1977, “The Ideology of a Therapeutic Social Movement: Alcoholics Anonymous”) says Dr. Silkworth worked at Towns from 1932 until his death in 1951.

Silkworth’s entire career had a psychiatric emphasis. He was a member of the psychiatric staff at the US. Army Hospital in Plattsburgh, New York, for two years (1917-1919) during World War I.

Dr. Silkworth also served as associate physician at the Neurological Institute of Presbyterian Hospital in Manhattan from 1919 to 1929. He had also been connected with Broad Street Hospital.

The Blumberg article leaves room for speculation about the circumstances under which Silkworth left the prestigious Presbyterian Hospital in 1929. It concludes that he probably was laid off during a staff reduction following the stock market crash of that same year. The article does not attempt to fill the time vacuum of approximately three years until it says Silkworth went to Towns.

Regardless of his starting date at Towns, Wilson said Silkworth’s arrival there was the turning point in the doctor’s life. Nearly all sources agree that he worked there approximately nineteen years.

Additionally, Dr. Silkworth was a major influence in persuading the management of Knickerbocker Hospital in upper Manhattan to set aside a small ward, beginning in 1945, for the treatment of alcoholics. Knickerbocker was the first general hospital in New York to do so. (This is significant because many general hospitals at that time would not admit alcoholics as alcoholics. Their doctors had to admit them under false diagnoses.) Dr. Silkworth served six years at Knickerbocker as director of alcoholic treatment, attending an estimated seven thousand alcoholics. Teddy R., a nurse who was an AA member, ran the alcoholism ward. Figures as to costs at Knickerbocker are unconfirmable. But, the fees and other expenses there were much less than at Towns, where patients paid $125.00 for one week of treatment, during the early and mid-1930’s. At Knickerbocker, drunks off the street with no financial resources were de-toxified.

William Duncan Silkworth died Thursday morning, March 22, 1951 of heart attack at his home, 45 W. 81st. Street, New York. He and his wife, Marie, had lived in Manhattan during their later years. But, it’s known that he commuted for part of the time he worked in New York from a home in Little Silver, New Jersey. Today, there’s a train station about one block away from that house, which-as of this writing — is still standing. But, it’s unclear whether the train station was there at the time Silkworth lived in Little Silver.

As noted previously, the book, “Alcoholics Anonymous,” reports that early AA members considered Dr. Silkworth a “—medical saint.” It was never a secret that his personal relationship with Alcoholics Anonymous was both deep and emotional. He was called, “-the little doctor who loved drunks” because he genuinely cared for and experienced communion with alcoholics. And, they loved him. An in-depth explanation can be found in, “Language of The Heart,” (p. 176).

In an article he wrote years later for The Grapevine, Bill Wilson noted that Dr. Silkworth treated some 40,000 alcoholics during his career. Wilson added, “He never tired of drunks and their problems. A frail man, he never complained of fatigue. During most of his career he made only a bare living. He never sought distinction; his work was his reward. In his last years, he ignored a heart condition and died on the job–among us drunks, and with his boots on.” All but one of the AA historians who influenced this writing believe that Dr. Silkworth held positions at both Towns and Knickerbocker Hospitals at the time of his death. But, it should be noted that the respected AA historian and author Mel B., who wrote much of “Pass It On,” the official AA biography of Bill Wilson, mentions only Silkworth’s affiliation with Knickerbocker Hospital at the time of the doctor’s death.

Wilson showed his gratitude to Silkworth in 1950 and ’51, when he and some associates tried to raise enough money to allow “Silkie” and Marie, to retire to New Hampshire. The doctor was going to be medical director of the treatment center, Beech Hill Farm, near Dublin, New Hampshire. But, Silkworth died before it could happen. So: Bill, noting Mrs. Silkworth’s strained financial circumstances, raised $25,000 for a Silkworth Memorial, to supplement the widow’s small income.

Dr. Silkworth’s death was announced to the Fellowship in the April 1951 version of the AA Grapevine. And, the article indicates AAs of that time considered Silkworth more than a “medical saint.” To those AA’s who knew him, William Duncan Silkworth was a hero. The April 1951 Grapevine article notes, “He freely risked his professional reputation to champion an unprecedented spiritual answer to the medical enigma and the human tragedy of alcoholism.” Historians point out that he might have been laughed out of the American Medical Association for holding such a view. Obviously, that did not happen.

Wilson, who previously had referred to Dr. Silkworth as “-AA’s first and best friend” eulogized Silkworth in the May 1951 Grapevine. And, his affection and sense of personal loss is expressed in a notation on a copy of the appeal for funds (found in The Collection of the General Service Conference of A.A.) It says, “Thank Heaven we started this before Silkie went.”

The Wilson article, written especially for The Grapevine, concludes with two questions: “Who of us in AA can match this record of Dr. Silkworth’s? Who has his measure of fortitude, faith and dedication?”.

SOURCES: The AA publications: “Alcoholics Anonymous”, “Pass It On”, “The Grapevine” and “Language of The Heart”; The Collection of the AA General Service Office; “Not-God” by Ernest Kurtz; “The Journal of Studies on Alcohol 1977” which contained “The Ideology of a Therapeutic Social Movement: Alcoholics Anonymous.” by Leonard Blumberg: published by The Center of Alcohol Studies, Rutgers University); “Dictionary of American Temperance Biography: From Temperance Reform to Alcohol Research, the 1600s to the 1980s” by Mark Edward Lender; “Lois Remembers” by Lois Burnham Wilson; “My Search For Bill W” by Mel B.; Yale University; New York University and private conversations with AA’s who knew Dr. Silkworth. Researched/written for: The Round Table of AA History by Mike O. (Michael O’Neil), of The Just Do It Big Book Study Group of Alcoholics Anonymous, DeBary, Florida. Updated/revised: 1999, 2000, and 2001.

Alcoholism, because it is such a profound social problem, has become the subject of considerable scientific and lay research. Many theories are being advanced as to what it is and why alcoholics are the way they are. It has become a very lucrative source of discussion for many. Out of a phantasmagoria of conflicting and often esoteric theories based on scant clinical findings, two sharply defined but quite divergent diagnoses have been arrived at. The first, that the disease is purely physiological, a glandular malfunction caused by a disturbed metabolism. The second, that it is purely psychological -alcoholics are essentially inadequate, mentally underdeveloped individuals, escapists, ego-centrics, even psychopaths. The proponents of these theories are hostile to each other but agree that those who take more moderate views and who work with the alcoholic to help him are to be held in gentle contempt. Needless to say, I am opposed to both extreme views. If we are to believe the physiological exponents, then many an athlete, soldier, professional man, business executive, statesman, and priest is a physical defective, when, as a matter of fact, he was as normal as you or I until he drank too much liquor. If we are to accept the phychological point of view, then I may offer in rebuttal statistics from Knickerbocker, Charles B. Towns, and St. John’s Hospitals in New York City, which show that out of 12,000 alcoholics treated in the past five years, 80 per cent were of Irish-American descent. Will you accept the conclusion that the Irish are an inadequate, underdeveloped and psychopathic race? I may add that as an associate physician at Neurological Hospital, I dealt with many neurotics and psychopaths. None were alcoholics. I have the greatest regard for scientific research on the subject and I am trying to do my share of it. However, the theorists, both extreme and moderate, have failed to tell us what alcoholism is or what to do about it. My conception of alcoholism is contained in the findings I published thirteen years ago. I have confirmed them after observing some 17,000 cases under treatment. Alcoholism is a disease, essentially physical in origin, a manifestation of an allergy. This accounts for the phenomenon of the 10 per cent of the population who, if they drank, lose control over alcohol. The psychological involvement is caused by the refusal of the alcoholic to ascribe his difficulties to alcohol, and his phychic dependence on it when he has reached the compulsive state of his addiction. So much for my own diagnosis. Whichever is correct, the fact remains -to the best of my knowledge -that no cure has yet been discovered. Not a single one. However, the disease has been arrested in nearly 100,000 alcoholics by a group that expounds no theory except absolute abstinence -Alcoholics Anonymous. It is not so difficult to understand or recognize the early symptoms of this disease. But let me first clarify a situation that has led to a great deal of confusion. Many of the psychological descriptions of the alcoholic are characteristic marks of the constitutional psychopath. If we accept, as many students assure us, that the alcoholic is a pathological liar, an escapist, an egocentric, and in fact a prey to all or many of the psychological terminology’s, we might just ask him why any effort at all is being made to rehabilitate him. It is essential to understand clearly that the average alcoholic was not born with all these social maladjustment’s. The constitutional psychopath may become an alcoholic, but he is not the type we are discussing here. It is most difficult to point out the type of man who can or will become an alcoholic. A.A. has set forth the following yardsticks: 1) Do you notice that you drink more than others among your acquaintances? 2) Are you beginning to cheat about how much you drink? 3) Are your work and general life beginning to be neglected? 4) Do you eat less when drinking? 5) Is liquor becoming essential to carry on many of the ordinary affairs of life? 6) Are you trying to deny all this and beginning to resent advice about it? 7) Are you saying, “I can stop anytime I wish,” and prove it for a short time only?

