PUBLISHED· BY THE N. Y. C. MEDICAL SOCIETY PHYSICIAN'S ON ALCOHOLISM, Inc. 167 East 80 St. New York 21, N.Y.

A MARCH 1966 VOL. I, NO.2 ©Copyright 1966 The N.Y.C. Medical. NEWSLETTER Society on Alcoholism, Inc.

I -HISTORIC RULING I 'TOTAL ABSTINENCE' TERMED A U.S. Court of Appeals tribunal in OBJECTIVE OF TREATMENT Richmond, Va., has rulee unanimously Alcoholic patients whose treatment led to total abstinence had the best chance that it is "cruel and unusual punish­ of marked improvement of social adaptation, according to Dr. D. L. Davies, director ment" to arrest and treat a chronic alco­ of psychiatry at Maudsley Hospital, London, England, a major teaching center. He holic as a criminal; he might, however, spoke at a seminar at Norwalk Hospital, Norwalk, Conn., about an. article .of. :I.Jis · be held for medical treatment. which had been widely thought to endorse treatment directed at·a return to so6Ial­ The case involved an individual who drinking. had been convicted of public intoxica­ Misunderstandings had arisen as a result of his report, "Normal Drinking tion more than 200 times and who esti­ in Reversed Alcoholics" published last mates that he has spent more than two­ year in the Quarterly Journal of Alcohol thirds of his life in jail. Studies. The article reports the elabo­ CENTRAL ISLIP OPENS Crux of the decision, which set aside rate follow-up studies of patients treated ALCOHOL FACILITY a 2-year sentence, was the court's state­ for alcoholism in Maudsley Hospital, in Dedication of the Charles K. Post Cen­ ment that alcoholism was "now almost an attempt to delineate the natural his­ ter for the rehabilitation of women alco­ universally accepted medically as a tory of alcoholism. Seven of the fifty pa­ holics at Central Islip Hospital on Feb. disease." tients, and four of sixty two controls 23, 1966 calls attention to the unique (alcoholics who had refused treatment) facilities provided for both male and had returned to social drinking seven to female patients with alcoholism at this eleven years after being first seen. state hospital. .... NKS ADH DIVERSION However, of the treated patients, ten A key feature of the program is the who continued to drink were either dead, inclusion of the patient in decisions re­ TO ALCOHOL DAMAGE in prison, had committed suicide, or had garding his length of stay and treatment otherwise deteriorated markedly. Eight­ procedures. Diversion of the enzyme, alcohol de­ een were abstinent, five of whom made All admissions, however, are voluntary hydrogenase, from its usual function­ marked improvement in social adapta­ and the patient must show a sufficient as yet unknown-to the task of detoxi­ tion. The twenty-two who were rated degree of motivation to enter the fying alcohol may produce the damage no worse or who managed some improve­ program willingly and to stay for a known to occur in alcoholism, postulated ment in drinking or social adaptation reasonable length of time. He must be Dr. Hugo Theorell, director of the included the "social drinkers". sober and free of serious mental or Nobel Institute of Biochemistry, at a Dr. Davies pointed out that the few physical disability. Harvey Lecture at the New York Acade­ patients who returned successfully to The hospital will accept acutely in­ my of Medicine. social drinking had, at the time of their toxicated alcoholics if :they are in suffi­ Although alcohol dehydrogenase had alcoholism, some unacceptable situation cient contact to sign a voluntary paper, been isolated from yeast in 1937, it was in their lives-such ,as , an \ffiSUccessful. according to Dr. Robert F. Wagner, As­ first extracted from horse liver by Bon­ marriage Or an inapproprif!te: job-which sistant Director in charge of the new pro­ nichsen and Wassen in 1948 in Dr. had been corrected by the time of fol­ gram. It will also accept both certified Theorell's Nobel Institute Laboratory in low-up. According to the· American ex­ alcoholics who have complicating psycho­ Stockholm. It has been scrutinized ex­ perts present at the conference, includ­ ses and unwilling alcoholics on a two-phy­ tensively there and elsewhere and is a ing Dr. Ruth Fox, Dr. Adele Streeseman, sician certificate in accordance with cur­ model for studying the kinetics of en­ and Marty Mann, these correspond to rent state regulations. "However," said zymes. Changes in light absorption and what is termed in J\.inerica, "situ,ational Dr. Wagner, "the latter types of cases are .. fluorescence, crystallography and analy­ drinkers". retained on the admission or infirmary ses using competitive inhibition with Although extensive psychiatric evalu­ services until well enough to be con­ pyrazole have all been possible. ation was performed, neither on ad­ verted to. voluntary patients before ad­ ,, In spite of the fact that liver alcohol mission to the hospital nor on discharge mission to the rehabilitation units." ·. dehydrogenase is one of the most in­ could it be predicted who would do well The rehabilitation procedure consists tensely studied of all enzymes, we have or who poorly. This would make it im­ of a· week of intensive orientation using at present no idea about its real role in possible to select patients to be advised lectures, demonstrations and visual aids. ~tabolism. Dr. Theorell noted that that they could return to social drinking.