manifest in disorders of nutrition, have not yet been studied with
satisfactory results. In chronic alcoholism the proportion of water is
increased, while that of fibrin is diminished. After death the blood
remains fluid. The red globules are diminished in number. The blood
also contains free fat, to which it owes its pale, opalescent, and
sometimes almost milky hue. The presence of fat has been demonstrated
after the injection of alcohol into the veins of animals.
_b_. Obesity.—Fat-infiltration and fat-accumulation must be regarded
as among the most characteristic disturbances produced by alcohol. Fat
is abundantly stored up in the subcutaneous tissues. The anterior
abdominal wall is especially liable to its accumulation. The heart,
kidneys, omentum, and mesenteries are also not infrequently the seat
of abnormally large accumulations of fat. Fat also collects in the
muscles and in the intermuscular planes, but to a less extent. Obesity
is not, however, so frequent in the advanced stages of alcoholism as
it is while the subject {616} has not yet lost the appearance of
health, and in a large proportion of the individuals it does not
manifest itself at all. It appears to depend largely upon the
character of the drink, and is especially frequent among those
addicted to excesses in beer. It is less common among wine-drinkers,
and relatively infrequent and of moderate degree in those who confine
themselves to spirits. A sedentary life, and perhaps also an
hereditary tendency, exerts an important influence upon the
development of obesity in alcoholism.
_c_. Alcoholic Cachexia.—The action of alcohol in excessive amounts
upon the nutrition of the body at large, and in particular upon the
nutrition of the nervous system, is radically unfavorable. This
unfavorable influence manifests itself from the beginning, while the
subject yet presents the appearance of health, and long before the
occurrence of either the symptoms or physical signs of organic
disease. The powers of resistance to unfavorable influences of all
kinds are diminished; the ability to endure hardships, privations, and
fatigue is lessened; sickness and injuries are badly borne;
complications are frequent and grave; and convalescence is apt to be
tardy and insecure. It is among the more striking peculiarities of the
alcoholic subject that blood-losses are badly borne and slowly
repaired. It is this want of tone, often latent for a long time under
ordinary circumstances, which unfits those addicted to alcohol for
Arctic and exploring expeditions and for military and scientific
enterprises involving prolonged hardship and exposure. In the course
of time disorders of the digestion, of hæmatosis, of circulation,
increase the difficulty and render it more apparent. The fat now
rapidly diminishes; anæmia develops; the complexion becomes dull,
earthy, or slightly jaundiced, the tissues flabby. Then follow
diarrhœa, hemorrhages from mucous surfaces, serous effusions, visceral
congestions of high degree, hypostasis, œdema, and progressive
deterioration of all the powers alike of the body and the mind until
the dyscrasia is complete.
The subjects of chronic alcoholism are especially prone to affections
of the respiratory tract and to the infectious diseases. They furnish,
as a rule, the earliest victims in epidemics. They not rarely die of
pneumonia. They develop troublesome delirium in simple maladies, and
in all acute affections the prognosis is unfavorable as compared with
that in persons of sober habits. As Clouston well says, “The whole
organism suffers sanative and mental lowering, alteration of functions
and of energizing.”
_B_. DERANGEMENTS OF THE NERVOUS SYSTEM: CEREBRO-SPINAL DISORDERS.—The
disorders of the central nervous system in chronic alcoholism are even
more numerous and more important than those already described. Many
transient and permanent disturbances of function occur without
anatomical lesions recognizable by existing methods of examination;
many others are associated with readily-discoverable changes of
structure. These changes are encountered in the blood-vessels, the
meninges, the substance of the cerebro-spinal axis, and in the
peripheral nerves. Much as they differ in appearance and in their
clinical manifestations, they may all be referred to three processes:
(_a_) congestion and inflammation; (_b_) sclerosis; and (_c_)
stentosis.
1. _Cerebral Disorders_.—The Cranium.—The bones of the skull are often
thicker and more dense than normal. This change implicates the {617}
diploë and the outer and inner tables. The last is then deeply
channelled for the blood-vessels and deeply indented for the
Pacchionian bodies, which are commonly hypertrophied.
The Vessels.—Disturbances of the cerebral circulation are among the
earliest and most important symptoms. Due primarily to the increased
action of the heart and vaso-motor dilatation of the blood-vessels
excited by repeated large amounts of alcohol, and secondarily to
permanent enlargement of the vessels in consequence of fatty or
atheromatous degeneration of their walls, some degree of active or
passive congestion is almost always present. It is probable also that
in consequence of irregular and complex disturbances of the
circulation secondary localized ischæmia occurs. Lentz states that
anæmia is more common in the cerebral substance than in the membranes.
The capillaries are usually much altered—sometimes uniformly dilated
to a considerable extent, sometimes forming capillary aneurisms. They
are more sinuous than normal, their walls show evidences of fatty
degeneration, and they sometimes contain minute thrombi. Extravasated
blood, in the form of circumscribed collections, of diffuse layers, or
finally of capillary hemorrhages, also occurs. These collections are
sometimes free, sometimes encysted.