These and numerous others are the slowly developing symptoms of disease. The phenomenon of craving will be the dominant factor, eventually to be complicated by a neurosis, compulsive in type. It is a disease so complex that, until the advent of A.A., there seemed small hope of arresting it. In common with certain other diseases, clinically we have no cure for chronic alcoholism. Since the amalgamation of alcoholics into groups, we are able to meet many alcoholics who are completely sober for periods of from two to twenty years. But, following one drink of alcoholic beverage, the phenomenon of craving promptly returns. They cannot drink in moderation. The disease was merely arrested. Granted that some of these people may be neurotics, self-centered, emotional individuals, are they therefore doomed to alcoholism? Such an admission would be evidence of our own inadequacy. Let us arouse ourselves. Let us recognize the urgent need of an educational campaign. Alcoholism is incurable but it can be prevented. Let us have an educational campaign among the clergy and in the seminaries. I am not advocating the “temperance movement.” We are interested in the 10 or 15 per cent of unfortunate people who cannot drink in moderation. Thousands of them are not the types that have been presented to us by the over zealous researchers. I believe we can escape this sorry picture by a properly integrated educational program. A.A. knows these same people: formerly violently anti-social, completely immoral, the despair of their friends and themselves; but now they are normal men and women, assuming all the responsibilities demanded by society, and even devoting a part of their lives to the assistance of others less fortunate. However, the addiction that requires this terrific struggle back to normal can be prevented by proper and timely education. The importance and need for this cannot, I believe, be overestimated. How important, then, how outstanding, becomes an educational program of prevention in your great body of men trained in religion. You have a problem within your own ranks, a problem which can well be met four-square by education. I have seen literally thousands of men with all types of degrees, with all different forms of training, and from all different classes and walks of life, who are tragic victims and sufferers of alcoholism. It is surprising, when we learn the case history of an alcoholic, to discover how little he really knew about alcohol in his youth and young manhood. This is true in case after case. It is by understanding and education, even at the eleventh hour, that hundreds and thousands of men are saved from insanity or premature death-the inevitable end of chronic or acute alcoholism. To you men there is presented a challenge. How many thousands of parishes of yours are there in the United States? Let us picture, if you will, a young assistant in a town or city of 15,000. What a wonderful thing it would be if this young priest started a Matt Talbot group in his city. What an example he would be to many men who have lost hope, men high in the business world, and perhaps many of them learned, men who secretly think that they are the only ones who have an alcoholic problem. Invited to attend a meeting of the Matt Talbot Group, they would meet fine fellow citizens. They would be reassured, and would find that they are not standing alone. They would renew or revive the practice of prayer, particularly meditation. Supposing in your larger cities Matt Talbot groups were organized in your Catholic parishes. Think what an army of crusaders there would be within your religion alone. You men of religion would soon be supplemented by thousands of enthusiastic members of Matt Talbot groups. This zeal would in turn be passed on by the fathers and mothers to their sons and daughters. The young assistant priest, who was interested in social work, at times becomes discouraged; but his bishop encouraged him, and counseled him to overlook any criticism or ridicule that might come to him directly or indirectly. The young priest persisted. Today many priests are calling on him for help for their friends, their parishioners, and in some instances, for members of the clergy who have themselves become alcoholics. The example of thousands of such priests would create a movement in this country which would not only benefit the laymen at large but would benefit the clergy as well. In our lifetime we have seen both the Russian and the former German government train their youths so that at the age of ten or eleven they were ardent and zealous Nazis or Communists. Is it too early then, to start the young seminarian when he starts his study of theology? There is no better time to teach the pitfalls and the insidiousness of alcohol. The true knowledge of the misery and suffering of intelligent men can well be brought to the understanding of young seminarians, stressing many times that this is a major problem confronting not only the young laymen of today and tomorrow, but also the young priest of today and tomorrow.

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.

The allergic nature of true alcoholism has been postulated in a previous paper (1). We there endeavored to show that alcohol does not become a problem to every person who uses it, and that the use of alcohol in itself does not produce a chronic alcoholic. Of those who are able to drink with impunity, however, a certain number will sooner or later develop this anaphylaxtic condition, in which the tissue cells are sensitized to alcohol. We believe that the alarming increase in such cases may be directly attributed to the failure of the medical profession to recognize the true alcoholic pathology and to treat the condition as a somatic dysfunction rather than as a combined physical condition and a psychological maladjustment. But before instituting treatment, it is essential to determine whether a case is acute or chronic; that is, allergic. To present all the minutiae of the treatment of allergic alcoholism in the space of one article is, of course impossible. It is necessary, though, first to divide these alcoholics roughly into two groups; namely, first, those who have reached an acute crisis and, therefore, require hospitalization either to avoid the crisis and prevent delirium tremens, or to bring the patient safely through such a crisis: and, second, those whose condition is such that, with proper treatment, no danger crisis exists. Practically all the cases would be in the second category if the patient’s condition was recognized and the proper treatment started promptly. However, through failure of the patient to reach the physician in time, or through failure of the physician to provide treatment, many do reach the crisis stage. It is, therefore, necessary to recognize three phases of treatment. The first phase applies only to those in the first category, referred to above, which ordinarily should have been avoided. The last two phases apply to both categories since they are necessary regardless of whether or not the patient had to go through the first phase. We might define these three phases as follows: 1, Management of the acute crisis; 2, physical normalization and cell revitalization so that craving is eliminated, and 3, mental and normal stabilization, which naturally involves some “normal psychology.” MANAGEMENT OF THE ACUTE CRISIS Regardless of the fact that such a stage is usually avoidable, it is not avoided in many instances, and, hence, its existence must be recognized, not only so that it may be properly treated, but also so that it may be avoided in a larger percentage of cases. If the physician has kept abreast of current developments in the handling of this problem, such a crisis exists only because it was there before the patient came to the physician. This being true, prompt and thorough measures must be taken before any body cell normalization is undertaken. In other words, with a crisis, a negative treatment is first required. We firmly believe that most such acute cases should be hospitalized, but, in selected cases, and where hospitalization is impossible, home treatment may be undertaken. As the most serious complication of acute alcoholism is acute delirium, the first consideration of the attending physician must be to determine whether or not this is imminent. The imminence of delirium tremens can usually be recognized within a few hours; its onset is recognized by: 1. A persistent rapid action of the heart (pulse rate to 140). 2. A rise in temperature to 100 F. plus. 3. Persistent insomnia not yielding to sedatives. 4. Increase in the tremors, which may include the muscles of the face, and progress to an ataxic gait. 5. Profuse perspiration (present in over half our cases). 6. The general picture of progressive alcoholism, although the patient is receiving practically no alcohol.

