acquired as one of the results of profound disturbance of the nervous
system, such as is produced by moral causes, by temporary or recurrent
insanity, by wounds and injuries of the head, by the infectious
diseases, especially syphilis, enteric and typhus fever, and
small-pox, and by inflammations of the meninges.
What may be the precise mode of action of alcohol in the production of
its acute effects yet remains a matter of conjecture. It cannot be
doubted that its primary and direct action is upon the nervous system,
and that the circulation is secondarily but rapidly implicated. But it
is quite impossible to say, in the present state of knowledge, what
this action is. It has been suggested that certain chemical
modifications of alcohol in the blood, or of the blood itself in the
presence of alcohol, cause these phenomena; that aldehyde is the
active agent in their production; that the chemical changes by which
alcohol is transformed into aldehydes, acetic acid, and finally into
carbon dioxide, deprive the blood of the oxygen necessary for the
proper performance of the functions of the nervous system.
Unfortunately for these views, neither the presence of aldehydes in
the blood in acute alcoholism, nor these transformations themselves,
have yet been demonstrated, and a high degree of deoxygenation of the
blood is frequently observed in asphyxia, the inhalation of nitrous
oxide, etc., without the train of symptoms characteristic of the
condition now under consideration.
It is more than probable that varying conditions of the cerebral
circulation, secondary in themselves, have much to do in the causation
of certain symptoms. The experimental investigations of Bernard and
others have established the fact that during the period of excitement
there is actual congestion of the meninges. This condition is
transient, and reproduced after each repetition of the dose. After a
time, or if the dose at first be excessive, the congestion is
succeeded by anæmia.
PATHOLOGICAL ANATOMY.—Upon the examination of the bodies of persons
who have died by accident while drunk or in consequence of drunkenness
itself, deep congestion of the cerebral meninges, and especially of
the pia, has been almost constantly observed. In the pia effusions of
blood are occasionally encountered. The condition of the cerebral
{596} substance is not always the same. It is in a majority of the
cases more or less deeply congested, yet it presents in other
instances no appreciable departure from the normal state, and in a
smaller number still there is actual anæmia.
The sinuses and choroid plexuses are distended with dark blood; the
cerebro-spinal fluid is increased, and often tinged with blood; the
ventricles are distended with fluid, which not rarely has an alcoholic
odor. Occasionally the ventricles contain blood, and hemorrhage into
the substance of the brain has been observed.
The condition of the elementary nervous tissues after death from acute
alcoholism is not yet known.
The lungs are deeply congested, with small extravasations of blood
into their substance, and often œdematous. Congestion of the liver,
spleen, and kidneys in varying degrees of intensity is also seen. The
pancreas is usually deeply injected, occasionally the seat of large
extravasations of blood. The mucous membrane of the stomach is
invariably deeply injected when the alcohol has been introduced into
the organism in the ordinary manner. The observation of Caspar that
post-mortem decomposition takes place with diminished rapidity has
been denied by Lancereaux and others.
Other post-mortem conditions appear to be neither constant nor
characteristic. The stomach usually contains partially digested food
and alcohol. Lallemand, Perrin, and Du Roy observed, both during life
and after death, in the blood of animals subjected to experiments,
great numbers of minute glistening points, which upon microscopic
examination proved to be fat-globules. The same condition has been
observed in man, not only when death has taken place owing to acute
alcoholism, but also when it has occurred during the digestion of a
hearty meal without alcohol. The blood itself is often fluid and
dark-colored; the heart sometimes empty, sometimes containing a few
soft clots. Tardieu[22] states that in sudden death during drunkenness
pulmonary apoplexy and meningeal apoplexy, if not constant lesions,
are at least extremely frequent, and almost characteristic. Baer, on
the other hand, denies the occurrence of specific or characteristic
lesions.
[Footnote 22: “Observationes médicales sur l'Etát d'Ivresse,” _Annales
d'Hygiene publique et de Médecine légale_, tome xl.]