The Meninges.—The dura mater is congested; occasionally it shows more
or less extensive areas of inflammation with exudation of lymph.
Purulent exudation in the absence of traumatism is rare. The lymph may
be deposited in the form of patches of varying extent, or it may form
more or less extensive false membranes. These accumulations are of
variable, often considerable, thickness, and constitute the condition
described as pachymeningitis hæmorrhagica interna, or, from the large
amount of blood which they contain, hæmatoma of the cerebral meninges.
They occupy the convexity of the brain, and are developed upon the
inner surface of the dura; they are usually nearly symmetrical in
outline, but of different thickness upon the two sides. They consist
of superimposed layers of lymph, between which, or within the
substance of which, are more or less extensive blood-extravasations,
either fluid, coagulated, or undergoing resorption. More frequently
the exudation consists of mere shreds of lymph within the cavity of
the arachnoid.
The arachnoid is almost invariably altered. Upon the convex surface of
the hemispheres, especially along the median fissure, it is thickened
and opaque. This condition may be uniform or distributed in patches,
and is apt to follow the line of the blood-vessels.
The pia mater is congested, often œdematous, not rarely the seat of
blood-effusions of greater or less extent.
The cerebro-spinal fluid is usually more abundant than normal, of a
deeper color, cloudy, sometimes tinged with the coloring matter of the
blood.
The Brain.—The intimate lesions of the substance of the brain are not
yet known. The volume of the encephalon, as a rule, undergoes no
change. Occasionally it appears to be swollen, and protrudes with some
degree of force through the incision first made in the membranes. More
commonly, the brain is throughout or in certain parts atrophied or
shrivelled, its convolutions flattened, its surface retracted. This is
sometimes the result of the pressure of collections of hemorrhagic or
inflammatory products.
{618} The consistence of the cerebral mass is sometimes increased; it
becomes harder, more resistant to pressure, and preserves its form
when removed from the cranium better than the normal brain. This
condition may be present throughout the brain or it may be localized.
In the latter case it is usually due to patches of sclerosis.
Softening in more or less extensive areas may occur in the advanced
stages of the more severe forms of chronic alcoholism. It is found
chiefly in the gray substance, where the vessels are more numerous,
especially in the cortex and central ganglia. In this as in other
affections cerebral softening is the result of obstruction of the
circulation in consequence of atheroma, thrombosis, or other change in
the arteries. It varies from simple diminution in consistency to
diffluence.
The nervous substance of the brain doubtless undergoes changes
proportionate to the degree and duration of its exposure to an
alcohol-charged blood. What these changes are has not yet been fully
determined. The nerve-cells of the cortex have been found rounded and
contracted, so that instead of being surrounded by a small lymph-space
they seem to be lying in large cavities, and so granular that the
nucleus can hardly be made out. Slight increase in the number of the
small round cells in the cortex and in the adjoining parts of the
white matter has also been observed (Hun). These changes are not,
however, constant. Not only has the microscopical morbid anatomy of
the lesions of nerve-substance peculiar to chronic alcoholism not yet
been worked out, but even macroscopic changes adequate to account for
symptoms that were during life serious, persistent, and apparently
referable to well-defined lesions, are sometimes absent altogether.
It is important to distinguish the disorders due to the direct action
of alcohol, which are often functional or dependent upon lesions too
subtle for recognition, from those which are secondary and dependent
for the most part upon coarser changes of structure.
In consequence of hyperæmia of the brain and its membranes there not
infrequently occur a sense of confusion or dulness, increasing to
headache, which may become almost unbearable, mental disturbances of
the most varied character, disorders of movement and sensation, and
disorders of the special senses.
Cerebral hemorrhage, to which the subjects of chronic alcoholism are,
in consequence of the vascular lesions already described, peculiarly
prone, manifests itself by the usual primary and secondary phenomena.
Meningeal hemorrhage, save in the form of hæmatoma, is rare except in
the advanced stages of paretic dementia.
The blood in alcoholic dyscrasia undergoes changes which favor its
transudation through the walls of the vessels; hence a tendency to
œdema and to accumulations in serous sacs. This tendency implicates
the structures of the nervous system in common with the organism at
large. The ventricles of the brain become distended with fluid, and
the brain-substance itself and the meninges not rarely become
œdematous in the last stage of chronic alcoholism, in consequence of
grave disturbances of the circulation or as complications of
affections of the lungs, heart, or kidneys. These conditions are
attended by mental obscuration, somnolence alternating with
sleeplessness, delirium, maniacal paroxysms, impairment {619} of
muscular power, of general and special sensibility, impaired reflexes,
inability to speak, deepening stupor, and death.