In the presence of the foregoing symptoms, the alcohol must not be abruptly discontinued. From our experience in thousands of cases, we believe the average patient properly treated without deprivation of alcohol will seldom develop delirium tremens. The patient must be adjusted to a controlling dose which is physiological for him – say one ounce every four hours, with an occasional ounce between, if symptoms increase. To relieve the pressure in the brain and spinal cord (unless spinal puncture is contemplated), dehydration must begin at once. Unless contraindicated, we begin with a large dose of physic, preferably a cathartic to be followed by a saline purgative. The chief contraindication is enlargement of the liver. If abdominal distention is present, catharsis must be discarded and high colonic irrigations of warm saline should be substituted. On the next day, if the abdomen is no longer distended, the cathartic can be administered advantageously. In patients who are obtreperous and uncooperative, these warm saline irrigations have a somewhat sedative action. The dehydration is continued for from three to four days, depending on the strength of the patient. In alcoholic gastritis, vomiting is common following the administration of saline purgatives by mouth. This simply amounts to a saline lavage, and the saline should not be repeated until it is retained. Acidosis is frequently present in these cases and should be recognized and treated by the usual methods. Remembering that we are still dealing with the acute stage and considering only the negative treatment, we must recognize that sleep must be induced. This is a prime necessity in view of the insomnia which is universal with these cases. Morphine should be avoided if at all possible, as it increases brain congestion and frequently leads to a fatal issue. Before a sedative is administered, the physician must ascertain whether one has been previously been given and action is delayed. The cumulative action of an additional dose is sometimes most serious. We have seen a number of instances in which a dose of morphine fired a whole train of sedatives that had been given previously with no effect, with promptly fatal results. If the patient contrives to get more alcohol than has been prescribed and large doses of sedatives must be administered, the depressant action of the alcohol, combined with the sedation, may culminate in a state of mental confusion leading to hallucinosis. On about the fourth day the alcohol can be entirely withdrawn, as by this time the crisis has been avoided or safely passed through and, hence, the patient is in the second phase of the treatment (which should have been the first stage in most cases, as previously noted). The following is typical of a patient who had to go through the first phase: Case I (Hospital No. 17). – Mr. M., aged forty-one. His family history was Negative. Personal history: The patient had been a moderate drinker for ten years, with no apparent interference with his work, which was exacting, or his family life, which was normal. The picture then changed over a period of a few months, so that alcohol became an immediate problem. He would abstain entirely for a week and then, on taking one drink, would again have to continue for a number of days, sometimes weeks. he could not understand this development in his case, believing it due to some lack of will power, and finally falling back on other alibis. Physical examination was negative as regards organic disease. The heart was rapid (pulse rate 120); blood pressure 180 -100. Generalized tremors were present. The facial expression was anxious and there was a general sense of apprehension. No food had been eaten for the previous three days and insomnia was marked. Treatment: Immediate detoxication was initiated by means of free catharsis and the cerebral pressure automatically relieved. He was allowed a moderate amount of alcohol, varied according to his condition. Sedatives were given in moderation, but not enough to cause a sudden “knock-out.” Following three days of this treatment, alcohol and sedatives were discontinued, and the patient, still being nervous and finding difficulty in sleeping, we decided to try an especially prepared combination consisting of an orthocolloidal iodine complex and an orthocolloidal gold. In one week’s time, there was a return to entire normalcy as regards the physical condition and the treatment was continued for a period of three weeks. PHYSICAL NORMALIZATION AND CELL REVITALIZATION In this phase are included all allergic patients who have either been kept clear of the acute crisis or who have been safely passed through that phase by hospitalization. Therefore, in this phase we are able to start to deal with alcoholism as a manifestation of an allergy. We have established to our satisfaction that this allergy is the result of the body cells becoming sensitized to alcohol. It naturally follows that the proper treatment is one which will desensitize the cells, restore them to normal, and add to their defensive mechanism by activating them and re-energizing them. Without such a corrective of the constitutional condition, neither the ordinary allergic patient who has not had a crisis, nor those who have passed through the crisis as a result of the negative treatment described above, can be benefited to any lasting extent. Since this body cell condition is a colloidal phenomenon, the logical treatment in the restoration to normal, physiologically, is the administration of an appropriate colloidal preparation such as that referred to in the case previously described. This particularly appeals to us in that our experience demonstrates that it relieves the necessity for the use of sedatives which often produce disastrous results, retard recovery and lead to various habit formations, and in addition, the danger of “let-down” is obviated, as illustrated with the following cases: Case II (Hospital No, 431). – A man of thirty-six just returning from China, where he had been drinking heavily for five or six months, presented himself for treatment, with the usual history. Following the standard method of detoxication, a tremor, of the intention type, persisted, which we were unable to relieve with the usual means of sedatives or physiotherapy. we then use the special colloidal iodine complex and colloidal gold, and, in about a week, there was a marked dimunition in the tremor. After two weeks of further treatment, the condition was scarcely noticeable and the craving for alcohol has not returned. Case III (Hospital No. 981). – A young man of twenty-eight had suffered severe attacks of migraine since the age of 14. He had been said to be allergic to many forms of food and had eliminated most type of food as a consequence. He had for some time been using morphine and hyocine for relief of the attacks of pain. For the last few months, he had been living in a room from which all light had been eliminated, believing that was of further benefit to him. His weight was eighty pounds. His mental attitude was one of despair and he had practically lost all interest in the general affairs of life. Following our detoxicating treatment, we decided, along with our usual procedure in such cases9 to try the special colloidal iodine complex and colloidal gold preparation (previously referred to as being appropriate with alcoholics). The result was that in the next two weeks he had gained fourteen pounds, was able to endure his attacks of migraine, which were much milder in character, was eating a mixed diet, moving about daily, and is talking of resuming his studies. However, these patients are still in the second phase of the entire condition, and elimination of the phenomenon of craving that follows the treatment does not constitute a cure. In some cases, desire never returns. In others, relapses occur, but it is noteworthy that the intervals between debauches are lengthened, and the sprees, when they do occur, are not prolonged. As in the case of any other allergy, the body can not usually be exposed again to the sensitizing agent without danger. In these patients, therefore, there can be no compromise with alcohol. The final cure rests with themselves. What we can do is to give them a sound physical basis on which to build the intelligently controlled mental attitude which is essential to their complete restoration. This however will be discussed when we outline the third phase of treatment. We must utter a word of caution here, however, which is that measures designed to contribute to the physical rehabilitation of the patient are not indicated while delirium tremens is imminent, but only when the crisis has been brought under control or where no such crisis exists. PSYCHOTHERAPEUTIC APPROACH Most of these allergics are above average in intelligence and become worthwhile members of society when freed from alcohol. In some, constitutional psychopaths, manic-depressives, and those in whom alcohol has produced a degenerative condition of the brain cells, the prognosis is bad; with these, temporary improvement is obtained but relapse is the rule. By this, we do not mean that, where the prognosis is bad, the alcoholic should be cast aside into the psychopathic scrap heap without any attempt at reclamation. Frequently, a patient with a seemingly complete mental breakdown shows a remarkable transformation after his system has been detoxicated and re-normalized. In other words, it is usually is impossible to predict whether there is anything left worth saving and on which to build, until he has been normalized by the treatment and medication described. When this has been done, then, for the first time, we can see what material we have to work with in trying to restore a normal attitude toward life. In allergics with physical ailments or deformities the prognosis is good, especially if during hospitalization the other condition can be remedied. But the largest group comprises individuals as normal as the rest of us except that they have become allergic to alcohol. They must be given an intelligent conception of their anaphylactic condition. Our approach is somewhat as follows: We endeavor to impress upon the patient that his condition is physical and not mental as regards the drug; that the reasons he gives for drinking (social and financial problems, escape from a feeling of inferiority, etc.) are but alibis. He has a medical problem to face, that a law of nature is working inexorably in his case as in a diabetic. We define allergy and interpret its characteristics, until we are sure he has grasped the fundamental nature of the case. He can then appreciate that only by entirely avoiding the toxic factor, alcohol, can he avoid an “attack” of alcoholism. If we can bring our detoxicated and cell normalized patient who has lost his craving for alcohol, to this viewpoint, he will be in a position to make a decision to forego its use. Without quibbling over words, we wish to differentiate between a decision and a resolution, or declaration, of which the alcoholic has probably made many. A resolution is an expression of a momentary emotional desire to reform. Its influence lasts only until he has an impulse to take a drink. A decision on the other hand, is the expression of a mental conviction, based on an intelligent conception of his condition. After a resolution is made the individual must fight constantly with himself; the old environmental forces are still arrayed against him, and he finally succumbs to his old means of escape. However, if he has made a decision, through understanding of facts appealing to his intelligence, he has changed his entire attitude. He can go back to his former environment, mix with his drinking friends (without concern, because his craving has been counteracted), and meet his worries and disappointments as a normal person: he is free from all the emotional restrictions that formerly activated him to drink. No will power is needed because he is not tempted. We have seen this reasoning operate successfully in many cases, even as we have seen many failures following what we term resolutions or declarations. MORAL PSYCHOLOGY We believe that this decision is in the nature of an inspiration. The patient knows he has reached a lasting conclusion, and experiences a sense of great relief. These individuals, introverts for the most part, whose interests center entirely in themselves, once they have made their decision, frequently ask how they can help others. Case III (Hospital No. 993). – A man of thirty-eight, who had been drinking heavily for five years, had lost all of his property and was practically disowned by his family, was brought to the hospital with a gastric hemorrhage. His general condition was typical of allergic alcoholism and apparently he was mentally beyond hope. Following through elimination and medical rehabilitation, he made a satisfactory physical return. He then took up moral psychology and, in two years’ time has entirely recovered his lost fortune and has been elected to a prominent public position. On meeting this patient recently, we experienced a strange sensation; while we recognized the features, a different man seemed to be speaking, as if a self-confident stranger had stepped into this man’s body. Case IV (Hospital No. 1152). – A broker, who had earned as much as $25,000 a year, and had come, through alcohol, to a position where he was being supported by his wife, presented himself for treatment carrying with him two books on philosophy from which he hoped to get a new inspiration: His desire to discontinue alcohol was intense, and he certainly made every effort within his own capabilities do to so. Following the course of treatment in which the alcohol and toxic products were eliminated and his craving counteracted, he took up moral psychology. At first, he found it difficult to rehabilitate himself financially, as his old friends had no confidence in his future conduct. Later he was given an opportunity, and is now a director in a large corporation. He gives part of his income to help others in his former condition, and he has gathered about him a group of over fifty men, all free from their former alcoholism through the application of this method of treatment and “moral psychology.” To such patients we recommend “moral psychology,” and in those of our patients who have joined or initiated such groups the change has been spectacular. (1) Silkworth, W.D. Alcoholism as a Manifestation of Allergy, Medical Record, March 17, 1937.