_C_. ACUTE POISONING BY ALCOHOL IN LETHAL DOSES.—The symptoms are much
modified when overwhelming doses of strong alcohol are introduced into
the organism at once or in the course of a short time. Here alcohol
produces death as an acute poison. The cases may be arranged in two
groups:
1. _Corrosive Poisoning_.—These cases are very rare. They are caused
only by undiluted alcohol, and depend upon the action of this agent in
coagulating albumen and disorganizing the tissues with which it comes
in contact by its affinity for the water which they contain. Absolute
alcohol is a powerful corrosive poison. It produces intense
phlegmonous inflammation of the œsophagus and stomach, with erosion of
the mucous membrane, accompanied by vomiting, diarrhœa with bloody
stools, prostration, and stupor. Death occurs by heart-failure. Among
the direct effects of large doses somewhat less concentrated are acute
and subacute gastritis with characteristic symptoms.
{597} Percy[23] injected by means of an œsophageal tube 90 grammes of
absolute alcohol into the stomach of a dog. Death followed in the
course of eight hours in consequence of violent gastro-intestinal
inflammation with ulceration. Dujardin-Beaumetz and Andigie found the
gastric and intestinal mucous membrane of dogs poisoned by alcohol,
red, deeply injected, and “presenting at certain points a black
coloration due to effused blood.” This fact they regard as worthy of
note, because in their experiments the toxic agent was introduced, not
by the mouth, but hypodermically, and they explain it by the
supposition—which appears to me warrantable—that it is due to
elimination by the mucous glands. Hence the congestion, softening, and
hemorrhage.[24] These observers also found that the symptoms were more
acute and the lesions more marked when poisoning was caused by propyl,
butyl, or amyl alcohol than when it was produced by ethyl alcohol.
[Footnote 23: _An Experimental Inquiry concerning the Presence of
Alcohol in the Ventricles of the Brain after Poisoning by that Liquid,
together with Experiments illustrative of the Physiological Effects of
Alcohol_, London, 1839.]
[Footnote 24: Chatin and Gublier have emphasized the fact that certain
poisons introduced by intravenous injection or by absorption through
the respiratory tract are eliminated by the intestines, with the
production of the same local symptoms as when administered by the
mouth (_Bulletin de l'Académie de Médecine_, Séance du 6 Novembre,
1877).]
2. _Acute Narcotic Poisoning_.—Much more common are the cases in which
death is rapidly produced by excessive doses of ordinary diluted
alcohol taken at once or rapidly repeated. This happens under various
circumstances, as when a drunkard avails himself of some favorable
opportunity to gratify to the full a bestial appetite, or upon a wager
drinks a number of glasses of spirits in quick succession or a given
quantity down, or when a man already drunk is plied by his companions
for pure deviltry. Suicide by this means is, in the ordinary sense of
the term, rare, and murder still more so. The latter crime has, as a
rule, been committed upon infants and children. Blyth[25] estimates
the fatal dose of absolute alcohol, diluted in the form of ordinary
whiskey, gin, etc., at from one to two fluidounces for any child below
the age of ten or twelve years, and at from two and a half to five
ounces for an adult. In the instance recorded by Maschka[26] two
children, aged respectively nine and eight years, took partly by
persuasion, afterward by force, about one-eighth of a pint of spirits
of 67 per cent. strength—about 1.7 ounces of absolute alcohol. Both
vomited somewhat, then lay down. Stertorous breathing at once came on,
and they quickly died. Taylor relates a case in which a quantity of
brandy representing about two fluidounces of absolute alcohol produced
death in a child seven years old.
[Footnote 25: _Poisons, their Effects and Detection_, Am. ed., New
York, 1885.]
[Footnote 26: Cited by Blyth.]