· The period is designed to acquaint the Jre is a Wide distribution of alcohol When evaluations were made six months alcoholic with the nature of his problem, dehydrogenase in organisms which never after discharge, 80% correlated with later to' stimulate his interest by identification -' come into contact with ethanol, so that follow-up. with· the group and to reassure him by (Continued on page 2, col. 3) (Continued on page 2, col. 1) ·(Continued on page 2, col. 2) Editorial: IN-PATIENT PERSPECTIVE ON FLAGYL FACILITIES Recent press reports of a drug claimed In a letter to PHYSICIAN'S ALCO­ to cure alcoholism, and called by the HOL NEWSLETTER, the manufachu­ New York Times, "a venereal disease er, G. W. Searle Co., says it is confining (If you have a patient who needs in­ drug", gave exaggerated hope to many its investigation to in-depth studies and patient treatment for alcoholism, these alcoholics and caused dismay among points out that it has no present license hospitals have open facilities.) those who treat them. for the distribution of metronidazole Central Islip State Hospital The first use of the drug, metroni­ other than for trichomoniasis. Central Islip, L.I., New York dazole (or Flagyl) , for alcoholism was Dr. Ruth Fox, director of medical re­ .516 CE 4-6262 reported in a single case by Jo Ann T. search for the National Council on Alco­ For admission, call Ward D-4 for men­ Taylor, Associate Clinical Professor of holism, states that Flagyl "is a little like Dr. S. Blume; Ward G-5 for women. Clinical Pharmacology of California Col­ calcium cyanamide which is used in lege of Medicine, U.C.L.A., in the Bul­ Japan. With either, a person can take Mt. Carmel Guild Hospital letin of the Los Angeles Neurological one or two drinks without becoming ill. 396 Straight Street Society ( 29: 158-62, Sept. 1964) . More than this produces a real Anta­ Paterson, New Jersey The dramatic report presents the ob­ buse-like effect. I cannot say that these 201 LA 5-1858 servations of the wife of an alcoholic are any improvement over Antabuse. For admission, call Father William Hall; treated with metronidazole. She records It has not yet been demonstrated that accepts both men and women. her husband's decreased interest in alco­ Flagyl takes away the desire for drink­ Trafalgar Hospital hol during the admini~tration of the ing." 161 East 90th Street drug for trichomonal urethritis and his With the memory of thalidomide fresh New York, New York later Antabuse-like reaction to it while in mind, wise physicians will be cau­ TR 6-6600 on a binge. She describes his rapid re­ tious in administering metronidazole, For admission, ask for Mrs. Kennedy, covery from delirium tremens after its used at present in short courses for Dr. Fisch, Dr. Dienstag. administration (four days later he was trichomoniasis, to alcoholics on a wide, back at work) and his aversion to alco­ long term or uncontrolled basis. We Westchester Division, New York hol thereafter during treatment with the await with interest careful double-blind Hospital drug. A three month period of sobriety studies on its usefulness. White Plains, New York ensued. 914 White Plains 9-8300 Dr. A. W. Pearson, in a preliminary CENTRAL ISLIP Will accept alcoholic patients only on a (Continued from page 1) study on acute withdrawal trials in 53 voluntary basis and those who are will­ a non-critical acceptance of his problem. patients, indicated Antabuse-like effects ing to accept six months treatment. At the end of this time he meets with in 2.5 per cent; subjective improvement $325.00 a week covers all charges. the staff and decides with them whether and tranquilization were the rule. Dr. or not he will stay and what forms of Freeport Hospital Philip Friedland, chief of the alcoholic treatment seem most appropriate to his 267 South Ocean Avenue unit at Meadowbrook Hospital, and Dr. case. In subsequent weeks the' alcoholic Freeport, L.I., New York Herbert Walzer of Queens General Hos­ is exposed to any or all modalities of Admission through AA Intergroup. Call pital have found promising results in rehabilitation including individual and OR 9-3355 and ask for Hospital Desk. 100 patients. group psychotherapy, group counselling, Doctors Hospital Evidence has been presented that occupational and recreational therapy 275 Warner Avenue metronidazole inhibits alcohol dehydro­ and pharmacological therapies. Roslyn