The beginning and subsequent development of a new approach to the problem of permanent recovery for the chronic alcoholic has already produced remarkable results and promises much for the future this statement is based upon four years of close observation. As this development is one, which has sprung up among alcoholic patients themselves and has been largely conceived and promoted by them, it is felt that this new treatment can be reported freely and objectively. The central idea is that of a fellowship of ex-alcoholic men and women banded together for mutual help. Each member feels duty bound to assist alcoholic newcomers to get upon their feet. These in turn work with still others, in an endless chain. Hence there is a large growth possibility. In one locality, for example, the fellowship had but three members in September, 1935, eighteen months later the three had succeeded with seven more These ten have since expanded to ninety. It is much more than a sense of duty, however, which provides the requisite driving power and harmony so necessary for success. One powerful factor is that of self-preservation. These ex-alcoholics frequently find that unless they spend time helping others to health they cannot stay sober themselves. Strenuous, almost sacrificial work for other sufferers is often imperative in the early days of their recovery. This effort proceeds entirely on a good will basis It is an avocation. There are no fees or dues of any kind, nor do these people organize in the ordinary sense of the word. These ex-alcoholic men and women number about one hundred and fifty. One group is scattered along the Atlantic seaboard with New York as a center. Another, and somewhat larger body, is locate in the Middle West. Many walks of life are represented, though business and professional types predominate. The unselfishness, the extremes to which these men and women go to help each other, the spirit of democracy, tolerance and sanity which prevails, are astonishing to those who know something of the alcoholic personality. But these observations do not adequately explain why so many gravely involved people are able to remain sober and face life again. The principle answer is each ex-alcoholic has had, and is able to maintain, a vital spiritual or “religious” experience. This so-called “experience” is accompanied, by marked changes in personality. There is always, in a successful case, a radical change in outlook, attitude and habits of thought, which sometimes occur with amazing rapidity, and in nearly all cases these changes are evident within a few months, often less. That the chronic alcoholic has sometimes recovered by religious means is a fact centuries old. But these recoveries have been sporadic, insufficient in numbers or impressiveness to make headway with the alcoholic problem as a whole. The conscious search of these ex-alcoholics for the right answer has enabled them to find an approach, which has been effectual in something like half of all the cases upon which it has been tried. This is a truly remarkable record when it is remembered that most of them were undoubtedly beyond the reach of other remedial measures. The essential features of this new approach, without psychological embellishment are: 1. The ex-alcoholics capitalize upon a fact, which they have so well demonstrated, namely: that one alcoholic can secure the confidence of another in a way and to a degree almost impossible of attainment by a non-alcoholic outsider. 2. After having fully identified themselves with their “prospect” by a recital of symptoms, behavior, anecdotes, etc., these men allow the patient to draw the inference that if he is seriously alcoholic, there may be no hope for him save a spiritual experience. They cite their own cases and quote medical opinion to prove their point. If the patient insists he is not alcoholic to that degree, they recommend he try to stay sober in his own way. Usually, however, the patient agrees at once. If he does not, a few more painful relapses often convince him. 3. Once the patient agrees that he is powerless, he finds himself in a serious dilemma. He sees clearly that he must have a spiritual experience or be destroyed by alcohol. 4. This dilemma brings about a crisis in the patient’s life. He finds himself in a position, which, he believes, cannot be untangled by human means. He has been placed in this position by another alcoholic who has recovered through a spiritual experience. This peculiar ability, which an alcoholic who has recovered exercises upon one who has not recovered, is the main secret of the unprecedented success, which these men and women are having. They can penetrate and carry conviction where the physician or the clergyman cannot. Under these conditions, the patient turns to religion with an entire willingness and readily accepts, without reservation, a simple religious proposal. He is then able to acquire much more than a set of religious beliefs; he undergoes the profound mental and emotional change common to religious “experience” (See William James’ Varieties of Religious Experience). Then too, the patient’s hope is renewed and his imagination is fired by the idea of membership in a group of ex-alcoholics where he will be enabled to save the lives and homes of those who have suffered as he has suffered. 5. The fellowship is entirely indifferent concerning the individual manner of spiritual approach so long as the patient is willing to turn his life and his problems over to the care and direction of his Creator. The patient may picture the Deity in any way he likes. No effort whatever is made to convert him to some particular faith or creed. Many creeds are represented among the group and the greatest harmony prevails. It is emphasized that the fellowship is non-sectarian and that the patient is entirely free to follow his own inclination. Not a trace of aggressive evangelism is exhibited. 6. If the patient indicates a willingness to go on, a suggestion is made that he do certain things which are obviously good psychology, good morals and good religion, regardless of creed. a. That he make a moral appraisal of himself, and confidentially discuss his findings with a competent person whom he trusts. b. That he try to adjust bad personal relationships, setting right, so far as possible, such wrongs as he may have done in the past. c. That he recommit himself daily, or hourly if need be, to God’s care and direction, asking for strength. d. That, if possible, he attend weekly meetings of the fellowship and actively lend a hand with alcoholic newcomers. This is the procedure in brief. The manner of presentation may vary considerably, depending upon the individual approached, but the essential ingredients of the process are always much the same. When presented by an ex-alcoholic, the power of this approach is remarkable. For a full appreciation one must have known these patients before and after their change. Considering the presence of the religious factor, one might expect to find unhealthy emotionalism and prejudice. This is not the case however; on the contrary, there is an instant readiness to discard old methods for new ones, which produce better results. For instance, it was early found that usually the weakest approach to an alcoholic is directly through his family or friends, especially if the patient is drinking heavily at the time. The ex-alcoholics frequently insist, therefore, that a physician first take the patient in hand, placing him in a hospital whenever possible If proper hospitalization and medical care is not carried out, this patient faces the danger of delirium tremens, “wet brain” or other complications After a few days’ stay, during which time the patient has been thoroughly detoxicated, the physician brings up the question of permanent sobriety and,’ if the patient is interested, tactfully introduces a member of the ex-alcoholics group. By this time the prospect has self-control, can think straight, and the approach to him can be made casually, with no intervention by family or friends. More than half of this fellowship has been so treated. The group is unanimous in its belief that hospitalization is desirable, even imperative, in most cases. What has happened to these men and women? For years, physicians have pursued methods, which bear same similarity to those outlined above. An effort is being made to procure a frank discussion with the patient, leading to self-understanding. It is indicated that he must make the necessary re-adjustment to his environment. His cooperation and confidence must be secured. The objectives are to bring about extraversion and to provide someone to whom the alcoholic can transfer his dilemma. In a large number of cases, this alcoholic group is now attaining these very objectives because their simple but powerful devices appear to cut deeper than do other methods of treatment because of the following reasons: 1. Because of their alcoholic experiences and successful recoveries they secure a high degree of confidence from the prospects. 2. Because of this initial confidence, identical experience, and the fact that the discussion is pitched on moral and religious grounds, the patient tells his story and makes his self-appraisal with extreme thoroughness and honesty. He stops living alone and finds himself within reach of a fellowship with whom he can discuss his problems as they arise. 3. Because of the ex-alcoholic brotherhood, the patient, too, is able to save other alcoholics from destruction. At one and the same time, the patient acquires an ideal, a hobby, a strenuous avocation, and a social life, which he enjoys among other ex-alcoholics and their families. These factors make powerfully for his extraversion. 4. Because of objects aplenty in whom to vest his confidence, the patient can turn to the individuals to whom he first gave his confidence, the ex-alcoholic group as a whole, or the Deity. It is paramount to note that the religious factor is all-important even from the beginning. Newcomers have been unable to stay sober when they have tried the program minus the Deity. The mental attitude of the people toward alcohol is interesting. Most of them report that they are seldom tempted to drink. If tempted, their defense against the first drink is emphatic and adequate. To quote from one of their number, once a serious case at this hospital, but who has had no relapse since his “experience” four and one-half years ago: “Soon after I had my experience, I realized I had the answer to my problem. For about three years prior to December 1934 I had been taking two and sometimes three bottles of gin a day. Even in my brief periods of sobriety, my mind was much on liquor, especially if my thoughts turned toward home, where I had bottles hidden on every floor of the house. Soon after leaving the hospital, I commenced to work with other alcoholics. With reference to them, I thought much about alcohol, even to the point of carrying a bottle in my pocket to help them through the severe hangovers. But from the first moment of my experience, the thought of taking a drink myself hardly ever occurred. I had the feeling of being in a position of neutrality. I was not fighting to stay on the water wagon. The problem was removed; it simply ceased to exist for me. This new state of mind came about in my case at once and automatically. About six weeks after leaving the hospital my wife asked me to fetch a small utensil, which stood on a shelf in our kitchen. As I fumbled for it, my hand grasped a bottle, still partly full. With a start of surprise and gratitude, it flashed upon me that not once during the past weeks had the thought of liquor being in my home occurred to me. Considering the extent to which alcohol had dominated my thinking, I call this no less than a miracle. During the past your pears of sobriety I have seriously considered drinking only a few times. On each occasion, my reaction was one of fear, followed by the reassurance, which came with my new found ability to think the matter through, to work with another alcoholic, or to enter upon a brief period of prayer and meditation. I now have a defense against alcoholism which is positive so long as I keep myself spiritually fit and active, which I am only too glad to do.” Another interesting example of reaction to temptation comes from a former patient; now sober three and one-half years. Like most of these people, he was beyond the reach of psychiatric methods. He relates the following incident: “Though sober now for several years, I am still bothered by periods of deep depression and resentment. I live on a farm, and weeks sometimes pass in which I have no contact with the ex-alcoholic group. During one of my spells I became violently angry over a trifling domestic matter. I deliberately decided to get drunk, going so far as to stock my guesthouse with food, thinking to lock myself in when I had returned from town with a case of liquor. I got in my car and started down the drive; still furious. As I reached the gate I stopped the car, suddenly feeling unable to carry out my plan. I said to myself, at least I have to be honest with my wife. I returned to the house and announced I was on my way to town to get drunk. She looked at me calmly, never saying a word. The absurdity of the whole thing burst upon me and I laughed and so the matter passed. Yes, I now have a defense that works. Prior to my spiritual experience I would never have reacted that way.” The testimony of the membership as a whole sums up to this: For the most part, these men and women are now indifferent to alcohol, but when the thought of taking a drink does come, they react sanely and vigorously. This alcoholic fellowship hopes to extend its work to all parts of the country and to make its methods and answers known to every alcoholic who wishes to recover as a first step, they have prepared a book called Alcoholics Anonymous*. A large volume of 400 pages, it sets forth their methods and experience exhaustively, and with much clarity and force. The first half of the book is a text aimed to show an alcoholic the attitude he ought to take and precisely the steps he may follow to affect his own recovery. He then finds full directions for approaching and working with other alcoholics. Two chapters are devoted to working with family relations and one to employers for the guidance of those who surround the sick man. There is a powerful chapter addressed to the agnostic, as the majority of the present members were of that description. Of particular interest to the physician is the chapter on alcoholism dealing mostly with its mental phenomena, as these men see it. By contacting personally those who are getting results from the book, these ex-alcoholics expect to establish new centers. Experience has shown that as soon as any community contains three or four active members, growth is inevitable, for the good reason that each member feels he must work with other alcoholics or perhaps perish himself. Will the movement spread? Will all of these recoveries be permanent? No one can say. Yet, we at this hospital, from our observation of many cases, are willing to record our present opinion as a strong “Yes” to both questions. *EDITOR’S NOTE. The book, Alcoholics Anonymous ($3.50) may be secured from The Alcoholic foundation, Post Box 658, Church Street Annex, New York City. JOURNAL-LANCET, Vol.46, July, 1939