The symptoms are uniformly the same. The period of excitement is
transient or absent altogether; occasionally the patient falls at once
to the ground while in the act of drinking or immediately thereafter;
complete coma, interrupted by shuddering convulsions, may terminate in
the course of a short time in death. If the fatal issue be delayed,
there are vomiting and involuntary discharges; the respiration becomes
slow, embarrassed, stertorous; the heart's action is feeble and
irregular, the pulse almost or wholly imperceptible; the temperature
rapidly falls several degrees: 90° F. has been observed. The pupils
are dilated; insensibility and muscular resolution are complete. The
face is bloated, cyanotic; the {598} surface bathed in a clammy sweat;
the mucous membrane of the mouth often swollen and blanched. Vomiting
is usual, but not constant, and there is occasionally thin mucous
diarrhœa, the stools being mixed with blood. If the patient survives
any considerable length of time, acute superficial gangrene of the
parts most exposed to pressure is liable to take place. Recovery is
rare; its possibility is, however, increased in proportion as the
subject is of vigorous constitution, previous sound health, beyond the
period of childhood, not yet approaching that of physiological
decadence, and as treatment is early instituted and carried out with
judgment.
The diagnosis is difficult, almost impossible, in the absence of
witnesses: it is rendered still more obscure by the fact that this, as
other forms of alcoholic coma, may be complicated by cerebral or
meningeal hemorrhage and by cerebral congestion, in themselves
fatal—lesions the onset of which may have been the cause of mental
aberration leading to the commission of impulsive alcoholic excesses.
The prognosis, in the highest degree unfavorable in all cases, is
rendered yet more so by the occurrence of intense cerebral and
pulmonary congestions.
The lesions found post-mortem are those of acute alcoholism, already
described. As this form of alcoholic poisoning frequently occurs in
the subjects of chronic alcoholism, the lesions of that condition are
often encountered, and must be distinguished from those due to the
lethal dose. Nor must we overlook the fact that in the action of
alcohol just described we have to do with a process differing from
ordinary acute alcoholism in degree rather than in kind—a
consideration which tends to simplify our notions of the pathology of
alcoholism in general.
II. Chronic Alcoholism.
The prolonged abuse of alcohol brings about a series of changes which
affect alike the organism at large and its various structures. The
changes thus brought to pass are of the most varied kind, and depend
upon individual differences too manifold and complex for enumeration
and classification. Among the more important of these individual
peculiarities are those which relate to temperament, constitution,
hereditary predisposition, occupation, social position, personal
habits, tendency to or already-existing disease of particular organs
and systems, and the like. The degree of the pathological change is
determined by the strength and quantity of alcohol consumed and the
duration of habitual excess. The human body is capable of adapting
itself to the habitual consumption of large quantities of alcohol,
just as to other directly acting agents of an injurious nature, such
as foul air, bad drinking-water, and unwholesome food, or even to the
action of substances dangerous to life, as opium or arsenic, and yet
presenting for a considerable time the appearance at least of health.
Degeneration of the tissues of the body and disorders of its functions
are nevertheless surely produced. These alterations are not the less
dangerous to health and life because they are insidious and remain for
a time latent. Furthermore, like the habit of which they are begotten,
they are progressive, and sooner or later declare themselves in open
disease.
{599} The condition, whether latent or manifest, that is produced by
prolonged habitual alcoholic excess is designated chronic
alcoholism.[27]
[Footnote 27: The writer, although fully aware of its imperfections,
regards the above definition of the term as more in accordance with
the present state of our knowledge of the subject, and therefore more
useful, than any other that he has been able to find. It is scarcely
necessary to repeat here that the restriction of the term chronic
alcoholism to accidental or occasional manifestations of a permanent
state is misleading and unscientific. The same criticism is applicable
to the attempt that has been made to establish this condition as a
substantive disease, chronic, progressive, and characterized
anatomically by inflammatory, sclerotic, and steatogenous processes.]
The symptoms of this condition, when fully established, differ within
wide ranges in kind and degree. They are the manifestations of
derangements of the viscera, of the nervous system, and of the mind.
Varying among themselves according as the stress of the pathological
action has fallen upon one organ or another, forming combinations at
once curious and inexplicable, developing quietly, without event,
almost imperceptibly at one time, breaking into the most furious
paroxysms at another, they present for our study perhaps the most
complex of chronic morbid conditions. The chronic alcoholism which is
latent is not, therefore, always without symptoms. They are, however,
often slight and escape observation, or when manifest they are not
infrequently ascribed to other causes; or, again, their etiological
relations being concealed or overlooked, they are exceedingly obscure
and puzzling. This is especially the case in the chronic alcoholism
produced by the secret tippling of otherwise respectable persons, and
especially women.
