Alcoholism.

Definition.—An intoxication, acute or chronic, due to the ingestion of a sufficient quantity of alcohol to produce muscular incoordination, mental disturbances, and finally narcosis. Certain terms are used to define peculiar conditions or phases of alcoholism, such as mania-a-potu, dipsomania, and delirium tremens.

Mania-a-potu is a temporary acute insanity, or "crazy drunkenness," occurring in a drinker of neurotic temperament.

Dipsomania is where there is a strong hereditary tendency to drink, and where the victim goes on a spree periodically, but during the intervals is free from any craving for drink.

Delirium tremens is where certain hallucinations are experienced, generally of a fearful character, such as being pursued by snakes, demons, vicious animals, etc., and is generally found in chronic alcoholism, though sometimes met with in the acute form.

Etiology.—Among predisposing causes may be mentioned the following:

Heredity, the offspring of drinkers often being of a nervous temperament, which craves stimulants.

Occupation, in which there is exposure to inclement weather, as by soldiers, sailors, cab-drivers, hucksters, etc. Those engaged in the manufacture and sale of liquors are also peculiarly exposed.

Grief and Despondency.—The loss of family or fortune results in broodings, which predispose the individual to dissipate his troubles by drink. Pain and failing health are often the first conditions that drive to drink.

Social Customs.—The custom of serving wines of various kinds at banquets is often the beginning of the drink-habit.

The exciting cause is either the intermittent or continued use of whisky, wine, or beer, and in females cologne-water.

Pathology.—Acute Alcoholism.—Where death is the result of acute alcoholism, the mucous membrane of the gastrointestinal canal is engorged, injected, and dark-red in color, and covered with a sticky, mucoid exudate. The brain and the kidneys show the same characteristic changes. A recent case of a young colored boy of eighteen, who drank two quarts of whisky on a wager and died twenty-four hours later, revealed the above conditions, which is typical of acute alcoholism.

Chronic Alcoholism.—In chronic alcoholism, changes of a more permanent character take place, depending somewhat upon the quality, and quantity, and kind of alcoholics consumed, and length of time used. While all the bodily tissues are more or less impaired, the brain, kidneys, and digestive system suffer most.

Spirituous liquors show connective-tissue changes, while malt drinks are more apt to result in fatty degeneration. Thus, in whisky-drinkers, chronic gastritis, with thickening of the mucosa, will be found.

The kidneys and liver are firm and sclerosed, due to fibroid degeneration. The brain, spinal cord, and arteries also show similar changes. In beer-drinkers, there is apt to be fatty degeneration of the kidneys, liver, and heart, and more or less dilatation of stomach.

Symptoms.—The symptoms of acute alcoholism have a wide range, affecting different temperaments in very different ways. In one, a spirit of generosity is early developed, the victim spending his substance with a lavish and prodigal hand. Another will be jovial, andi endeavor to amuse his companions, while a third early develops a pugnacious attitude, is quarrelsome and vicious.

The first effect of drink is one of stimulation and exhilaration, attended by vascular relaxation, which is accompanied by a sense of warmth, the face being flushed and rosy. As the system becomes more impressed by the intoxicant, the drinker passes into the second stage; there is now muscular incoordination, a more cyanotic appearance of the face, and the speech is maudlin or delirious. This is followed by the third stage, in which helplessness, acute coma, heavy, stertorous breathing, a slow, full pulse, dilated pupils, a purplish, bloated countenance, relaxed, clammy skin, and frequently incontinence of urine and feces, are the prominent symptoms.

The coma is usually not so profound but that the patient may respond to repeated shakings or pressure upon the supraorbital notch, though his mutterings are unintelligible. Acute alcoholism may stop short of the third stage, especially if but little of the stimulant is taken.

Mania-a-potu.—In some neurotic individuals a few drinks are sufficient to develop a maniacal condition, characterized by an ungovernable temper, the demon of drink carrying everything before it. The face is flushed, the pulse full and bounding, with great excitation of the nervous system, which manifests itself by unearthly screams or destructive tendencies. Thus, in the case of Mr. A——, a farmer of industrious habits and peaceful mind, a few drinks of whisky, on coming to town, transformed him into a veritable fighting demon. His arrest and incarceration could only be accomplished by the aid of half a dozen assistants, which was followed by unearthly yells and cursings, until he was completely exhausted.

Mr. B——, an industrious carpenter, only needed a few drinks to make him "crazy," when he would undertake to beat his wife and children and demolish the furniture, and by the time he could be overpowered, his home looked as though visited by a cyclone.