In a study of carefully recorded histories of alcoholics in our hospital, two important facts appear to be outstanding. Expressed briefly, they are: 1) A majority or our patients do not wish to have an alcoholic problem. They lead busy lives & would like to enjoy the fruits of their efforts, but they cannot stop the use of alcohol. 2) These patients cannot use alcohol in moderation. The allergic nature of true alcoholism was postulated in a previous paper. We then endeavored to show that alcohol does not become a problem to every person who uses it, & that the use of alcohol in itself does not produce a chronic alcoholic. The phenomenon of craving must be present as a manifestation of an allergy. Once established in an individual, one drink creates a desire for more. It sets this person aside as a separate entity. It creates a conflict that ends in a form of neurosis. Looking further at the record of these unfortunates, we find that the majority could not drink in moderation from the very beginning. Whether 20, 30, or 50 years of age, they soon become a problem to themselves & to their friends. Now in analyzing these alcoholic-minded persons, there is no one physical or psychical fact that is sufficiently constant to justify its use as the basis of an accepted theory. Such phrases as “escape from reality” & “inferiority complex” hold true for some, but not all, while heredity, only son, & implied spoiling in childhood, account for a few more. They all lead to confusion & have no answer. Eliminate the constitutional psychopaths, the moral & mental defectives, & there remains a large class, neurotic in type, for whom something is worth doing. Remember we are discussing the chronic alcoholic, not the man who drinks more than is good for him but has no resulting problem. Apparently all these people – good, bad & indifferent – have one thing in common: they cannot drink in moderation. We believe they show manifestations of an allergy to alcohol. They may abstain from use of alcohol for a month or a year, but on taking it again in any form, they at once establish the phenomenon of craving. This fact is well known to all alcoholics & creates their major problems in the early stages of their drinking habits. They complain about it, too. Why, we naturally ask, in the early years of drinking, while they still have the ability to choose, do these people not solve this problem by the complete discontinuance of alcohol? Some do, but many are like the rest of us who do things we know we should not, but like to do them anyway. Many really believe they can drink as they see others doing, & enjoy themselves. For many reasons, most of which are social or even physical, the idea of drinking is developed gradually. As this idea advances, daily life becomes more secure, but these men are unwilling to accept the facts as presented to them. The act of drinking (in the end damaging) is followed by certain comfortable emotional states that make it a pleasure. They prove to themselves that they can stop drinking by going on the wagon for varying periods, but even as life becomes more complicated, they still persist in that old, original idea. Up to this time, in what one might call the first period of alcoholism there are methods employed to help these persons return to a normal life & accept the fact that their old idea of drinking must be discarded forever. We ourselves have treated some of them with permanent results, but the majority continues along the primrose path. The history of these people & their families present from now on, one of the real tragedies of human life & is too well known to comment on further here. This begins the second stage. Understood by no one & not understanding themselves, they enter an ever-widening circle, remorse, penance, new transgressions, new penance, until they lose all capacity for spontaneous action. They sacrifice themselves for a perversive idea & defying the law of nature (allergy) operating in their case, pay the penalty. They have lost all pleasure in normal life. Based on their underlying neurotic nature, they develop a compulsion type of thinking, and, although not a true compulsion neurosis, it is surely a borderline type. The patient now acts under what has been called by Wechsler a psychic imperative, the dreaded terminal state of paralysis of the will. The predisposing factor in bringing about this definite state of insecurity is the conflict brought about by alcoholism. It is not within the scope of this paper to discuss the complications of the obsessional neurosis, which are, in fact, the most elastic of all the neuroses, but in this particular type it seems to permit a retreat from the ever-increasing anxieties induced by the advancing chronic alcoholism. This compulsive thinking is apparently a purely intellectual process occurring more frequently among persons of relatively higher intellectual attainment, from which class, by the way, comes the average chronic alcoholic. Characteristic of all compulsion types of thinking is the relatively good insight that accompanies them. The victim knows his impulse to drink is wrong but he is helpless before it. Wives may plead, friends argue, & employers threaten, but he is no longer amenable to impression. He is unable to resolve between opposing impulses. He cries out in agony, “I must stop, I cannot be like this; but I cannot stop; someone must help me.” If he has sufficient means, he has by now been treated by psychiatrists, good men, who fully realize the unfavorable prognosis, but who, often without remuneration, give freely of their time to help the victim. I have often seen psychoanalysis of an alcoholic, instead of breaking up the compulsive thinking; start the person further theorizing on his own illness. We know that, as a rule, the only relief from psychoanalysis is in making the so-called transfer, & experience has taught us that this is gratifyingly successful if accomplished. If successful, it must be based on respect & confidence on the part of the patient. It can seldom be accomplished in this class of patients, except by one who has suffered in the same manner & has recovered. In other words, to accomplish the transfer of this compulsive idea by the plan we have seen developed, an ex-alcoholic who has recovered by the same means be the medium employed. Such a medium can explain convincingly, not only that the transfer of the compulsive thinking can be made, but also he can prove how he did it himself successfully. We physicians have realized for a long time that some form of moral psychology was of urgent importance to alcoholics, but its application presented difficulties beyond our conception. What with our ultramodern standards, our scientific approach to everything, we are perhaps not well equipped to apply the powers of good lying outside our synthetic knowledge. About four years ago, we hospitalized a young man for severe chronic alcoholism, &, while under our care he developed a plan that seemed to me to be a combination of psychology & religion. He never drank any form of alcohol again. Later he requested the privilege of being allowed to tell his story to other patients &, perhaps with some misgiving, we consented. The cases we have followed through have been most interesting: in fact many of them are amazing. The unselfishness of these men as we have come to know them, the entire absence of profit motive & their community spirit, are indeed inspiring to one who has labored long & wearily in the field of alcoholism. They believe in themselves, & still more in the Power which pulls chronic alcoholics back from the gates of death. Of course, prior to & in preparation for the application of this plan, it is, in my opinion, essential to detoxicate the alcoholics by hospitalization. You then have a subject whose brain is clear & whose mind is receptive & temporarily free from his craving. I hesitate here to attempt even an outline of the plan as employed by these men. Sufficient to say, perhaps, that following many failures, they gradually devised a plan or procedure that led them to make this so-called transfer to one greater than themselves, to God. The whole story is admirably told in a book written by them entitled “Alcoholics Anonymous”. It would seem to me that they have wrung from the Eternal a new application of an old truth that is sufficient equipment to restore the patient in his fight for sobriety. The results seem to flow naturally from a follow-up of honest effort. To make any such plan practical they have also projected this transfer beyond the individual to the group. The information of these men into groups, each one with the hand of fellowship passing on his experiences to others, helping those who have newly joined to adjust themselves, actively engaged in gathering in new members, seems to me the most practical application of their moral psychology, to assure their “transfer” of being permanent. (Although I have met some 30 or more of these ex-alcoholics. I relate my experience with two of them.) About one year prior to this experience a man was brought in to be treated for chronic alcoholism. He had but partially recovered from a gastric hemorrhage & seemed to be a case of pathological mental deterioration. He had lost everything worthwhile in life, & was only living, one might say, to drink. He frankly admitted & believed that for him there was no hope. Following the elimination of alcohol there was found to be no permanent brain injury. He accepted the plan outlined in the book. One year later he called to see me, & I experienced a very strange sensation. I knew the man by name & partly recognized his features, but there all resemblance ended. From a trembling, despairing, nervous wreck, had emerged a man brimming over with self-reliance & contentment. I talked with him for some time, but was not able to bring myself to feel that I had known him before. To me he was a stranger, & so he left me. More than three years have now passed with no return to alcohol. When I need a mental uplift, I often think of another case brought in by a physician, prominent in New York City. The patient made his own diagnosis, & deciding that his condition was hopeless, had hidden in a deserted barn, determined to die. He was rescued by a searching party, & in desperate condition brought to me. Following his physical rehabilitation, he had a talk with me in which he frankly stated he thought the treatment a waste of time & effort, unless I could assure him, which no one ever had, that in the future he could have the will power to resist the impulse to drink. His alcoholic problem was so complex, & his depression so great, that we felt his only hope would be through what we then called “moral psychology,” & we doubted if even that would have any effect. However, he did adopt the ideas contained in this book. He has not had a drink for more than three years. I see him now & then, & he is as fine a specimen as one could wish to meet.

