PAINS OF ALCOHOLISM.
A very important class of pains, which are occasionally confounded with
true neuralgias, are those which occur in certain forms of chronic
alcoholism. The diagnosis of their true nature is a matter of the utmost
consequence, and the failure to recognize them for what they are may
have very disastrous results. It is a curious fact that this consequence
of chronic alcoholic poisoning has been entirely overlooked by some of
the best known writers on that affection; it has, however, been
described by Mr. John Higginbottom, and also by M. Leudet.
It must be clearly understood that the pains of which we are now to
speak are not among the common consequences of chronic excess in drink.
The affections of sensation which most usually occur in alcoholism take
the shape either of anaesthesia, or of this combined with anomalous
feelings partaking more or less of the character of formication. Chronic
drinking has also a tendency, in its later stages, when the nutrition of
the nervous centres has been considerably impaired by the habit, to set
up true neuralgia, of a formidable type, in subjects who are
hereditarily predisposed to neuroses. But the affection of which I now
speak may occur at any stage except the very earliest, and, though often
severely painful, is essentially different both in its seat and in its
general characters, from neuralgia proper.
The earliest symptoms from which the patient usually suffers in these
cases are insomnia, and intense depression of spirits, which, however,
is not incompatible, indeed is frequently combined, with a morbid
activity and restlessness of thought. There is generally marked loss of
appetite, but often there is none of the morning nausea so
characteristic of the common forms of alcoholism. Nor is there,
ordinarily, any special unsteadiness of the muscular system. The pains
are usually first felt in the shoulder and down the spine; but as the
case progresses they especially attack the wrist and ankles; and it is
in these latter situations that I have found them to be most decidedly
complained of. Their similarity to neuralgia consists (_a_) in their
somewhat paroxysmal character; (_b_) in their frequently recurring at
about the same hour of the day, most commonly toward night; and (_c_) in
their special aggravation by bodily and mental fatigue.
Their differences from neuralgia are--(_a_) that they never follow the
course of a recognizable single nerve; (_b_) that they are nearly always
present in more than one limb, and usually in both halves of the body,
at the same time; and (_c_) especially, that they are far less promptly
and effectually relieved by hypodermic morphia than are the true
neuralgias; indeed, opiates very frequently only slightly alleviate the
pain, while they excite and agitate the patient and render sleep
impossible. On the contrary, a large dose of wine or brandy will never
fail to procure temporary comfort and induce sleep, at least until the
patient reaches an advanced stage of the disorder, and is, in fact, on
the verge of delirium tremens.
I am not quite sure that I am right in believing that there is a special
physiognomy for this form of chronic alcoholism, and yet I am much
inclined to believe that there is. All the patients whom I have seen
suffering with it have presented a peculiar brown sallowness of face,
and a general harsh dryness of the skin, which has usually lost its
natural clearness, not only in the face, but even more remarkably in the
hands, which are so dark-colored as to appear as if they were dirty.
There is usually considerable leanness of the limbs, and, though the
abdomen may be somewhat prominent, this does not seem to depend much on
the presence of fat, but rather on relaxation of the abdominal muscles,
and sometimes flatulent distention of the stomach and intestines. The
hands are usually hot, sometimes quite startlingly so.
Some of the patients suffer, besides the pains in the limbs (which they
often describe as resembling the feeling of a tight band pressing
severely around the ankles or wrists), from frequent or occasional
attacks of genuine hemicrania; such a combination is to me always a
suspicious sign, and induces me immediately to direct my attention to
the possibility of chronic alcoholic poisoning. Otherwise, the
limb-pains are often spoken of as resembling rheumatism, but there is no
swelling of joints, and usually no decided tenderness of the painful
parts. The patient has usually a particular worn and haggard appearance,
complains of intense fatigue after the most moderate muscular exertion,
and is usually utterly indisposed to physical exercise even though the
mind, as already said, may display a feverish activity.
So far as I have seen, the subjects of this affection are by far the
most frequently women; and I am inclined to attribute this
predisposition of the sex not to inherent peculiarities of female
organization, but to the fact that a much larger proportion of
intemperate women than of intemperate men indulge in secret excess. They
never get drunk, probably, but they fly to the relief of alcohol upon
every trivial occasion of bodily or mental distress; and this habit may
have been going on for years before it comes to be suspected by their
friends or their medical attendant. Meantime, they have been more or
less looked upon, and have looked upon themselves as, "debilitated" and
"neuralgic" subjects, and have come, either with or without mistaken
medical advice, to consider free stimulation as the proper treatment for
the very ailments which have been produced by their own unfortunate
habits. I cannot avoid the expression of the misgiving, that imperfect
diagnosis, and consequent erroneous prescription, have done great harm
in many such cases. It has happened to me no less than three times
within the last six months to be called to lady patients, all suffering
from alcoholism induced by a habit of taking stimulants for the relief
of so-called neuralgic pain; and in the most distressing of these the
mischief had been greatly aggravated by a prescription of brandy, based
on the erroneous idea that the pains were truly neuralgic. I have
already protested against this kind of medication, even in cases that
are truly neuralgic in character; but it is doubly mischievous where
given for a state of things which actually depends on alcoholic excess.
It is undoubtedly very difficult, sometimes, to elicit the truth, even
in cases where we may entertain considerable suspicion that alcoholic
excesses are the real cause of the pains which the patient calls
neuralgic; more especially where the patient is aware that he or she is
taking an amount of alcohol which is seriously damaging to health. And
it is therefore necessary to look out for every possible additional help
to our diagnosis. Besides the cardinal features of the disease--the
insomnia, loss of appetite, foul breath, haggard countenance, and pains
encircling the limbs near the joints rather than running longitudinally
down the extremities there are certain moral characteristics of the
patient that often tells a significant tale. The drinker, especially if
a woman, is shifty, voluble, and full of plausible theories to account
for this and the other phenomenon. It will be well to try the effects of
a somewhat sudden though not uncourteous remark, to the effect that the
diet should be strictly unstimulating. If this be introduced with some
abruptness, in the course of a conversation not apparently leading to
it, the patient's manner will not unfrequently betray the truth; while,
if our suspicions are groundless, we shall also probably perceive that,
in the unconscious, or frankly surprised, expression of the countenance.
We may sometimes derive crowning proof of the existence of alcoholic
excess by cautious questions which at least reveal the fact that the
patient suffers from spectral hallucinations; this is a far commoner
occurrence in chronic alcoholism than is generally supposed; it needs to
be inquired for with great tact, but, when established beyond doubt, and
joined to insomnia and the peculiar foul breath, is of itself sufficient
to establish a positive diagnosis of alcoholic poisoning.
The results of treatment, in true neuralgia and in alcoholic pains,
respectively, establish an important difference between these
affections. In the former malady, for instance, the hypodermic injection
of morphia always produces striking palliative, and very often curative
effects. In alcoholic pains this remedy either affords only trifling
relief, or more commonly aggravates the malady by increasing the general
nervous excitement; and the only true treatment is at once to suspend
all use of stimulants, to administer quinine, and to insist upon a
copious nutrition. If any hypnotic must be employed, let it be chloral,
or bromide of potassium with cannabis Indica. It will be well also to
put the patient upon a somewhat lengthened course of cod-liver oil.
There is one special symptom from which the chronic alcoholist often
suffers acutely, namely a hypersensitiveness to cold; for this I found
the use of Turkish bath two or three times a week, for three or four
weeks, very useful in one case that was under my care. It will be
important to insist that the patient shall take the bath only after that
shorter method which I have described in speaking of the prophylaxis of
true neuralgia.