A system of practical medicine. By American authors. Vol. 5

by Unknown

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.