Contemporary literature contains a wealth of information about chronic alcoholism, with here and there accounts of satisfactory methods of treatment. While we assume that these methods must represent some progress, yet as long as physicians are consulted in increasing numbers by worried mothers and heartsick wives and thousands of letters are written by victims of alcohol following an article suggesting possible help. One appreciates that the whole picture is still one of desperation. Scientific investigation of causes and problems of relief as undertaken by The Research Council on Problems of Alcohol should receive our earnest support. This scientific and unbiased group is almost certain to render a great service to humanity in the future. But what of the present, of the problems of alcohol as they are presented today? What of the alarming number of important men, victims of alcohol, or at least laboring under diminished efficiency? This paper will endeavor to answer some part of these questions. We are dealing with a complex human problem not very well understood by any of us, so it might help a little if we first attempt to clear up some of the confusion by stating a few facts, at least they seem to be such to us. Any accurate attempt at grouping alcoholics is difficult, as one type frequently blends into another. Subject to this qualification we may classify these problem drinkers as follows: 1. Those who do not wish to stop. They generally admit the fallacy of their position and are a source of annoyance to all. 2. The constitutional psychopaths. They have a wealth of resolutions but a paucity of results. 3. The manic-depressive type. They often end their own lives. 4. This leaves roughly speaking the majority of alcoholics who prior to developing an alcoholic problem were average men and women of neurotic tendency and often great intelligence. Another source of confusion it seems to us is that these people have a physical as well as a mental problem. The physical problem is that they cannot drink in moderation either by the use of will power, application of intelligence or any other form of persuasion. In 1937 I suggested, based on clinical evidence, that the phenomenon of craving, limited to this type of drinker, was an allergic manifestation. This man is the true alcoholic. He is generally the “spree drinker.” Whether this theory will stand the test of further research, it is a fact that when free from alcohol the physical condition returns to normal; but the patient is still alcoholic conscious. Another source of confusion is the difficulty found to persuade man while drinking to undertake any helpful measure. After thorough detoxication, by hospitalization, they can be approached. We shall now try to tell very briefly the most satisfactory answer to chronic alcoholism after detoxification that we know, although the psychic phenomenon that transfers a person from an alcoholic to a nonalcoholic could be more easily discussed if we understood better the original cause of his compulsion to drink. Also, we must emphasize that unfortunately in presenting a possible relief for the alcoholic, reservation must be made as to its application, and suitable types must be selected. Not over fifty percent can or will follow the mental discipline that must be experienced to obtain relief by the method we are about to describe. Moreover, to introduce a semi-religious note into a medical article there must be enough solid sense behind the sentiment to make it really practical. Some seven years ago an alcoholic developed an idea which while not new in itself was unique in its application. It would take too long to tell the story here but perhaps the fundamental principle of this plan is that the alcoholic for reasons best understood by psychiatrists is not sufficient unto himself. He is not the captain of his own soul. The approach to this plan, by means of which forces within the man are put to work, must be through the medium of a former alcoholic who has received help by the same means. You will be gratified at the confidence these ex—alcoholic men and women instill into the skeptical or reluctant alcoholic. These men and women form into groups, the agreed purpose of which is not only to help themselves but to convey the plan to others in distress and in this way come again to realize the real joy of living. Through their efforts to help others they become true extroverts. It has proved so successful that groups have formed in over a hundred cities throughout the United States in seven years, and there have been approximately thirty— five hundred men and women relived of their alcoholic problems. What is true in the realm of science is true in the personal lives of these men and women. They readjust the principles by which they shall live. With intelligence, faith, and the cooperation of the group subject to the limitations stated above, this man becomes the captain of his own soul and victory is certain. The power these men and women learn to draw from, provided they have this desire and faith, is apparently sufficient for their purpose. The Rev. Harry Emerson Fosdick, speaking of this group, says with his usual clarity, to quote in part: “Now comes a movement, an astonishing, apt and pertinent movement, where men who have been in the thick of this thing, who have faced the hopelessness of the situation, who have felt they never could get well, have found resources of strength, and have come out and there is not a thing about alcoholism they do not know. I think that, psychologically speaking, there is a point of advantage in the approach that is being made in this movement that cannot be duplicated. There is another element in this movement that interests me – its tolerance, its breadth, its inclusiveness, its catholicity. Here is a movement that puts its arm around medicine on the one side, and religion on the other. I think the spirit in which this work is carried on is wise and promising. No one is a prophet but I suspect there is a long road ahead for this movement.” The physician while an earnest seeker after truth is in no position to recommend all the fads presented to him. Here is a plan emanating from no “authority,” no leaders, nothing to sell, strictly ethical, and asking for and receiving the cooperation of physicians. A statement from two physicians in Philadelphia, Dr. A.W. Hammer, surgeon, and Dr. C. Dudley Saul, chief resident of St. Lukes’s and Children’s Hospital will illustrate this growing sentiment, to quote in part: “We can testify as physicians to the increasing interest in this movement among members of the medical profession, and we are grateful for the opportunity that the group has given us of aiding in the recovery of the unfortunate victims of alcoholism.” To illustrate further the spirit of cooperation with physicians, a statement by William G. Turnbull,M.D., superintendent of the Philadelphia General Hospital: “The Alcoholics Anonymous under the leadership of Mr. B. has been working in this institution for the past year. I feel that this organization has done definite good as several men whom I know have been chronic alcoholics have apparently stopped drinking. The organization has given no trouble in the institution, has fitted in well with our organization, and I am glad to endorse them to any institution where there is work for them to do.” Also, Dr. John F. Stouffer, physician and psychopathologist of the same hospital, states in part: “In our opinion this is a very worthwhile undertaking and we feel that your cooperation with them will be beneficial to those concerned.” A letter written by Dr. R. E. Blaisdell, medical superintendent of Rockland State Hospital, New York, to a fellow physician, should interest those sincerely seeking the value of this movement. I quote in part: “During the past year Mr. D. and others of the group have been interested in extending the benefits of Alcoholic Anonymous to recovered alcoholics of the hospital, who are about to leave the institution or prior to and after the return to their homes in the community. We think he has been of great assistance to us in bringing about personality adjustments among our recovered alcoholics to the end that a large percentage of them become total abstainers, take up their family responsibilities and become useful citizens again in community life.” Mr. John D. Rockefeller, Jr. who has contributed so much to the advancement of medical science states: “For some time I have been greatly interested in Alcoholics Anonymous, a movement by ex—alcoholics on behalf of others in need. Already outstanding results have been produced by their wise and self—sacrificing methods. I believe they are deserving of support. I am giving them mine.” The Charles B. Towns Hospital, of New York City, one of the few hospitals specializing in the treatment of alcoholism, states, to quote in part: “We have followed the development and growth of this movement from its inception. The attitude of the men of this group as we have observed them is above reproach. As ex-alcoholics we have found them to appreciate the necessity of proper medical treatment to eliminate the craving for alcohol, restore appetite and sleep, before the patient is ready for introduction to a possible permanent relief. They have been of definite assistance in enabling us to lift men and women out of their alcoholic problem and return them as useful members of society.” For further information of the methods used by this group I would urge all physicians to read a most interesting article by Dr. P. L. Smith, published in the July issue of the Psychiatric Quarterly, the official organ of the New York State Department of Mental Hygiene. Dr. Smith reports 50.1 percent recovery in a group of 111 alcoholics. Conclusion In conclusion, why men and women begin to use alcohol for pleasure or some sort of satisfaction peculiar to themselves and continue as problem drinkers is unknown. This mental state has many symptoms suggesting a neurosis with an obsessional trend. All those having to treat a neurotic personality with an obsessional type of thinking have found the prognosis unfavorable. This seems to be particularly illustrated in the alcoholic. While science is still seeking a remedy for this situation these men offer us at least a breathing spell that has proved fifty—percent efficient. If a man can, through the ministrations of this group become a part of the Universal Process and knows that he is a part, that is security. He accepts ideas that have been subjected to tests of experience. Above all else, it means seeing the truth, acknowledging the truth, and following the truth at all times, regardless of consequences.

The mystery of slips is not so deep as it may appear. While it does seem odd that an alcoholic, who has restored himself to a dignified place among his fellowmen and continues dry for years, should suddenly throw all his happiness overboard and find himself again in mortal peril of drowning in liquor, often the reason is simple.

People are inclined to say, “there is something peculiar about alcoholics. They seem to be well, yet at any moment they may turn back to their old ways. You can never be sure.”

This is largely twaddle. The alcoholic is a sick person. Under the technique of Alcoholics Anonymous he gets well – that is to say, his disease is arrested. There is nothing unpredictable about him any more than there is anything weird about a person who has arrested diabetes.

Let’s get it clear, once and for all, that alcoholics are human beings. Then we can safeguard ourselves intelligently against most slips.

In both professional and lay circles, there is a tendency to label everything that an alcoholic may do as “alcoholic behavior.” The truth is, it is simple human nature.

It is very wrong to consider any of the personality traits observed in liquor addicts as peculiar to the alcoholic. Emotional and mental quirks are classified as symptoms of alcoholism merely because alcoholics have them, yet those same quirks can be found among non-alcoholics too. Actually they are symptoms of mankind!

Of course, the alcoholic himself tends to think of himself as different, somebody special, with unique tendencies and reactions. Many psychiatrists, doctors, and therapists carry the same idea to extremes in their analyses and treatment of alcoholics.

Sometimes they make a complicated mystery of a condition which is found in all human beings, whether they drink whiskey or buttermilk.

To be sure, alcoholism, like every other disease, does manifest itself in some unique ways. It does have a number of baffling peculiarities which differ from those of all other diseases.

At the same time, any of the symptoms and much of the behavior of alcoholism are closely paralleled and even duplicated in other diseases.

The slip is a relapse! It is a relapse that occurs after the alcoholic has stopped drinking and started on the A.A. program of recovery. Slips usually occur in the early states of the alcoholic’s A.A. indoctrination, before he has had time to learn enough of the A.A. techniques and A.A. philosophy to give him a solid footing. But slips may also occur after an alcoholic has been a member of A.A. for many months or even several years, and it is in this kind, above all, that often finds a marked similarity between the alcoholic’s behavior and that of “normal” victims of other diseases.

No one is startled by the fact that relapses are not uncommon among arrested tubercular patients. But here is a startling fact – the cause is often the same as the cause which leads to slips for the alcoholic.

It happens this way: When a tubercular patient recovers sufficiently to be released from the sanitarium, the doctor gives him careful instructions for the way he is to live when he gets home. He must drink plenty of milk. He must refrain from smoking. He must obey other stringent rules.

For the first several months, perhaps for several years, the patient follows directions. But as his strength increases and he feels fully recovered, he becomes slack. There may come the night when he decides he can stay up until ten o’clock. When he does this, nothing untoward happens. Soon he is disregarding the directions given him when he left the sanitarium. Eventually he has a relapse.

The same tragedy can be found in cardiac cases. After the heart attack, the patient is put on a strict rests schedule. Frightened, he naturally follows directions obediently for a long time. He, too, goes to bed early, avoids exercise such as walking upstairs, quits smoking, and leads a Spartan life. Eventually, though there comes a day, after he has been feeling good for months or several years, when he feels he has regained his strength, and has also recovered from his fright. If the elevator is out of repair one day, he walks up the three flights of stairs. Or he decides to go to a party – or do just a little smoking – or take a cocktail or two. If no serious aftereffects follow the first departure from the rigorous schedule prescribed, he may try it again, until he suffers a relapse.

In both cardiac and tubercular cases, the acts which led to the relapses were preceded by wrong thinking. The patient in each case rationalized himself out of a sense of his own perilous reality. He deliberately turned away from his knowledge of the fact that he had been the victim of a serious disease. He grew overconfident. He decided he didn’t have to follow directions.

