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 {575}
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 {576} 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 {577} 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 {578} 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. Richardson[3] 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]
[Footnote 3: _On Alcohol_, Lond., 1875.]
[Footnote 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 {579} 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.
[Footnote 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 {580} 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, {581} 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]
[Footnote 6: _Pflüger's Archiv für Physiologie_, Band viii., 1874.]
[Footnote 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.