Heights, L.I., New York genase. Other effects are being studied. The decision to release is reached Admission through AA Intergroup. Call The presence of neurological damage or mutually by both patient and staff. If OR 9-3355 and ask for Hospital Desk. severe liver disease are at present con­ requested, assistance in the area of job sidered contraindications to its use. placement, as well as assistance through various social agencies is available. ADH DIVERSION The units are staffed by supervising (Continued from page 1) TREATMENT GOAL and senior psychiatrists, psychologists, (Continued from page 1) social workers, lay alcoholism counsellors, its usual physiological function must be All patients in the study group were occupational and recreational therapists, sought elsewhere. treated with Antabuse as well as with nursing and ward personnel among When alcohol is present, ADH works psychiatric and milieu therapy. Any al­ whom, notes Dr. Wagner, there is a on it in preference to other substrates, coholic patients who gave indications of free exchange of opinion and a well­ preventing performance of its normal sexual aberrations, pathological lying, defined interdisciplinary approach. function. In other words, the unknown or gambling were excluded from the Geographic limitations on admission function is postponed while ethanol is group under study. confine the program to residents of oxidized in the body; if this function is The report quoted the statistics of Manhattan below Fourteenth Street; of of vital importance, its lapse could even­ these and other studies which show the west side of Manhattan below 86th tually cause the damages known to oc­ suicides among untreated alcoholics to Street; and of Suffolk County. Selected cur in chronic alcoholism. be 55 times the normal and mortality to patients from other areas may be ad­ Liver ADH has been characterized as be five times the normal. mitted when a bed is available but only having a molecular weight of 84,000; it Dr. Davies concluded that although a if contact has been made with the hos­ was, at first, thought to have two atomc small percentage of patients treated as pital in advance to determine whether of zinc per mole, but it has recently bee1. alcoholics may later be able to return the patient conforms to admissions cri­ shown to have four atoms of zinc. Amino to normal drinking patterns, the goal of teria. The program can accommodate acid composition has also been largely treatment is lifelong abstinence. seventy males and thirty females. determined. Doctor Lieber, as well as other re­ PROBES ACTION OF ALCOHOL searchers, had previously shown that alcohol increases the concentration of IN PRECIPITATION OF GOUT lactate in the blood. He now postulated that the observed effect of alcohol on the A mechanism through which alcohol prove a causal relationship between al­ urinary acid excretion could be due to may play a role in the precipitation of cohol and the uric acid elevation, Dr. this rise in lactate. Measurements of attacks of gout has been investigated by Lieber's next step was to determine blood lactate demonstrated the merit of a Cornell researcher. By-products of al­ whether alcohol per se is capable of al­ the hypothesis. The rise was about two cohol oxidation in the liver result in in­ tering its level. Pure ethanol was given times the amount known to affect uric creased levels of lactate in the blood. to subjects on a diet constant in purine. acid excretion. It was further demon­ This, in turn, results in a decrease in Alcohol, administered orally to some and strated that an individual who had been urinary uric acid excretion, leading to intravenously to others, was accompanied given ethanol in the previous study and what Doctor Charles S. Lieber of the by a rise in serum uric acid with a re­ who was now given lactate, achieved University's Medical College calls alco­ turn to normal after alcohol had been levels of lactate in the blood which were holic hyperuricemia secondary to renal discontinued. An infusion of saline solu­ equal to those produced by alcohol. retention of uric acid. tion given the same individuals caused Again there was a rise in serum uric Dr. Lieber became intrigued with the no significant change in the serum uric acid and a fall in urinary uric acid out­ problem of the relationship of alcohol acid level. put. Thus it was substantiated that un­ and acute attacks of gout when a patient, In a subsequent study, Dr. Lieber der metabolic ward conditions the fall who suffered from alcoholic liver disease, found that alcohol given over a 12 to in uric acid excretion which alcohol pro­ experienced repeated attacks of gout 24 hour period, preceded and followed duces is due, at least in part, to the clearly precipitated by alcoholism. by control periods, again resulted in effect of the increase in blood lactate. In twelve