Now that is precisely what happens with the alcoholic – the arrested alcoholic, or the alcoholic in A.A. who has a slip. Obviously, he decides to take a drink again some time before he actually takes it. He starts thinking wrong before he actually embarks on the course that leads to a slip.

There is no reason to charge the slip to alcoholic behavior or a second heart attack to cardiac behavior. The alcoholic slip is not a symptom of a psychotic condition. There’s nothing screwy about it at all. The patient simply didn’t follow directions.

For the alcoholic, A.A. offers the directions. A vital factor, or ingredient of the preventive, especially for the alcoholic, is sustained emotion. The alcoholic who learns some of the techniques or the mechanics of A.A. but misses the philosophy or the spirit may get tired off following directions – not because he is alcoholic, but because he is human. Rules and regulations irk almost anyone, because they are restraining, prohibitive, negative. The philosophy of A.A. however, is positive and provides ample sustained emotion – a sustained desire to follow directions voluntarily.

In any event, the psychology of the alcoholic is not as different as some people try to make it. The disease has certain physical differences, yes, and the alcoholic has problems peculiar to him, perhaps, in that he has been put on the defensive and consequently has developed frustrations. But in many instances, there is no more reason to be talking about “the alcoholic mind” than there is to try to describe something called “the cardiac mind” or the “TB mind.”

I think we’ll help the alcoholic more if we can first recognize that he is primarily a human being – afflicted with human nature.

Anyone who tried to impress a drinking alcoholic with the approach, “You can’t have your cake and eat it, too,” would probably draw a scornful, “So what! Who wants any cake? Tony, make it a double this time.” The same idea expressed as, “You can’t have your bottle and drink it, too,” might get his attention because to a drinking alcoholic a fresh unopened bottle, brimming brightly with abundance, is a symbol of good things to come. He knows well enough, of course, that he can’t drink it and still have it, but he blocks his mind to the inevitability of that horrible moment when the last bottle will be empty. The untapped bottle remains a symbol to the non-drinking alcoholic, at least to the alcoholic who has dried up in A.A. So long as it stands unopened it represents drinks he has not taken, and the good things of life he has found by not drinking. Yet now and then a persevering soul tries to have both the figurative and the liquid contents of the bottle. He tries to make an impossible compromise. In the opinion of a man who has administered personally to at least 10,000 alcoholics, the attempt to make this kind of compromise is one of the most common causes of failure to get a safe hold on A.A. Dr. W.D. Silkworth, genial and beloved little patriarch at Towns Hospital, New York, for twelve years and now (1945) also in charge of the new A.A. ward at Knickerbocker, also New York, defines it as the “alcoholic double-cross.” “The majority who slip after periods of sobriety,” says Dr. Silkworth, “having double-crossed themselves into thinking that somehow they can have the unopened bottle and drink it, too. Even though they have been in A.A. and going to meetings, and following parts of the program, they have accepted it with reservations somewhere. They actually have been one step ahead of a drink. Then they began playing around with the notion they can drink a little and still have the good things of A.A. The outcome is an inevitable as the bottle becoming empty once it has been opened by the alcoholic.” When Dr. Silkworth discusses A.A. “slips” his usually cheerful face becomes serious even a little grim. Through his long years of practice in the field, he has become increasingly sympathetic, but not case-hardened, to alcoholics. He understands what they experience. Having been one of the first in his profession to support A.A. and having guided scores of alcoholics into A.A., he also appreciates the fact that a “slip” for an A.A. involves an extra degree of remorse and misery. Dr. Silkworth is particularly emphatic on one point. “Slips are not the fault of A.A. I have heard patients complain, when brought in for another drying out, that A.A. failed them. The truth, of course, is that they failed A.A. But this mental maneuvering to transfer the blame is obviously another indication of fallacious thinking. It is another symptom of the disease.” A quick way to get Dr. Silkworth’s appraisal of A.A. is to ask him how he thinks “slips” can be prevented. “First,” he explains, “let’s remember the cause. The A.A. who “slips” has not accepted the A.A. program in its entirety. He has a reservation, or reservations. He’s tried to make a compromise. Frequently, of course, he will say he doesn’t know why he reverted to a drink. He means that sincerely and, as a matter of fact, he may not be aware of any reason. But if his thoughts can be probed deeply enough a reason can usually be found in the form of a reservation.” “The preventive, therefore, is acceptance of the A.A. program and A.A. principles without any reservations. This brings us to what I call the moral issue and to what I have always believed from the first to be the essence of A.A.” “Why does this moral issue and belief in a power greater than oneself appear to be the essential principle of A.A.? First, an important comparison is found in the fact that all other plans involving psychoanalysis, will-power, restraint and other ingenious ideas have failed in 95 per cent of the cases. A second is that all movements of reform minus a moral issue have passed into oblivion.” “Whatever may be the opinions one professes in the matter of philosophy -whether one is a spiritualist or a scientific materialist – one should recognize the reciprocal influence which the moral and physical exert upon each other. Alcoholism is a mental and physical issue. Physically a man has developed an illness. He cannot use alcohol in moderation, at least not for a period of enduring length. If the alcoholic starts to drink, he sooner or later develops the phenomenon of craving.” “Mentally, this same alcoholic develops an obsessive type of thinking which, in itself a neurosis, offers an unfavorable prognosis through former plans of treatment. Physically – science does not know why – a man cannot drink in moderation. But through moral psychology – a new interpretation of an old idea – A.A. has been able to solve his former mental obsession. It is the vital principle of A.A., without which A.A. would have failed even as other forms of treatment have failed.” “To be sure, A.A. offers a number of highly useful tools or props. Its group therapy is very effective. I have seen countless demonstrations of how well your ‘24-hour plan’ operates. The principle of working with other alcoholics has a sound psychological basis. All of these features of the program are extremely important.” “But, in my opinion, the key principle which makes A.A. work where other plans have proved inadequate is the way of life it proposes based upon the belief of the individual in a Power greater than himself and the faith that this Power is all sufficient to destroy the obsession which possessed him and was destroying him mentally and physically.” “For many years I faced this alcoholic problem being sure of one scientific fact – that detoxication by medical treatment must precede any psychiatric approach. I have tried many of these orthodox psychiatric approaches and invented some new ones of my own. With some patients I would be coldly analytical, if they were of the so-called ‘scientific’ type who is apt to have a superior attitude toward anything emotional or spiritual. With others, I would try the ‘scare’ method, telling them that if they continued to drink they would kill themselves. With still others, I would attempt the emotional appeal, working both the patient and myself into a lather. He might be moved to the point of shaking hands dramatically and telling me, with tears streaming down his face, that he was never going to take another drink. And I knew that the probability was he would be drunk again within two weeks or less.” “Since I have been working with A.A. the comparative percentage of successful results has increased to an amazing extent.” “The percentage of success that A.A. has scored leaves no doubt that it has something more than we as doctors can offer. It is, I am convinced, your second step. Once the A.A. alcoholic has grasped that, he will have no more “slips.”

Dr. William Duncan Silkworth died of a heart attack in his home in New York, Thursday morning, March 22. Thus we of A.A. have lost the physical presence of the great doctor who was our first friend. He gave deep understanding and great encouragement to an infant society in the days when a lack of understanding or a word of discouragement might easily have killed it. He freely risked his professional reputation to champion an unprecedented spiritual answer to the medical enigma and the human tragedy of alcoholism. Without his blessing, our faith might well have died in its birth. He was a luminous exception to the rule that only an alcoholic understands an alcoholic. He knew us better than we knew ourselves… .better than we know each other. Many of us felt that his medical skill, great as that was, was not at all the full measure of his stature. Dr. Silkworth was something that it is difficult even to mention in these days. He was a saintly man. He stood in an unusual relationship to truth. He was able to see the truth of a man, when that truth was deeply hidden from the man himself and from everyone else. He was able to save lives that were otherwise beyond help of any kind. Such a man cannot really die. Our friend has only left us….for a while.

