ALCOHOLISM.
BY JAMES C. WILSON, M.D.
DEFINITION.—Alcoholism is the term used to designate collectively the morbid phenomena caused by the abuse of alcohol.
SYNONYMS.—Alcoholismus, Ebrietas, Ebriositas, Temulentia, Drunkenness, Delirium potatorium, Mania potatorium, Delirium tremens, Chronic alcoholic intoxication, Dipsomania; Ger. Trunkenheit, Trunksucht; Fr. Ivresse, Ivrognerie.
These terms are in common use to describe such conditions and outbreaks in alcoholic individuals as amount to veritable morbid states or attacks of sickness, but they are not interchangeable, nor are they all sufficiently comprehensive to constitute true synonyms. They are names applied to various conditions due to acute or chronic alcohol-poisoning properly and distinctively comprehended under the general term alcoholism.
CLASSIFICATION.—It was formerly the custom to restrict this term to affections of the general nervous system induced by continued excesses in the use of alcoholic drinks.1 But the nervous system bears the brunt of the attack and suffers beyond all others alike in transient and in continued excesses. The artificial restriction of the term to the cases caused by continued excesses was therefore illogical in itself, and has been productive of much needless difficulty in the treatment of the subject and in the classification of the cases. The use of the term chronic alcoholism to denote an established condition, and of acute alcoholism to describe outbreaks of various kinds which occur in individuals subject to that condition, has also proved a source of embarrassment to the student. Not less vague has been the employment of such terms as delirium tremens, mania-a-potu, and the like, which are unsatisfactory in themselves, and tend to exalt symptoms at the expense of the morbid condition of which they are only in part the manifestation. I am of the opinion—which is at variance with established usage—that the systematic discussion of alcoholism requires that all forms of sickness, including drunkenness, due to that poison must receive due consideration, and that the term acute alcoholism, hitherto used in a sense at once too comprehensive and too variable, should be reserved for those cases in which the sudden energetic action of the poison is the occasion of like sudden and intense manifestations of its effects. Furthermore, the uncertainty and lack of precision in the use of the terms acute and chronic alcoholism are due to errors of theory formerly almost universal in medical writings and popular belief concerning the disease. The chief source of these errors was the recognition only of the more acute nervous affections caused by alcoholic excess—delirium tremens, maniacal excitement, and terrifying hallucinations—and the belief that these conditions occurred only after a temporary abstinence in the course of habitual or prolonged indulgence. It has now long been known that abstinence from drink by no means necessarily precedes the outbreak of mania or delirium, and modern researches have established the existence of a chronic alcoholic intoxication of long duration extending over a period of months or years, in which such outbreaks merely exhibit the full development of symptoms that have already been occasionally and partially recognizable.
1 Anstie, Reynolds's System of Medicine, vol. ii., 1868.
The following arrangement of the topics will facilitate the discussion of the subject in the present article, and serve, I trust, a useful purpose for the classification of cases in accordance with existing knowledge:2
I. Acute Alcoholism: Drunkenness, Debauch.
A. Ordinary or Typical Form.
B. Irregular Forms.
1. Maniacal;
2. Convulsive;
3. In persons of unsound mind.
C. Acute Poisoning by Alcohol: Lethal doses.
II. Chronic Alcoholism.
A. Visceral Derangements.
1. Local disorders:
a. Of the digestive system;
b. Of the liver;
c. Of the respiratory system;
d. Of the circulatory system;
e. Genito-urinary system.
2. Disorders of special structures:
a. Of the locomotor apparatus;
b. Of the skin.
3. General disorders:
a. The blood;
b. Obesity;
c. Cachexia.
B. Derangements of the Nervous System: Cerebro-spinal Disorders.
1. Cerebral disorders.
2. Spinal disorders.
3. Disorders of the peripheral nerves.
4. Disorders of the special senses.
C. Psychical Derangements.
1. The moral sense.
2. The will.
3. The intellect.
4. Alcoholic delirium in general.
5. Delirium tremens.
6. Alcoholic insanity:
a. Melancholia;
b. Mania;
c. Chronic delirium;
d. Dementia;
e. Paretic dementia.
III. Hereditary Alcoholism.
IV. Dipsomania.
2 This classification is in part based upon that of Lentz, De l'Alcoholism et de ses Diverses manifestations, etc., Bruxelles, 1884—a prize essay.
HISTORY.—The history of the abuse of alcohol would be the history of society from the most remote period until the present time, not only among civilized but among barbarous races of men, for the abuse of narcotics, of which alcohol is at once the most important and the most widely used, forms a dark background to the broad picture of healthful human progress. In truth, the most sketchy account of our knowledge of the effects of alcoholic excess, as manifested in the individual and in society at large, interesting as it might prove to the general reader, would be out of place in this article. To be of real value it would necessarily embody a record of experiences so vague, facts so indeterminate, opinions so at variance, and citations so numerous, that they would require for their mere presentation a volume rather than an article. The object of the writer in the following pages shall be, therefore, to present the subject in its present aspect, without reference, beyond that which is absolutely necessary, to considerations of mere historical interest. This being the case, he considers further apology for the lack of laborious historical studies unnecessary.
ETIOLOGY.—A. Predisposing Influences.—We are at this point confronted with a series of problems the complex nature and grave importance of which appeal with peculiar urgency to all thoughtful physicians. Their discussion, however, involving as it does unsettled questions of great moment in social science, is beyond the scope of the present article. A few practical points only can occupy our attention.
The influences which predispose to alcoholism arise from unfavorable moral, social, and personal conditions.
Among the unfavorable moral conditions may be mentioned a want of wholesome public sentiment on the subject in communities. This arises too often, but by no means exclusively, from poverty and its attendant evils ignorance and vice. Rum is at once the refuge and the snare of want, destitution, and sorrow. To the vacant and untrained mind it brings boons not otherwise to be had—excitement and oblivion. That both are brief and bought at a ruinous cost exerts little restraining influence. Of equal if not greater importance are the influences which spring from ill-regulated and demoralizing domestic relations, and the absence of motive and the contentment which properly belong to the family as an organization. Everywhere also do we find in example a potent influence. In the individual, in addition to hereditary propensities, the evil results of a lax, over-indulgent, or vicious early training, as shown in a want of power of application, of moral rectitude, in self-indulgence, craving for excitement, and a weak will, powerfully predispose to the temptations of alcoholic excess.
Among social conditions which must be regarded as predisposing influences occupation takes the first rank. The occupations which render those pursuing them especially liable to alcoholism may be divided into two classes—those in which the temptation to drink is constantly present, and those in which the character of the work begets a desire for stimulation, while the opportunities for the gratification of the desire are but little restricted.
To the first of these groups belong all classes of workmen in distilleries, breweries, and bottling establishments; keepers and clerks of hotels, public houses, and restaurants; the barmen and waiters in the same trades; the salesmen who travel for dealers in wines and spirits. To this group must also be referred the professional politician of the lowest order. These occupations have furnished by far the larger number of cases that have come under my care, both in hospital and in private practice.
To the second class belong occupations involving great exposure to the inclemency of the weather. We frequently find cabmen, expressmen, coal-heavers, hucksters, and street-laborers habitually addicted to excesses in alcohol. The stringent regulations of corporations exert a powerful protective influence in the case of men employed on railways, ferry- and other steamboat service, and in and about dépôts and stations. Exhausting toil under unfavorable circumstances as regards heat and confinement predisposes to drink, as in the case of foundrymen, workers in rolling-mills, stokers, and the like. The men-cooks who work in hotels and restaurants are especially liable to alcoholism. Monotony of occupation, as in the cases of cobblers, tailors, bakers, printers, etc., especially when associated with close, ill-ventilated workrooms and long hours of toil, exerts a strong predisposing influence. Persons following sedentary occupations suffer from excesses sooner than those whose active outdoor life favors elimination. To the monotony of their occupations may be ascribed in part, at least, the disposition of soldiers, ranchmen, sailors, etc. to occasional excesses as opportunities occur. Irregularity of work, especially when much small money is handled, as happens with butchers, marketmen, and hucksters, also often leads to intemperance.
The lack of occupation exerts a baleful influence. Men-about-town, the frequenters of clubs, dawdlers, and quidnuncs often fall victims to a fate from which occupation and the necessity to work would have saved them. In this connection it may be permitted to call attention to the custom of treating as enormously augmenting the dangers to which such persons are habitually exposed in the matter of alcoholic excesses. The occasional moderate use of alcohol in the form of wine with food and as a source of social pleasure is not fraught with the moral or physical evils attributed to it by many earnest and sincere persons. It is, on the contrary, probable that the well-regulated and temperate use of sound wines under proper circumstances and with food is, in a majority of individuals, attended with benefit. Those who suffer from the effects of excesses do not usually reach them by this route, nor would they be saved by any amount of abstinence on the part of temperate and reasonable members of society.
When we turn our attention to the unfavorable personal conditions which predispose to alcoholism, we at once enter upon the familiar field of work of the practical physician. Numerous influences having their origin in the individual himself, some occasional, others constant, all urgent, demand our careful consideration. Some of the conditions out of which these predisposing influences spring are tangible and easy of recognition; others are elusive and uncertain. To point them out is, unfortunately, not to remedy them. As a rule, they have wrought their evil effects long before the individual has cause to regard himself in the light of a patient.
First in importance is heredity. A peculiar inherited constitution of the nervous system is as influential in leading to alcoholic excess and in aggravating its disastrous effects as any other cause whatsoever. A considerable proportion of individuals who suffer from alcoholism are found upon inquiry to come of parents who have been addicted to drink. A still greater number belong to families in which nervous disorders, and in particular neuralgia, epilepsy, and insanity, have prevailed. Others, again, are the offspring of criminals. It can no longer be doubted that particular causes of nervous degeneration in one or both parents may lead to the hereditary transmission of a feeble nervous organization, which, on the one hand, renders its possessor peculiarly liable to neuroses of every kind, and, on the other hand, an easy prey to the temptation to seek refuge from mental and physical suffering in occasional or habitual narcotic indulgence. Thus, as Anstie pointed out, “the nervous enfeeblement produced in an ancestor by great excesses in drink is reproduced in his various descendants, with the effect of producing insanity in one, epilepsy in another, neuralgia in a third, alcoholic excesses in a fourth, and so on.” When it is possible to obtain fairly complete family histories, covering two or three generations, in grave nervous cases, facts of this kind are elicited with surprising frequency. The part which heredity plays in many of the more inveterate and hopeless cases of alcoholism is wholly out of proportion to the obvious and easily recognizable part played by momentary temptation. To the failure to recognize the real agency at work in such cases must be ascribed the disappointment of too many sanguine and unsuccessful social reformers.
Various forms of disease exert a predisposing influence to alcoholic excesses. In the first place, bodily weakness and inability to cope with the daily tasks imposed by necessity impel great numbers of persons of feeble constitution, especially among the laboring classes, to the abuse of alcohol.
In the second place, many conditions of chronic disease attended by suffering are susceptible of great temporary relief from the taking of alcohol. Especially is this the case in the neuralgias, in phthisis, in dysmenorrhœa and other sexual disorders of women, in the faintness and depression of too-prolonged lactation, in the pains and anxieties of syphilis, and in the malaise of chronic malaria. When the patient has learned that alcohol is capable of affording relief from suffering, it is but a short step through ignorance or recklessness to habitual excess.
The administration of alcohol during convalescence from attacks of illness is not unattended by the danger of subsequent abuse. It is well for the physician to inform himself of the hereditary tendencies and previous habits of the patient before assuming the responsibility of continuing alcohol beyond the period of acute illness under these circumstances; and it is a rule never to be disregarded that the stimulant ordered by the physician is to be regulated by him in amount, and discontinued when the patient passes out of his care.
Irregularities of the sexual functions in both sexes, and especially sexual excesses, strongly predispose to alcoholism. The custom of administering to young women suffering from painful menstruation warming draughts containing gin, brandy, or other alcoholic preparations in excessive amounts is a fertile cause of secret tippling.
The abuse of tobacco, to the depressing effects of which alcohol is a prompt and efficient antidote, must be ranked as an important predisposing influence.
Depressing mental influences of all kinds tend strongly to drinking habits. This is true of persons in all classes of society.
Habit constitutes an influence the importance of which can scarcely be over-estimated. Much of the drinking done by active business-men has no other cause than this. Alcohol, like opium and other narcotics, exerts its most pernicious influence through the periodical craving on the part of the nervous system for the renewal of the stimulating effects which it causes, while it progressively shortens the period and diminishes the effect by its deteriorating action upon the nutrition of the peripheral and central nervous tissues.
B. The Exciting Cause.—Alcohol, or ethyl hydrate, is the product of the fermentation of solutions which contain glucose or a substance capable of transformation into glucose. Other alcohols, as propyl, butyl, and amyl alcohol, etc., are also formed in small quantity in the fermentation of saccharine liquids. Ethyl alcohol is the type of the series, and forms the normal spirituous ingredient of ordinary alcoholic beverages. The others when present, except in minute quantities, constitute impurities. Their toxic effects are much more pronounced than those of ethyl alcohol.
Alcohol is a colorless mobile liquid having an agreeable spirituous odor and a pungent, caustic taste, becoming fainter upon dilution. It mixes with water and ether in all proportions.
Alcoholic beverages form three principal groups: 1, spirits, or distilled liquors; 2, wines, or fermented liquors; and 3, malt liquors.
1. The various spirituous liquors, as whiskey, gin, rum, brandy, etc., contain, in addition to the ethyl alcohol and water common to them all, varying minute proportions of ethereal and oily substances to which each owes its peculiar taste and odor. These substances are œnanthic, acetic, and valerianic ethers, products of the reaction between the corresponding acids and alcohol, and various essential oils. Traces of the other alcohols are also present. Amyl alcohol, the so-called fusel oil, is present in new and coarse spirit, but especially in that derived from potatoes, in considerable amounts. It is to this ingredient that potato spirit owes its peculiarly deleterious properties. Richardson3 experimentally produced with amyl alcohol phenomena analogous to delirium tremens in man. Spirits also frequently contain sugar, caramel, and coloring matters derived from the cask, to which certain products of the still also owe in part their flavor. These liquors are of varying strength, and contain from 45 to 70 per cent. of absolute alcohol by volume.4
3 On Alcohol, Lond., 1875.
4 Vide Baer, Der Alcoholismus, Berlin, 1878.
Liqueurs (anise, kümmel, curaçoa, Benedictine, etc.) are the products of the distillation of alcohol with various aromatic herbs, sweetened, or of its admixture with ethereal oils and sugar. These compounds contain a very high percentage of alcohol. Two of them, absinthe and kirsch, by reason of their peculiarly dangerous properties deserve especial mention.
Absinthe is an alcoholic distillate of anise, coriander, etc. with the leaves and flowers of the Artemisia absinthium, which yields a greenish essence. This liqueur contains from 60 to 72 per cent. of alcohol, and exerts a specific pernicious effect upon the nervous system, largely due to the aromatic principles which it contains.5 Kirsch, which owes its peculiar flavor to the oil of bitter almonds and hydrocyanic acid which it contains in varying and often relatively large proportions, is still more dangerous. The toxic effects produced by these liqueurs are of a very complex kind, and scarcely fall within the scope of this article.
5 As early as 1851, Champouillon (referred to by Husemann, Handbuch der Toxicologie) called attention to the fact that the French soldiers in Algiers, in consequence of excessive indulgence in absinthe, suffered especially from mania and meningitis. Decaisne (La Temperance, 1873, Étude médicale sur les buveurs d'absinthe) found absinthe in equal doses and of the same alcohol concentration to act much more powerfully than ordinary spirits, intoxication being more rapidly induced and the phenomena of chronic alcoholism earlier established. Pupier (Gazette hébdom., 1872) found in those addicted to the use of absinthe marked tendency to emaciation and to cirrhosis of the liver; and Magnan (Archives de Physiol., 1872) asserts that the chronic alcoholism due to this agent is characterized by the frequency and severity of the epileptic seizures which accompany it. There is reason to believe that the consumption of absinthe in the cities of the United States is increasing.
2. Wines are the product of the fermentation of the juice of the grape. Their chemical composition is extremely complex. They owe their general characteristics to constituents developed during fermentation, but their special peculiarities are due to the quality of the grape from which they are produced, the soil and climate in which it is grown, and the method of treatment at the various stages of the wine-making process. So sensitive are the influences that affect the quality of wine that, as is well known, the products of neighboring vineyards in the same region, and of different vintages from the same ground in successive years, very often show wide differences of flavor, delicacy, and strength.
The most important constituent of wine is alcohol. To this agent it owes its stimulating and agreeable effects in small, its narcotic effects in large, amounts. The proportion of alcohol, according to Parkes, Bowditch, Payen, and other investigators, varies from 5 to 20 per cent. by volume, and in some wines even exceeds the latter amount. The process of fermentation, however, yields, at the most, not more than 15 to 17 per cent. of alcohol, and wines that contain any excess of this proportion have been artificially fortified.
Further constituents of wine are sugar, present in widely varying amounts, and always as a mixture of glucose and levulose—inverted sugar; traces of gummy matter, vegetable albumen, coloring matters, free tartaric and malic acid, and various tartrates, chiefly potassium acid tartrate, or cream of tartar. In some wines there are found also traces of fatty matters. Tannin is likewise found. Small quantities of aldehyde and acetic acid are due to the oxidation of alcohol. The acetic acid thus formed further reacts upon the alcohol, forming acetic ether. To the presence of traces of compound ethers, acetic, œnanthic, etc., wines owe their bouquet. Carbon dioxide, produced in the process of fermentation, is retained to some extent in all wines, and is artificially developed in large quantities in champagnes and other sparkling wines.
Much of the stuff sold as wine, even at high prices, in all parts of the world, is simply an artificial admixture of alcohol, sugar, ethereal essences, and water. The wines rich in alcohol are especially liable to imitation.
Wine is the least harmful of alcoholic drinks. In moderate amounts and at proper times its influence upon the organism is favorable. In addition to its transient stimulating properties, it exerts a salutary and lasting influence upon the nutrition of the body. Only after prolonged and extreme abuse, such as is sometimes seen in wine-growing countries, does it lead to alcoholism.
3. Malt liquors—beer, ale, porter, stout, etc.—are fermented beverages made from a wort of germinated barley, and usually rendered slightly aromatic by hops. This process is known as brewing. Malt liquors, of which beer may be taken as the type, contain from 3.75 to 8 per cent. by volume of alcohol, free carbon dioxide, variable quantities of saccharine matters, dextrin, nitrogenized matters, extractive, bitter and coloring matters, essential oil, and various salts. Much importance has been ascribed to the quantity of malt extractive in beer: it has even been seriously spoken of as fluid bread. But, granting the nutritive value of the malt extractives, it is, as compared with the nutritive value of the grain from which they are derived, so small that beer must be regarded as a food of the most expensive kind.
Sound beer is wholesome and nutritious, and serves a useful purpose in the every-day life of a considerable part of the earth's population. But it is wholesome only in moderate amounts. Its excessive consumption results in progressive deterioration of mind and body. Undue accumulation of fat, diminished excretion of urea and carbon dioxide, are followed by disturbances of nutrition. Incomplete oxidation of the products of tissue-waste leads to the abnormal formation of oxalates, urates, etc., to gout, derangements of the liver, and gall-stones. In long-continued excesses in beer one of the effects of the lupulin is to enfeeble the powers of the reproductive organs. The inordinate consumption of beer induces intellectual dulness and bodily inactivity, and lessens the powers of resistance to disease. The dangers of acute and chronic alcoholism are obvious. Five glasses of beer of 5 per cent. alcohol strength contain as much alcohol as half a beer-glassful of spirits of 50 per cent.
The moderate consumption of beer in communities is to some extent a safeguard against alcoholism. To secure this end, however, the beer must be sound and of light quality. The stronger beers, and especially those which are fortified with coarse spirits, besides the direct dangers attending their use, tend rapidly to the formation of spirit-drinking habits.
The action of alcohol varies according to its degree of concentration, the quantity ingested, and its occasional or habitual use. On the one hand, when well diluted, taken in small amount and occasionally only, it may be without permanent effect upon any function or structure of the body; on the other hand, its frequent administration in large doses and but little diluted is, sooner or later, surely followed by widespread tissue-changes of the most serious kind.
The Physiological Action of Alcohol.—Alcohol is very rapidly taken up by absorbent surfaces. According to Doziel,6 it has been detected in the venous and arterial blood and in the lymph of the thoracic duct a minute and a half after its ingestion. It is very slightly if at all absorbed by the unbroken skin. Denuded surfaces and extensive wounds permit its absorption, as in the case of surgical dressings, and instances of intoxication from this cause have been recorded. It is also freely absorbed in the form of vapor by the pulmonary mucous surfaces. Some surfaces, as the pleura and peritoneum, absorb it, as has been demonstrated by the effects following its injection into those cavities. Its constitutional effects are also rapidly developed after hypodermic injection. Under ordinary circumstances, however, it is by the way of the absorbents and veins of the gastric mucous membrane that alcohol finds its way into the blood. It is probable that the greater part of the alcohol taken into the stomach undergoes absorption from that organ, and that very little of it reaches the upper bowel. Alcohol is readily absorbed by the rectal mucous membrane. Having entered the blood, it reaches all the organs of the body, and has been recovered by distillation not only from the blood itself, but also from the brain, lungs, liver, spleen, kidneys, and various secretions.7
6 Pflüger's Archiv für Physiologie, Band viii., 1874.
7 Strauch, De demonstratione Spiritus Vini in corpus ingesti, Dorpati, 1862.
Lentz and other observers believe that certain organs have a special affinity for alcohol. The author named and Schulinus place the brain first in this respect, and in the next rank the muscles, lungs, and kidneys. But Lallemand and Perrin regard the liver and the brain as having an equal affinity for alcohol. The opinion of Baer, who rejects the view that alcohol has an especial predilection for particular organs, is more in accordance with known physiological law. This observer holds that alcohol, having found its way into the blood, circulates uniformly throughout the whole organism, and explains the greater amount recoverable from certain organs as due to the fact that these organs contain more blood than others.
The elimination of alcohol is at first rapid, afterward very gradual. It begins shortly after ingestion, and in the course of two or three hours one quarter, and perhaps much more, of the amount passes from the organism. Nevertheless, after the ingestion of large amounts traces of alcohol were discovered on the fifth day in the urine by Parkes and Wollowicz, although the elimination by the lungs had entirely ceased.
Elimination takes place for the most part by way of the kidneys, the lungs, and the skin; alcohol has been recovered also from the bile, saliva, and the milk.
Whatever may be the affinity of certain organs for alcohol, whatever the channels by which it is eliminated, the general belief is that some portion of it undergoes chemical decomposition within the body. The steps of this process and its ultimate results are as yet unknown; nor, indeed, are the proportional amounts decomposed and eliminated established. Some observers regard the amount eliminated as less than that decomposed. Others suppose that the amount consumed within the body is relatively very small as compared with that disposed of by elimination. It is, however, established that the sojourn of alcohol in the body, unlike that of many other toxic substances, is transient, and that in the course of from twenty-four to forty-eight hours after the ingestion of a moderate amount there remain only traces of this substance.
The local action of alcohol upon organic tissues depends upon its volatility, its avidity for water, its power to precipitate albuminous substances from solution and to dissolve fats, and, finally, upon its antiseptic properties.
Applied externally and permitted to evaporate, it produces a fall of temperature and the sensation of cold; if evaporation be prevented, a sensation of warmth is experienced, the skin reddens, and, if the action be prolonged, desquamation results. The sensation produced when diluted alcohol is applied to mucous surfaces is burning and stinging; when concentrated, it may excite inflammation.
Dilute alcohol has been much employed as a surgical dressing for wounds and ulcerated surfaces. Its value for this purpose depends on its stimulating properties, by virtue of which it exerts a favorable influence upon granulating surfaces; and on its antiseptic qualities, which are, however, much inferior to those of salicylic and carbolic acids among organic substances and to the chlorides among the inorganic salts.
The direct action of alcohol upon the mucosa of the digestive system depends upon the quantity ingested and degree of concentration. In moderate amounts and diluted to the extent of 50 per cent. or more, it produces a sensation of warmth in the tissues over which it passes. This sensation is due in part to the impression upon the nerve-endings, and in part to reflex hyperæmia, which is at once excited. In individuals unaccustomed to its use reflex contractions of the constrictor muscles of the pharynx, with gagging, are sometimes provoked. The secretion of saliva and of the gastric juice is increased, diluted alcohol being, in respect to its physiological effect in stimulating the buccal and gastric mucous glands, inferior to no other agent. This action is due as much to reflex as to local action, as has been shown experimentally by the application of a few drops of alcohol to the tongue of a dog with gastric fistula, increased secretion of gastric juice immediately resulting.
It is in consequence of this action that moderate doses of diluted alcohol exert a favorable influence upon the appetite and digestion. Increased amounts of food are well borne; fats especially are more tolerable and better digested; and a more energetic peristalsis favors the absorption of the food solutions. In those habituated to the use of alcohol these effects do not always follow; and if the amount be increased or the repetition become frequent, some part of the alcohol undergoes in the stomach, with the food, acid fermentation, and acid eructations or vomitings occur. With these phenomena is associated gastro-hepatic catarrh with its characteristic symptoms—loss of appetite, feeble digestion, diarrhœa alternating with constipation, sallowness, mental depression, and headache. In still greater amounts and little diluted, alcohol is capable of exciting acute gastritis or congestion and catarrhal inflammation of the liver.