individuals hospitalized for a rise in serum uric acid which was as­ The question of whether a similar acute alcoholic intoxication, Dr. Lie­ sociated with a remarkable decrease in mechanism plays a role in patients spon­ ber found that each had an initial serum uric acid excretion. At the peak of the taneously and acutely intoxicated was uric acid level which was higher when alcohol effect, uric acid excretion was not answered conclusively. However, he was acutely intoxicated than there­ only about one-half to one-fifth of the some direct evidence that the mechan­ after. In half of these, the level of serum lowest control value, with a return to ism does play such a role was provided uric acid was above the upper limit of normal after cessation of alcohol intake. when measurements of blood alcohol normal. These values fell when the pa­ Assuming a normal and stable rate of and blood lactate in eight individuals tient recovered. On the average, the fall uric acid production, such a decrease in brought to the hospital in an intoxicated was 40 per cent. urinary excretion of uric acid could condition indicated that while the alco­ Noting that these observations did not amount for the observed rise. nol content was predictably high, the blood lactate was, if anything, higher than the levels which had been achieved under hospital conditions. STUDY LINKS ALCOHOL, CANCER Concluding that it is reasonable to assume that alcoholic hyperuricemia is A study has shown a significant re­ sumption for pairs matched by tobacco due at least in part to a decrease in uric lationship between heavy alcohol con­ use, and vice versa. The findings clearly acid excretion, secondary to the increase sumption, smoking, and cancer of the indicated that both factors are inde­ in blood lactate, Dr. Lieber pointed out mouth and pharynx. pendently associated with cancer of the that when alcohol is oxidized in the liver Working with patients at three New mouth and pharynx. under the influence of alcohol dehydro­ York City VA Hospitals, Doctors An­ The data were based on routine ad­ genase, it is converted to acetaldehyde. drew Z. Keller and Milton Terris studied missions information, presumed to be Since it is known that this oxidation is 598 cases of cancer of the mouth and comparatively reliable for tobacco use. coupled with reduction of ·pyruvate to pharynx and an equal number of age­ Social attitudes towards alcoholism plus lactate, he reasoned that this would ac­ matched controls admitted to these hos­ the imminent reduction in VA benefits to count for the increase in hepatic lactate pitals between 1953 and 1963. known or admitted alcoholics may in­ and also for the increase in blood lactate. duce respondents to report their drink­ No association of cancer of the mouth ing habits inaccurately. It is likely, and pharynx was found with syphilis therefore, that the data presented on or diabetes mellitus. There was no asso­ alcohol consumption were underesti­ COMMUNITY ACTION ciation with race. Both alcohol and to­ mates. New York City and the metropolitan bacco consumption were associated with Supporting evidence was found in area is to have the services of the newly­ cancer of the mouth and pharynx. How­ two areas where cancer of the mouth formed Committee on Alcoholism un­ ever, these habits are known to be re­ and pharynx paralleled known incidence der the aegis of the Community Council lated. Of the 2.58 cases in this series who rates of alcoholism. With patients of the of New York, a health and welfare or­ were heavy drinkers, 3.5 per cent are al­ Jewish religion, among whom alcoholism ganization. The committee will study so heavy smokers; this was true for only is rare, there was a low incidence of and plan community-based facilities for 15 per cent of the 286 cases who were these cancers; and with patients having the prevention and treatment of alco­ not heavy drinkers. A similar relationship cirrhosis of the liver among whom alco­ holism. was demonstrated among the controls. holism is frequent, the incidence was Chairman is R. Brinkley Smithers, The manifest association of heavy high. president of the National Council on ,Al­ Jrinking and heavy smoking made it The investigators concluded that this coholism and of the Smithers Founda­ necessary to test the independent roles study provides positive evidence of the tion. He said that the Committee will be of alcohol and tobacco. This was done by relationship of alcohol use to cancer of composed of public health officials, examining the data on alcohol con- the mouth and pharynx. health specialists and civic leaders. REHABILITATION FURTHURED MEETINGS

