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.