When we come to study the action of alcohol upon the circulatory system, we find that in small doses it has little or no influence either upon the action of the heart or the condition of the vessels. In augmented amounts it increases the action of the heart both in force and frequency, and the arterial blood-pressure. After large doses these effects quickly pass away, and the circulation becomes depressed. The heart's action grows feebler, often slower, the pulse weaker; blood-pressure sinks and arterial tension is diminished. Its physiological action is that of a direct stimulant to the heart and the pneumogastric nerve; its toxic action, that of a depressant. Upon the vaso-motor system the action is from the first that of a depressant. Dilatation of capillary vessels and increased afflux of blood manifest themselves in the flushed face, brilliant eyes, and warmth of surface which are familiar phenomena. Frequent repetition tends to permanently impair the activity of the peripheral circulation. Hence the visible vascular twigs and rubicund nose that characterize the physiognomy of the habitual drinker.
This congestion no less affects the internal organs, setting up, by interference with their functions, chronic derangements of nutritive processes on the one hand, and on the other the liability to acute local diseases and complications.
The reactions which take place between the blood and alcohol remain, notwithstanding the energy devoted to their investigation, among the unsolved problems of physiological chemistry. It were a profitless task to here review the researches into this subject or to set forth their conflicting results. It may be stated that conclusions based upon the reactions between blood drawn from the vessels and tested with alcohol in the laboratory are wholly inapplicable to the inquiry. While it is generally conceded that some part of the alcohol ingested undergoes decomposition within the organism, what the steps of the process are and what the products are have not yet been demonstrated. Rossbach and Nothnagel8 state that it has not yet been possible to detect in the organism the products of the oxidation of alcohol—namely, aldehyde, acetic acid, and oxalic acid; nevertheless, acetic acid formed in the economy by the general combustion of alcohol may form acetates, which, undergoing decomposition, are transformed into carbonates and water, and are eliminated as such in the urine.9 This view is also held by Parkes.10
8 Cited by Peeters, L'Alcool, physiologie, pathologie, médecine légale, 1885.
9 Henri Toffier found in the brain of a man who died of acute poisoning by alcohol not only alcohol, but also aldehyde: Considerations sur l'empoisonment aiqu par Alcohol, Paris, 1880.
10 Journal of Practical Hygiene, 4th ed., Lond., 1873.
According to Peeters, the action of alcohol upon the blood may be summed up as follows: That portion of the ingested alcohol which undergoes decomposition takes from the blood some part of its oxygen for this purpose, with the result of a diminished amount of oxygen and an increase of carbon dioxide, the blood thus being made to resemble venous blood. A part of the oxygen destined for the oxidation of waste products being thus diverted, these substances are not completely transformed. In this respect also blood charged with alcohol resembles venous blood. Alcohol even when diluted is capable of retarding the combustion of oxidizable organic substances, and there is no reason to doubt that this agent has in the blood the same chemical properties that it elsewhere possesses.
The exhalation of some part of the alcohol circulating in the blood by the way of the pulmonary mucous membrane interferes with the elimination of carbon dioxide, with the result that the latter agent further tends to accumulate in the blood.11
11 David Brodie, Medical Temperance Journal, October, 1880.
Alcohol must act, to some degree at least, directly upon the water of the blood and upon its albuminoid principles. The products of the reactions normally taking place within the corpuscles pass with greater difficulty into serum containing alcohol as the current of osmosis tends rather from the serum to the corpuscles. It is in accord with this fact that the corpuscles of alcoholized animals have been found relatively large.
The blood of individuals who have died in a state of alcoholic intoxication has been frequently found to contain an unusual amount of fatty matter in a fine state of subdivision.
Upon the respiration the influence of alcohol is twofold: it modifies the respiratory movements and the results of the respiratory processes. After moderate doses the movements are accelerated without disturbances of rhythm; after large doses the respiratory acts become embarrassed, feeble, irregular, finally wholly diaphragmatic.
Alcohol modifies the results of respiration in a constant manner and in all doses. This modification consists in a decrease in the amount of oxygen absorbed and carbon dioxide exhaled. This effect is usually more marked when alcohol is taken fasting than during digestion.
The influence of alcohol upon the renal secretion is that of a diuretic, but the fact must not be overlooked that this tendency is much increased by the large amount of water which alcoholic drinks necessarily contain. But that alcohol acts as a diuretic, even in small doses and altogether independently of the water with which it is taken, does not admit of doubt. The changes in the urine are qualitative as well as quantitative. The amount of urea, uric acid, and other solids is always notably diminished. The diminution of the amount of phosphoric acid is even greater than that of the nitrogenized substances, especially during the period of excitation.
The diuretic effect of alcohol is dependent upon its direct action on the parenchyma of the kidneys, the qualitative changes in the urine upon its influence on nutrition.
Upon the temperature of the body alcohol has a marked effect. The sensation of warmth experienced after moderate doses is chiefly subjective, and is accompanied by a very slight actual rise in temperature, amounting to some fraction of a degree Fahrenheit, and of but short duration. This rise is followed by a rapid fall, amounting to a degree or more below the norm. This effect is manifested within the course of an hour after the administration, and is of comparatively brief duration, being largely influenced by the condition of the individual at the time as regards mental or physical exercise, digestion, and the like. It is in part due to the increased loss of heat from the surface of the body, favored by more active cutaneous circulation, but chiefly to the action of alcohol in retarding oxidation and the activity of nutritive changes. Toxic doses are followed by marked fall of temperature. The influence of alcohol upon the temperature is more pronounced in febrile conditions than in health.
The influence of physiological doses of alcohol upon the nervous system is, among all its effects, the most marked and the most difficult to describe with exactitude. It is usual to regard this agent as a stimulant and to separate the period of its direct effects into two stages—that of excitement and that of depression. John Hunter defined stimuli as agents which increase some natural action or tendency, in contradistinction to irritants, which produce actions altogether abnormal. Anstie12 sought to restrict the use of the term stimulant to agents which by their direct action tend to rectify some deficient or too redundant natural action or tendency. Without entering upon the discussion of the doctrine of stimulation, I may say that the views of Anstie have served a useful purpose in making clear some vexed questions. In accordance with these views, the physiological action of alcohol is followed neither by excitement nor by depression, and when its administration is followed by these conditions, its action is not truly physiological, but narcotic or toxic.
12 Stimulants and Narcotics, Lond., 1864.
The effects of this agent upon the nervous system vary within very wide limits according to innumerable conditions which relate to the temperament, health, habits, occupation of the individual, season, climate, social circumstances, and the quantity, kind of alcoholic drink, and its mode of administration. Its first action in moderate doses and under circumstances free from complications is to increase the functional activity of the brain: the ideas flow more easily, the senses are more acute, speech is fluent, and movement active. These effects accompany the increase in the heart's action, the slight rise in temperature already described, and increased activity of the organism in general. They appear to be in part due to the direct action of the substance upon the cerebrum, and in part to increased activity of the circulation. The effect upon the nervous system has been compared by Nothnagel to the effect, in a higher sphere, of strong moral impulses. Without otherwise modifying existing traits of character, such impulses call them into action, and lead to the accomplishment of deeds quite impossible under ordinary circumstances. To a man worn out by some prolonged task which from sheer fatigue he despairs of finishing, let there be announced some joyful news; he at once feels refreshed, applies himself with renewed energy to his work, and perhaps finishes it with ease. In kind at least this is the effect also of alcohol.
But the limits of the physiological effects are easily transcended, and the manifestations then become those of its toxic influence, between the slightest grades of which and drunkenness the difference is one rather of degree than of kind. These effects must therefore be described under the heading Acute Alcoholism.
Passing to the influence of alcohol upon nutrition, we recognize two modes of action. Of these the first is direct and in part local, and results from the stimulation of the glandular apparatus of the mucous membrane of the mouth and stomach, from increased activity of the circulation, and from direct stimulation of the pneumogastric nerve. Hence increased secretion of the digestive juices, augmented appetite, more active peristalsis, and improved digestion, to which, indeed, the direct action of alcohol upon the cerebrum doubtless contributes. It is to these effects that the favorable influences of this agent in the extremes of life, when it is so well borne and so useful, must be largely attributed.
The second mode of action is indirect and general. It has been shown that alcohol diminishes the amount of carbon dioxide expired and of oxygen inspired, that it diminishes the quantity of urea excreted, and that it lowers the temperature of the body. It follows that normal oxidation goes on more slowly—that there is diminished tissue-change. Alcohol supports the body, not by nourishing it as a food, but by curtailing waste; it favors nutrition, not by augmenting the receipts, but by cutting down the expenses of the organism. But nutrition and waste are in health correlated and complementary. They are, in fact, essential and associated processes of life, of which one is not more necessary than the other to the maintenance of health. In various pathological states the arrest of waste is a cardinal indication, and for this purpose alcohol holds the first place. But in health this action itself is pathological, and the beginning of evil. The fat accumulation of the drunkard is due in part to the sugar and starchy matter taken in malt liquors, but much more to this control of waste, as is shown by the fact that spirit-drinkers who have sufficient food also often become fat. Alcoholic excesses tend not only to fat accumulation, but also to fatty degeneration of the tissues. The opinion that alcohol in any dose or under any circumstances is a food in the ordinary acceptation of the term is no longer tenable. Chauffard has well said: “Not only is alcohol not an aliment; it is the very reverse. Not only does it not contribute to the nutrition of the body; it opposes it and destroys it little by little.”13
13 This opinion is at variance with the views generally entertained by English and American writers upon materia medica. T. Lauder Brunton (Textbook of Pharmacology, Therapeutics, and Materia Medica, Am. ed., 1885) regards “all the evidence as pointing to the fact that alcohol is a food, and in certain circumstances, such as febrile conditions, may be a very useful food; but in health, when other kinds of food are abundant, it is unnecessary, and, as it interferes with oxidation, it is an inconvenient form of food.”
THE PATHOLOGICAL ACTION OF ALCOHOL.
I. Acute Alcoholism.
In accordance with the classification laid down at the beginning of this article, the term acute alcoholism is here used to denote the various forms of primary alcoholic intoxication in contradistinction to the conditions which are brought about by the gradual but long-continued action of the poison, and to the violent and sometimes abrupt outbreaks which are secondary to these conditions. From this point of view, which is at variance with the established usage of writers upon alcoholism, but which is here adopted in the hope that it will tend to simplify the treatment of a subject at present in much confusion, acute alcoholism includes all forms of drunkenness, from mere transient derangement of the normal functions of life, scarcely amounting to tipsiness, to profound intoxication. It includes also poisoning by lethal doses. Chronic alcoholism may be the outcome of frequent repetitions of acute alcoholism at short intervals, or it may result from the constant abuse of alcohol in doses so small that the evidences of its poisonous effects are at no time actively manifested. I hope to be able to show that the seemingly acute outbreaks, the symptoms of which chiefly relate to the nervous system, that occur after the condition of chronic alcoholism is fully established, are commonly preceded for a longer or shorter period by imperfectly developed symptoms of an analogous character, and that these outbreaks differ in essential particulars from acute alcoholism in all its forms.
That persons suffering from some degree of chronic alcoholism may, and as a matter of common occurrence do, after excessive doses suffer from acute alcoholism—in other words, get drunk—is too obvious to demand more than passing consideration at this point; but it is scarcely necessary to point out to those who are familiar with the life-history of such individuals that the time comes when no degree of excess will produce the ordinary manifestations of transient intoxication. It is then that phenomena of another and more serious kind are apt to occur. The difference is that between the reactions of normal or as yet quasi-normal tissues and alcohol on the one hand, and on the other the manifestations induced by the supersaturation of tissues previously alcoholized to the point of an acquired tolerance. This tolerance of the nervous system is in a high degree a pathological condition, and is therefore in an equally high degree unstable and liable to be overthrown by accidents of various kinds as well as by extraordinary excess in alcohol.
The variety of forms and admixtures in which alcohol is taken is so great, and the susceptibility of individuals to its action so different, that it would be a hopeless task to attempt to describe the manifold phases of acute alcoholism. Unfortunately, most of them are too familiar. The following description embraces the more important phenomena, and is intended to serve as a type:
A. THE ORDINARY OR TYPICAL FORM.—The physiological effects of alcohol in moderate doses are followed by no reaction, but they are evanescent. When, however, the dose is repeated at short intervals and the effect is sustained, the condition by its continuance becomes pathological, and the subject enters upon the prodromic period of acute alcoholism. From this condition to that in which the poison manifests its distinctly toxic effects the transition is a speedy one. The face becomes flushed, the eyes brilliant; the heart's action increases in force and frequency; muscular force seems augmented; there is excitation of the mental processes; intelligence seems more active; ideas flow readily; preoccupation ceases; anxieties are forgotten. The future is full of hope, the past has lost its sorrows, its regrets. The powers of expression are brought into fullest play; conversation becomes animated, brilliant, often sparkling and keen. Reason is thrown aside, the judgment relaxed; vanity, pride, rashness, assert themselves. Emotions, sentiments, habitually repressed, are manifested without reserve, often with emphasis and insistance. Hence the proverb, In vino veritas.
Then speech degenerates into loquacity; improper confidences are made, indiscretions committed; the bent of disposition is made clear; he who is by nature sad grows sombre, melancholy; he who is irritable becomes cross and quarrelsome; the generous man grows lavish, and a good-natured fellow is everybody's friend. But this intensification of normal characteristics is by no means invariable. Not seldom do we see the timid man become in his cups violent and aggressive, the refined coarse, and the gay melancholy. The sensation of increase in muscular force manifests itself in unusual activity. Gesticulation is frequent, energetic, and apt; there are bodily restlessness and desire to move about. Shouts of laughter, bursts of song, are followed by a disposition to easily-provoked quarrels. At this stage there are evidences of some degree of cerebral congestion. The temples throb, the heart is full, and dizziness is felt. The skin is moist, the mouth pasty, thirst is experienced, and there is frequent desire to pass water. There yet remains some degree of self-control. The phenomena which characterize this condition are more or less transient, and if alcohol be now discontinued they speedily cease, commonly in sleep, sometimes without it, and are followed by sensations of weariness and fatigue, with headache, gastric disturbances, and temporary loss of appetite.
If, however, the influence of alcohol be pushed beyond this point, the manifestations of mere exaltation of function give place to grave perversion of the processes of life. A gradually increasing vertigo is associated with obscured intelligence, dulled imagination, blunted and confuted perception, disjointed ideation, and incoherent speech. The recollection grows indistinct, the will purposeless. Now the baser passions are aroused; evil impulses and illusions of all kinds sway the drunken man. All control of conversation and action is lost. Reason is replaced by delirium, and he becomes a maniac, dangerous alike to himself and to others, liable upon some sudden impulse to commit the most atrocious crimes.
The countenance betrays the profound disturbance of the intellectual and moral nature: its expression is changed, its lines are blurred; the flush deepens, the veins are distended, the arteries pulsate visibly, the gaze is staring, the pupils contracted. The respiration, at first quickened, becomes irregular. The heart's action is rapid and bounding, and sometimes there is palpitation. Somnolence soon deepens into an invincible desire to sleep. At this point great muscular relaxation not infrequently occurs in connection with vomiting, profuse sweating, and dilatation of the pupils.
Muscular movements are irregular and uncertain, the gait vacillating and staggering; the movements of the superior extremities, wanting in precision, become trembling and awkward. At the same time speech becomes embarrassed. Articulation is difficult and imperfectly executed. At length standing becomes impossible; the drunkard, profoundly poisoned, sinks helplessly to the ground, and not infrequently the control of the sphincters is lost. The development of this condition is accompanied by a gradual perversion of general and special sensibility. Dull headache, ringing in the ears, phosphenes, and other disturbances of vision, hallucinations of taste and smell, are followed by abrogation of the special senses. Loss of cutaneous sensibility, beginning at the extremities, invades the whole body, and finally the subject sinks into more or less profound coma, from which it is no longer possible to arouse him. Muscular resolution is complete, sensation is lost; the face is now bloated, deeply flushed, sometimes livid, sometimes ashy pale; the pupils are dilated; the temperature below normal; the respiration stertorous and accompanied by abundant mucous râles. The pulse is feeble, fluttering, the surface covered with sweat, and involuntary evacuations take place.
VARIETIES.—Three varieties of acute alcoholism are recognized by Lentz—the expansive, the depressive, and the stupid. The first is characterized by gayety, self-satisfaction, and content. The drunkard, smiling and happy, is satisfied with the present and full of hope for the future. The second variety is characterized by sadness and melancholy. The drunkard becomes sombre and taciturn; if he talk at all, it is to bewail his misfortunes and to recount his mishaps. In the third variety the period of excitement is wanting and the drunkard passes rapidly into a condition of stupor.
Great as are the modifications of the course of acute alcoholism under different circumstances and in different individuals, it is evident, upon close investigation, that its phenomena—and especially those which relate to the nervous system—manifest themselves in a progressive series more or less constant in the majority of persons. This series includes three well-characterized periods: 1. The stage of functional exaltation of the nervous system; 2. The stage of functional perversion; 3. The stage of depression.
We may, then, recognize the degrees of acute alcoholism corresponding to these stages.14 Of these, the first scarcely goes beyond the stage of excitement already described, and if the dose have been moderate or its repetitions not too long continued, the symptoms gradually subside, leaving perhaps no sequels beyond slight headache, tinnitus aurium, some degree of muscular relaxation, and mental depression.
14 These stages correspond to the three degrees of alcoholic intoxication recognized and described by German writers as Rausch, Betrunkenheit, and Besoffenheit. To these may be added the prodromic period, designated as Weinwarme Zustand. These three degrees are known to the French as l'ivresse légère, l'ivresse grave, and l'ivresse suraiguë.
The second degree is characterized by partial abolition of intelligence, of general and special sensation, and of motor power. Hence incoherent speech, extravagant actions, blunted perceptions, hallucinations and delusions, inco-ordination of movements, a reeling gait, and not rarely vomiting and involuntary discharges of urine and feces. This degree of acute alcoholism usually ends in deep sleep with abundant perspiration, to which succeed great lassitude and depression, accompanied by much gastro-intestinal derangement, of which the symptoms are inability to take food, coated tongue, viscid mouth, foul breath, repeated vomiting, and occasionally diarrhœa. These sequels are less serious in those individuals accustomed to excesses than in others.
In the third degree the subject falls by gradual stages or abruptly into more or less profound coma. The abolition of intelligence, sensation, and motion is complete. The face is now swollen, livid, or pale, the pupils dilated, the respiration stertorous, the pulse feeble, often slow, sometimes imperceptible, the surface cool and often bathed in sweat. The man is dead drunk. The symptoms are now of the gravest kind. It is no uncommon occurrence for this condition to end in death.
Well characterized as these three degrees of alcoholic intoxication are, they are not, when occurring successively in the same individual, separated by abrupt lines of demarcation. On the contrary, the evolution of the symptoms is from the beginning to the close a gradual and progressive one.
While the scope of this article precludes extended discussion of the symptoms of acute alcoholism—which, indeed, present an almost endless variety in their intensity and combination—yet it seems necessary to the elucidation of the subject to point out some of the more prominent modifications due to variations in the conditions under which alcohol acts upon the organism.
First among these are differences in the nature and composition of the drink. Here we have to do not only with the well-known differences in alcoholic beverages, as spirits, wines, and malt liquors, and their quality and grades, but also with differences in the chemical nature of the alcohols themselves which enter into their composition. The principal of these alcohols are—
| Methyl alcohol, | CH3OH. |
| Ethyl alcohol, | C2H5OH. |
| Propyl alcohol, | C3H7OH. |
| Butyl alcohol, | C4H9OH. |
| Amyl alcohol, | C5H11OH. |
Richardson was the first to call attention to the differences in the physiological and pathological action of the members of this series. Other observers, among whom may be named Dujardin-Beaumetz and Andigie,15 and Rabuteau,16 have also investigated the subject. The researches of these observers have established the fact that the effects of the different alcohols in depressing the temperature of the body and in paralyzing sensation and motion are exactly the same, but that their narcotic influence upon the nervous system increases, dose for dose, in proportion to the amount of carbon which they contain. Ethyl alcohol is, with the exception of methyl alcohol or wood-spirit, the least rich in carbon and the least dangerous to health.17 The increased consumption of alcohol, both as a beverage and in the arts, the demand for cheap, coarse spirits producing their primary narcotic effects with promptness, and the cupidity of manufacturers, have led to the almost universal adulteration of the liquors of commerce with the more dangerous alcohols.18 So extensive has this substitution of the high-carbon alcohols for ethyl or ordinary spirit of wine become that it has been suggested that alcoholism should be divided into ethylism, amylism, propylism, and butylism—not so much for clinical reasons as to direct attention to the composition of alcoholic drinks and to their deleterious properties.19
15 Recherches expérimentales sur la Puissance toxique des Alcools, Paris, 1879.
16 “Contributions à l'Étude des Effets physiologiques et therapeutiques d'Alcool,” Compt. rend. Société de Biologie, 1870-71.
17 “Methylic alcohol is the safest of the series of bodies to which it belongs” (B. W. Richardson, Lectures on Alcohol).
18 M. Girard, chief of the municipal laboratory in Paris, has recently called attention to the enormous diminution in the production of alcohol by the natural method—that is to say, by the distillation of wine. The falling off he ascribes to the ravages of the phylloxera. This loss is made up by the substitution of spirits obtained by the distillation of various fermented grains, potatoes, beets, molasses, etc. To give some idea of the extent to which the alcohols of industry at present replace the alcohols of wine, he cites the following figures: From 1840 to 1850 the mean annual production of alcohol in France was 891,500 hectoliters, of which the alcohols of wine amounted to 715,000 hectoliters. In 1883 the product reached 1,997,280 hectoliters, of which alcohols obtained by the distillation of wine amounted to only 14,678 hectoliters.
19 Peeters, L'Alcool, 1885.
The effects of propyl, butyl, and amyl alcohols upon the nervous system are not only more marked than those of ethyl alcohol, but they are more rapid. The stage of excitement is speedily induced, and its manifestations are intense. Hence the preference often manifested by drunkards for cheap, coarse spirits. On the other hand, the stage of depression quickly follows, and is itself of relatively shorter duration than that induced by ethyl alcohol, probably for the reason that the amount required to bring it about is smaller. Muscular resolution soon becomes general and complete; insensibility speedily succeeds; the fall of temperature is rapid; vomiting, occasionally absent in the intoxication produced by ethyl alcohol, is the rule, and is frequently repeated. Muscular tremor—and especially is this true of amyl alcohol—comes on earlier, is more general and more marked, and lasts longer than that which occurs in consequence of excess in ethyl alcohol. Richardson states that the complex alcohols are more slowly eliminated than ethyl alcohol, but the French observers are of a different opinion.
But these differences in action are probably rather differences in degree than in kind. Peeters says: “Ethyl alcohol is less dangerous than the more complex members of the series. It is less irritating, less charged with carbon, its specific gravity is less, its fumes are less dense and escape more readily from the economy; its action ought to be less profound, less prolonged, than that of butyl, propyl, and amyl alcohol, but it is of the same nature. It is not qualitatively but quantitatively different. I suspect that the effects of liquors containing ethyl alcohol are, as a rule, less decidedly injurious, by reason of the more favorable surroundings of those who can afford to use them.”
The three principal groups of the alcoholic drinks of commerce produce, independently of the properties of the different kinds of alcohol which they contain, forms of acute alcoholism which differ in important respects.
The intoxication induced by the exclusive use of malt liquors is dull and heavy, slow in coming on, and of long duration. The stage of excitement is relatively brief, not often characterized by gayety, often brutal; drowsiness soon supervenes and deepens slowly into unconsciousness. The after-effects are disagreeable and prolonged. The enormous quantity of fluid and the large amount of malt extractives cause gastro-hepatic derangements of a more or less distressing kind. To the hops must be ascribed the prolonged dulness which is so characteristic of the after-effects of beers and ales. The influence of the various substances used in the adulteration of beers without doubt modifies the symptoms of the alcoholism which these beverages cause when impure. These substances consist of glucose, various vegetable bitters, and salt—articles not necessarily hurtful in small amounts, but capable of exerting deleterious action when taken in excess and in connection with the normal ingredients of beer.
The intoxication produced by pure wines is, as a rule, characterized by a bodily and mental activity strongly in contrast with the drunkenness produced by malt liquors. The drunkard is usually gay and vivacious—at all events, lightly merry or not hopelessly despondent. His mood is variable, changing from grave to gay. The first stage is prolonged, and the manifestations of the later stages less grave, nor are the sequels apt to be so severe. The action is that of ethyl alcohol and certain ethereal substances, the latter being present, however, only in minute amounts. The rapidity of the effects depends upon the proportion of alcohol which the wine contains, which varies from about 7 per cent. in the clarets to 15, to 18, or even to 20 per cent. in port and madeira. The sparkling wines, moselle and champagne, produce more transient effects than the still wines—a fact probably to be explained by their greater and more prompt diuretic action.