BY SELF-IMAGE EXPERIENCE National Council on Alcoholism An­ nual Meeting and Institutes, Waldorf­ A trio of researchers from the Jeffer­ row character, bum, ungrateful son," Astoria, N.Y.C., April 12-15; Affiliat son Medical College and Eastern Penn­ etc. Although this had been preceded Workshop, April13: Annual Symposium, sylvania Psychiatric Institute have im­ by three similar incidents in the past, N.Y.C. Medical Society on Alcoholism. plemented the advice so familiar to said Dr. Paredes, none had frightened many alcoholics . . . "you should see him before. "The same night he decided yourself as others see you." to quit drinking. A week later he ob­ Experimenting with a technique they tained a job where he is still employed. BOOKS call the "self-image experience," Dr. He joined Alcoholics Anonymous and Alfonso Paredes, associate professor of has attended their meetings regularly." New Primer On Alcoholism, Marty psychiatry, in association with Drs. It has been several months since his Mann, Holt Rinehart and Winston, Inc. F:loyd S. Cornelison, Jr. and Peter Welt, rehabilitation. presented at the nineteenth clinical con­ Dr. Paredes said that the objective of Progress In Liver Diseases, H. Popper vention of the American Medical Associa­ the approach is "not to shame the patient and F. Schaffner, Editors, 2nd Edition, tion the case history of an alcoholic but to show him an aspect of himself that Grone and Stratton, 1965, N.Y. confronted with his own behavior-on he may not have appreciated." He stressed Physician's Manual on Alcoholism, Saul film. that the method is not a cure, nor even a Cohen, M.D., The Saskatchewan Bu­ The investigators report that the ex­ therapy, but that its value lies in startling reau on Alcoholism. perience acted as a stimulus to t.~e ac­ the alcoholic into a realization of his Alcoholism, Neil Kessel, M.D., and Henry ceptance of treatment and that the tech­ condition. Walton, M.D., Penguin Books Inc. 1965 nique merits further clinical evaluation. Dr. Paredes related the history of a 47-year old unemployed salesman REACTION TO HUSBANDS' SOBRIETY brought intoxicated to the hospital. A Sobriety in an alcoholic is associated married to non-alcoholics, the investiga­ film was made of his behavior with a with decreased personality disturbance in tors found the most disturbance in the recording of his comments. The alcoholic his wife, according to a psychomeb·ic wives of active alcoholics, and the least patient saw the film and heard the re­ study by psychologist Kate L. Kogan and in the wives of non-alcoholics. The wives cording a few days ;1fter his admission; sociologist Joan K. Jackson of the Uni­ of sober alcoholics were intermediate. his reactions while watching were also versity of Washington School of Medi­ filmed. His response to seeing his own These findings were most consistent cine. with the theory that both premarital behavior for the first time was one of Whereas this niay appear obvious, it personality disturbance and the stress or detachment, Dr. Paredes observed; at has been widely held that women with living with an active alcoholic contributt.. one point, he said, he almost smiled. pathological personality needs selected to disturbance in the wives, but were Subsequently, however, he retui:ned husbands who were, or were likely to be­ inconsistent with the supposition that for cons.1,1ltation, commenting that the come, alcoholics. If the alcoholic im­ sobriety in the alcoholic would increase film had . ~oused his curiosity. He was proved, this would lead to psychological the disturbance in the wife. The findings then shown· the second film, which de­ decompensation in the wife. also support the view that treatment of picted both his behavior while drunk Analyzing the results of Minnesota the alcoholic patient should be directed and his demeanor while observing the Multiphasic Personality Inventory tests at his own disturbance, while that of the earlier film. on 26 women whose husbands were so­ wife should be directed at increasing her That night, the patient reported hear­ ber at least 12 consecutive months, 50 own comfort with herself while living ing imaginary voices calling him "skid wives of active alcoholics, and 50 wm nen with an alcoholic spouse. (26QJAS 486)

PHYSICIAN'S ALCOHOL NEWSLETTER Non-_Profit Org. Published quarterly by N. Y. C. Medical U.S. POSTAGE Society on Alcoholism, lnp. Publication has 167 East 80 Street PAID been made p o~s ible by a grant from the New York 21, N.Y. New York, N.Y. Christopher D. Smithers Foundation. Permit No. 6929 Return Requested

EDITORIAL BOARD

Editor-in-Chief - Frank A. Seixas, M.D.­ lnternist, Sec'y N.Y. Med. Soc. on Alcohol­ ism; Executive Editor, Fred Zeserson. Asso· ciate Editors- Luther Cloud, M.D.- Intem­ ist, Asst. Medical Director, Equitable Life Assur. Co., Ruth Fox, M.D.- Psychiatrist. Medical Director, Nat'! Council on Alcohol­ ism. Stanley Gitlow, M.D.-Asso. Clinical Prof. Medicine, New York Medical College. Sidney Greenberg, M.D.-Internist, Consul­ tation Center for Alcoholism. Percy Ryberg, M.D.-Psychiatrist, Med. Director ACCEPT