Chronic Alcoholism.—The disease—for so it must be considered—comes on insidiously, gradually undermining the vital forces, and inflicting both moral and physical ruin.

The victim of chronic alcoholism loses his industrious habits, and as slight exertion results in fatigue, loss of energy and un-willingness to work replaces the habit of thrift. General and mental depression follow, headache, malaise, and impaired appetite, with a dirty, furred tongue, a characteristic bad breath, resembling the mash-tub, constipation, alternating with diarrhea, insomnia and muscular tremor, are among the earlier symptoms.

Digestive disturbance is almost constant, the patient vomiting-before breakfast, and suffering with gastric distress after eating. Thirst is excessive, but only partially relieved by drinking. Tremor of the hands and tongue is soon noticed, and though at first it can be controlled, soon passes beyond the power of the patient, even affecting his gait, which becomes ataxic.

The muscles are flabby, there is a venous congestion of the face, and acute rosacea paints the drinker's nose a purplish red. In beer-drinkers, dilatation of the stomach is quite common. The mental or moral sensibilities are blunted, the will and conscience are paralyzed, and falsehood and deceit replace truth and fair-dealing.

As the physical, mental, and spiritual forces give way, there is less resistance to diseased conditions, which accounts for the high mortality, in pneumonia,, influenza, dysentery, and kindred diseases, occurring in alcoholics.

Delirium Tremens.—Although this may follow a single attack of a hard and prolonged spree, it is more apt to occur in chronic drinkers. In some cases delirium tremens is not the result of excessive excitement, but makes its appearance when the person has ceased to drink, either from inability of the stomach to receive it, or because they desire to sober up. Hence it is the withdrawal of the stimulant at a time when the system is accustomed to its use. In other cases it comes on while the person is still drinking to excess. There is therefore a delirium of drunk-enness following the debauch immediately, and another that makes its appearance in from two to seven days afterwards.

"In the first case, the person has ceased to drink, and the excitement of the nervous system is dependent upon the withdrawal of the stimulant. It may commence as early as the second day, or at any time during the week after ceasing the use of stimulants.

"The symptoms are those of prostration. We find that there is great irritation of the stomach, frequently thirst, sometimes nausea, and in all cases an entire loss of appetite, the patient having usually taken but little, if any, food for several days. The pulse is generally slow, and the hands and feet are cold and clammy; he is anxious and dejected, sighs frequently, and complains of oppression about the precordia. These symptoms continue sometimes for two or three days, at others for but a few hours. The restlessness and vigilance of the patient are now increased, and the countenance has a peculiarly wild expression; mental delusions now occur, at first at intervals, and easily displaced by reasoning- with him, but at last, becoming fixed and constant, he sees curious shapes and beings, snakes, devils, dragons, assassins, etc., and is in continual fear of his life, or of future retribution.

"It is singular that these visions are so generally frightful, and strike the poor sufferer with mortal terror, and yet the cases are very rare where it is otherwise. He sees them on his bed, peeping" and laughing at him from behind the furniture, grasping at him from the air, climbing on his body, and it is impossible to displace these fancies. Occasionally they take human shapes, but are still objects of terror, as murderers, thieves, etc., and he tries various means to escape from their clutches, even in some cases to jumping out of the window.

"The intensity of this delirium varies in different cases, the patient being managed with ease in some, but in others requiring" to be held down in bed to prevent him from injuring himself and others. During this time the skin is harsh and dry, the pulse frequent and small, the tongue dry and furred, and the appetite entirely lost. The secretions are all diminished, the patient is feeble, and there is an unnatural tremor of the muscles. Continuing in this way for a variable period, it may terminate by a subsidence of the excitement, and by a deep sleep, from which the patient awakes free from these morbid fancies. In other cases the delirium becomes more and more severe, until finally the system sinks under it, the patient dying from the fourth to the twelfth day.

"In the second case the delirium comes on as a termination of the spree, the person continuing to drink even after the attack has commenced. In some the drunkenness assumes a violent form, the patient being furious, vicious, and controlled with difficulty. When we examine the case we find the face flushed, the eyes bright, the pupils contracted, the pulse hard, and the patient irritable and with difficulty controlled. The evidence of delirium tremens is the same as above noted, for in all cases the phantoms are frightful. In this, however, the patient does not suffer quietly, but manifests a disposition to resist and combat the evil shapes. At last, when the hallucinations are continuous, the patient is in a constant state of furious excitement, which continues until the nervous system gives way and death results." (Scudder.)