The foregoing remarks apply only to pure wines. The intoxication which follows the use of artificial compounds sold in all parts of the world as wines betrays in its course and symptoms the high percentage and toxic characters of the mixed alcohols which form their essential ingredients.
The intoxication which follows excesses in the various spirits of commerce presents no special characters. Its symptoms are determined to a considerable extent by the relative purity—that is, freedom from admixture with the various complex alcohols—of the liquor by which it has been produced. Potato spirit causes drunkenness which is profound, overwhelming, and preceded by a brief period only of excitement.
Even more important than the kind of liquor is its quantity. Here, however, it is impossible to formulate precise statements. A few glasses of wine will produce effects in some persons more decided than much strong spirits in others. Those conditions which favor the absorption of alcohol hasten the production and augment the intensity of alcoholism; and the contrary is true. Thus, alcohol taken while fasting does much more harm than the same amount taken with a meal. Intense excitement, anger, mortification, or other violent emotion is said by Lentz to increase the effects of alcohol. Sudden transition from a warm to a cold atmosphere intensifies the action. That this effect of cold is due to suppression of perspiration, and the consequent interference with one of the elements of elimination, is much less likely than that it is due to the further depressing influence of cold upon the nervous system, already depressed by the alcohol imbibed. Occupation has in an indirect way much to do with the facility with which alcohol is borne. Hard work, requiring great and continuous muscular effort, especially in the open air, diminishes the liability to acute alcoholism, while sedentary occupations and confinement strongly predispose to it. These well-recognized facts are to be accounted for by the influence of different occupations and modes of life upon the elimination of the poison. Persons who are debilitated by chronic disease or are convalescent from acute maladies, and the otherwise feeble and anæmic, are peculiarly obnoxious to the action of alcohol. Previous custom and hereditary peculiarities of organization exert an influence upon the liability of individuals to acute alcoholism, and upon its nature when induced.
Persons of an impressible nervous organization are peculiarly prone to the evil effects of drink. With such persons slight excess is often followed by serious consequences; the intellectual disturbance is early developed and out of proportion to the derangements of motility and sensation. The effects of alcohol are manifested more promptly and more intensely in children and women than in men or in the aged. Drunkenness is induced more rapidly and with smaller quantities of alcohol in summer than in winter, in warm than in cold countries.
B. IRREGULAR FORMS OF ACUTE ALCOHOLISM.20—1. The Maniacal Form.—The outbreak is usually sudden, sometimes occurring after the ingestion of comparatively small quantities of alcohol; at others after excesses which in a certain proportion of the cases have already ceased. The transition from a condition apparently normal, or marked at most by mental concentration, restlessness, and some degree of irritability, to furious mania is sometimes almost instantaneous, and the subsidence of the latter no less swift. More commonly there are prodromic symptoms, among which are general malaise, præcordial distress, palpitations, flushing of the face, vertigo, tinnitus aurium, phosphenes, and dull, throbbing headache. The attack is characterized by maniacal excitement, usually of a furious kind. The restlessness is, however, far from being aimless and purposeless. On the contrary, impelled by the wildest passions, transported with rage, the patient seeks the destruction of life and property, and wreaks his fury alike upon animate and inanimate objects. So great is his strength for the time being that several strong men may be scarcely able to restrain him. He pours forth a torrent of commingled threats and curses, in which may be heard unintelligible, and often inarticulate, sounds. He is beside himself, yet, so far as can be learned, there are neither hallucinations nor delusions by which his fury can be explained. In this respect the condition is wholly unlike that form of alcoholic mania in which the actions are explained by the imaginary surroundings and circumstances of the patient. In the maniacal form of acute alcoholism the most trifling incident, a word, a look, are sufficient to produce a tempest of rage that may end in scenes of violence. Nevertheless, the patient yet retains for a time some notion of his surroundings. At length, however, he falls into a state of complete unconsciousness, and the delirium is like that of fever, of the delusions of which no recollection afterward remains. This form of acute alcoholism is almost invariably associated with the symptoms of a high degree of cerebral hyperæmia. The hands are hot, the eyes injected, the pupils dilated or contracted, the expression eager. There are abundant secretion of saliva, frequent and irregular respiration, a rapid pulse—often exceeding 100—throbbing arteries, distended veins, and a hot skin, often bathed with sweat. The urine is scanty and constipation usual. There is, as a rule, increased sensibility to light and sound. The attack is liable to come to a tragic close in murder or suicide.
20 Ivresses anormales ou pathologiques of the French writers.
The termination of the paroxysm is as abrupt as its onset. Some abatement of its violence is quickly followed by signs of mental and bodily exhaustion; this deepens into profound sleep, which often lasts from twelve to twenty-four hours, and from which the patient awakes clear, tranquil, and as if nothing had happened, or dimly recollecting the occurrences that have passed as a hideous dream. In a small proportion of the cases the sleep deepens into coma which ends in death.
2. The Convulsive Form.—The analogy to the form just described is very close. Here, however, the morbid manifestations directly relate to the muscular system. The attack is commonly sudden, often abrupt. When prodromes occur, they are such as have been described as preceding the maniacal form—mental irritability, headache, præcordial distress, etc. The attack is thus described by Lentz: “The phenomena consist not in ordinary convulsions, but in convulsiform movements of remarkable disorder, only to be compared with the extraordinary convulsive movements of grave hysteria. We have happened to see several cases during the attack. These patients threw themselves to the ground, giving themselves up to the most irregular and disorderly contortions, rolling from side to side, throwing the body into the air, striking out with the legs and arms, kicking at random, biting at persons and things—now knocking the head against the floor, again rising for a moment, only to fall back and commence again the same contortions. Their movements are energetic and violent. There are madmen whom it is dangerous to approach by reason of the violence of their movements, but they are certainly much less dangerous than those suffering from the maniacal form of acute alcoholism, for their morbid motility has no tendency to take the shape of co-ordinated actions. It is movement wasted in pure loss. Their muscular energy is excessive; it is difficult to restrain them. To resume: the peculiarity of these movements is this, that they are not intentional, but that they are rather purely convulsiform, automatic.
“Another phenomenon of this form, one of its characteristic symptoms, is the state of intellectual enfeeblement which accompanies it. The loss of consciousness is complete, and were it not for the movement produced by the convulsions the patient would be plunged into a condition of profound coma. He has not the least knowledge of himself; not even delirium denotes intellectual activity; only an occasional harsh cry or inarticulate sound indicates the existence of mind.”
The other symptoms differ but little from the maniacal form. The duration of the attack varies from a few hours to half a day; its termination is usually abrupt, the patient falling into a condition of extreme exhaustion with stupor, or into a deep and prolonged sleep, from which he awakens without the slightest recollection of the attack through which he has passed.21
21 Consult also Dict. des Sciences méd., t. xxvi.
3. Acute Alcoholism, in Persons of Unsound Mind.—The insane, imbeciles, epileptics, and persons suffering from nervous diseases are, as a rule, abnormally susceptible to the action of alcohol, and present more or less striking peculiarities in the symptoms which it causes. Brief notice of certain of these peculiarities is in accordance with the scope and plan of this article.
In general paralysis propensity to alcoholic excesses is not rarely an early symptom. The subject is very susceptible to the action of alcohol, and under its influence rapidly passes into a state of intense excitement, characterized by incoherence, delirium, excessive restlessness, and unwillingness to seek repose until exhaustion is complete. It is under the influence of this easily-provoked alcoholic excitement that the vagabondage, quarrels, thefts, robberies, incendiarisms, and other grave crimes observed during the first stage of this form of insanity are often committed.
Imbeciles and idiots are likewise quickly, and often intensely, excited by alcohol. They are then apt to be quarrelsome, perverse, and ungovernable, defiant of authority, and capable of shocking crimes, often evincing latent vicious tendencies previously wholly unsuspected.
Epileptics are easily affected by alcohol, and usually violent in the stage of excitement; not rarely this period terminates in a true epileptic seizure.
The drunkenness of the dipsomaniac is characterized by a prolonged, uninterrupted stage of excitement without the stage of depression. Such individuals are capable of consuming in their periodical excesses large amounts of drink without the evolution of the ordinary successive phenomena of acute alcoholism.
Persons of unsound mind are, as a rule, so susceptible to the influence of alcohol, and suffer so promptly and intensely from its primary effects, that they are rarely able or permitted to consume a sufficient quantity to bring about a comatose state.
The irregular forms of acute alcoholism are only to be explained by the inherited or acquired constitutional peculiarities of individuals. To attempt to explain them in any case by the quality of the alcohol by which they are induced meets with the difficulty indicated in the fact that they are isolated and comparatively rare, even where the coarser spirits are habitually consumed. They occur in individuals who habitually commit excesses, but they cannot be viewed as manifestations of chronic alcoholism, for the reason that they also occasionally occur in those who are not habitual drinkers, and even in persons who have not for a long time previously tasted strong drink. Furthermore, as has been pointed out, they are not only occasionally, but indeed even as a rule, induced by relatively small amounts of alcohol. They are then the manifestations of idiosyncrasy. One of the striking peculiarities of this peculiar bodily organization is this very susceptibility to the action of alcohol in doses smaller than are taken with impunity by ordinary individuals. It is also characterized by a special tendency to delirium in febrile states, to hallucinations, to disturbances from trifling changes in climate, food, or manner of life, to irritability of the nervous system, and in particular of the vaso-motor system, and by a tendency to convulsions. With these tendencies is associated an unstable mental and moral character. Such persons are liable to headaches, vertigo, and epistaxis—signs of cerebral hyperæmia, which is easily induced—and their family histories indicate strong hereditary tendencies to neurotic disorders, and not rarely addiction to alcohol on the part of one or several ancestors.
But this idiosyncrasy is by no means always an inherited one. It is acquired as one of the results of profound disturbance of the nervous system, such as is produced by moral causes, by temporary or recurrent insanity, by wounds and injuries of the head, by the infectious diseases, especially syphilis, enteric and typhus fever, and small-pox, and by inflammations of the meninges.
What may be the precise mode of action of alcohol in the production of its acute effects yet remains a matter of conjecture. It cannot be doubted that its primary and direct action is upon the nervous system, and that the circulation is secondarily but rapidly implicated. But it is quite impossible to say, in the present state of knowledge, what this action is. It has been suggested that certain chemical modifications of alcohol in the blood, or of the blood itself in the presence of alcohol, cause these phenomena; that aldehyde is the active agent in their production; that the chemical changes by which alcohol is transformed into aldehydes, acetic acid, and finally into carbon dioxide, deprive the blood of the oxygen necessary for the proper performance of the functions of the nervous system. Unfortunately for these views, neither the presence of aldehydes in the blood in acute alcoholism, nor these transformations themselves, have yet been demonstrated, and a high degree of deoxygenation of the blood is frequently observed in asphyxia, the inhalation of nitrous oxide, etc., without the train of symptoms characteristic of the condition now under consideration.
It is more than probable that varying conditions of the cerebral circulation, secondary in themselves, have much to do in the causation of certain symptoms. The experimental investigations of Bernard and others have established the fact that during the period of excitement there is actual congestion of the meninges. This condition is transient, and reproduced after each repetition of the dose. After a time, or if the dose at first be excessive, the congestion is succeeded by anæmia.
PATHOLOGICAL ANATOMY.—Upon the examination of the bodies of persons who have died by accident while drunk or in consequence of drunkenness itself, deep congestion of the cerebral meninges, and especially of the pia, has been almost constantly observed. In the pia effusions of blood are occasionally encountered. The condition of the cerebral substance is not always the same. It is in a majority of the cases more or less deeply congested, yet it presents in other instances no appreciable departure from the normal state, and in a smaller number still there is actual anæmia.
The sinuses and choroid plexuses are distended with dark blood; the cerebro-spinal fluid is increased, and often tinged with blood; the ventricles are distended with fluid, which not rarely has an alcoholic odor. Occasionally the ventricles contain blood, and hemorrhage into the substance of the brain has been observed.
The condition of the elementary nervous tissues after death from acute alcoholism is not yet known.
The lungs are deeply congested, with small extravasations of blood into their substance, and often œdematous. Congestion of the liver, spleen, and kidneys in varying degrees of intensity is also seen. The pancreas is usually deeply injected, occasionally the seat of large extravasations of blood. The mucous membrane of the stomach is invariably deeply injected when the alcohol has been introduced into the organism in the ordinary manner. The observation of Caspar that post-mortem decomposition takes place with diminished rapidity has been denied by Lancereaux and others.
Other post-mortem conditions appear to be neither constant nor characteristic. The stomach usually contains partially digested food and alcohol. Lallemand, Perrin, and Du Roy observed, both during life and after death, in the blood of animals subjected to experiments, great numbers of minute glistening points, which upon microscopic examination proved to be fat-globules. The same condition has been observed in man, not only when death has taken place owing to acute alcoholism, but also when it has occurred during the digestion of a hearty meal without alcohol. The blood itself is often fluid and dark-colored; the heart sometimes empty, sometimes containing a few soft clots. Tardieu22 states that in sudden death during drunkenness pulmonary apoplexy and meningeal apoplexy, if not constant lesions, are at least extremely frequent, and almost characteristic. Baer, on the other hand, denies the occurrence of specific or characteristic lesions.
22 “Observationes médicales sur l'Etát d'Ivresse,” Annales d'Hygiene publique et de Médecine légale, tome xl.
C. ACUTE POISONING BY ALCOHOL IN LETHAL DOSES.—The symptoms are much modified when overwhelming doses of strong alcohol are introduced into the organism at once or in the course of a short time. Here alcohol produces death as an acute poison. The cases may be arranged in two groups:
1. Corrosive Poisoning.—These cases are very rare. They are caused only by undiluted alcohol, and depend upon the action of this agent in coagulating albumen and disorganizing the tissues with which it comes in contact by its affinity for the water which they contain. Absolute alcohol is a powerful corrosive poison. It produces intense phlegmonous inflammation of the œsophagus and stomach, with erosion of the mucous membrane, accompanied by vomiting, diarrhœa with bloody stools, prostration, and stupor. Death occurs by heart-failure. Among the direct effects of large doses somewhat less concentrated are acute and subacute gastritis with characteristic symptoms.
Percy23 injected by means of an œsophageal tube 90 grammes of absolute alcohol into the stomach of a dog. Death followed in the course of eight hours in consequence of violent gastro-intestinal inflammation with ulceration. Dujardin-Beaumetz and Andigie found the gastric and intestinal mucous membrane of dogs poisoned by alcohol, red, deeply injected, and “presenting at certain points a black coloration due to effused blood.” This fact they regard as worthy of note, because in their experiments the toxic agent was introduced, not by the mouth, but hypodermically, and they explain it by the supposition—which appears to me warrantable—that it is due to elimination by the mucous glands. Hence the congestion, softening, and hemorrhage.24 These observers also found that the symptoms were more acute and the lesions more marked when poisoning was caused by propyl, butyl, or amyl alcohol than when it was produced by ethyl alcohol.
23 An Experimental Inquiry concerning the Presence of Alcohol in the Ventricles of the Brain after Poisoning by that Liquid, together with Experiments illustrative of the Physiological Effects of Alcohol, London, 1839.
24 Chatin and Gublier have emphasized the fact that certain poisons introduced by intravenous injection or by absorption through the respiratory tract are eliminated by the intestines, with the production of the same local symptoms as when administered by the mouth (Bulletin de l'Académie de Médecine, Séance du 6 Novembre, 1877).
2. Acute Narcotic Poisoning.—Much more common are the cases in which death is rapidly produced by excessive doses of ordinary diluted alcohol taken at once or rapidly repeated. This happens under various circumstances, as when a drunkard avails himself of some favorable opportunity to gratify to the full a bestial appetite, or upon a wager drinks a number of glasses of spirits in quick succession or a given quantity down, or when a man already drunk is plied by his companions for pure deviltry. Suicide by this means is, in the ordinary sense of the term, rare, and murder still more so. The latter crime has, as a rule, been committed upon infants and children. Blyth25 estimates the fatal dose of absolute alcohol, diluted in the form of ordinary whiskey, gin, etc., at from one to two fluidounces for any child below the age of ten or twelve years, and at from two and a half to five ounces for an adult. In the instance recorded by Maschka26 two children, aged respectively nine and eight years, took partly by persuasion, afterward by force, about one-eighth of a pint of spirits of 67 per cent. strength—about 1.7 ounces of absolute alcohol. Both vomited somewhat, then lay down. Stertorous breathing at once came on, and they quickly died. Taylor relates a case in which a quantity of brandy representing about two fluidounces of absolute alcohol produced death in a child seven years old.
25 Poisons, their Effects and Detection, Am. ed., New York, 1885.
26 Cited by Blyth.
The symptoms are uniformly the same. The period of excitement is transient or absent altogether; occasionally the patient falls at once to the ground while in the act of drinking or immediately thereafter; complete coma, interrupted by shuddering convulsions, may terminate in the course of a short time in death. If the fatal issue be delayed, there are vomiting and involuntary discharges; the respiration becomes slow, embarrassed, stertorous; the heart's action is feeble and irregular, the pulse almost or wholly imperceptible; the temperature rapidly falls several degrees: 90° F. has been observed. The pupils are dilated; insensibility and muscular resolution are complete. The face is bloated, cyanotic; the surface bathed in a clammy sweat; the mucous membrane of the mouth often swollen and blanched. Vomiting is usual, but not constant, and there is occasionally thin mucous diarrhœa, the stools being mixed with blood. If the patient survives any considerable length of time, acute superficial gangrene of the parts most exposed to pressure is liable to take place. Recovery is rare; its possibility is, however, increased in proportion as the subject is of vigorous constitution, previous sound health, beyond the period of childhood, not yet approaching that of physiological decadence, and as treatment is early instituted and carried out with judgment.
The diagnosis is difficult, almost impossible, in the absence of witnesses: it is rendered still more obscure by the fact that this, as other forms of alcoholic coma, may be complicated by cerebral or meningeal hemorrhage and by cerebral congestion, in themselves fatal—lesions the onset of which may have been the cause of mental aberration leading to the commission of impulsive alcoholic excesses.
The prognosis, in the highest degree unfavorable in all cases, is rendered yet more so by the occurrence of intense cerebral and pulmonary congestions.
The lesions found post-mortem are those of acute alcoholism, already described. As this form of alcoholic poisoning frequently occurs in the subjects of chronic alcoholism, the lesions of that condition are often encountered, and must be distinguished from those due to the lethal dose. Nor must we overlook the fact that in the action of alcohol just described we have to do with a process differing from ordinary acute alcoholism in degree rather than in kind—a consideration which tends to simplify our notions of the pathology of alcoholism in general.
II. Chronic Alcoholism.
The prolonged abuse of alcohol brings about a series of changes which affect alike the organism at large and its various structures. The changes thus brought to pass are of the most varied kind, and depend upon individual differences too manifold and complex for enumeration and classification. Among the more important of these individual peculiarities are those which relate to temperament, constitution, hereditary predisposition, occupation, social position, personal habits, tendency to or already-existing disease of particular organs and systems, and the like. The degree of the pathological change is determined by the strength and quantity of alcohol consumed and the duration of habitual excess. The human body is capable of adapting itself to the habitual consumption of large quantities of alcohol, just as to other directly acting agents of an injurious nature, such as foul air, bad drinking-water, and unwholesome food, or even to the action of substances dangerous to life, as opium or arsenic, and yet presenting for a considerable time the appearance at least of health. Degeneration of the tissues of the body and disorders of its functions are nevertheless surely produced. These alterations are not the less dangerous to health and life because they are insidious and remain for a time latent. Furthermore, like the habit of which they are begotten, they are progressive, and sooner or later declare themselves in open disease.
The condition, whether latent or manifest, that is produced by prolonged habitual alcoholic excess is designated chronic alcoholism.27
27 The writer, although fully aware of its imperfections, regards the above definition of the term as more in accordance with the present state of our knowledge of the subject, and therefore more useful, than any other that he has been able to find. It is scarcely necessary to repeat here that the restriction of the term chronic alcoholism to accidental or occasional manifestations of a permanent state is misleading and unscientific. The same criticism is applicable to the attempt that has been made to establish this condition as a substantive disease, chronic, progressive, and characterized anatomically by inflammatory, sclerotic, and steatogenous processes.
The symptoms of this condition, when fully established, differ within wide ranges in kind and degree. They are the manifestations of derangements of the viscera, of the nervous system, and of the mind. Varying among themselves according as the stress of the pathological action has fallen upon one organ or another, forming combinations at once curious and inexplicable, developing quietly, without event, almost imperceptibly at one time, breaking into the most furious paroxysms at another, they present for our study perhaps the most complex of chronic morbid conditions. The chronic alcoholism which is latent is not, therefore, always without symptoms. They are, however, often slight and escape observation, or when manifest they are not infrequently ascribed to other causes; or, again, their etiological relations being concealed or overlooked, they are exceedingly obscure and puzzling. This is especially the case in the chronic alcoholism produced by the secret tippling of otherwise respectable persons, and especially women.
To facilitate description, we shall consider the derangements of the viscera, the nervous system, and the mind in regular order, according to the scheme on [p. 574]. But the reader will observe that whatever may be the prominence of particular symptoms or groups of symptoms in any given case, all parts of the organism are involved, and that there is no such thing as chronic alcoholism restricted to any particular viscus or group of viscera, to the nervous system, or to the mind.
A. VISCERAL DERANGEMENTS.—There is nothing specific in the lesions of chronic alcoholism. The chronic hyperæmia, steatosis, and sclerosis induced by alcoholic excesses differ in no respect from those conditions brought about by other causes. That which is specific is the evolution of a series of morbid changes in the different structures of the body under the influence of a common and continuously acting cause. The digestive system is affected, as a rule, long before the vascular or the nervous system.
1. Local Disorders.—a. Disorders of the Digestive System.—The Mouth and Throat.—The action of insufficiently diluted alcohol upon the mucous tissues is that of an irritant. The habitual repetition of this action causes subacute or chronic catarrhal inflammation. The condition of the tongue varies with that of the stomach. The mouth in acute alcoholism is apt to be pasty and foul, the tongue slightly swollen and coated with a more or less thick yellow fur; there is often also an increase of saliva; in chronic alcoholism the tongue is usually small, sometimes red, sometimes pale, often smooth from atrophy of the papillæ, not rarely deeply fissured. In a word, the condition of this organ is that seen in the various forms of subacute or chronic gastritis. The salivary secretion is often notably diminished, the sense of taste impaired. Relaxation of the throat and uvula and granular pharyngitis are common. Those who, whilst leading a sedentary life, are inclined to the pleasures of the table and a free indulgence in spirituous liquors often suffer from these affections. Mackenzie28 states that the worst cases of chronic catarrh of the throat generally arise from the habitual abuse of the stronger forms of alcohol. The associated influence of tobacco in the causation of this group of affections is not to be disregarded.
28 Diseases of the Pharynx, Larynx, and Trachea, 1880.
Lancereaux encountered ulceration of the œsophagus, and Bergeret a case of narrowing of that organ, in chronic alcoholism.29
29 Peeters regards it as probable that the connective-tissue hyperplasia and resulting stenosis seen in the stomach as a result of the action of alcohol may also occur in the œsophagus.
The Stomach.—In addition to functional dyspepsia, which is scarcely ever absent in chronic alcoholism, all forms of gastritis, from simple erythematous inflammation of the mucous membrane to sclerosis and suppurative inflammation of the stomach, are encountered. Armor30 assigns to the habit of spirit-drinking, especially to the habit of taking alcohol undiluted on an empty stomach, a high place among the causes of indigestion. He regards this habit as a prominent factor in the production of chronic gastric catarrh—a condition very frequently present in indigestion. This observer also regards the excessive use of alcohol as the most frequent among the direct exciting causes of gastric inflammation in this country, exclusive of acid or corrosive poisons. Next to errors in diet as a cause of chronic gastritis he places the immoderate use of alcohol, especially by persons whose general health and digestive powers are below a healthy standard. The primary lesions are vascular dilatation and hyperæmia. The mucous membrane is discolored, red or bluish, in scattered patches of varying size, with occasional ecchymoses of a bluish hue or spots of pigmentation. These patches occupy more commonly the region of the cardia and the lesser curvature. Vascular injection is conspicuous; the veins are dilated, tortuous; the mucous glands hypertrophied; the surface covered with thick, ropy, acid-smelling mucus. After a time permanent changes in the mucous membrane are set up. It undergoes atrophy or softening; or, again, it becomes hardened, thickened, and contracted, its rugæ more prominent, its surface mammilated—sclerosis. Grayish-brown pigmentation, the remains of former blood-extravasations, is seen at many points. Minute retention-cysts are formed in consequence of the occlusion of the ducts of certain glands. The submucous connective tissue and the muscular coat occasionally undergo, in consequence of prolonged gastritis, local hypertrophy.
30 See this System of Medicine, Vol. II. pp. 446, 464, 470.
Acute suppurative inflammation of the stomach, with purulent infiltration of, or the formation of abscesses in, the submucous tissue, has been met with in drunkards. It is extremely rare, and results from the violent irritant action of large doses of strong alcohol in subjects debilitated by previous excesses.