A drunk is lying on a bed in a hospital, and a doctor is sitting beside the bed. The drunk is talking earnestly to the doctor. “…a wave of depression came over me,” the drunk is saying. “I realized that I was powerless – hopeless – that I couldn’t help myself, and that nobody else could help me. I was in black despair. And in the midst of this, I remembered about this God business.. .and I rose up in bed and said, “If there be a God, let him show himself now!” (A doctor specializing in alcoholism hears all kinds of crazy stories from drunks in all stages of de-fogging. You’d expect him to have his tongue in his cheek at this point.) “All of a sudden, there was a light,” the drunk goes on, “a blinding white light that filled the whole room. a tremendous wind seemed to be blowing all around me and right through me. I felt as if I were standing on a high mountain top…” (You’d think a doctor would become hardened after listening to these drunks rave day after day. It’s a discouraging, thankless field… alcoholism.) The drunk continued: “I felt that I stood in the presence of God. I felt an immense joy. And I was sure beyond all doubt that I was free from my obsession with alcohol. The only condition was that I share the secret of this freedom with other alcoholics and help them to recover.” The drunk paused and turned to the doctor. “Ever since it happened, I’ve been lying here wondering whether or not I’ve lost my mind. Tell me, doctor – am I insane – or not?” The drunk was Bill W. Fortunately for Bill — fortunately for A.A. — fortunately for the thousands of us who have come after – the doctor was Dr. Silkworth. By great good luck – or by the grace of God (depending upon your viewpoint) – the doctor was Dr. Silkworth. It would have been so easy to dismiss Bill’s experience as hallucination, one of the many possible vagaries of a rum-soaked brain. And a disparaging word from the doctor right at this point could have choked off the tender shoot of faith and killed it. Alcoholics Anonymous might have got started somewhere else, somehow. Or it might not. Certainly it wouldn’t have started here. Very possibly the life of every one of us A.A.’s hung on the doctor’s answer to the question, “Am I insane?” It was there that Dr. Silkworth made the first of his indispensable contributions to A.A. He knew – by an insight that no amount of medical training alone can give a man – that what had happened to Bill was real, and important. “I don’t know what you’ve got,” he told Bill, “but whatever it is, hang on to it. You are not insane. And you may have the answer to your problem.” The encouragement of the man of science, as much as the spiritual experience itself, started A.A. on its way. When Dr. Silkworth died of a heart attack in his home in New York early in the morning of March 22nd, even those A.A.s who knew him best and loved him most awoke to the realization that we had lost a greater friend, a greater doctor, a greater man than we had ever realized. It was particularly hard to appreciate the greatness of the man while Dr. Silkworth was yet with us, because of his profound personal modesty and the disarming gentleness, the unassuming and almost invisible skill, with which he accomplished his daily miracles of medical and spiritual healing. We know that he was a prodigious and relentless worker, but still it was a shock to discover that in his lifetime of work with those who suffer our disease, he had talked with 51,000 alcoholics – 45,000 at Towns Hospital and 6,000 at Knickerbocker! Yet he was never in a hurry. And he had no “formulas,” no stock answers. Somehow he found out very early that the unexpected was to be expected in alcoholism, and for a man who knew as many of the answers as he did, he came to each new case with a wonderfully open mind… the great and classic example of which is his handling of Bill. And this gentle little doctor with his white hair and his china blue eyes – child’s eyes, saints eyes – was a man of immense personal courage. It must be remembered that he went much farther than merely encouraging Bill’s faith in his spiritual experience, he saw to it that Bill was permitted to come back into Towns Hospital to share his discovery with other alcoholics. Today – when “carrying the message to others” has become a very respectable part of an undeniably effective program – it is easy to forget that “carrying the message” in the beginning was a highly unorthodox undertaking. It had no precedent and no history of success; most authorities would have turned thumbs down on it as just plain screwball. Again, we forget how our technique has been mellowed and refined by the wisdom of experience. We know that the blinding light and the overwhelming rush of God-consciousness are not necessary, that they are indeed very rare phenomena and that the great majority of recoveries among us are of the much less spectacular gradual and educational kind. But in the beginning, the “hot flash” was stressed – nay, insisted upon. Dr. Silkworth had his professional reputation to lose, and nothing whatever to gain, by permitting and encouraging this unheard-of procedure of one God-bitten drunk trying to pass on his strange story of a light and a vision to other alcoholics – most of whom at that time received it with lively hostility or magnificent indifference. Then Bill met Dr. Bob, and the first few drunks, incredulously, began to make their incredible recoveries. The infant society, without a book, without a program really, and without a reputation or standing of any kind – began its growth. We forget how halting and feeble that early growth was, how bedeviled with obstacles in a world skeptical of spiritual experience and often hostile to it. Dr. Silkworth from the beginning threw all of his weight as a doctor, a neurologist, a specialist in alcoholism, into aiding the progress of this mongrel and highly unpedigreed society in every possible way. He committed social and professional heresy right and left in order to publish and implement his burning faith in a movement which as yet only half-suspected its own destiny and which had to grope rather blindly to find terms for its own faith in itself. When there was need for money to publish the book Alcoholics Anonymous, Dr. Silkworth used his personal influence without stint to help raise the money. As a preface to the book he wrote the chapter titled, “The Doctors Opinion,” giving A.A. his praise and approval without reservation or qualification- at a time when there were only a thin one hundred of us dried up! He was indeed our first friend, and indeed a friend in need. His faith in us was firmer than our faith in ourselves. Bill says: “Without Silky’s help, we never would have got going – or kept going!” Again, his contribution was indispensable. Why did he do it? The answer to that is the answer to Dr. Silkworth’s whole career: he loved drunks. Why he loved drunks is a secret known only to God and the doctor – and perhaps the doctor himself did not wholly understand the mystery. “It’s a gift,” he used to say, his eyes twinkling. He discovered his gift very early in his medical practice. He was graduated from Princeton in 1896, and took his medical degree at New York University in 1900. Then he interned at Bellevue; and it was while working at Bellevue that he found he was drawn to alcoholics, and they to him. When nobody else could calm a disturbed drunk, Dr. Silkworth could. And he found, rather to his amazement, that even the toughest and most case-hardened of drunks would talk to him freely – and that many of them, even more amazingly, wept. It became evident that he exerted – or that there was exerted through him – some kind of thawing influence on the life-springs of the alcoholic. Yet the years that followed were full of discouragement. There were two years on the psychiatric staff at the U.S. Army Hospital at Plattsburg, N.Y., during the first world war, followed by several years on the staff of the Neurological Institute of the Presbyterian Hospital in New York. Twice he entered into private practice, only to be drawn back into hospital work with alcoholics. His work continued on at Charles B. Towns Hospital, New York, a private hospital specializing in alcoholism and drug addiction. Here, Dr. Silkworth’s special skill with alcoholics – and his growing understanding and love for them – had full scope. Yet he estimated that the percentage of real recoveries among the alcoholics he worked with was only about 2 per cent. The large number of hopeless cases, and the deep degrees of human tragedy and suffering involved, weighed heavily upon the gentle doctor. He was often profoundly discouraged. Then came Bill – and A.A. One who has known the doctor intimately over many years has said this about it: “Silky never told me this. It’s my own opinion. But I believe that A.A. was Silky’s reward. All those years he plodded along – treating drunks medically – defending them – loving them – and not getting anywhere much. And then God said: “All right, little man, I’m going to give you and your drunks a lift!” And when the lighting struck, there was Silky, right where he belonged – in the midst of it!” Early in his career, at a time when alcoholism was almost universally regarded as a willful and deliberate persistence in a nasty vice, Dr. Silkworth came to believe in the essential goodness of the alcoholic. “These people do not want to do the things they do,” he insisted. “They drink compulsively, against their will.” One of the early drunks whom Dr. Silkworth treated, a big husky six-footer, dropped on his knees before the doctor, tears streaming down his face, begging for a drink. “I said to myself then and there,” Dr. Silkworth related, – this is not just a vice or habit. This is compulsion, this is pathological craving, this is disease!” He loved drunks – but there was nothing in the least degree fatuous or sentimental about that love. It could be an astringent love, an almost surgical love. There was the warmest of light in those blue eyes, but still they could burn right through to the bitter core of any lie, any sham. He could see clean through egotism, bombast, self-pity and similar miserable rags that we drunks use so cleverly to hide our central fear and shame. All this he did – without hurting anyone. While insisting rigorously that recovery was possible only on a moral basis – “You cannot go two ways on a one-way street” – he never preached, never denounced, never even really criticized. He brought you, somehow, to make your own judgments of yourself, the only kind of judgments that count with an alcoholic. How did he do it? “It’s a gift.” Just coming into his presence was like walking into light. He not only had vision – he gave vision. There is not room here – nor has there been opportunity for the necessary research – to consider his status as a medical man. It can be said that he held a position of very high eminence in his profession. He encountered opposition to some of his views, and he was latterly the recipient of very widespread recognition and praise for his work. It is literally true that he was the world’s greatest practical authority on alcoholism. His pioneering work in the concept of alcoholism as a manifestation of allergy has been validated by later experience and has been the subject of a great deal of medical interest and research just recently. Dr. Silkworth’s was a great contribution to the establishment and development of the alcoholic treatment center at Knickerbocker Hospital in New York. In later years, he was sought out for consultation and advice by doctors and by those in charge of state and city alcoholic treatment projects. There was a steady stream of visitors, some of them from foreign lands. Also, every day, there were long distance telephone calls from those seeking further help, those seeking his advice – all over the U.S. There remain these things to be noted: Dr. Silkworth was a small man, well under medium height. His complexion was ruddy. His remarkable eyes have been mentioned. His hair was snow white and no member of A.A. knew him otherwise, for he was already well along in years when our relationship began. You would say that the habitual expression of his face was a smile you thought about it, and realized that the features were really nearly always in repose, and the impression of a smile arose actually from a certain light about his face. ( Too many of us have noticed it to be mistaken!) He loved to be well dressed – was, in fact, quite dapper – and in this he was not without a certain whimsical and self- recognized vanity. Nurses – the hospital staff – everyone who worked with him quite plainly and simply adored him. He was unfailingly gentle, courteous, thoughtful. He was happily married, and he and Mrs. Silkworth shared a delight in growing things – in flowers – in gardening. He was utterly and completely indifferent to money, to position, to personal gain or prestige of any kind. He was a saintly man. We drunks can thank Almighty God that such a man was designated by the divine Providence to inspire and guide us, individually and as a group, on the long way back to sanity. And now – in this anonymously written journal of an anonymous society – I hope I may be permitted, in closing, the anomaly of a personal note. You see, Dr. Silkworth saved my life. I was one of those “hopeless” ones whom he reached and brought back to life – to A.A. – and to God. And I have wanted very much to write this tribute faithfully and well, in the name of all those who share my debt and gratitude. And yet I have realized from the beginning that this article will please nobody. To those who knew and loved the saintly doctor, it will seem insufficient. And so, some of those who didn’t know him will think it overdone, for the truth about Dr. Silkworth is strong medicine in a materialistic age.   This dilemma would be tolerable, were it not for a third difficulty: I have written all along in the uneasy knowledge that what is said here is by no means pleasing to the doctor himself. The incident of physical death certainly has not placed him beyond knowledge of what goes on here below. And that he will not be pleased with all this, because while he was stern about very few things, he was sternly and seriously opposed to the publication of his own name and fame. I take comfort, however, in the fact that his sense of humor most certainly will have survived his recent transition to a new home. And I feel sure that his disapproval of the present essay will be tempered by amusement, and by the priceless gift he gave us all so freely while he was yet as we are – his great love.