To facilitate description, we shall consider the derangements of the
viscera, the nervous system, and the mind in regular order, according
to the scheme on p. 574. But the reader will observe that whatever may
be the prominence of particular symptoms or groups of symptoms in any
given case, all parts of the organism are involved, and that there is
no such thing as chronic alcoholism restricted to any particular
viscus or group of viscera, to the nervous system, or to the mind.
_A_. VISCERAL DERANGEMENTS.—There is nothing specific in the lesions
of chronic alcoholism. The chronic hyperæmia, steatosis, and sclerosis
induced by alcoholic excesses differ in no respect from those
conditions brought about by other causes. That which is specific is
the evolution of a series of morbid changes in the different
structures of the body under the influence of a common and
continuously acting cause. The digestive system is affected, as a
rule, long before the vascular or the nervous system.
1. _Local Disorders_.—_a_. Disorders of the Digestive System.—The
Mouth and Throat.—The action of insufficiently diluted alcohol upon
the mucous tissues is that of an irritant. The habitual repetition of
this action causes subacute or chronic catarrhal inflammation. The
condition of the tongue varies with that of the stomach. The mouth in
acute alcoholism is apt to be pasty and foul, the tongue slightly
swollen and coated with a more or less thick yellow fur; there is
often also an increase of saliva; in chronic alcoholism the tongue is
usually small, sometimes red, sometimes pale, often smooth from
atrophy of the papillæ, not rarely deeply fissured. In a word, the
condition of this organ is that seen in the various forms of subacute
or chronic gastritis. The salivary secretion is often notably
diminished, the sense of taste impaired. Relaxation of the throat and
{600} uvula and granular pharyngitis are common. Those who, whilst
leading a sedentary life, are inclined to the pleasures of the table
and a free indulgence in spirituous liquors often suffer from these
affections. Mackenzie[28] states that the worst cases of chronic
catarrh of the throat generally arise from the habitual abuse of the
stronger forms of alcohol. The associated influence of tobacco in the
causation of this group of affections is not to be disregarded.
[Footnote 28: _Diseases of the Pharynx, Larynx, and Trachea_, 1880.]
Lancereaux encountered ulceration of the œsophagus, and Bergeret a
case of narrowing of that organ, in chronic alcoholism.[29]
[Footnote 29: Peeters regards it as probable that the
connective-tissue hyperplasia and resulting stenosis seen in the
stomach as a result of the action of alcohol may also occur in the
œsophagus.]
The Stomach.—In addition to functional dyspepsia, which is scarcely
ever absent in chronic alcoholism, all forms of gastritis, from simple
erythematous inflammation of the mucous membrane to sclerosis and
suppurative inflammation of the stomach, are encountered. Armor[30]
assigns to the habit of spirit-drinking, especially to the habit of
taking alcohol undiluted on an empty stomach, a high place among the
causes of indigestion. He regards this habit as a prominent factor in
the production of chronic gastric catarrh—a condition very frequently
present in indigestion. This observer also regards the excessive use
of alcohol as the most frequent among the direct exciting causes of
gastric inflammation in this country, exclusive of acid or corrosive
poisons. Next to errors in diet as a cause of chronic gastritis he
places the immoderate use of alcohol, especially by persons whose
general health and digestive powers are below a healthy standard. The
primary lesions are vascular dilatation and hyperæmia. The mucous
membrane is discolored, red or bluish, in scattered patches of varying
size, with occasional ecchymoses of a bluish hue or spots of
pigmentation. These patches occupy more commonly the region of the
cardia and the lesser curvature. Vascular injection is conspicuous;
the veins are dilated, tortuous; the mucous glands hypertrophied; the
surface covered with thick, ropy, acid-smelling mucus. After a time
permanent changes in the mucous membrane are set up. It undergoes
atrophy or softening; or, again, it becomes hardened, thickened, and
contracted, its rugæ more prominent, its surface mammilated—sclerosis.