Gastric ulcer is much more common. The abuse of alcohol is regarded as an indirect cause of this lesion by the majority of writers. In the present state of knowledge alcohol as usually taken can scarcely be regarded as a direct cause of ulceration. Nevertheless, gastric ulcer is relatively common in alcoholic subjects. Leudet31 found gastric ulcer in 8 of 26 necropsies of drunkards. Baer and Lentz also regard the abuse of alcohol as a very common cause of ulceration. The ulcers are usually superficial, occupy by preference the neighborhood of the cardia and the lesser curvature, and are apt to be multiple. In these respects they differ from simple gastric ulcer. The latter lesion is also probably as frequent, if indeed not more frequent, in individuals dying of chronic alcoholism than in others.
31 Clinique médicale de l'Hôtel Dieu à Rouen, 1874.
The view formerly entertained that alcohol was an important cause of cancer of the stomach has been shown by Kubik, Magnus, Huss, Engel, and others to be untenable. Carcinoma ventriculi is rarely associated with chronic alcoholism.
The dimensions of the stomach are rarely normal. Dilatation is usually present in the early stages, and in beer-drinkers throughout; in the advanced course of alcoholism due to spirit-drinking the organ undergoes, in consequence of changes secondary to prolonged inflammation, more or less contraction, which is in many cases irregular.
Dyspeptic symptoms are common: the appetite is variable, irregular, and at length wholly lost. There is especially distaste for food in the morning. This, together with the disordered state of the secretions of the mouth and a feeling of nervous depression on rising, leads to the disastrous habit of taking spirits early in the day. Gastric digestion is performed with difficulty; it is accompanied by sensations of distension and weight, by flatulence and acid eructations. Heartburn is a common symptom. The drunkard is not rarely tormented by an uneasy craving or sense of emptiness in the region of the stomach, which he temporarily allays by nips and pick-me-ups and morsels of highly-seasoned foods at odd times, with the result of still further damage to his digestion and the complete loss of appetite for wholesome food at regular hours. In the course of time the characteristic morning sickness of drunkards is established. On arising there is nausea, accompanied by vomiting—sometimes without effort or pain, at others attended by distressing retching and gagging. The matter vomited consists usually of viscid mucus, at first transparent, then flaky, and at length, if the efforts be violent, of a green or yellow color from the admixture of bile. These symptoms ordinarily do not recur until the following day. In other cases vomiting is more frequent, recurring at irregular periods during the day, and not uncommonly an hour or two after the ingestion of food. When gastric ulcer is present, portions of the vomited matter are often dark and grumous like coffee-grounds or the settlings of beef-tea, and are found upon microscopic examination to contain blood-corpuscles. Actual hæmatemesis may also occur under these circumstances, and be repeated from time to time. The quantity of blood thrown up is frequently small; at times, however, it is excessive, and occasionally so great as to cause death.
Common as are the evidences of gastric disturbance in chronic alcoholism, they are far from being constant, and it is worthy of note that in proportion to the number of the cases serious gastric affections are, except in the later stages, relatively infrequent.
The Intestines.—Lesions of the small intestine due to alcoholism are extremely rare. Even when simple or ulcerative inflammation of the stomach is localized at, or extends to, the pylorus, it rarely passes any great distance into the gut. The large intestine is, on the contrary, frequently the seat of chronic inflammatory processes. Here we find vascular engorgement, patches of pigmentation, localized thickening of the mucous and submucous tissues, enlargement of the solitary glands, and an excessive secretion of viscid mucus. The tendency to permanent vascular dilatation, which is a characteristic result of alcoholic habits, constitutes a powerful predisposing influence in the causation of hemorrhoids, which are common. Alcohol acts directly upon the hemorrhoidal plexus of veins, and indirectly by causing permanent congestions of more or less intensity in the greater number of the abdominal viscera. When a prolonged course of excesses in alcohol has led to chronic congestion with hypertrophy, cirrhosis, or other structural change in the liver which is capable of causing permanent mechanical obstruction of the portal circulation, hemorrhoids constitute a very common affection in the group of morbid entities secondary to these conditions.
The symptoms of intestinal derangement are in the beginning, as a rule, slight and occasional. They consist of uneasy sensations or colicky pains in the abdomen, a feeling of fulness with or without tympany, and constipation alternating with diarrhœa: in a word, they are the symptoms of acute or subacute intestinal indigestion terminating in an attack of intestinal catarrh. Attacks of this kind repeat themselves in a considerable proportion of the cases with variable but increasing frequency, until at length the conditions of which they are the expression become permanent, and the patient suffers, among other distressing symptoms hereafter to be described, from chronic diarrhœa. The stools are now of the most variable character—occasionally bilious, sometimes containing small dark scybalous masses, rarely formed, but usually containing more or less abnormal mucus, too much fluid, and traces of blood. Indeed, at this stage several causes—among which I may mention visceral congestions, local inflammation of the intestinal mucous membrane, dilatation of the hemorrhoidal veins, and structural changes in the liver—conspire to determine blood toward the interior of the intestinal tube. Traces of blood in the stools are therefore frequent, and actual hemorrhage and the appearance of the dark, tarry, and altered blood formerly described under the term melæna are by no means rare. Colliquative diarrhœa and dysenteric attacks also occur, and at length an intense enteritis with uncontrollable diarrhœa may end the life of the patient. The conditions just described lead to rapid emaciation, and contribute when present to the establishment of the cachexia so marked in many cases of chronic alcoholism.
The Glands.—The salivary glands were found by Lancereaux32 to have undergone softening, with granulo-fatty changes in their epithelium. If such changes are among the usual effects of alcohol, they are doubtless productive of alterations in the saliva, which explain, in part at least, the dryness of the mouth so frequent among drunkards.
32 Dictionnaire de Médecine, art. “Alcoholism.”
The pancreas is, as the result of interstitial inflammation, the seat of similar changes. It is sometimes enlarged and softened, sometimes atrophied, shrivelled, or cirrhotic. In the latter condition its consistence is firm, its surface uneven, its color deep yellow, brown, or pale. Hyperplasia of the interacinous connective tissue, with subsequent contraction and atrophy and destruction of the glandular tissue, characterizes the more chronic forms of pancreatitis, and the organ is frequently the seat of scattered minute blood-extravasations. I have already alluded to the enlargement of the solitary glands which constitutes a feature of the condition of the large intestine. The solitary glands and Peyer's patches of the small intestine are rarely altered.
b. Disorders of the Liver.—Next in order to the stomach, the liver is more directly exposed to the action of alcohol than any other viscus. For this reason lesions of the liver are frequent and grave. It is worthy of note, however, that in a small proportion of cases of chronic alcoholism terminating fatally, with widespread evidences of the destructive action of alcohol upon the other organs of the body, the liver has been found, both in its macroscopic and microscopic appearances, wholly normal. Absorbed by the gastric vessels, alcohol passes directly, by way of the portal vein, into the parenchyma of the liver, there giving rise to various disturbances, the nature of which is determined by the tendencies of the individual on the one hand, and on the other hand by the character of the alcohol consumed. The danger of hepatic disease is in direct proportion to the amount and the concentration of the alcohol habitually taken. The steady drinkers of spirits of whatever kind, whether gin, brandy, whiskey, or rum, present the largest proportion of diseases of the liver. These affections are far less common among beer-drinkers, and infrequent among wine-drinkers in wine-growing countries. In this connection it is to be borne in mind that the presence of food in the stomach retards to some degree the absorption of the alcohol ingested, and to a certain extent constitutes a means of dilution.
Hepatic disorders due to alcohol may be arranged in two groups: first, congestion and inflammation; second, fatty infiltration or steatosis; and the inflammatory process may affect chiefly the interstitial connective tissue on the one hand, giving rise to sclerosis, or on the other the glandular substance, constituting a true parenchymatous inflammation.
Congestion.—Congestion of the liver is an early lesion. It is brought about by the direct irritant action of the alcohol itself in part, and in part by the extension of inflammation from the stomach by continuous mucous tracts. Its development is insidious. Anatomically, the condition is characterized by vascular dilatation, moderate tumefaction, slight increase in the consistence of the organ; the surface is of a deeper red than normal; on section the color is more intense and the oozing more abundant. At a later period we have, as the result of chronic congestion, the cyanotic liver; the color is brownish or violet, mottled, and on section the surface is granular and the lobules distinct. The organ may now be somewhat diminished in size, but it lacks the firmness of sclerosis and the hobnail appearance due to the contraction of the interlobular connective tissue in that condition.
The symptoms of congestion of the liver are the familiar symptoms of gastro-hepatic catarrh, varying from the transient disturbance known as biliousness to serious sickness, characterized by acute gastro-intestinal phenomena, with vomiting, headache, and other derangements of the nervous system—constipation, succeeded by diarrhœa and by more or less distinct jaundice. The graver forms of hepatic congestion are characterized by intense nausea, frequent vomiting, pain and soreness in the epigastrium and right hypogastrium, the physical signs of augmentation of the volume of the liver, and well-marked yellow discoloration of the conjunctivæ and skin. These attacks are usually afebrile: the pulse is slow; there is considerable nervous and mental depression, a tendency to vertigo, and occasional syncope. The urine is scanty and high-colored, and presents the reactions of bile-pigment. Muscular tremor, especially marked in the extremities and tongue, is often present, but is to be attributed rather to the direct action of alcohol upon the nervous system than to the condition of the liver.
Hepatitis.—There are two principal forms of inflammation of the liver induced by alcohol—parenchymatous hepatitis and interstitial hepatitis or sclerosis.
Several varieties of parenchymatous hepatitis have been described. The anatomical discrimination of these varieties is attended with less difficulty than their clinical diagnosis. One of the more serious is diffused parenchymatous hepatitis or acute yellow atrophy. Alcoholic excesses appear to constitute a predisposing influence to this grave disorder (Lentz). In several cases prolonged and repeated excesses have preceded its development. It is a true parenchymatous inflammation, in which the glandular elements of the organ undergo disintegration. The liver is diminished in volume in all its diameters. It is of a uniform yellow color; its tissue is soft and friable; upon section the hepatic cells are found to be replaced by a granular detritus mingled with globules of coloring matter and a greasy, grayish-yellow liquid exudation.
The symptoms of this affection are those of an acute parenchymatous hepatitis of the gravest kind. In the early stages there is intense jaundice, gastro-intestinal disturbance, and fever, followed by speedy evidences of profound toxæmia. The patient rapidly falls into the so-called typhoid state, with a tendency to coma. The prognosis is, in the greater number or cases, a fatal one. So close is the resemblance between acute yellow atrophy of the liver and the phenomena of acute phosphorus-poisoning that by many observers these two conditions are held to be identical.33
33 Consult this System of Medicine, Vol. II., article “Acute Yellow Atrophy of the Liver.”
There is little doubt that the view now generally held, that acute yellow atrophy is due to the action of some unknown toxic principle, is correct. Alcoholic excess must therefore be regarded merely in the light of a predisposing influence. Acute yellow atrophy of the liver is an exceedingly rare disease.
Suppurative Hepatitis.—Abscess of the liver is in temperate climates infrequent as the direct result of alcoholic excess. It is frequently ascribed, however, to improper alcoholic indulgence, especially when combined with the eating of large quantities of improper food, in tropical and subtropical climates. A form of hepatitis has been described by Leudet under the head of chronic interstitial hepatitis with atrophy. The symptoms are for the most part not very well marked, and consist chiefly in general malnutrition, which may in fact be dependent upon the associated gastric disturbance. Chronic jaundice is usually present.
Interstitial Hepatitis.—Cirrhosis of the liver is in a large proportion of cases directly attributable to alcoholic excess. In this view the greater number of observers coincide. But that alcohol is not the sole cause of chronic interstitial hepatitis has been abundantly established. As long ago as 1868, Anstie34 wrote as follows: “Considering the enormous quantities of spirituous liquors which are drunk by many of the patients who apply for relief from the consequences of chronic alcoholism, it would be natural for the reader who holds the usual opinion as to the origin of cirrhosis of the liver to expect that serious symptoms produced by the latter disorder must often complicate cases of the former. The case is, however, far otherwise in my own experience. Of the immense number of patients in whom the nervous disorder has been clearly identified, I have only seen thirteen cases in which the symptoms of cirrhotic disease called for any special treatment, although a certain degree of cirrhosis was doubtless present in many of the others; and I cannot avoid the conclusion that some very powerful element over and above the influence of alcoholic excess is needed to produce the severe type of that disease.” Formad35 states as the result of his investigations as coroner's physician of the city of Philadelphia that cirrhosis of the liver is much less common in alcoholic subjects than has been generally thought. My own experience during eleven years as attending physician at the Philadelphia Hospital leads me to endorse this opinion.
34 A System of Medicine, Reynolds, vol. ii. p. 74.
35 Proceedings of the Pathological Society of Philadelphia, Dec., 1885.
The anatomical lesions of chronic interstitial hepatitis consist essentially in hyperplasia and hypertrophy of the connective tissue of the organ. The progress of the affection is insidious and gradual; some degree of enlargement, due in part to congestion and in part to interstitial exudation, is followed by gradual diminution, with retraction of the new connective tissue. When the connective-tissue new formation is excessive, and retraction fails to take place, the organ remains permanently enlarged (hypertrophic cirrhosis). During the first period the volume of the organ is increased, its consistence is more firm, and its surface is slightly granular. The second period is characterized by induration, with diminution of the volume of the organ and alteration of its form. The surface is uneven, deeply granular, and usually of a mottled yellow color. The tissue is firm, creaking under the knife. The connective tissue is enormously increased, the glandular elements being proportionately atrophied.
The contracting connective tissue exercises at the same time a compressing influence upon the hepatic cells and upon the vascular supply throughout the organ; the radicals of the portal vein and the branches of the hepatic artery are alike compressed, and in part obliterated. The same is true of the bile-ducts. The functional activity of the liver, at first diminished, is finally, to a considerable extent, arrested. In consequence of these physical alterations in the structure of the organ, the symptoms, which are at first insignificant, become progressively more grave, until at length they constitute complications of the most serious kind.
It can be no longer asserted that the interstitial hepatitis produced by alcohol presents specific characters. It nevertheless differs in many respects from that form due to valvular lesions of the heart, in which there are induration, usually augmentation in the volume of the organ, and persistent congestion. Congestion, in truth, is the chief characteristic of the latter form, in which the surface is smooth and glistening, of a deep brown or violet hue, and on section yellowish or brown—a condition which has been well described under the term cyanotic liver.
Sclerotic changes due to alcohol usually affect the organ throughout. In this respect alcoholic cirrhosis differs from that form due to syphilis in which the lesions are irregularly distributed.
The functional disturbances due to cirrhosis are, in the beginning, obscure in themselves and masked by the concomitant gastric derangement. Later, ascites constitutes the chief as well as the most constant symptom. It is rarely altogether absent. Emaciation is also a prominent symptom. No affection, not even diabetes or phthisis, produces loss of flesh so rapid, so marked, and so significant as cirrhosis of the liver in chronic alcoholism. Not only do the adipose tissues waste, but the muscles themselves undergo rapid atrophy. This fact is not surprising when we consider that the lesions of the liver give rise to grave interference with every function of that organ. In addition to the more common gastric symptoms, there is constipation, not rarely alternating, without assignable cause, with serous and sometimes bloody diarrhœa. Epigastric distress, epistaxis, and hemorrhages from other mucous surfaces are common, and are due in part to the disturbance of the general circulation, and in part to alterations in the character of the blood itself. The physical signs indicate in the early stages increase, and afterward diminution, in the volume of the liver. Enlargement of the superficial abdominal veins is a characteristic sign. Cirrhosis of the liver is a grave affection, the course of which, at first slow, afterward more rapid, almost invariably leads to a fatal termination.
Fatty Degeneration of the Liver.—Steatosis of the liver is of extremely common occurrence in the advanced stages of alcoholism. The anatomical changes consist in accumulation of fat-globules in the liver-cells. French writers distinguish two varieties of hepatic steatosis: first, that in which the cellular elements undergo no change beyond that of an accumulation of fat-globules within their substance; and second, that in which the liver-cells undergo an actual disintegration, in the course of which fat-granules are formed, and which is, as a matter of fact, a true fatty degeneration. The first of these conditions is not incompatible with the functional integrity of the organ, and is in many instances unattended by symptoms, being discovered only upon examination after death. Its occurrence is to be explained by the imperfect oxidation of waste products due to the constant presence of alcohol in the blood, and by the habitual excess of fat in the latter fluid. When fatty infiltration is of moderate amount there are no changes in the volume or the contour of the organ, and the condition is recognized only on microscopical examination. At a later stage the organ becomes enlarged, particularly in its antero-posterior diameter. The surface is now smooth and glistening, its color yellow or reddish-yellow; upon section it is anæmic, of a yellowish color, with patches of a reddish hue, and its consistence is diminished. The indentation caused by pressure of the finger persists. Under the microscope the hepatic cells are enlarged, rounded, packed with fat-globules of varying size. In some of the cells these globules coalesce and form more or less extensive drops of fat. The bile which is secreted in this condition presents in most instances the normal characteristics.
Disorders of digestion do not occur in consequence of the fatty change in the liver until the lesion has reached an advanced stage; nevertheless, they constitute the earliest symptoms of this condition. Imperfect digestion, accompanied with flatulence, distension of the belly, epigastric tenderness, with light-colored stools, and constipation alternating with diarrhœa, are common symptoms. There is no pain properly referable to the region of the liver. Whilst icterus does not occur, there is, nevertheless, a peculiar earthy pallor of the complexion and persistent greasiness of the skin—conditions, however, which are not in themselves sufficiently marked to possess, in the absence of other signs, clinical value.
The second form of fatty degeneration, in which the liver-cells undergo actual and destructive metamorphosis, accompanied by the production of fat, is of a much more serious character. It appears to constitute the stadium ultimum of various forms of interstitial hepatitis, and is manifested by symptoms of the gravest character, in many particulars much like those met with in acute yellow atrophy—namely, visceral congestions, hemorrhages from mucous surfaces, serous effusions, profound and rapidly developing anæmia, nervous depression, and coma.
Biliary Catarrh.—The biliary ducts are usually the seat of catarrhal inflammation, due less perhaps to the direct irritant action of the alcohol than to the extension of the inflammation of the gastric mucous membrane in the form of gastro-duodenal catarrh. Gall-stones are not common in alcoholism.
The spleen is, as a rule, enlarged, soft, and friable; occasionally it is small and shrivelled. No characteristic changes in its contour and structure have been recorded.
The great omentum and mesentery are loaded with fat, very often to an extreme degree. This condition is more marked in the chronic alcoholism of beer-drinkers than in that of spirit-drinkers. Not infrequently there are found evidences of chronic peritonitis, which has been attributed by Lancereaux, in the absence of other assignable cause, to the effect of alcohol itself. The symptoms of this condition are usually obscure, consisting of diffused dull pain, augmented upon pressure, diarrhœa, digestive troubles, and abdominal distension, sometimes voluminous, often irregular.
c. Disorders of the Respiratory System.—The Larynx.—Catarrhal inflammation of the mucous membrane of the air-passages is common in drunkards. Some degree of subacute or chronic laryngitis is an early symptom of chronic alcoholism. It may result from repeated attacks of acute alcoholism, or it may be among the first signs of excesses that are continuous, without at any one time being extreme. In the production of this local trouble the direct action of alcohol is reinforced by the foul and smoke-laden air of the apartments in which tipplers spend much of their time and by heedless exposure to the vicissitudes of the weather. The anatomical changes are those of chronic laryngitis in general, hyperæmia of the mucous membrane with minute ecchymoses, local destruction of epithelium with superficial ulcerations or granulating surfaces. The mucus is often thick, opaque, and adherent.
These lesions are accompanied by more or less decided impairment of function. The voice is hoarse and husky; there is fatiguing laryngeal cough, usually harsh and grating in character, and attended by scanty muco-purulent expectoration. This cough is often paroxysmal; especially is it apt to be so on rising, and it then provokes the vomiting previously described.
The Bronchi.—After a time similar anatomical changes are brought to pass in the bronchial tubes. Subacute bronchitis is little by little transformed into the chronic form, characterized by hyperæmia and thickening of the mucous membrane, extending to the finer twigs, with submucous infiltration and implication of the connective-tissue framework of the lung. The exudation, tough and adherent or fluid and copious, occasions more or less frequent cough, and interferes with the function of respiration. Hence it is common to encounter in the subjects of chronic alcoholism bronchiectasis, pseudo-hypertrophic emphysema, easily excited or permanent dyspnœa, asthmatic seizures, and some degree of cyanosis. These local affections, interfering with the circulation of the blood and its proper aëration, react unfavorably upon the nutrition of the organism at large, and largely contribute to the production of the ultimate dyscrasia.
The Lungs.—Pulmonary congestion and œdema are of common occurrence. Favored by the action of alcohol upon the vaso-motor system, they are readily excited by the careless habits and frequent exposures of the subject. The lesions occupy by preference the lower and posterior parts of the lungs, and consist in relaxation of the parenchyma, with vascular dilatation and serous infiltration. The vesicles are capable of distension, but contain little air. The tissue is friable, deep-red or brownish in color, and floats upon water. The symptoms of this condition are sometimes obscure: usually they consist in a sensation of constriction of the thorax, more or less dyspnœa, mucous expectoration, sometimes streaked with blood, and lividity of the countenance and finger-tips. The chief physical signs are impaired percussion resonance and mucous, subcrepitant, and occasionally a few scattered crepitant râles.
Pulmonary Apoplexy.—When the congestion is extreme, blood may escape into the parenchyma of the lung with laceration of its substance. This lesion is more frequent in intense acute alcoholism than in the chronic form.
Pneumonia.—Habitual alcohol-drinkers are far more liable to pneumonia than others. It has even been asserted that alcohol is of itself capable of acting as an efficient exciting cause. Whilst it is indisputable that the action of this agent upon the pulmonary blood-vessels and in favoring pulmonary congestion constitutes a powerful predisposing influence, it cannot be admitted, regard being had to the fact that it is largely eliminated by the lungs, that alcohol can, in the absence of a specific cause, ever produce a specific acute febrile disease, such as croupous pneumonia. The pneumonia of alcoholic subjects, like that of aged persons and that occurring in the convalescence from acute diseases, is apt to be latent. The exudation is often of limited extent; the symptoms are insidious, and the striking clinical features of the ordinary frank form of the affection are not rarely absent altogether. It is no infrequent occurrence that pneumonia is overlooked in the delirium tremens which it has induced.
The anatomical changes are those of the ordinary form. The prognosis is always grave. When recovery occurs resolution is often tedious and prolonged.
Catarrhal pneumonia is also common. It is marked by its usual phenomena.
The most striking fact in the pneumonia of alcoholic individuals is the contrast between the local and the constitutional symptoms. The former are in the greater number of the cases insignificant and easily overlooked. Even the physical signs, when sought for, are often obscure and indeterminate: relative dulness, enfeebled or absent vesicular murmur, faint scattered crepitation masked by mucous râles, and a bronchial respiratory sound scarcely appreciable, are all that can be detected upon physical examination. In strong contrast to this almost negative picture is that of the constitutional disturbance, which is commonly of the gravest kind. The prostration is extreme; there is delirium with tremor, restlessness, sleeplessness, mental agitation, profuse sweating, feeble action of the heart, gastro-intestinal irritation, with vomiting and often complete inability to retain food. The temperature-curve lacks the characters of pneumonia of the ordinary form. Not seldom is febrile movement absent altogether.
The view that alcohol, independently of and in the absence of other lesions, occasionally produces changes in the lungs analogous to the chronic interstitial inflammatory processes of cirrhosis of the liver—i.e. fibroid phthisis—is not borne out by clinical or pathological investigation, and appears to be wholly without foundation in fact.
Pulmonary Phthisis.—The question whether or not chronic alcoholism exerts any influence in the production and evolution of pulmonary phthisis has been the subject of no little fruitless controversy. There are medical men of experience who do not hesitate to affirm that the abundant use of alcohol constitutes in certain cases an actual prophylaxis, while there are others who insist with equal positiveness that alcoholic excesses favor the development of this affection. Whatever may be the influence of alcohol in depressing the forces of the body and in the production of serious lesions of pulmonary structures, and thus predisposing the subject to phthisis, it can be asserted with confidence that it does not directly cause any form of phthisis whatever. The alcoholic phthisis of Lancereaux, Richardson, Drysdale, and others cannot be now regarded as a distinct, independent affection. The process of exclusion by which alcohol was made to seem the real cause of the disease in 36 of 2000 of the cases examined by Richardson was not sufficiently rigid to meet the requirements of our present knowledge. There is reason to believe that by its favorable influence upon the appetite and digestion, its power to reduce temperature, its retarding influence upon tissue-waste, alcohol in moderate quantities is of great use in the management of this affection. That phthisical subjects occasionally seem to derive benefit from, and to lengthen their lives by, excesses in alcohol is capable of explanation—first, by the fact that an extraordinary tolerance for alcohol is natural to or acquired by certain individuals; and, second, by the favorable influence of alcohol upon ulcerative and suppurative processes, and in determining connective-tissue new formation—a process by which certain inflammatory products, including tubercle, are capable of being rendered inert. The foregoing remarks are applicable to all forms of pulmonary phthisis.