Diagnosis.—Acute alcoholism is not usually difficult to recognize, though a careful examination should be made of each case, since apoplexy, concussion of the brain, and uremic coma have been taken for a case of "dead drunk." In an acute coma from drink, the breathing will be heavy or stertorous, and by vigorously shaking the person, or by pressing hard upon the supraorbital notch, the patient can be aroused, and though his mutterings may not be very intelligible, we recognize that the impressions are made upon the brain.

The whisky-breath also corroborates the other symptoms. We are not to overlook the fact, however, that the patient may have fallen in an attack of apoplexy, or from a blow on the head, and whisky or brandy has been given by the bystanders in an effort at resuscitation, or the patient may have had a drink or two before an attack or an injury, in which case the whisky breath should not deceive us.

The diagnosis of chronic alcoholism will be made from the history of the case; the tremor of the hand and tongue; the furred tongue; bad breath and gastric irritability; the bloated face, red nose, and the disturbed mental or moral condition of the patient.

Delirium tremens will be recognized by the history of the case, the marked uneasiness and restlessness of his manner, and the peculiar wildness of his countenance; the seeing of unpleasant and hideous things can hardly be mistaken for any other condition.

Mania-a-potu will be recognized by the violent fury of the individual while under the influence of drink.

Prognosis.—In acute cases the prognosis is generally favorable, unless large quantities of whisky are taken, when death may result in a few hours.

In chronic alcoholism, permanent recovery seldom takes place, owing to progressive changes in brain, kidney, liver, gastro-intestinal canal, and, in fact, the tissues generally. Even though the individual permanently abstains from the use of spirituous and malt liquors, tissue changes can not be removed entirely.

Bright's disease, insanity, epilepsy, cirrhosis of the liver, and other serious lesions are apt to result.

Treatment.—The treatment for acute alcoholism is quite simple. If seen before the patient reaches the stage of coma, an emetic, followed by teaspoonful doses of liquor ammonia acetas, every thirty or sixty minutes, will generally straighten or sober up the patient; the patient, of course, abstaining from the fresh use of drink. Howe's viburnum cordial and nux vomica should be given for several days. If the patient has reached the stage of coma, he will sleep off the effects of his drunk, when the above remedies may be effectively used.

There is not only a physical degeneration, but a mental and moral one as well, and chronic alcoholics do better when placed in special retreats or homes for the inebriates. The patients tolerate the withdrawal of stimulants better than when at their own home, and they are encouraged by the presence of convalescents, and their will is strengthened, and by the judicious use of tonics, iron, strychnia, gold, and like preparations, a certain per cent are permanently cured.

The general health must be looked after, and nutrition improved. Exercise in the open air, baths, massage, and a good tonic, such as the triple phosphate of iron, quinine, and strychnia, will prove beneficial. To induce sleep, passiflora in teaspoonful doses, trional, gelsemium, and hyoscyamus should be given in preference to opiates; in fact, the physician should avoid opiates, as he would whisky, for the danger of acquiring the drug habit is very great.

The patient is to be encouraged, his will strengthened, and his moral and spiritual nature cultivated. Unfortunately, there is no specific drug for alcoholism. If the patient can be interested in philanthropic work, such as rescuing other unfortunates, much good will result.

In treating delirium tremens, we find two directly opposite conditions. In one there is enfeeblement; the pulse is small and frequent, the face is pallid, there is great prostration, the extremities are inclined to be cold, and the hallucinations are terrifying. Such a patient needs stimulants, tonics, and restoratives. Alcoholic stimulants, however, should be withheld. Acetate of ammonia, nux vomica, strychnia, hot broths, highly spiced, and the hot bath are followed by happy results. Where the stomach is too irritable to retain foods, an enema of hot beef-tea, will often be received and accomplish much good.

Where there is great excitation, with flushed face, full bounding pulse, throbbing of the carotids, and great nervous excitement, as shown by the wild active delirium, the treatment will be directly the opposite of the above. Veratrum and gelsemium, one dram of each, in a half glass of water, and a teaspoonful every thirty or sixty minutes, will bring about good results. This may be followed by chloral 2 drams, morphia 2 grains, aqua 2 ounces. Teaspoonful every hour until the patient drops asleep, and the battle is won.

The after treatment in each case will be along rational lines. In one it will be belladonna, nux vomica, hydrastis, quinine, etc. In the other, gelsemium, rhus, passiflora, etc.

The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.