Grayish-brown pigmentation, the remains of former
blood-extravasations, is seen at many points. Minute retention-cysts
are formed in consequence of the occlusion of the ducts of certain
glands. The submucous connective tissue and the muscular coat
occasionally undergo, in consequence of prolonged gastritis, local
hypertrophy.
[Footnote 30: See this _System of Medicine_, Vol. II. pp. 446, 464,
470.]
Acute suppurative inflammation of the stomach, with purulent
infiltration of, or the formation of abscesses in, the submucous
tissue, has been met with in drunkards. It is extremely rare, and
results from the violent irritant action of large doses of strong
alcohol in subjects debilitated by previous excesses.
Gastric ulcer is much more common. The abuse of alcohol is regarded as
an indirect cause of this lesion by the majority of writers. In the
present state of knowledge alcohol as usually taken can scarcely be
regarded as a direct cause of ulceration. Nevertheless, gastric ulcer
is relatively {601} common in alcoholic subjects. Leudet[31] found
gastric ulcer in 8 of 26 necropsies of drunkards. Baer and Lentz also
regard the abuse of alcohol as a very common cause of ulceration. The
ulcers are usually superficial, occupy by preference the neighborhood
of the cardia and the lesser curvature, and are apt to be multiple. In
these respects they differ from simple gastric ulcer. The latter
lesion is also probably as frequent, if indeed not more frequent, in
individuals dying of chronic alcoholism than in others.
[Footnote 31: _Clinique médicale de l'Hôtel Dieu à Rouen_, 1874.]
The view formerly entertained that alcohol was an important cause of
cancer of the stomach has been shown by Kubik, Magnus, Huss, Engel,
and others to be untenable. Carcinoma ventriculi is rarely associated
with chronic alcoholism.
The dimensions of the stomach are rarely normal. Dilatation is usually
present in the early stages, and in beer-drinkers throughout; in the
advanced course of alcoholism due to spirit-drinking the organ
undergoes, in consequence of changes secondary to prolonged
inflammation, more or less contraction, which is in many cases
irregular.
Dyspeptic symptoms are common: the appetite is variable, irregular,
and at length wholly lost. There is especially distaste for food in
the morning. This, together with the disordered state of the
secretions of the mouth and a feeling of nervous depression on rising,
leads to the disastrous habit of taking spirits early in the day.
Gastric digestion is performed with difficulty; it is accompanied by
sensations of distension and weight, by flatulence and acid
eructations. Heartburn is a common symptom. The drunkard is not rarely
tormented by an uneasy craving or sense of emptiness in the region of
the stomach, which he temporarily allays by nips and pick-me-ups and
morsels of highly-seasoned foods at odd times, with the result of
still further damage to his digestion and the complete loss of
appetite for wholesome food at regular hours. In the course of time
the characteristic morning sickness of drunkards is established. On
arising there is nausea, accompanied by vomiting—sometimes without
effort or pain, at others attended by distressing retching and
gagging. The matter vomited consists usually of viscid mucus, at first
transparent, then flaky, and at length, if the efforts be violent, of
a green or yellow color from the admixture of bile. These symptoms
ordinarily do not recur until the following day. In other cases
vomiting is more frequent, recurring at irregular periods during the
day, and not uncommonly an hour or two after the ingestion of food.
When gastric ulcer is present, portions of the vomited matter are
often dark and grumous like coffee-grounds or the settlings of
beef-tea, and are found upon microscopic examination to contain
blood-corpuscles. Actual hæmatemesis may also occur under these
circumstances, and be repeated from time to time. The quantity of
blood thrown up is frequently small; at times, however, it is
excessive, and occasionally so great as to cause death.
Common as are the evidences of gastric disturbance in chronic
alcoholism, they are far from being constant, and it is worthy of note
that in proportion to the number of the cases serious gastric
affections are, except in the later stages, relatively infrequent.