The Pleuræ.—The pleura is sometimes the seat of patches of fibrinous exudation of varying extent and thickness, which are, according to Lentz, the expression of the formative action which constitutes one of the modalities of alcoholism, and which are of the same nature as the fibrinous exudations which occur in the peritoneum and the dura mater. These false membranes cause pleural adhesions, and occasionally contain within their meshes a turbid serous fluid.
d. Disorders of the Circulatory System.—The Heart.—This organ is usually implicated to a greater or less extent in the course of chronic alcoholism. Lesions of the muscular substance are more common than those of the valvular apparatus.
Hypertrophy is common. It affects usually both sides of the heart—the left, however, more than the right—and is associated with some degree of dilatation. The part played by alcohol in the production of cardiac hypertrophy is a dual one: first, that of constantly-repeated direct stimulation of the heart; second, that of the indirect stimulation to over-action caused by the necessity to overcome the obstacles which the lesions of the viscera interpose to the circulation of the blood in the later periods of the disease. Nor are the lesions of the blood-vessels themselves, hereafter to be described, without influence in inducing hypertrophy. Bollinger and Schmidbauer have shown that the habitual consumption of beer in excessive quantities leads to cardiac hypertrophy of characteristic form. Both sides of the heart participate in the overgrowth: there is enormous increase in the volume of the primitive muscular elements, with enlargement of the nuclei. Whether or not actual numerical increase in the muscular fibres takes place cannot be determined. This form of enlargement of the heart occurs in the absence of lesions of the valves, disturbances of the pulmonary circulation, arterial sclerosis, atheroma, or granular kidneys. Some few of these cases of so-called idiopathic hypertrophy are perhaps due to prolonged excessive bodily effort and bodily strain. But the greater number are only to be explained by habitual excesses in beer-drinking, as shown by carefully worked-out personal histories of the patients. Neither fatty degeneration nor myocarditis enters into the pathological process under consideration. The hypertrophy is due to the direct action of the alcohol consumed, to the enormous amount of fluid introduced into the body, and to the easily-assimilated nutritive constituents of the beer itself. Furthermore, such habits are often associated with great bodily activity and a relatively luxurious manner of life. The greater number of alcoholic subjects who suffer from this form of hypertrophy perish after brief illness with symptoms of heart-failure. At the necropsy are discovered moderate dropsy, congestion and brown induration of the lungs, congestion of the liver, spleen, kidneys, and other organs, bronchitis and moderate serous effusions or general anasarca. Death is probably due to paralysis of the cardiac nerves and ganglia. This form of hypertrophy is of course much more common among men than among women. It is much less common in this country than in Germany, but is occasionally met with among brewers' employés.
Fibroid Degeneration.—This condition has been ascribed to a number of causes, among which long-continued excess in alcohol is unquestionably an important one. Bramwell holds the opinion that in a certain proportion of cases of this description, in which fibroid degeneration of the heart is connected with similar changes in the kidneys (sclerosis), the lesions of both organs are due to alcoholism. Alcoholic fibrosis differs in no respect from that due to other causes. The condition may escape recognition by the unaided eye if it be disseminated throughout the muscle and the change consist in thickening of the perimysia around undivided fibres. The heart is larger than normal, perhaps a little paler, and its consistency a little more firm. When, as is more commonly the case, the fibroid change is localized, and masses of new tissue are developed in and around the muscular fibres, the heart assumes a flecked or streaked appearance, due to the contrast between the yellowish-white fibroid tissue and the brownish-red muscular structure. The microscope shows excessive development of fibrous tissue, with atrophy of muscular fibres. The effect is to weaken the force of the heart's action, and to weaken the walls of the cavities at the affected parts in such a manner as to cause local bulgings or cardiac aneurisms.
The symptoms and physical signs of fibroid degeneration of the heart are very obscure and indefinite, and the diagnosis is always attended with difficulty, and in many cases is impossible. Jubel-Renoy, however, regards the diagnosis as having already attained some clinical exactitude, and regards as important the association of the following diagnostic data: first, feebleness of the systole and the pulse, with augmentation of the frequency without irregularity; second, moderate enlargement, varying within considerable limits; and third, absence of murmurs in the greater number of the cases. Death is apt to occur suddenly. Welch, upon investigation of the clinical histories of cases in which fibroid degeneration of the heart was found after death, concluded that they might be clinically grouped as follows: first, cases in which there is no symptom of heart disease; second, cases of sudden death without previous heart symptoms; third, sudden death preceded by one or more attacks of angina pectoris; fourth, after cardiac insufficiency of a few days' standing; and fifth, in cases of old heart disease.
Fatty Heart.—Under the term fatty heart two distinct pathological conditions are comprised. Of these the first is fatty infiltration, which consists in an excessive development of the normal subpericardial fat, with a deposition of fat-cells in considerable number between the muscular fibres of the myocardium. This condition occurs chiefly in individuals suffering from general obesity, and is particularly apt to occur in alcoholic obesity. Large masses of fat fill the grooves and furrows of the organ, the surface of which is covered with a thick layer of yellowish fat. The right heart is first and most affected, but in advanced cases the whole heart may be encased in a thick fatty layer. When the fat-cells infiltrate the intermuscular spaces, they exert pressure which may produce atrophy and degeneration of the muscular elements. This condition may exist to a certain extent without symptoms, but it is, however, apt to be manifested by a certain amount of cardiac dyspnœa and inability to endure excessive strain or acute illness. In cases in which the fatty infiltration attains a high grade, inducing by mechanical pressure degenerative changes in the muscular substance of the heart, there are signs of embarrassment of the circulation. The precise diagnosis is usually difficult, often impossible.
The second form of fatty heart is known as fatty degeneration, and consists in changes in the muscular fibres by which the albuminoid constituents are broken up and replaced by microscopic particles of fat. After a time the transverse striæ disappear, and the functional activity of those muscular fibres which are affected is completely lost. All conditions which interfere with the supply of oxygen to the muscular tissue or which seriously derange its nutrition are capable of producing fatty degeneration. Among these are alcoholic excesses. The color of the heart is paler than normal, usually fawn or pale buff. It has been described as the faded-leaf color. The consistence is softer than normal, the wall of the heart in many instances being readily broken down by the pressure of the finger. The left ventricle is the part most likely to be affected, the papillary muscles being often profoundly altered. Next in order the right ventricle is involved, then the left auricle, and finally the right auricle. When this form of degeneration is due to disease of the coronary arteries, the lesion is usually localized, sometimes limited to the distribution of the branch of the artery which is affected.
Upon microscopical examination the affected muscular fibres are found to contain minute molecules of fat, often of a uniform size, sometimes arranged in rows, but commonly distributed irregularly throughout the substance of the fibre. The transverse striæ are indistinct, and sometimes wholly absent. The functional activity of the affected fibres is seriously interfered with or wholly lost, and as a result the force of the circulation is greatly weakened. These two forms of fatty change are occasionally associated. Among the more common symptoms are shortness of breath upon exertion, with dry hacking cough. In advanced cases the dyspnœa may become constant. The fatal issue is sometimes preceded by the Cheyne-Stokes respiration. Other symptoms are due to cerebral anæmia. The memory is impaired, the patient becomes wayward and irritable, and is apt to become faint upon suddenly changing from the recumbent to the erect posture, and in most instances is incapable of concentrated mental effort or active bodily exertion.
The Blood-vessels.—Capillary dilatation is one of the earliest and most persistent effects of alcohol. The visceral congestions which constitute so important a factor in the pathology of alcoholism are in part the result of the paralyzing action of alcohol on the vaso-motor system, and in part of the degenerative changes in the unstriped muscular fibres of the arterial walls.
Atheroma.—Alcoholic excesses play an important part in the etiology of atheromatous degeneration of the arterial walls, not so much by the direct action of the alcohol itself, as by its indirect action in increasing the tension in the main trunks, and in leading to an irregular life in which excitement, sudden and severe exertion, exposure to cold, and depressing influences of all kinds play a part.
Valvular lesions of the heart do not occur as a direct result of the action of alcohol.
e. Disorders of the Genito-urinary Apparatus.—The Kidneys.—Alcohol, as has been shown above, is a diuretic. In large doses it produces renal congestion. Ollivier36 observed acute transient albuminuria resulting from the influence of excessive doses of alcohol.
36 Essai sur les Albuminuries produites par l'Elimination des Substances toxiques, Paris, 1863.
Much difference of opinion exists as to the part played by alcohol in the causation of the various forms of Bright's disease. It was at one time thought that a large proportion of the cases were due to the abuse of this substance. Bright held this view, and Christison attributed from three-fourths to four-fifths of all cases of granular degeneration of the kidneys to the abuse of spirits. The latter considered that not alone in notorious drunkards was this result likely to occur, but even in those accustomed to the moderate daily consumption of spirits with only occasional excesses. This opinion for a long time largely prevailed among English writers. Of late years, however, in consequence partly of the teachings of Anstie and Dickinson, partly of more precise methods of reasoning, the direct causative relation between chronic alcoholism and disease of the kidneys has come to be questioned. Nevertheless, many teachers of authority adhere to the former view. It is, however, more than probable that the action of alcohol is not of itself capable of producing these effects in the absence of other causes, among which are insufficient or improper diet, irregular living, damp dwelling-places, occupations necessitating great or prolonged exposure to cold and wet or such exposure from accidental causes—circumstances to which those who, especially among the poorer classes, are addicted to drink are peculiarly liable. Nor must we overlook the influence of exposure to paludal poison, of lead, and of heredity in the causation of diseases of the kidneys. While alcohol cannot be regarded as the direct exciting cause of acute or chronic nephritis, chronic alcoholism acts as an influence predisposing to the development of these affections in persons otherwise liable to them.
Congestion of the Kidneys.—The general action of alcohol in inducing visceral hyperæmia is aided by its special diuretic action in causing chronic congestion (cyanotic kidney). The kidney is of a dark violet-red hue, slightly enlarged, especially in its transverse diameter, of a consistence firmer than normal, and bleeds freely upon section.
Acute parenchymatous nephritis is of rare occurrence in chronic alcoholism. Of chronic parenchymatous nephritis Bartels37 writes: “I may say that alcoholic excesses, to which the disease is by many attributed, cannot be charged with being the cause of it. None of the cases treated by me occurred in drunkards, and in no instance have I encountered the large white kidney at the autopsies of notorious drinkers, of which I have made a not inconsiderable number during my many years' active hospital service.” The same author in discussing the etiology of chronic interstitial nephritis (contracted kidney) enters a protest against the view which is widespread in England that the abuse of spirituous liquors favors the development of the genuine contracted kidney. He says: “In the first place, among all the patients whom I have treated, three only were brandy-drinkers to any notorious excess, while by far the greater number who were affected with this complaint had lived remarkably abstemious lives. In the second place, throughout my twenty-five years of active service as a hospital physician I have had the most abundant opportunity of watching the consequences of intemperance, both at the bedside and upon the post-mortem table; yet these three cases have hitherto been the only ones in which I have found atrophied kidneys in the bodies of habitual drunkards.” Baer also testifies to the infrequency of contracted kidneys among drunkards.
37 Ziemssen's Cyclopædia of Medicine.
Fürstner detected by very exact testing a trace of albumen in the urine of almost all cases of delirium tremens examined. Its presence was, however, transient, and appeared to be not associated with structural changes in the kidneys.38
38 Berliner klin. Wochenschrift, 1876, No. 28.
Fatty infiltration and fatty degeneration of the kidneys occur in chronic alcoholism, the former as part of the general fat accumulation, the latter as a result of the general nutritive disturbances.
Amyloid degeneration is rare, and can in no case be ascribed to the direct action of alcohol.
Griesinger saw excessive diabetes insipidus follow a prolonged and severe attack of acute alcoholism in a man twenty-eight years old, and terminate fatally in the course of four months. Ebstein attributes the polyuria of acute alcoholism to lesions of the brain.
Glycosuria is rare among drunkards.
The Bladder.—Catarrh of the bladder is not rare in chronic alcoholism, especially in that form originating from excesses in malt liquors. This condition, however, scarcely occurs with sufficient frequency to be regarded as in any sense a symptom of alcoholism.
The Genital Organs.—The subjects of alcoholism are especially prone to sexual disorders of all kinds—a fact to be explained by the influence of alcohol on the imagination, and especially upon the sexual appetite, its debasing effect on the moral sense and upon the judgment, and the indifference to the consequences of exposure which it begets. In the later stages of chronic alcoholism sexual power is apt to be greatly enfeebled or wholly lost. This condition, which is usually attended also by loss of sexual desire, is to be attributed to the action of alcohol upon the nervous system rather than upon the sexual organs themselves. It has nevertheless been established that long-continued alcoholic excesses are apt to be followed by atrophy of the testicles. Lancereaux has described a condition of these organs resembling in all respects senile atrophy. On the other hand, Huss attributed the impotence of alcoholic subjects to loss of nervous tone. In the female, alcoholism produces disturbances of menstruation and premature menopause. Alcoholic excesses are said also to produce a liability to abortion, and Lancereaux has observed atrophy of the ovaries in alcoholic subjects.
2. Disorders of Special Structures.—a. Disorders of the Locomotive Apparatus.—The muscles at large, like the heart, are liable to fatty infiltration and degeneration. Fatty infiltration, frequent at some period in the course of the affection, is apt to be widespread. The muscles are paler than normal, softer in consistence, and streaked with fat. True fatty degeneration is less frequent, and apt to be localized. Here the muscular fibres lose their striation, and present within the myolemma minute fatty deposits in the form of granules. This change is accompanied by atrophy. The symptoms consist in feebleness and difficulty in movement and in locomotion.
Changes in the bones, notably enlargement of and increase in the contents of the medullary canal in the long bones, and arthropathies of various kinds, have been observed in alcoholic subjects.
b. Disorders of the Skin.—Alcohol is a sudorific, and is largely eliminated by the skin. This effect is purely physiological; therefore the moderate and occasional use of alcohol exerts an influence rather favorable than otherwise upon the tegumentary structures, but in repeated excesses it gives rise to more or less cutaneous irritation. The skin, partly for this reason, and partly because it shares in the general disturbance of nutrition, becomes dry, harsh, and scaly; after a time the face, and especially the nose and neighboring parts, assumes in many instances a violaceous hue, the minute superficial cutaneous veins are enlarged, and acne is common. The resulting appearance is almost characteristic of the habits of the individual. Alcoholic subjects frequently suffer from pruritis, urticaria, and eczema. In certain cases the skin, instead of being dry and harsh, is soft and unctuous, and in others, especially in the more advanced cases, it becomes slightly yellow or earthy in hue. Owing in part to changes in the nutrition, and in part to vascular dilatation, the skin of the extremities is not rarely mottled and cyanotic. In certain forms of alcoholism of the nervous system, and particularly in alcoholic paralysis, in which we have to do with multiple peripheral neuritis, the skin of the affected parts, especially that overlying the atrophied muscles, becomes, in consequence of trophic changes, dusky in color and hard, smooth, and glossy. It has been stated that chronic alcoholism is a cause of pellagra, and numerous observations have been advanced in support of this view (Hardy). The excessive rarity of this condition in countries in which the abuse of alcohol is most common renders it probable that the occasional association of these affections is accidental rather than causal. Chronic alcoholism predisposes to gangrene of the skin and to bed-sores; slight wounds readily inflame and are slow to heal; alcoholic subjects are especially predisposed to erysipelas, while the enfeeblement of the circulation and the lowered tone in the later stages of chronic alcoholism often result in œdema of the inferior extremities.
3. General Disorders.—In addition to the various local disorders thus far described, the prolonged excessive indulgence in alcohol leads to profound disturbances of the processes of nutrition, which are manifested in alterations in the blood, in excessive accumulation of fat, and in a well-marked cachexia.
a. The Blood.—The alterations in the blood, although sufficiently manifest in disorders of nutrition, have not yet been studied with satisfactory results. In chronic alcoholism the proportion of water is increased, while that of fibrin is diminished. After death the blood remains fluid. The red globules are diminished in number. The blood also contains free fat, to which it owes its pale, opalescent, and sometimes almost milky hue. The presence of fat has been demonstrated after the injection of alcohol into the veins of animals.
b. Obesity.—Fat-infiltration and fat-accumulation must be regarded as among the most characteristic disturbances produced by alcohol. Fat is abundantly stored up in the subcutaneous tissues. The anterior abdominal wall is especially liable to its accumulation. The heart, kidneys, omentum, and mesenteries are also not infrequently the seat of abnormally large accumulations of fat. Fat also collects in the muscles and in the intermuscular planes, but to a less extent. Obesity is not, however, so frequent in the advanced stages of alcoholism as it is while the subject has not yet lost the appearance of health, and in a large proportion of the individuals it does not manifest itself at all. It appears to depend largely upon the character of the drink, and is especially frequent among those addicted to excesses in beer. It is less common among wine-drinkers, and relatively infrequent and of moderate degree in those who confine themselves to spirits. A sedentary life, and perhaps also an hereditary tendency, exerts an important influence upon the development of obesity in alcoholism.
c. Alcoholic Cachexia.—The action of alcohol in excessive amounts upon the nutrition of the body at large, and in particular upon the nutrition of the nervous system, is radically unfavorable. This unfavorable influence manifests itself from the beginning, while the subject yet presents the appearance of health, and long before the occurrence of either the symptoms or physical signs of organic disease. The powers of resistance to unfavorable influences of all kinds are diminished; the ability to endure hardships, privations, and fatigue is lessened; sickness and injuries are badly borne; complications are frequent and grave; and convalescence is apt to be tardy and insecure. It is among the more striking peculiarities of the alcoholic subject that blood-losses are badly borne and slowly repaired. It is this want of tone, often latent for a long time under ordinary circumstances, which unfits those addicted to alcohol for Arctic and exploring expeditions and for military and scientific enterprises involving prolonged hardship and exposure. In the course of time disorders of the digestion, of hæmatosis, of circulation, increase the difficulty and render it more apparent. The fat now rapidly diminishes; anæmia develops; the complexion becomes dull, earthy, or slightly jaundiced, the tissues flabby. Then follow diarrhœa, hemorrhages from mucous surfaces, serous effusions, visceral congestions of high degree, hypostasis, œdema, and progressive deterioration of all the powers alike of the body and the mind until the dyscrasia is complete.
The subjects of chronic alcoholism are especially prone to affections of the respiratory tract and to the infectious diseases. They furnish, as a rule, the earliest victims in epidemics. They not rarely die of pneumonia. They develop troublesome delirium in simple maladies, and in all acute affections the prognosis is unfavorable as compared with that in persons of sober habits. As Clouston well says, “The whole organism suffers sanative and mental lowering, alteration of functions and of energizing.”
B. DERANGEMENTS OF THE NERVOUS SYSTEM: CEREBRO-SPINAL DISORDERS.—The disorders of the central nervous system in chronic alcoholism are even more numerous and more important than those already described. Many transient and permanent disturbances of function occur without anatomical lesions recognizable by existing methods of examination; many others are associated with readily-discoverable changes of structure. These changes are encountered in the blood-vessels, the meninges, the substance of the cerebro-spinal axis, and in the peripheral nerves. Much as they differ in appearance and in their clinical manifestations, they may all be referred to three processes: (a) congestion and inflammation; (b) sclerosis; and (c) stentosis.
1. Cerebral Disorders.—The Cranium.—The bones of the skull are often thicker and more dense than normal. This change implicates the diploë and the outer and inner tables. The last is then deeply channelled for the blood-vessels and deeply indented for the Pacchionian bodies, which are commonly hypertrophied.
The Vessels.—Disturbances of the cerebral circulation are among the earliest and most important symptoms. Due primarily to the increased action of the heart and vaso-motor dilatation of the blood-vessels excited by repeated large amounts of alcohol, and secondarily to permanent enlargement of the vessels in consequence of fatty or atheromatous degeneration of their walls, some degree of active or passive congestion is almost always present. It is probable also that in consequence of irregular and complex disturbances of the circulation secondary localized ischæmia occurs. Lentz states that anæmia is more common in the cerebral substance than in the membranes.
The capillaries are usually much altered—sometimes uniformly dilated to a considerable extent, sometimes forming capillary aneurisms. They are more sinuous than normal, their walls show evidences of fatty degeneration, and they sometimes contain minute thrombi. Extravasated blood, in the form of circumscribed collections, of diffuse layers, or finally of capillary hemorrhages, also occurs. These collections are sometimes free, sometimes encysted.
The Meninges.—The dura mater is congested; occasionally it shows more or less extensive areas of inflammation with exudation of lymph. Purulent exudation in the absence of traumatism is rare. The lymph may be deposited in the form of patches of varying extent, or it may form more or less extensive false membranes. These accumulations are of variable, often considerable, thickness, and constitute the condition described as pachymeningitis hæmorrhagica interna, or, from the large amount of blood which they contain, hæmatoma of the cerebral meninges. They occupy the convexity of the brain, and are developed upon the inner surface of the dura; they are usually nearly symmetrical in outline, but of different thickness upon the two sides. They consist of superimposed layers of lymph, between which, or within the substance of which, are more or less extensive blood-extravasations, either fluid, coagulated, or undergoing resorption. More frequently the exudation consists of mere shreds of lymph within the cavity of the arachnoid.
The arachnoid is almost invariably altered. Upon the convex surface of the hemispheres, especially along the median fissure, it is thickened and opaque. This condition may be uniform or distributed in patches, and is apt to follow the line of the blood-vessels.
The pia mater is congested, often œdematous, not rarely the seat of blood-effusions of greater or less extent.
The cerebro-spinal fluid is usually more abundant than normal, of a deeper color, cloudy, sometimes tinged with the coloring matter of the blood.
The Brain.—The intimate lesions of the substance of the brain are not yet known. The volume of the encephalon, as a rule, undergoes no change. Occasionally it appears to be swollen, and protrudes with some degree of force through the incision first made in the membranes. More commonly, the brain is throughout or in certain parts atrophied or shrivelled, its convolutions flattened, its surface retracted. This is sometimes the result of the pressure of collections of hemorrhagic or inflammatory products.
The consistence of the cerebral mass is sometimes increased; it becomes harder, more resistant to pressure, and preserves its form when removed from the cranium better than the normal brain. This condition may be present throughout the brain or it may be localized. In the latter case it is usually due to patches of sclerosis. Softening in more or less extensive areas may occur in the advanced stages of the more severe forms of chronic alcoholism. It is found chiefly in the gray substance, where the vessels are more numerous, especially in the cortex and central ganglia. In this as in other affections cerebral softening is the result of obstruction of the circulation in consequence of atheroma, thrombosis, or other change in the arteries. It varies from simple diminution in consistency to diffluence.
The nervous substance of the brain doubtless undergoes changes proportionate to the degree and duration of its exposure to an alcohol-charged blood. What these changes are has not yet been fully determined. The nerve-cells of the cortex have been found rounded and contracted, so that instead of being surrounded by a small lymph-space they seem to be lying in large cavities, and so granular that the nucleus can hardly be made out. Slight increase in the number of the small round cells in the cortex and in the adjoining parts of the white matter has also been observed (Hun). These changes are not, however, constant. Not only has the microscopical morbid anatomy of the lesions of nerve-substance peculiar to chronic alcoholism not yet been worked out, but even macroscopic changes adequate to account for symptoms that were during life serious, persistent, and apparently referable to well-defined lesions, are sometimes absent altogether.
It is important to distinguish the disorders due to the direct action of alcohol, which are often functional or dependent upon lesions too subtle for recognition, from those which are secondary and dependent for the most part upon coarser changes of structure.
In consequence of hyperæmia of the brain and its membranes there not infrequently occur a sense of confusion or dulness, increasing to headache, which may become almost unbearable, mental disturbances of the most varied character, disorders of movement and sensation, and disorders of the special senses.
Cerebral hemorrhage, to which the subjects of chronic alcoholism are, in consequence of the vascular lesions already described, peculiarly prone, manifests itself by the usual primary and secondary phenomena. Meningeal hemorrhage, save in the form of hæmatoma, is rare except in the advanced stages of paretic dementia.
The blood in alcoholic dyscrasia undergoes changes which favor its transudation through the walls of the vessels; hence a tendency to œdema and to accumulations in serous sacs. This tendency implicates the structures of the nervous system in common with the organism at large. The ventricles of the brain become distended with fluid, and the brain-substance itself and the meninges not rarely become œdematous in the last stage of chronic alcoholism, in consequence of grave disturbances of the circulation or as complications of affections of the lungs, heart, or kidneys. These conditions are attended by mental obscuration, somnolence alternating with sleeplessness, delirium, maniacal paroxysms, impairment of muscular power, of general and special sensibility, impaired reflexes, inability to speak, deepening stupor, and death.
2. Spinal Disorders.—Lesions of the spinal cord or its membranes have been rarely discovered. When present they have been invariably associated with similar or corresponding lesions of the brain or its envelopes. Leyden39 states that not only do the cerebral meninges present inflammatory changes in chronic alcoholism, but the meninges of the cord are sometimes found in an analogous condition; that pachymeningitis hæmorrhagica interna spinalis has also been observed, as well as other forms of spinal meningitis, with thickening and discoloration of the pia and dura; and that œdema of the pia has been especially noted. While anatomical lesions of the cord are less frequent than lesions of the brain, nutritive and functional disturbances, as manifested in the general symptomatology, are quite as common in one as in the other.
39 Klinik des Rückenmarkskrankheiten.
3. Disorders of the Peripheral Nerves.—Magnus Huss found no change in the peripheral nerves in five cases in which they were carefully examined. Lancereaux discovered degenerative changes in the peripheral filaments in alcoholic paralysis. Leudet found hypertrophy of the neurilemma and alterations in the cubital nerve in an individual suffering from chronic alcoholism in whom this nerve was paralyzed. Dejerine40 observed in two fatal cases of alcoholic paralysis neuritis of peripheral nerves with integrity of the nerve-roots, the spinal ganglia, and the cord. In one of Dreschfeld's cases of alcoholic paralysis,41 in which the cord was found perfectly normal, the “sciatic appeared thin and grayish, and was surrounded by a great deal of adipose tissue. Vertical sections showed, when treated with perosmic acid and stained afterward with picro-carmine, a moniliform appearance of the nerve-tubes, due to breaking up of the myelin; the nuclei were increased, and there was also some interstitial cell-infiltration. Transverse sections showed in some few places an increase in the diameter of the axis-cylinder, and again the interstitial infiltration.”
40 Archives de Physiologie nerv. et patholog., No. 2, 1884.
41 Brain, Jan., 1886.
Disorders of General Sensibility.—Disorders of general sensibility are among the earliest of the nervous phenomena of chronic alcoholism. They occur in the following order: hyperæsthesia, dysæsthesia, and anæsthesia. Disturbances of sensibility manifest themselves, quite independently of hallucinations, as sensations of malaise, of discomfort, of chilliness, of cramps, or of abnormal warmth or cold. Sometimes they amount merely to momentary discomfort, at other times to extreme pain. They are usually limited, often to the feet and legs, sometimes to the hands and arms; again, they are experienced in the trunk, and especially in the back. They are most common during the evening; less frequently they are induced by the warmth of the bed; and, again, they are experienced on rising. They are apt to be associated with occipital or frontal headache.
Among the most frequent nervous phenomena of chronic alcoholism are disturbances of sleep. Sleep is light, uneasy, and disturbed, difficult to obtain, troubled with dreams, and unrefreshing. More or less complete insomnia is by no means rare. It is more apt to occur, however, after acute exacerbations of alcoholism than in the ordinary chronic condition.
Hyperæsthesia manifests itself as an increased sensibility to pain, to mere contact, to temperature, and in an exaggeration of the muscular sense. Two general forms may be distinguished—the superficial and deep. The former usually manifests itself by an exaggerated sensibility of the skin, especially along the course of the superficial nerves and at their points of emergence from the deeper structures. The latter consists in a more or less intense sensation of pain, often diffuse, sometimes almost unbearable, and associated with a sensation of heat or cold, which is most commonly experienced in the lower extremities. It is often referred by the patient to the deeper muscles or to the bones and joints, and is increased by movement or pressure.
Anæsthesia is a much more common occurrence. It is usually developed during the later period of chronic alcoholism, and may implicate the skin, the mucous tissues, or the deeper structures. It presents all degrees from mere impairment to absolute loss of sensation. In the latter case, contact, pain, temperature, and electrical stimulation equally fail to excite sensation. In the deep anæsthesia of alcoholism pressure and electro-muscular sensibility are alike impaired. The muscular sense is also enfeebled or abolished. The regions which are the seat of anæsthesia are, as a rule, of a lower temperature than those in which sensation is normal. The anæsthesia may extend to the conjunctiva, and even to the cornea and to the mucous membrane of the mouth and throat. It has also been observed in the mucous membrane of the genitalia and at the verge of the anus.
Disorders of Motion.—Disorders of motion consist of tremor, subsultus, spasm, convulsions, muscular paresis, and palsies. Tremor is a very frequent phenomenon in chronic alcoholism. It consists generally of a series of rapid rhythmical movements. Sometimes the extent of the movement is increased and their rhythm irregular. They are then choreiform. The tremor may be continuous; much more frequently it only appears in the morning. The subject has then some difficulty in dressing himself, particularly in buttoning his clothing, in shaving himself, and in raising a cup to his lips. This symptom commonly ceases after the ingestion of a certain quantity of alcohol, only to return on the following morning or after a considerable period of abstinence. Voluntary movements intensify the tremor. It most commonly affects the upper extremities, next in frequency the muscles of the face, and finally the lower extremities. In rare cases it affects the muscles of the whole body. Alcoholic tremor affecting the hands and arms renders the subject awkward and interferes with his ability to work; affecting the lower extremities, it gives rise to an embarrassing, irregular gait; affecting the lips and tongue, it produces hesitation of speech or stammering, and when it is of a high degree articulation may be so imperfect that conversation is impossible; affecting the muscles of the eyes, it gives rise to nystagmus. Tremor is not infrequently associated with subsultus tendinum, spasmodic contractions, and cramps. These phenomena are usually localized, and affect by preference the muscles of the face and those of the lower extremities.
Loss of muscular power, which may pass, little by little, into complete palsy, also occurs. It is, however, neither constant nor proportionate to the gravity of the case in other respects. Whilst, as a rule, it is developed insidiously, it occasionally shows itself with suddenness. In the latter case it is usually preceded by some acute complication, and may disappear as quickly as it came. At first it is a mere feebleness, which, beginning in the fingers, extends to the hands and arms. It may after a time manifest itself in the feet. More or less muscular paresis is invariably associated with the tremor above described.
Alcoholic Paralysis.—The earliest account of alcoholic paralysis is that of James Jackson,42 who designated the disease, from its most prominent symptom, arthrodynia. He attributes it to ardent spirits, and chiefly observed it among women. “This arthrodynia comes on gradually. It commences with pain in the lower limbs, and especially in the feet, and afterward extends to the hands and arms. The hands may be affected first in some instances, but in all cases in the advanced stage of the disease the pain is more severe in the feet and hands than in the upper limbs. The pain is excruciating, and varies in degree at different times. It is accompanied by a distressing feeling of numbness. After the disease has continued a short time there take place some contraction of the fingers and toes and inability to use these parts freely. At length the hands and feet become nearly useless. The flexor muscles manifest, as in other diseases, greater power than the extensors, and the whole body diminishes in size, unless it be the abdomen; but the face does not exhibit the appearance of emaciation common to many visceral diseases. The diminution is especially observable in the feet and hands. At some time the skin of these parts acquires a peculiar appearance. The same appearance is noticed in a slighter degree in the skin of other parts. This appearance consists in great smoothness and shining, with a sort of fineness of the skin. The integument looks as if tight and stretched, without rugæ or wrinkles—somewhat as when adjacent parts are swollen. The skin is not discolored. In this disease there is not any effusion under the skin, and the character which it assumes arises from some change in the organ itself.”
42 New England Journal of Medicine and Surgery, vol. xi., 1822, “On a Peculiar Disease resulting from the Use of Ardent Spirits.”
Since Jackson's day, Huss, Lancereaux, Leudet, and others have described various forms of paralysis due to alcohol. Wilks43 under the term alcoholic paraplegia described a form of alcoholic paralysis of which he had seen numerous cases, especially in women addicted to alcoholic excesses. The symptoms are severe pain in the limbs, especially the lower ones, with wasting, numbness, anæsthesia, only slight power of movement or total inability to stand. The symptoms are not unlike those of ataxia. Wilks regarded the disease as due to degeneration of the cord and thickening of the membranes. Several of the cases terminated in recovery in a comparatively short time after the abrupt and complete withdrawal of alcohol. Since that time a number of cases have been reported by various observers.44
43 Lancet, 1872, vol. i. p. 320.
44 See, in particular, Hun, American Journal of the Medical Sciences, April, 1885, “Alcoholic Paralysis.” This paper contains a valuable résumé of the reported cases up to that time. Consult also Dreschfeld, Brain, July, 1884, and January, 1886.
Hun concludes that alcoholic paralysis may be regarded as a special form of disease with the following symptoms: “Neuralgic pains and paræsthesiæ of the legs, gradually extending to the upper extremities, and accompanied at first by hyperæsthesia, later by anæsthesia, and in severe cases by retardation of the conduction of pain. Along with these symptoms appears muscular weakness, which steadily increases to an extreme degree of paralysis, and is accompanied by rapid atrophy and great sensibility of the muscles to pressure and to passive motion. Both the sensory and motor disturbances are symmetrically distributed. The paralysis attacks especially the extensor muscles. In addition to these motor and sensory symptoms, there is also a decided degree of ataxia. The tendon reflexes are abolished, and vaso-motor symptoms, as œdema, congestion, etc., are usually present. Symptoms of mental disturbance are always present in the form of loss of memory or transient delirium.”
Lesions of the cord are absent, but degenerative processes in the peripheral nerves have been discovered in a number of cases. The symptoms are those of multiple neuritis, and the essential lesions consist in degenerative changes in the peripheral nerve-fibres. The associated mental derangement, tremor, and ataxia have been ascribed to changes in the cerebral cortex.
Dreschfeld has divided the cases, according to the more prominent symptoms, into two clinical groups—alcoholic ataxia and alcoholic paralysis.
The ataxic form represents a milder type. The symptoms are lancinating and shooting pains in the lower extremities, sometimes in the upper, with areas of anæsthesia and retarded sensibility. The muscles are painful upon pressure, and atrophy may be moderate or absent altogether. Inco-ordination is marked. The tendon reflexes are absent. Shooting pains down the legs to the toes of a paroxysmal character, and followed by a sense of numbness, also occur. Eye symptoms are wanting.
The paralytic form is usually associated with atrophy, affecting chiefly the extensors of the fingers and toes. The paralysis and atrophy in some cases come on acutely, in others more slowly. When the patients come under observation they are usually unable to stand or walk, and it is therefore not easy to make out whether or not the paralytic stage has been preceded by a stage of ataxia. As the sensory phenomena in these cases are the same as in the first group, it is probable that pseudo-ataxic symptoms have preceded the slowly oncoming paralysis. Paralysis and atrophy of the extensors of the fingers and toes, with paresis of the other muscles, are associated with the sensory phenomena above described. Tendon reflexes are absent; the superficial reflexes are much diminished. Recovery takes place in a considerable proportion of the cases upon the withdrawal of alcohol. The atrophy and paralysis pass away altogether, the tendon reflexes are restored, and the disturbances of sensation disappear. In the greater number of these cases persistent delusions are present.
Lancereaux45 describes alcoholic paralysis as symmetrical, affecting either the upper or lower extremities and gradually extending toward the trunk. The lower extremities are invariably more affected than the upper, and the extensor than the flexor muscles. There is diminished reaction to electricity, and anæsthesia is present. The brain and spinal cord are normal, but the peripheral nerves show extensive degenerative changes.
45 Gazette des Hôpitaux, No. 46, 1883.
4. Disorders of the Special Senses.—a. The Sight.—Disorders of vision are among the most frequent and the earliest symptoms of chronic alcoholism. Phosphenes, scintillations, sensations of dazzling, muscæ volitantes, and streams of light are often complained of. These phenomena may be constant or transient. Diplopia and other visual disturbances of the most irregular and annoying character also occur. Sometimes there is dyschromatopsia; the colors are confounded: red appears brown or black, and green appears gray, etc. In the more advanced stages amblyopia may occur. The acuity of vision rapidly diminishes, sometimes to the point that the patient with difficulty distinguishes the largest print. Objects appear as seen through a fog, and their outlines are distinguished only after repeated and close effort. Again, blindness almost absolute occurs for the course of some minutes—passes away rapidly, only to return again at intervals. Not infrequently the sight is better in the morning and evening than during the day. Achromatopsia, characterized by enfeeblement, and not infrequently by the momentary loss of the power to recognize colors, and particularly the secondary tints, also occurs. Cases of Daltonism occasionally seem to depend, to some extent at least, upon alcoholic disturbances of vision. Impairment of the power to distinguish colors must not, however, be confounded with the difficulty experienced by many alcoholic subjects in recognizing different colors successively presented to the eye with some degree of rapidity. Such individuals are able to distinguish colors when sufficient time is permitted them. Their difficulty depends upon tardiness of perception, such as is often experienced by neurasthenic subjects in recognizing faces in a crowd, rather than upon any failure in the power of recognizing colors. As a rule, the disorders of vision are not permanent, at least in the beginning. Later, they are of longer duration, and alcoholic amblyopia occasionally degenerates into irremediable amaurosis. Ophthalmoscopic examination reveals at first no appreciable lesion, and the disturbance of circulation, venous stasis, and peri-papillary infiltration thus observed appear to be inadequate to explain the visual disturbance. Atrophy of the optic nerve occasionally occurs as a direct result of alcoholism. Nystagmus has been frequently observed. The state of the pupils is variable and without constant relation to the acuity of vision. The pupils are not infrequently uniformly dilated, contracting slowly under the influence of light. More rarely they are permanently contracted; occasionally they are unequal. These modifications are often without demonstrable relation to anatomical lesions.46
46 Vide this System of Medicine, Vol. IV. p. 803.
b. The Hearing.—The disturbances of hearing encountered in chronic alcoholism are in many respects analogous to those of sight. Patients complain of curious subjective sensations, which are described as humming or whistling sounds, the ringing of bells, music, or the murmur of a crowd. At times the sense of hearing is so exquisite that the least noise causes pain. On the other hand, hearing may be greatly impaired, diminishing by degrees until it becomes in some cases, without recognizable lesion, almost or completely lost.
c. The Taste.—As a rule, the sense of taste is impaired in chronic alcoholism; occasionally it is wholly lost.
d. The Smell.—The sense of smell is in most cases to some extent, and in many cases greatly, impaired, the most powerful odors being scarcely perceived by old topers.
Alcoholic Epilepsy.—Alcohol, and especially that combination of alcohol with oil of wormwood and aromatics known as absinthe, is capable of producing convulsive seizures resembling epilepsy. Certain forms of alcoholic convulsions can scarcely be distinguished from ordinary epilepsy. Acute alcoholism may be an exciting cause of the convulsive seizures in an epileptic. Alcoholic epilepsy is, however, peculiar to chronic alcoholism, and particularly in individuals in whom there is an hereditary tendency to nervous disorders. Once established, alcoholic epilepsy may continue even after the alcoholic habit has been discontinued. The attack is usually followed by marked mental disturbances. These vary from profound dulness to stupor or mania; they last from some hours to several days, and present the characters of similar conditions following non-alcoholic epileptic paroxysms.
C. PSYCHICAL DERANGEMENTS.—Yet more important than the visceral and nervous lesions of chronic alcoholism are the indications which it affords of a progressive debasing influence upon the mind. The moral sense, the will, and the intellect are involved successively in a process of deterioration, which, manifesting itself only in part and by little at first, becomes after a time general and plain to all the world, and ends at length in ruin more complete and more hopeless than that of the body. Indeed, it not infrequently happens that while the general health appears to be good and the nervous system, save in transient disturbances of function, presents no evidence of the toxic action of alcohol upon its tissues, serious psychical disorders are established. The alcoholic subject develops propensities, otherwise latent, that tend to refer him to the criminal or the insane classes of society. The psychical debasement, of which these propensities are the outcome, is, like the alcohol habit itself, progressive. This fact cannot be too strongly insisted upon. Like the loss of vascular tone, the sclerosis, the steatosis which alcohol induces in the body, this mental deterioration is cumulative and destructive. It is to its psychical manifestations that alcoholism owes its chief importance, not only as a study in pathology, but also as a problem of the gravest moment in social science.
1. The Moral Sense.—Deterioration of the sense of moral obligation is among the earlier of the mental phenomena of alcoholism. The moral sense is perverted and enfeebled. Sentiments of honor, of dignity, of reputation, and of decency are no longer cherished or regarded. The amenities of social life and the proprieties of personal conduct are disregarded or set at naught. He who was punctilious, considerate, and thoughtful becomes negligent, selfish, and indifferent to sentiments of honor and emulation; he gives himself up to indulgences formerly considered unworthy; his reputation and that of his family are no longer matters of concern to him; respect for public opinion is replaced by cynicism. Little by little the conception of duty, of justice, of honor are lost to him, or if he regards them at all it is rather as subjects for idle and purposeless discussion than as motives to regulate his life. These changes are gradual and progressive, their evolution being largely influenced by the hereditary traits and previous moral culture of the individual. The deterioration of the sense of right, and the coincident exaltation of those passions which are normally under its control, lead to the commission of the crimes peculiar to the early period of alcoholism. Indifference is another characteristic of this period—indifference not incompatible with a selfishness of the most intense kind. The sense of obligation to the family is forgotten, and the responsibility of providing for and caring for others is unfelt. If the drunkard's own wants, and especially his craving for drink, are gratified, the necessities of those formerly dear fail to move him. The affections are not only enfeebled, but they are also perverted; not rarely they are replaced by aversion, disdain, and hatred. The individual who has been calm, reasonable, and patient becomes excitable, perverse, and intolerable of contradiction or opposition. Prone to acts of sudden violence, he becomes gloomy, taciturn, and preoccupied. He is disturbed by fixed tormenting ideas or by vague pursuing terrors. He thus becomes self-conscious, irritable, fault-finding, and easily provoked to passion. The character, after a time, undergoes still more decided change: alternations of indifference and irritability characterize his varying moods. After a time the joys and the sorrows of life alike fail to provoke real feeling. At length the confirmed sot manifests moral traits that are simply infantile; he laughs without motive, he weeps without cause.
2. The Will.—At the same time the will undergoes an enfeeblement even more marked. Except in paroxysms of transient excitement it is feeble and uncertain. The subject of chronic alcoholism scarcely knows his own mind under ordinary circumstances. Aware of his duties and his obligations, he is unable to discharge them. Especially does he lack the power to say No. Vacillation, indecision, and dependence upon others become characteristic traits. This loss of moral energy, combined with the loss of physical power brought about by continued and repeated excesses, begets at once a distaste for the ordinary occupations of life and an inability to perform them.
3. The Intellect.—Loss of intellectual power comes last. In some cases it shows itself only after the most prolonged excesses, when the body itself is becoming thoroughly broken down. Exceptionally, fitful intellectual power is curiously sustained to the last. The first evidence of intellectual failure consists in diminution of vivacity and readiness. The intellectual state is marked by apathy, obtuseness, and indifference; mental processes are performed slowly and with difficulty. This is perhaps one of the causes of the mental indolence characteristic of alcoholism. After a time the drunkard becomes timid, loses confidence in himself, and is unwilling to engage in enterprises demanding mental effort. Some tardiness of appreciation then shows itself; conversation becomes difficult; ideas are not spontaneous, but must be sought for; replies are not made with the usual promptness; it is difficult to arouse and fix the attention. The sense of self-respect is now lost, and it is almost impossible to make the subject comprehend his degradation. The intellectual deterioration becomes more and more marked. The memory fails little by little and becomes treacherous. Names and dates are recalled with difficulty. The conversation is interrupted by an inability to choose the proper words with precision, hence hesitancy, interruptions, and various forms of circumlocution. The power of argument and of reasoning is now much impaired, the judgment is uncertain, the association of ideas is inexact, and at length the intellectual degradation attains a degree that unfits the subject for the ordinary relations of life.
The above-described derangements of the viscera, of the nervous system, and of the mind are the morbid phenomena induced by long-continued excesses in alcohol. Whether merely functional or dependent upon recognizable anatomical lesions, they indicate pathological changes in the organism which are radical, and which under the influence of the continuously acting cause are progressive. Taken together, they constitute the condition known as chronic alcoholism. In view of the familiar experiences of every-day life, it is hardly necessary to repeat that these derangements are manifested in all degrees of intensity and in the most variable and complex combinations. The specific nature of chronic alcoholism is, in truth, due not to the derangements themselves, the greater number of which are such as we may encounter in morbid states not occasioned by alcoholic excesses, but to the combinations in which they occur in consequence of the action of the specific cause upon the organism as a whole. The prominence of particular symptoms or groups of symptoms in any given case is to be accounted for largely, if not wholly, by individual peculiarities.
Chronic alcoholism, however latent it may be, however sedulously concealed, warps the life of the individual in all its relations. In its advanced degrees it amounts to mental and physical dyscrasia. Between these extremes is every grade of incapacity and degradation. It is beyond the scope of this article to discuss the moral, social, or medico-legal bearings of this condition. Its purely medical relations are sufficiently obvious from what has gone before. It has been the writer's aim to make clear the existence and nature of the continuing condition.
It remains to describe certain other psychical disturbances which occur in chronic alcoholism, and which require separate consideration for the reason that they are accidental rather than essential, many cases running their course without their manifestation.
4. Alcoholic Delirium in General.—True alcoholic delirium, presenting the traits about to be described, is never the result of the direct primary action of alcohol upon the nervous system. Transient excesses produce acute alcoholism, drunkenness, which, varied as its manifestations are, differs essentially from that peculiar delirium which occurs only in individuals in whom the nervous system has undergone those nutritive changes that are brought about by prolonged alcoholic saturation.
The most striking peculiarity of this delirium relates to the hallucinations which attend it. These are almost invariably visual; occasionally they are also auditory. Their objects, whether men, animals, or things are in constant and unceasing motion, appearing and disappearing, coming and going, and changing from place to place with extreme rapidity. In this respect they differ from the hallucinations of other forms of delirium, of which the objects are fixed and more or less permanent. As a result of this peculiarity, the objects of alcoholic delirium are almost invariably multitudinous, as swarms of vermin, herds of animals, multitudes of demons, and the like.
A second peculiarity is the restlessness of the delirium. The patient is invariably uneasy, apprehensive, always on the alert, declaring that some calamity threatens him or that some evil is about to befall him. In consequence of these apprehensions even momentary repose is wanting. If he lies down for a moment, it is only to rise again and peer under the bed or into the corners, turning his head from side to side in search of some realization of the fears that torment him. This sense of apprehension impels the patient to hurry ever onward from place to place in search of the repose which he nowhere finds. It is increased to positive terror by the ever-varying and constantly-renewed hallucinations which torment him, and from which he seeks to escape, no matter how great the obstacles to be overcome.
A third peculiarity of alcoholic delirium is insomnia. This condition is of the must marked and stubborn character, even continuing for several days in succession.
5. Delirium Tremens.—This is the characteristic form of alcoholic delirium, and, as is indicated by the name, is invariably accompanied by tremor. It must be looked upon as an episode or epiphenomenon of chronic alcoholism. It is rare that even prolonged temporary excesses in persons ordinarily sober are followed by delirium tremens. Such excesses in the subjects of chronic alcoholism are, however, perhaps the most common cause of this condition. Orgies, especially when associated with venereal excesses, very frequently terminate in delirium tremens. Occasionally also, but much less frequently than was formerly supposed, the abrupt discontinuance of alcohol is followed by the outbreak. Other exciting causes are violent emotions, as anger or fright; hardships, such as prolonged hunger, over-exertion, or watching; acute maladies, as pneumonia, dysentery, erysipelas, the exanthemata, or rheumatism; finally, serious traumatisms, with or without great loss of blood. Delirium tremens usually occurs in those addicted to the abuse of spirits, less frequently in beer-drinkers, and comparatively rarely in those whose excesses have been restricted to wine. The attack does not, as a rule, begin abruptly; its prodromes usually consist in an exaggeration of the previously existing symptoms of chronic alcoholism. The patient complains of malaise, restlessness; he becomes depressed, morose, anxious without cause, apprehensive of some calamity, or he is more impatient and choleric than before. The ability to apply himself to his ordinary occupations is lost. He complains of vertigo, ringing in the ears; sleep is disturbed, or there is already insomnia. At the same time the stomach is deranged, appetite is lost, the tongue is covered with a thick yellowish-white fur, and there is constipation or diarrhœa. The period of prodromes may last from a few days to a week.
The outbreak is characterized by delirium, without, at least in the greater number of cases, absolute loss of consciousness. That is to say, it is possible by addressing the patient with energy or by strongly arousing his attention to interrupt the delirium and for a moment recall the patient to himself. In the graver cases, however, loss of consciousness appears to be complete. The subjective impression of the delirium, as recollected at the termination of the attack, is that of a sense of overwhelming confusion and inability to recollect or co-ordinate the ideas that were crowding upon the brain. The hallucinations, as has already been indicated, relate almost exclusively to the organ of sight, more rarely to the hearing; also, and exceptionally, to the other organs of sense. They are almost always either terrifying or repugnant. The objects of the hallucinations of the sight have already been described. They consist of animals, serpents, and monsters, which crowd into the apartment, coming usually toward the patient, disappearing in the walls, in the floor, under the bed, or among the bed-clothing. These visions are usually aggressive, threatening the patient, throwing themselves upon him, striking him, or tearing at his vitals. They are sometimes replaced by phantoms, spectres of the most horrible character, skeletons, death's-heads, or by flames which surround the patient and threaten to consume him. Sometimes the hallucinations relate to the daily occupation of the patient, and he pursues his tasks with a feverish and distressing anxiety. These hallucinations are almost invariably of the most fleeting, incoherent, and variable kind.
Auditory hallucinations occur usually in individuals of marked neurotic tendencies. They are apt to be more coherent than the hallucinations of vision, and are often of the nature of those which occur in the delirium of persecution. Sometimes they consist of cries, of chiding, of menacing voices, of the repetitions of obscene words and suggestions; sometimes they are cries of horror or the roars of animals, sometimes explosions or the discharge of firearms; or, again, they are terrifying threats. Hallucinations of taste and smell are much more rare, and occur in the subacute forms of delirium tremens. The patient complains of annoying odors or disagreeable tastes, either constantly present or upon the taking of food or drink. Disturbances of general sensibility show themselves in hallucinations in regard to sensations of pricking, burning, or tearing of the surface of the body, or of animals or vermin crawling over the patient. Hallucinations relating to the sexual instinct are far from rare. The hallucinations of every form are apt to be more frequent and more troublesome during the night than during the day.
Restlessness, fear, and anxiety are characteristic phenomena of delirium tremens. The patient is not only terrified by the imaginary objects which surround him, but often in their temporary absence he experiences an equal degree of fear for which he can assign no cause. It is to this condition of apprehension that is due the desire to escape from his present surroundings which is so characteristic of the delirium in question. Under its influence the patient occasionally commits acts of violence of the most serious kind. Sometimes the delirium is more quiet: the patient converses with individuals whom he supposes to surround him; he busies himself with his familiar occupations, giving orders, directing work, dictating letters, and arranging his affairs. At other times the delirium takes the form of apprehension of poisoning, and food and medicine are alike stubbornly refused.
The countenance, as a rule, is animated, the eyes brilliant and injected, the look fixed or peering, but always eager, or the expression may be haggard and agitated. The physiognomy, although largely influenced by the character of the delirium, may be said to be in most cases characteristic.
Sensation is usually impaired; especially is this true of sensibility to pain.
Tremor, although occasionally slight, may be said to be never wholly absent. Sometimes it affects the muscles of all parts of the body; more commonly it is limited to the hands, arms, tongue, and lips; less frequently it manifests itself in the lower extremities. Slight tremor may be increased by causing the patient to hold his hands extended with the fingers separated. The movements of the hands consist of rapid rhythmical oscillations of nearly equal extent and duration. The tongue is protruded with a rapid jerking movement, and withdrawn with equal suddenness. It shows fibrillar trembling. The trembling is increased by voluntary movement, and is ordinarily associated with some loss of motor power. The gait is often hesitating and awkward; movements of the upper extremities are executed with difficulty, and speech is irregular and interrupted. The motor disturbances are occasionally associated with choreiform movements or actual epileptic convulsions.
Insomnia is a constant condition. It usually persists throughout the attack, and occasionally proves troublesome for several weeks after convalescence is in other respects complete.
In the absence of pulmonary complications the respiration is not disturbed, save as a result of the restlessness and physical effort which sometimes quicken it. The same statement is true of the pulse. The action of the heart is usually enfeebled, and the first sound weak. The temperature is normal. The skin is frequently bathed in copious perspiration. There is complete loss of appetite, and in most cases inability to retain food. Thirst is constant, often tormenting. The tongue is sometimes moist, and coated with thick white or yellow fur; sometimes hard and dry, sometimes red. The urine is scanty, dark-colored, and sedimentary. It occasionally shows traces of albumen. Constipation is the rule.
The duration of delirium tremens is from three to seven, or even ten or twelve, days. The course of the attack is paroxysmal or remittent. The symptoms usually undergo some improvement during the day, only to become more urgent at night. The periods of remission are occasionally marked by transient slumber; the recovery by prolonged and deep sleep. But this is by no means the rule. Several varieties of delirium tremens have been described by writers upon the subject. These are—the grave form, characterized by violence of the motor disturbances, aggravated delirium, and gravity of the general condition; the febrile form, in which after the third or fourth day the temperature, without pulmonary or other discernible complications, suddenly rises to 104° F. or beyond that point, with great aggravation of the general symptoms; the adynamic form, marked by failing heart-power, feeble or imperceptible pulse, profuse sweats, collapse, stupor, which deepens into coma and ends in death; and finally, the subacute form. Here the patient is quiet, but restless. The delirium scarcely passes beyond the limits of occasional wandering, and relates chiefly to matters connected with the daily interests and occupations of the patient. Tremor is more or less marked, and sleeplessness is stubborn.
The termination of delirium tremens is in—1, recovery; 2, in death; 3, in the chronic form; and 4, in other forms of insanity.
1. Recovery.—Except in the grave forms recovery may be said to be the rule. Occasionally ushered in by a prolonged, almost critical, sleep, more frequently it takes place by gradual improvement. In the latter case the remissions are more and more prolonged, and attended by increasing repose alike of body and of mind, and by tendency to sleep. The hallucinations become feebler and less tormenting, at length recurring only in the evening or at night, and especially as the patient is about falling asleep. The anxiety and restlessness grow less urgent, consciousness becomes more secure, the trembling diminishes, and recovery is slowly established. The tremor is apt to persist some days into convalescence.
2. Death.—This mode of termination is not very common in the ordinary forms of delirium tremens. In the grave forms it is usual, sometimes occurring suddenly, sometimes gradually from intensification of the symptoms and failure of nervous power; or it may occur in consequence of pulmonary, cerebral, or renal complications; finally, the fatal termination is often due to the acute disease or the traumatism by which the delirium tremens has been excited, and of which it is, in fact, a complication.
3. Chronic Delirium Tremens.—This mode of termination, described by Lentz, is rare. The acute phenomena subside; the restlessness and the mental agitation diminish. Insomnia gives place to sleep, which is light and disturbed by dreams and nightmare; most of the hallucinations lose their activity and frequency, and finally disappear. The changing delirium settles into a fixed delirium of persecution; the tremor, while it becomes fainter, persists, and the condition is permanent.
4. Other Forms of Insanity.—This mode of termination has been studied especially by Magnan, who has classified the cases of delirium tremens into three different groups, according to their tendency to recover or to the development of mental alienation. The first group includes those cases which run a favorable course and terminate in complete convalescence; the second group, those cases in which the convalescence is prolonged and characterized by repeated relapses; the third group is composed of cases which likewise show a strong tendency to relapse, but in which the delirium continues after the other active symptoms have subsided. This form shows itself most frequently among the subjects of hereditary alcoholism. After repeated attacks the delirium becomes chronic. Morbid mental phenomena replace or accompany symptoms more directly referable to organic disturbances of the nervous system. Tremor gradually diminishes and disappears, the gastric symptoms subside, insomnia passes away, even hallucinations disappear, or at all events become infrequent; but the delirium which developed coincidently with these symptoms continues, and finally becomes chronic, losing to a great extent its original characteristics and constituting a form of insanity. Finally, dementia constitutes an occasional mode of termination in delirium tremens. It does not often develop immediately, although cases of this kind have been recorded. More commonly, the alcoholic subject, losing little by little his mental activity after each attack of delirium tremens, subsides by degrees into absolute and irremediable dementia. Paretic dementia may also develop after prolonged alcoholic excesses characterized by repeated attacks of delirium tremens.
The anatomical lesions after death from delirium tremens shed no light on the pathogenesis of the condition. Meningeal congestion, œdema of the pia mater and of the cortical substance of the brain, scattered minute extravasations of blood, and some augmentation of the cerebro-spinal fluid have been observed. In the greater number of cases no lesions whatever beyond those characteristic of chronic alcoholism have been discovered.
6. Alcoholic Insanity.—Among the psychical derangements, it remains to notice briefly the more prominent forms of insanity which develop in the course of chronic alcoholism, in consequence either of hereditary or of acquired morbid mental tendencies. These are—a, melancholia; b, mania; c, chronic delirium; d, dementia; e, paretic dementia.
Alcohol is the most common of all the causes of insanity. Clouston47 estimates that from 15 to 20 per cent. of the cases of mental disease may be put down to alcohol as a cause, wholly or in part. Those forms of insanity in the production of which alcohol is merely an occasional cause are not, however, properly included in the group of alcoholic insanities. Still less are we to include in this group cases of symptomatic dipsomania; that is to say, cases of insanity in which morbid impulse to drink constitutes a prominent symptom of the prodromic or fully-developed periods of various forms of mental disorder.
47 Clinical Lectures on Mental Diseases, Am. ed., 1884.
Alcoholic insanity manifests itself as an outcome of chronic alcoholism, just as epileptic and hysterical insanity show themselves as the outcomes of epilepsy and hysteria. This group properly includes various forms of mania-a-potu, especially the maniacal form of acute alcoholism, delirium tremens, and other transitory psychoses which occur in acute and chronic alcoholism.
In truth, the mental derangements of ordinary drunkenness constitute in many cases a form of transient insanity. These forms, have, however, already been considered at sufficient length. Dipsomania, for reasons already stated, cannot be regarded, either in its symptomatic form or in its essential form, as belonging to the group of alcoholic insanities.
a. Melancholia.—Melancholia is the most frequent form of true alcoholic insanity. It may begin abruptly or gradually, with changes of character, vague disquietude, great irritability, and disturbances of sleep amounting in many cases to insomnia. Hallucinations of hearing are characteristic. In this respect the morbid mental condition in question is in strong contrast with delirium tremens, in which the hallucinations are principally visual. The hallucinations of hearing usually consist of accusing or threatening voices. These voices inform the patient that he is to be poisoned, assassinated, murdered, or that outrages of all kinds are to be committed upon him; they accuse him of murder, of robbery, of rape, and of other shameful crimes. Præcordial distress is also apt to be present. In consequence of these hallucinations of hearing the patient falls into a profound melancholia, often characterized by suicidal impulses which are sometimes the direct outcome of hallucination, at other times blind and unreasoning. There is apt to be cephalalgia and insomnia. Trembling is not usually a marked symptom. Local anæsthesia and hyperæsthesia, if they occur, are transient. The ordinary duration of this form of alcoholic melancholia is much longer than that of delirium tremens, sometimes extending throughout several months. The termination usually is in recovery, less frequently in chronic delirium.
b. Mania.—This form of alcoholic insanity is characterized by various hallucinations which present peculiar characters. Thus, the hallucinations of vision commonly relate to supernatural apparitions, attended with luminous phenomena of various kinds. These visions may be occasional or they may be frequently repeated, or the hallucinations may consist of images of emperors, kings, princes, and potentates, or of military chieftains, in the midst of whom the patient passes his existence. Or, again, the hallucinations may be made up of historical scenes, pageants, the movements of armies, battles, and the coronations of kings, or they may be landscapes pleasant to the eye—snow-clad mountains, valleys filled with flowers, magnificent forests, and the like. These phantasmagoria are by no means fixed; on the contrary, they are of the most shifting character.
Auditory hallucinations are even more frequent, and quite as changeable. They bear a more or less well-defined relationship to the hallucinations of vision. They consist not rarely of promises of money, honors, titles, and the like. Sometimes they are voices from heaven, even the voice of God himself, commanding the patients to perform definite acts and promising in return equally definite blessings.
Hallucinations of general sensibility occur much less frequently. When present, they consist of various painful sensations, giving rise to the delusions of blows, stabs, bites of animals, electrical discharges, etc. In consequence of these hallucinations the delusions are often of a grandiose character. Patients believe themselves to be God, the pope, or some great potentate, or enormously rich, etc.
The somatic condition depends upon the degree of chronic alcoholism existing at the time of the manifestation of the mania. There are usually marked tremor, hesitation and uncertainty of speech, stubborn sleeplessness. Acute mania may show itself abruptly, attaining its full development in the course of a few days, or the development may be gradual. The prognosis in alcoholic mania is unfavorable; recoveries are rare. The fatal termination is sometimes the result of the maniacal condition itself, and sometimes the result of visceral complications. This form of insanity occasionally terminates in chronic delirium.
c. Chronic Delirium.—This form of alcoholic insanity is one of the terminations of acute alcoholic melancholia and of acute alcoholic mania. It is also one of the results of repeated attacks of delirium tremens. Finally, it may develop independently of these affections.
Developing independently, chronic delirium is usually of rapid invasion, and is characterized by the prodromes common to the various forms of alcoholic insanity—irritability, headache, vertigo, insomnia, etc. Hallucinations of hearing are very common, and relate principally to the sexual life of the patient. Voices taunt him with the fact that he is maimed or impotent; he hears persons whispering that he is about to be castrated or that he is the subject of loathsome venereal diseases, or they declare that he is known to be addicted to vile crimes and bestiality. Hallucinations of sight are much less common; those of the other special senses occasionally occur. The delirium takes the form of delusion of persecution. The patient believes himself the object of plots and conspiracies; his enemies are seeking to ruin his good name, to tarnish his reputation, to poison him. They put filth in his food or charge him with electricity; they steal away his vital force or his sexual power; they taunt him; they mock him; they beat him and rob him.
A delusion so frequent as to be almost characteristic of chronic alcoholic delirium relates to marital infidelity.48 The patients cherish unjust and often absurd suspicions of the virtue of their wives. These delusions arise independently of hallucinations either of sight or hearing, and are of the greatest importance, because they supply logical motives for the most appalling and brutal crimes.
48 “The combination of a delusion of mutilation of the sexual organs with the delusion that the patient's food is poisoned, and that his wife is unfaithful to him, may be considered to as nearly demonstrate the existence of alcoholic insanity as any one group of symptoms in mental pathology can prove anything” (Spitzka, Insanity, N. Y., 1883).
Alcoholic delirium differs in the transitory and incoherent character of its delusions from ordinary chronic delirium, in which the delusions are much more apt to be fixed and permanent.
d. Dementia.—This is a common terminal condition of alcoholism. It may develop, without the intervention of other forms of mental disease, in the course of chronic alcoholism as a mere intensification of the intellectual and moral degradation of that condition. This is especially liable to occur in hereditary alcoholism. Dementia also closes the scene in a considerable proportion of cases characterized by repeated attacks of delirium tremens. It likewise constitutes the terminal condition in other forms of alcoholic insanity.
The symptoms are sometimes so slight as to escape ordinary observation. More commonly they are fully developed. As compared with ordinary dementia, they present but little that is characteristic. Alcoholic dements are perhaps more filthy and more difficult to manage, duller and more mischievous, than others. Their somatic disorders are more marked. In them hyperæsthesias are replaced by anæsthesias; sleep is apt to be irregular and disturbed; the hallucinations characteristic of the antecedent alcoholic psychosis now and then reappear. Slowly-developing failure of intellect, forgetfulness, stupor, end in more or less complete loss of mental power. Nevertheless, a small proportion of the milder cases are capable of arrest under treatment.
e. Paretic Dementia.—Alcoholism is an important etiological factor in the production of this condition. The intellectual disorders and motor disturbances which characterize it, varied as they are, are associated with cerebral lesions, and especially with lesions of the cortex equally varied—lesions which are common in chronic alcoholism. These lesions vary from meningeal congestion and inflammation to profound inflammatory and degenerative alterations in the cerebral substance.
Paretic dementia may develop after long-continued excesses without previous appreciable mental or cerebral symptoms. In such cases it presents no specific indications of its alcoholic origin. The difficulty of determining the influence of alcohol in its causation is increased by the fact that alcoholic excesses—symptomatic dipsomania—are frequent in the prodromic and early stages of this form of mental disease. Paretic dementia may also develop after repeated attacks of delirium tremens. Here the early attacks end in recovery apparently complete; later, the convalescence is unsatisfactory and prolonged, leaving some indications of intellectual enfeeblement, which, after renewed attacks, increases, and is accompanied by delusions of grandeur, embarrassment of speech, unequal dilatation of the pupils, and general paresis. The prognosis is practically hopeless.
III. Hereditary Alcoholism.
This term has been used in a somewhat vague manner to designate the morbid tendencies and pathological conditions directly transmitted by alcoholic subjects to their offspring. Chronic alcoholism on the part of one or both parents may be followed by morbid manifestations in the child. The hereditary transmission of the effects of alcoholism has been recognized from remote antiquity. Aristotle believed that a woman given to drunkenness would bear children with the same tendency. Plutarch affirms that the children of drunkards will abandon themselves to the same vice. Hippocrates speaks of the distressing effects of drunkenness upon the product of conception. Bacon states that many idiots and imbeciles are born of drunken parents. In more recent times the fact has been generally recognized that many maladies caused by the abuse of alcohol are liable to be transmitted to succeeding generations, and that alcoholism may in this way, in the course of two or three generations, lead to the complete extinction of families. Alcoholism on the part of the parents certainly exerts an unfavorable influence upon the health of their children, who are especially disposed to cerebral congestion, hypochondriasis, intellectual feebleness, and insanity. Two forms of hereditary alcoholism have been recognized: First, that in which the disease or defect of the parent is transmitted to the offspring; and second, that in which the disease or defect is not directly transmitted to the offspring, but a morbid tendency which manifests itself in diseases or defects of a different kind.49
49 1. Heredite de similitude, Alcoolisme hereditaire homotype; 2. Heredite de transformation, Alcoolisme hereditaire heterotype.
1. The appetite for strong drink is frequently transmitted from parents to the children, just as other traits of the mind or body. Sometimes it develops early, sometimes late in life; as a rule, however, this hereditary propensity shows itself at an early age, and is apt to be intensified at the time of puberty and the menopause. Objections have been urged against the theory of hereditary alcoholism. Among these the strongest is perhaps that the taste for drink in the offspring of alcoholic subjects is the result rather of opportunity and example than of heredity. The frequency with which alcoholic tendencies develop themselves in children reared and educated away from their parents, and the number of cases in which these tendencies show themselves only at an advanced period of life, long after the influence of example in childhood has ceased, sufficiently disprove this assumption. The hereditary influence does not, however, invariably manifest itself in the desire for drink. On the contrary, not rarely it consists in feebleness of nervous constitution, characterized by irritability, want of mental repose, or a restless or vicious disposition which demands constant excitement. Hence such individuals, although intellectually well developed, are often scarcely more than moral imbeciles, in whom the passion for drink may be replaced by the opium habit, addiction to gaming and to other vices, and whose career is shaped largely by an inordinate and insatiable craving for excitement of all kinds. Hereditary alcoholism follows the laws of heredity in general. The tendency may be transmitted directly from one generation to another, or may skip one or more generations, taking in the intermediate periods some different form.
2. The second variety is that in which the symptoms of chronic alcoholism are manifested in the offspring in the absence of the direct action of alcohol; that is to say, not the taste for alcohol, but the results of the gratification of that taste are transmitted, just as epileptic or hysterical patients may transmit to their offspring epilepsy or hysteria; thus it is not rare to encounter in the descendants of alcoholic parents perverted sensation, both general and special, hyperæsthesia, anæsthesia, flying neuralgias which do not always follow the course of particular nerves, but frequently affect in a general way the head or the members or manifest themselves as visceral neuralgias. These persons are much troubled with headache from slight causes and with migraine. Nor are disturbances of vision rare, nor vertigo. Insomnia is also frequent in such individuals, and augments the other symptoms. Digestive troubles also frequently occur, notwithstanding a regular and perfectly temperate life. Such persons are often subject to hallucinations of sight and hearing, and are liable to have delirium in trifling illnesses.
The second form of hereditary alcoholism manifests itself in a wholly different manner. The descendants, without a special appetite for strong drink, and in the absence of the special morbid manifestations above described, are singularly liable to mental and nervous diseases of various kinds. Among these convulsions and epilepsy are especially frequent; hysteria and various forms of insanity also occur. In this group of cases we find every degree of arrest of intellectual development, from mere feeble-mindedness to complete idiocy. As manifestations of the influence of alcoholism upon the offspring may be cited certain moral peculiarities otherwise inexplicable, such as are seen in children who at a very tender age show themselves vindictive, passionate, and cruel, to whom the sufferings of others afford pleasure, who torment their companions and torture their pets, and show precocious vicious tendencies of all kinds. Later in life these persons become lazy, intolerant of discipline, vagabonds, unstable of character, without the power of application and without moral sense. Given to drink, defiant of law, they constitute the great body of tramps, paupers, and criminals. The children of alcoholic subjects are often feeble and puny, pale, badly nourished, and curiously subject to morbid influences.
IV. Dipsomania.
Dipsomania, which has also been described under the term oinomania, is rather a form of insanity than of alcoholic disease. The characteristic symptoms are, however, in the greater number of instances, due to indulgence in alcohol. The subjects of this affection usually belong to families in which insanity, and especially this particular form of insanity, is hereditary.
There are two forms of dipsomania—the essential and the symptomatic. Of these, the latter is the more frequent. Its consideration requires in this connection very few words. It manifests itself by an irresistible desire on the part of many insane people for alcohol. It occurs both in the prodromic and in the fully-established periods of insanity. It is especially common in various forms of mania and in the prodromic periods of general paralysis. The dominating influence in essential dipsomania is heredity. Occasional causes may bring on particular attacks, but their influence is secondary. Dipsomania cannot be looked upon as a distinct recurrent affection in an otherwise healthy person. At some period in their lives, and often long before the occurrence of characteristic paroxysms, dipsomaniacs show peculiarities indicating defects of mental organization. Certain symptoms of dipsomania are often mistaken for its cause. Thus, dyspepsia is more frequently an effect than a cause of the alcoholic excesses. The despondency, irritability, restlessness, hysterical manifestations, and insomnia which precede the attack are not the cause of it: they are its earliest symptoms.
The affection usually begins insidiously and is progressive. As a rule, although not always, it begins in early adult life. The manifestations of this disease are essentially intermittent and paroxysmal, but the impulse to drink must be regarded as a symptom which may be replaced by other irresistible desires of an impulsive kind, such as lead to the commission and repetition of various crimes, as the gratification of other depraved appetites, robbery, or even homicide. The paroxysms are at first of short duration, and are followed by return to the previous regular and decent manner of life. They become, however, by degrees, more violent and more prolonged. At first lasting for a few days or a week, by and by they extend to periods of a month or six weeks, the attack wearing itself out, and recurring with a periodicity sometimes variable and sometimes constant. In the intervals of these attacks for a considerable time the patients very often lead sober, chaste, and useful lives. At length, however, evidences of permanent mental trouble are manifested, and the case settles into confirmed insanity. The attack is usually preceded by evidences of mental derangement; the patient becomes restless and irritable; sleep is irregular and unrefreshing; he complains of general malaise, and is anxious, troubled by vague apprehensions. He presently abandons his usual occupations and gives himself up to disordered impulses, among which alcoholic excesses are the most frequent and the most easily gratified. Sometimes the patient passes his time at taverns drinking with all comers; at others he shuts himself up in a chamber and gratifies his desire for drink to the most extreme degree alone. Dipsomaniacs not rarely leave their homes and associates without warning or explanation, and pass the period of the paroxysm among associates of the most disreputable character. The desire for drink is gratified at all costs, and not infrequently they return to their friends without money and without sufficient clothing, most of it having been sold or pawned in order to purchase drink. The paroxysm is succeeded by a period of more or less marked mental depression, during which the patient not rarely voluntarily seeks admission to some asylum.
The true nature of dipsomania is frequently overlooked. As a symptom of hereditary insanity it is in striking contrast with the habitual propensity to drink which occurs in the ordinary alcoholic subject. The latter seeks occasions to drink. He renews his excesses not intermittently, but habitually. If in consequence of disgrace or misfortune or under strong moral suasion he is for a time abstemious, it is only to renew and to continue his indulgence upon the first favorable occasion. On the contrary, the true dipsomaniac recognizes his malady and struggles against it. Even more: for a time he shows much skill in concealing it. He avoids occasions to drink, and, reproaching himself for his mad and unreasonable desire, seeks by every means to overcome his impulse to it. The ordinary drunkard may become insane because he drinks; the dipsomaniac drinks because he is insane.50
50 Magnan, Le Progrès médical, 1884.
Dipsomaniacs are apt to manifest precocious or retarded intellectual development. They are from infancy or childhood especially prone to convulsive or other paroxysmal nervous phenomena. They are often choreic, often hysterical. This association with instability of the nervous system is related to the fact that dipsomania is more common in women than in men.
DIAGNOSIS.—1. Acute Alcoholism.—The diagnosis of the ordinary form of acute alcoholism, with the exception of alcoholic coma, requires no consideration. The diagnosis of alcoholic coma from profound coma due to other conditions is, in the absence of the previous history of the case, always attended with difficulty, and is in certain cases quite impossible. It is therefore of great practical importance to obtain the history where it is possible to do so. The odor of alcohol upon the breath is of less positive diagnostic value than would at first thought appear. In the first place, sympathetic bystanders may have poured alcoholic drinks down the throat of one found unconscious, or, in the second place, individuals who have taken a certain amount of drink may be, and not unfrequently are, seized with apoplexy in consequence of the excitement thereby induced. The more common conditions with which alcoholic coma is confounded are apoplexy from cerebral hemorrhage and narcotic poisoning, especially opium-poisoning. To these may also be added uræmic coma and, under exceptional circumstances, sunstroke. In all these cases the circumstances under which the individual has been found are of diagnostic importance.
In alcoholic coma the pupils are more commonly dilated than contracted, the heart's action feeble, the respiration shallow, the muscular relaxation symmetrical, and the temperature low. There is a strong odor of alcohol upon the breath.
In apoplexy from cerebral hemorrhage the condition of the pupils will depend upon the location of the clot. They may be moderately dilated, firmly contracted, or unequal. The enfeeblement of the heart's action is, as a rule, less marked than in profound alcoholic coma. The pulse may be small or full and slow or irregular. It is usually slow and full. The respiration is often, although not invariably, slow and stertorous. Not uncommonly, the eyes and also the head deviate from the paralyzed side. If the coma be not absolute, the muscular relaxation is unilateral. The temperature is at first slightly below the normal, but less, as a rule, than in alcoholic coma; after several hours it rises to or above the normal.
In complete opium narcosis the insensibility is profound; the heart's action is slow or rapid, but feeble; the respirations slow and shallow or quiet or stertorous; the face at first flushed, afterward pallid and cyanosed; the pupils minutely contracted or dilated as death approaches; and the muscular relaxation complete, with abolition of reflex movements. In cases of doubt it is important to use the stomach-pump.
Uræmic coma is apt to be preceded by or alternate with convulsions. The pupils are more commonly slightly contracted than dilated, but are without diagnostic significance. The temperature is not elevated; it may even be low. The face may be pallid, pasty, and puffy, and there may be general anasarca if the nephritis be parenchymatous. On the other hand, in interstitial nephritis there is hypertrophy of the heart, without evidence of valvular disease, and some degree of puffiness of the lower extremities. In doubtful cases the urine should be drawn by a catheter and subjected to chemical and microscopical examination.51 Diabetic coma occurs suddenly without convulsions. This condition may be suspected when the emaciation is extreme or upon the recognition of sugar in the urine.
51 The following is the method recommended by Green (Medical Chemistry, Philadelphia, 1880) for the detection of alcohol in the urine: If its reaction be acid, the urine is exactly neutralized by potassium acid carbonate. It is then distilled on a water-bath in a flask or retort connected with a condensing apparatus. When about one-sixth of the liquid has passed over the distillate will, if alcohol be present, present the following characteristics: first, the peculiar alcoholic odor; second, a specific gravity lower than water; third, upon being mixed with dilute sulphuric acid and treated with a few drops of potassium bichromate solution the liquid becomes green, owing to the separation of chromic oxide; the odor of aldehyde may at the same time be observed. This reaction is not characteristic, but may serve to confirm other tests. Fourth, if dilute alcohol be shaken with an excess of solid and dry potassium carbonate in a test-tube, the greater part of the water will be appropriated by the potassium carbonate, and two layers of liquid will be formed. The alcohol constitutes the upper layer, and if sufficiently concentrated will burn upon the application of a flame. Finally, a small trace of alcohol may be separated from the urine without difficulty after the ingestion of alcoholic liquids by means of a good fractionating apparatus. Less than 1 per cent. of alcohol cannot be detected.
Sunstroke is characterized by dyspnœa, gasping respiration, jactitation, and intense heat of the skin. The pulse varies. It may be full and labored or feeble and frequent. The face is usually flushed. The pupils, at first contracted, are afterward dilated. The coma is apt to be interrupted by transient local or general convulsions.
It is impossible to lay down any rules by which the maniacal form of acute alcoholism may be at once diagnosticated from acute mania from other causes. For the characteristics of the convulsive form of acute alcoholism and those forms which occur in persons of unsound mind the reader is referred to the descriptions of those conditions. The diagnosis of acute poisoning by alcohol in lethal doses can only be established during life by investigation of the history of the case.
II. Chronic Alcoholism.—The lesions of chronic alcoholism, as has already been pointed out, are not in themselves peculiar to that condition. Many of them occur with more or less frequency in morbid states not induced by alcohol. It is their association and progressive character which gives to chronic alcoholism its individuality. The occasional prominence of certain symptoms or groups of symptoms may thus in particular cases lead to some confusion of diagnosis, especially where the history is unknown or the habits of the individual are concealed. In the greater number of cases, however, the association of symptoms is such as to render the diagnosis, even in the absence of a direct history, a comparatively easy one.
Chronic alcoholism is a condition rather than a disease—a condition characterized by varying lesions of the viscera and nervous system, by profound disturbances of nutrition, and by grave mental and moral derangements. This fact being recognized, the cardinal error of diagnosis to be guarded against is that of overlooking the condition upon which the disease itself with which we have to do depends or is associated. Congestion, inflammation, sclerosis, and steatosis affect the various organs of the body and produce their characteristic symptoms. Profound and lasting disturbances of nutrition demand our attention. Psychical derangements of all grades, from mere moodiness to confirmed and hopeless insanity, take place. These affections must be diagnosticated for themselves here as elsewhere in clinical medicine. The recognition of the underlying condition can, however, alone supply the key to their true pathology.
Delirium tremens is occasionally diagnosticated with difficulty from some forms of insanity not caused by drink. Here transitory and fixed delusions, not mere terrors and hallucinations, are of importance, not less than the absence of the varied and complex associations of symptoms which are characteristic of alcoholism. The delirium of the acute infectious diseases may be mistaken for delirium tremens. Pneumonia, typhoid fever, and the exanthemata occasionally begin with delirium resembling in some respects delirium tremens. Here the history of the case, the pyrexia, and the general condition of the patient are sufficient to establish the diagnosis if the danger of error be borne in mind.
III. Hereditary Alcoholism.—The diagnosis of this condition can only be established by careful investigation of the family history and systematic study of the stages of progression by which the morbid condition presented by the patient has been reached.
IV. Dipsomania.—The diagnostic points are the hereditary transmission of this or other forms of insanity—the mental instability of the patient in early life and in the intervals of the paroxysms, the intermittent or cyclical recurrence of the attack, the morbid impulses of a different kind associated with the impulse to drink, and the struggle of the patient against his recurring impulses to uncontrollable excesses.
PROGNOSIS.—The prognosis in acute alcoholism of the ordinary form is favorable, so far as the immediate attack is in question. The prognosis in rapidly-developing, overwhelming coma from enormous doses of alcohol is in the highest degree unfavorable. Acute coma from moderate doses usually passes off in the course of some hours. It occasionally, however, terminates in fatal pneumonia.
The prognosis in delirium tremens of the ordinary form is favorable. It becomes, however, more and more grave with each recurring attack. Delirium tremens in patients suffering from advanced disease of the heart, lungs, liver, or kidneys, or complicated by acute diseases of these organs, is apt to prove fatal.
The prognosis of chronic alcoholism is gloomy. If the lesions be not advanced, permanent discontinuance of alcoholic habits may be followed by restoration of health, but, unfortunately, the discontinuance is too often merely temporary, the habit being too strong to be permanently broken off.
The prognosis in hereditary alcoholism is unfavorable, both as regards the alcoholic habit and as regards the development of serious diseases of the nervous system under adverse circumstances, even in the absence of the direct action of alcohol.
The prognosis in dipsomania is unfavorable. The paroxysm may recur many times without apparent serious result; the patient in the course of some days or weeks recovers, abandons his evil courses, and resumes his usual occupations. After a time, however, the insanity of which the dipsomania is the recurring manifestation declares itself as a more or less permanent state. The outbreaks become more frequent and more prolonged, the mental condition in the intervals progressively more morbid, until the patient lapses by degrees into confirmed insanity.
The prognosis in all forms of alcoholism, both acute and chronic, is rendered in a high degree uncertain by the psychical disorders which characterize so many of its phases. In consequence of some of these conditions the patient loses at once his appreciation of bodily dangers and his power to avoid them; by reason of others, to escape imaginary evils he plunges into real ones; and finally some of them are of such a nature that they impel him to the blind and unreasoning commission of the most grievous crimes, including suicide and homicide.52
52 “I believe that more suicides and combined suicides and homicides result in this country from alcoholism in its early stages than from any other cause whatsoever” (T. S. Clouston, Clinical Lectures on Mental Diseases, Am. ed., 1884).
TREATMENT.—The prophylaxis of alcoholism has regard to communities at large and to individuals. The prevention of the evils of excess by the control of the sale of drink constitutes one of the more important objects of state medicine. At the same time, the traffic in alcohol is curiously evasive of legal enactments. The difficulties attending the enforcement of sumptuary laws are well known. Restrictive laws concerning the making and sale of alcoholic drinks, while partaking of the nature of sumptuary laws are of more comprehensive character, being obnoxious to powerful commercial interests and to the sense of personal liberty of large numbers of persons of all classes. As a result of organized opposition and individual violation they are to a great extent inoperative as regards the prevention of alcoholism.
Aside from the question of revenue from taxation, the practical influence of law is in this matter somewhat limited, being confined chiefly to the prevention of the sale of liquors to minors and persons already intoxicated, and to ineffectual attempts in certain countries to regulate the quality of the drink sold. The penalties for personal drunkenness which does not lead to overt acts are, as a rule, wholly inadequate to restrain it. The best results upon anything like an extended scale have been obtained by the co-operative action of philanthropic individuals in endeavoring to influence the moral tone, especially among workingmen, to diminish temptations, and to provide for leisure hours, in the absence of drink, reasonable amusements and occupation to occupy the time ordinarily spent in taverns and similar places.
The decrease in the consumption of alcoholic drinks in the United States within recent years is doubtless due in part to increasing popular knowledge concerning the dangers of alcoholic excess and to the growth of a more wholesome public sentiment. It is, however, in part also due to poor wages among workingmen.
As regards the individual, prophylaxis against alcoholism consists either in total abstinence from, or in the most guarded indulgence in, alcoholic beverages. It is unfortunate that individuals whose moral and physical organization is such as renders them most liable to suffer from the consequences of alcohol are by that very fact most prone to its temptations, and hence contribute largely to the subjects of alcoholism. These individuals are found among the ignorant, the very poor, and especially among neurotic subjects of all classes of society. Due consideration of this fact cannot fail to establish the responsibility of those fortunately not belonging to these classes, in two respects: first, that of example; and second, that of personal restraint from the standpoint of heredity. The influence of heredity among races addicted to alcohol has not yet attracted the attention it deserves. It is probable that much of the tolerance for alcohol exhibited by individuals, families, or even nations, is to be accounted for by heredity. Still more probable is it that most of the evils and crimes that befall alcohol-drinking communities and individuals are due directly or indirectly to the abuse of this agent. No argument against the indulgence in narcotics can be more potent than that derived from a consideration of the laws of heredity.
I. The Treatment of Acute Alcoholism.—The medical treatment of mere drunkenness requires no consideration. The rapid elimination of alcohol, and the transient nature of its pathological effects in excesses which are not repeated or prolonged, explain the spontaneous recovery, which is usually sufficiently prompt and permanent. The physical suffering and mental distress following unaccustomed excesses are of salutary influence. Under certain circumstances a powerful effort of the will is sufficient to control, at all events for a time, the more moderate effects of alcohol. A similar result follows the use of cold douches, the Turkish bath, and full doses of certain preparations of ammonium, particularly the officinal solution of the acetate of ammonium. In alcoholic stupor of an acute kind the patient may be left to himself, care being taken that the clothing is loosened and that the position is such as to prevent local paralysis from the nerve-pressure. Alcoholic coma, if of moderate intensity, may be managed in the same way. Profound alcoholic coma requires, however, more energetic measures. Frictions, artificial warmth, stimulating enemata, as of turpentine or of hot salt and water, an ounce to the pint, hypodermic injections of strychnia or atrophia in minute doses and occasionally repeated, inhalations of ammonia, and occasional cold affusions, followed by brisk frictions with warm flannel and faradism of the respiratory muscles, may be needed to tide over the threatened fatal collapse. The stomach should be at once washed out with hot coffee.
In the convulsive form of acute alcoholism chloral in twenty-grain doses, repeated at intervals until sixty grains have been given, usually serves to arrest, or at all events to moderate, the paroxysm. It may be administered by the mouth or in double doses by the rectum. If chloral be inadmissible by reason of weakness of the circulation, paraldehyde may be substituted in doses of from half a drachm to one drachm, repeated at intervals of from one to two hours until quietude is produced. Where the convulsive paroxysms are of great violence it may be necessary to control them by the cautious administration of ether by inhalation.
The mania of acute alcoholism calls for energetic management. To avert injury to the patient himself or to those about him he must be confined, if practicable, in a suitable apartment in a hospital; if not, in his own house and carefully watched. Here, as a rule, paraldehyde, chloral, or large doses of the bromides constitute our most efficient means of medication.
In all forms of acute alcoholism it is a rule admitting of no exception to at once withhold alcohol in every form and all doses. If, under exceptional circumstances, great nervous depression or flagging circulation seems to call for the use of alcohol in small amounts, it is far better to substitute other drugs. The frequently repeated administration of hot beef-tea or rich broths in small doses, with capsicum and the use of the various preparations of ammonia, or small doses of opium with or without quinia and digitalis, proves useful in proportion to the skill and discrimination with which they are selected and repeated. It is a good plan to commence the treatment with an active purge.
In the acute collapse following excessive doses—lethal doses—the stomach is to be immediately emptied by the tube or pump and washed out with warm coffee. In the absence of the stomach-tube emesis may be provoked by the use of mustard or sulphate of zinc or by hypodermic injection of apomorphia. The patient must be placed in the recumbent posture and surrounded with hot blankets. The cold douche may be occasionally applied to the head and face, and the muscles of respiration may be excited to action by faradism. Artificial respiration and friction of the extremities may also be required. Inhalations of ammonia may be used. The flagging heart may be stimulated by occasionally tapping the præcordia with a hot spoon—Corrgan's hammer. Hypodermic injections of digitalis may also be employed. Overwhelming doses of alcohol, leading promptly to collapse, usually prove fatal despite all treatment.
II. The Treatment of Chronic Alcoholism.—Whatever may be the prominence of particular symptoms or groups of symptoms, whether they indicate derangement of the viscera, of the nervous system, or of the mind, whatever their combination, the fundamental therapeutic indication in chronic alcoholism is the withdrawal of the poison. The condition is directly due to the continuous action of a single toxic principle: its relief when practicable, its cure when possible, are only to be obtained by the discontinuance of that poison. This is a matter of great, often of insurmountable, difficulty. The obstacles are always rather moral than physical. Occasional or constant temptation, the iron force of habit, the malaise, the faintness, the craving of the nervous system, and, worse than all, the enfeebled intellectual and moral tone of the confirmed drunkard, stand in the way. Even after success seems to have been attained, and the patient, rejoicing in improved physical health and in the regained companionship and consideration of his family and friends, feels that he is safe, it too often happens that in an unguarded moment he yields to temptation and relapses into his old habits. A patient of the writer, after seven years' abstinence from drink, again became its victim in consequence of the incautious suggestion of a young medical man, met at a summer hotel, to take brandy for some transient disorder, and died after eight months of uncontrollable excesses. It is necessary to guard the patient against the temptation to drink. To secure this he may he sent as a voluntary patient for a length of time to a suitable institution, or, still better, he may place himself under the care of a conscientious, clear-headed country doctor in a sparsely-settled region, preferably in the mountains or at the seaside. The malaise, depression, insomnia, and other nervous symptoms when of moderate degree are best treated by abundance of nutritious and easily-assimilable food, taken often and in moderate amounts. To this end gastro-intestinal disturbances may be practically disregarded, except in so far as they regulate the selection of a highly nutritious diet. As a matter of fact, in the early periods of chronic alcoholism, while visceral lesions of a grave character are yet absent, appetite and digestion alike improve in the majority of cases upon the withdrawal of alcohol, provided a sufficiently abundant and easily assimilable dietary is insisted upon. Grave visceral lesions characterize a more advanced alcoholic cachexia and necessarily complicate the treatment. Nevertheless, even here the indication is the withdrawal of the poison. The nervous symptoms require special medication. The whole group of tonics, from simple bitters to quinia and strychnia, is here available. It is impossible to lay down rules for the treatment of particular cases except in the most general manner. In the absence of conditions calling for special treatment, such as gastritis, hepatic or pulmonary congestion, fatty heart, etc., good results follow the frequent administration of small doses of quinia and strychnia; thus, the patient may take one grain of quinia six or eight times a day, or a little gelatin-coated pill containing 1/200–1/100 of a grain of strychnia every hour during the waking day, amounting in all to one-twentieth, one-tenth, or one-fifth of a grain in the course of twenty-four hours. This treatment is often followed by the relief of tremor, the quieting of nervous irritability, and the production of good general results. The malaise, the general depression, and especially the sinking feeling at the pit of the stomach so often complained of by patients, are best relieved by food. Fluid extract of coca is also useful in these conditions. The value of cocaine in the management of the nervous symptoms of chronic alcoholism, and in particular as a temporary substitute for alcohol, is doubtful. The writer, having used it in a number of cases by the mouth and hypodermically in doses of ¼–1 grain, has had variable results. In some cases it temporarily relieved the craving and concomitant symptoms; in others it failed wholly: in one instance one-fourth of a grain was followed by great nervous depression. It is desirable not to inform the patient of the nature of the remedy, especially if its use be followed by good results, lest the cocaine itself supplant alcohol as an habitual narcotic. Cold or tepid sponging, the occasional hot bath at bedtime, and the Turkish bath are useful adjuvants to the treatment. As a rule, opium is contraindicated. Sleep often follows the administration of a cupful of hot broth or milk at bedtime. Lupulin is here useful, and the writer has come to regard an ethereal extract of lupulin in doses of from one to three grains as a valuable and harmless hypnotic. If necessary, hypnotic doses of chloral or paraldehyde may be used, but care is required in their administration, and their early discontinuance is advisable. If anæmia be profound, chalybeate tonics do good, and among the preparations of iron pills of the dried sulphate with carbonate of potassium (Blaud's pills) are especially useful.
The obesity of drunkards, as a rule, diminishes on the withdrawal of alcohol. Under circumstances of partial or complete abstinence from drink measures to reduce the weight of such patients are wholly inadmissible.
In conditions characterized by failure of mental power, in beginning dementia or threatened insanity, the syrup of the hypophosphites, the compound syrup of the phosphates, or cod-liver oil should be administered. These remedies are likewise useful in various forms of alcoholic paralysis, as are also faradism and galvanism employed secundum artem. The various forms of alcoholic insanity require special treatment, only to be had in institutions designed for the care of patients suffering from mental diseases in general.
Whilst it is desirable in the treatment of all forms of chronic alcoholism to secure the permanent discontinuance of the alcoholic habit, the skill, judgment, and experience of the physician must determine the degree of rapidity with which this, when practicable, is to be done. The number of cases in which alcohol can be discontinued at once and finally is limited; those in which it can be wholly given up in the course of a few days constitute the largest proportion of the cases; finally, in a small number of cases alcohol can only be withdrawn cautiously and by degrees.53 Whilst it is in most cases essential to remove the patient from his customary surroundings and companionships, it is in the highest degree important to provide for him mental occupation and amusement. To this end a wholesome open-air life, with sufficient daily exercise to induce fatigue, is highly desirable, as indeed is the companionship of interested and judicious friends.
53 It must be borne in mind that in chronic alcoholism acute maladies of all kinds, including traumatism, both accidental and surgical, act as exciting causes of delirium tremens. The part played by the abrupt diminution or withdrawal of alcohol under such circumstances is often an important one. It is the opinion of the writer that a certain amount of alcohol should be administered for a time at least in the accidental injuries and acute sicknesses of alcoholic subjects, and that the reduction should be gradually made.
The Treatment of Delirium Tremens.—The patient should be confined in a large, well-aired apartment, without furniture except his bed, and when practicable he should have a constant attendant. The favorable influence of a skilful nurse in tranquillizing these patients is very great. The custom of strapping them to the bed by the wrists and ankles is to be deprecated. If the case be a mild one, and especially during convalescence, open-air exercise in the sunshine with an attendant is of benefit; care must, however, be taken to guard against the danger of escape.
Under no circumstances should visitors be permitted to see the patient. In young persons the treatment may be preceded by an active saline or mercurial purge. In elderly persons, those suffering from cachectic conditions, or in cases characterized by marked debility and feeble circulation—conditions frequent in persons who have had repeated attacks—it is not desirable to purge. Alcohol should be either wholly withdrawn or more or less rapidly diminished. It must be replaced by abundant food in the form of concentrated broths or meat-extracts. In cases of vomiting these must be given hot and in small doses frequently repeated. Bitter infusions may also be given, or milk or equal parts of milk and Vichy water. If there be thirst, the effervescent waters may be given freely. Patients often drink with satisfaction and apparent benefit hop tea, which may be made simply with water or with equal parts of water and porter.
The medicinal treatment will depend to a large extent upon the peculiarities of the case. In mild cases a combination of the watery extract of opium in small doses, not exceeding a quarter of a grain, with quinia and digitalis, repeated every four or six hours, is often useful. Although the view once entertained that the graver symptoms were the result of prolonged sleeplessness is no longer tenable, the induction of sleep, or at all events of mental and physical repose, is among the more important therapeutical indications. For this purpose hypnotic doses of opium are not only not desirable, but are even, in the majority of instances, attended with danger. The sleep which follows repeated and increasing doses of opium in delirium tremens has too often terminated in coma deepening into death. As calmatives, extract of cannabis indica, hyoscyamus, or the fluid extract of piscidia are useful. As hypnotics, the bromides, chloral, and paraldehyde yield, in the order here given, the best results. The bromides are better in large single doses than in small doses often repeated, better in combination than singly. Chloral, either by the mouth or by the rectum, in doses of from twenty to forty grains, is often followed by beneficial sleep. It is contraindicated where the heart's action is much enfeebled. Paraldehyde, in doses of half a drachm to one drachm, repeated at intervals of two or three hours until sleep is induced, is still more efficient. This drug may be administered without the fear of its exerting a depressing influence upon the heart. The depression characteristic of grave delirium tremens may be combated by repeated small doses of champagne or by carbonate of ammonium in five- or ten-grain doses; the vomiting, by withholding food and medication by the mouth, and giving them for some hours wholly by the rectum or hypodermically. Excessive restlessness is sometimes favorably influenced by cold affusion, followed by brisk friction and warm blankets with continuous artificial heat. The cold pack has proved useful.
Digitalis may be employed, ex indicatione symptomatica, but the enormous doses of tincture of digitalis used by the late Jones of Jersey and others are here mentioned only to be condemned.
To sum up, the chief indications for treatment are complete isolation, the withdrawal of alcohol, abundant, readily assimilable, nutritious food, and control of the reflex excitability of the nervous system.
III. Hereditary Alcoholism.—The treatment of the vicious propensities of the descendants of alcoholic parents does not fall directly within the province of the physician. It is among the most difficult problems of education. The recognition of the cause of evil traits manifested in childhood and youth may do something to avert dangers commonly unsuspected. All things considered, the outlook is not hopeful. The recognition, on the part of the physician, of the influence of hereditary alcoholism in cases of arrested development, feeble organization, or declared disease of the nervous system will perhaps do less to aid his treatment in many cases than to reconcile him to its want of full success. The cry of warning is to those who are eating sour grapes that the teeth of their children will be set on edge.
IV. Dipsomania.—The general indications for the treatment of dipsomania are two: first, the management of the paroxysm; second, the control of the general condition itself.
First, then, during the paroxysm the patient must be saved, in so far as is possible, from the danger of injuring himself or others and from squandering his property. If the excesses are of such a degree as to render it practicable, the same treatment must be carried out as in cases of acute alcoholic mania and delirium tremens—namely, confinement in a suitable apartment under the care of an experienced nurse and the control of the doctor. Unfortunately, this plan is not always practicable in the early days of the outbreak. Here tonics, coca, and repeated small doses of quinia and strychnia are of advantage. Courses of arsenic at the conclusion of, and in the intervals between, the paroxysms are of use, on account of the excellent influence they exert on the general nutrition. These may be advantageously alternated with iron, cod-liver oil, and the compound syrup of the phosphates or of the hypophosphites. Hydrotherapy may also be used with advantage, and the influences of a well-regulated hydropathic establishment are much more favorable than those of institutions specially devoted to the treatment of alcoholic subjects. In the latter the moral atmosphere is apt to be bad; the patients support each other, and too often conspire to obtain in secret that which is denied them openly, or, if the discipline be too strict for this, they sympathize with each other in their restraint, react unfavorably upon each other in the matter of shame and loss of self-respect, and plot together to secure their liberty.
Few dipsomaniacs in the earlier periods are proper subjects for treatment in hospitals for the insane. If cerebral excitement or sleeplessness persist after the paroxysms, chloral, paraldehyde, or the bromides in large doses may be used to secure sleep. Various combinations of the bromides are often of use where the single salts fail. It must not be forgotten that during the paroxysm there is great danger lest the patient do himself or others harm. When there are indications of an impending attack, and during the period of depression following the attacks, benefit is derived from the daily use of bitter infusions. As a matter of fact, however, the management of these cases is among the most unsatisfactory of medical undertakings. The difficulty is increased by the latent character of the mental disorder in the intervals between the attacks. Even when such patients voluntarily enter hospitals for the insane, they cannot be retained there sufficiently long to derive any permanent benefit. What we want is, in the words of Clouston, “an island where whiskey is unknown; guardianship, combined with authority, firmness, attractiveness, and high, bracing moral tone; work in the open air, a simple natural life, a return to mother Earth and to Nature, a diet of fruits, vegetables, bread, milk, eggs, and fish, no opportunity for one case to corrupt another, and suitable punishments and deprivations for offences against the rules of life laid down. All these continued for several years in each case, and the legal power to send patients to this Utopia for as long a period as medical authority determines, with or without their consent.”