2. _Spinal Disorders_.—Lesions of the spinal cord or its membranes
have been rarely discovered. When present they have been invariably
associated with similar or corresponding lesions of the brain or its
envelopes. Leyden[39] states that not only do the cerebral meninges
present inflammatory changes in chronic alcoholism, but the meninges
of the cord are sometimes found in an analogous condition; that
pachymeningitis hæmorrhagica interna spinalis has also been observed,
as well as other forms of spinal meningitis, with thickening and
discoloration of the pia and dura; and that œdema of the pia has been
especially noted. While anatomical lesions of the cord are less
frequent than lesions of the brain, nutritive and functional
disturbances, as manifested in the general symptomatology, are quite
as common in one as in the other.
[Footnote 39: _Klinik des Rückenmarkskrankheiten_.]
3. _Disorders of the Peripheral Nerves_.—Magnus Huss found no change
in the peripheral nerves in five cases in which they were carefully
examined. Lancereaux discovered degenerative changes in the peripheral
filaments in alcoholic paralysis. Leudet found hypertrophy of the
neurilemma and alterations in the cubital nerve in an individual
suffering from chronic alcoholism in whom this nerve was paralyzed.
Dejerine[40] observed in two fatal cases of alcoholic paralysis
neuritis of peripheral nerves with integrity of the nerve-roots, the
spinal ganglia, and the cord. In one of Dreschfeld's cases of
alcoholic paralysis,[41] in which the cord was found perfectly normal,
the “sciatic appeared thin and grayish, and was surrounded by a great
deal of adipose tissue. Vertical sections showed, when treated with
perosmic acid and stained afterward with picro-carmine, a moniliform
appearance of the nerve-tubes, due to breaking up of the myelin; the
nuclei were increased, and there was also some interstitial
cell-infiltration. Transverse sections showed in some few places an
increase in the diameter of the axis-cylinder, and again the
interstitial infiltration.”
[Footnote 40: _Archives de Physiologie nerv. et patholog._, No. 2,
1884.]
[Footnote 41: _Brain_, Jan., 1886.]
Disorders of General Sensibility.—Disorders of general sensibility are
among the earliest of the nervous phenomena of chronic alcoholism.
They occur in the following order: hyperæsthesia, dysæsthesia, and
anæsthesia. Disturbances of sensibility manifest themselves, quite
independently of hallucinations, as sensations of malaise, of
discomfort, of chilliness, of cramps, or of abnormal warmth or cold.
Sometimes they amount merely to momentary discomfort, at other times
to extreme pain. They are usually limited, often to the feet and legs,
sometimes to the hands and arms; again, they are experienced in the
trunk, and especially in the back. They are most common during the
evening; less frequently they are induced by the warmth of the bed;
and, again, they are experienced on rising. They are apt to be
associated with occipital or frontal headache.
Among the most frequent nervous phenomena of chronic alcoholism are
disturbances of sleep. Sleep is light, uneasy, and disturbed,
difficult to obtain, troubled with dreams, and unrefreshing. More or
less complete insomnia is by no means rare. It is more apt to occur,
however, after acute exacerbations of alcoholism than in the ordinary
chronic condition.
{620} Hyperæsthesia manifests itself as an increased sensibility to
pain, to mere contact, to temperature, and in an exaggeration of the
muscular sense. Two general forms may be distinguished—the superficial
and deep. The former usually manifests itself by an exaggerated
sensibility of the skin, especially along the course of the
superficial nerves and at their points of emergence from the deeper
structures. The latter consists in a more or less intense sensation of
pain, often diffuse, sometimes almost unbearable, and associated with
a sensation of heat or cold, which is most commonly experienced in the
lower extremities. It is often referred by the patient to the deeper
muscles or to the bones and joints, and is increased by movement or
pressure.
Anæsthesia is a much more common occurrence. It is usually developed
during the later period of chronic alcoholism, and may implicate the
skin, the mucous tissues, or the deeper structures. It presents all
degrees from mere impairment to absolute loss of sensation. In the
latter case, contact, pain, temperature, and electrical stimulation
equally fail to excite sensation. In the deep anæsthesia of alcoholism
pressure and electro-muscular sensibility are alike impaired. The
muscular sense is also enfeebled or abolished. The regions which are
the seat of anæsthesia are, as a rule, of a lower temperature than
those in which sensation is normal. The anæsthesia may extend to the
conjunctiva, and even to the cornea and to the mucous membrane of the
mouth and throat. It has also been observed in the mucous membrane of
the genitalia and at the verge of the anus.
Disorders of Motion.—Disorders of motion consist of tremor, subsultus,
spasm, convulsions, muscular paresis, and palsies. Tremor is a very
frequent phenomenon in chronic alcoholism. It consists generally of a
series of rapid rhythmical movements. Sometimes the extent of the
movement is increased and their rhythm irregular. They are then
choreiform. The tremor may be continuous; much more frequently it only
appears in the morning. The subject has then some difficulty in
dressing himself, particularly in buttoning his clothing, in shaving
himself, and in raising a cup to his lips. This symptom commonly
ceases after the ingestion of a certain quantity of alcohol, only to
return on the following morning or after a considerable period of
abstinence. Voluntary movements intensify the tremor. It most commonly
affects the upper extremities, next in frequency the muscles of the
face, and finally the lower extremities. In rare cases it affects the
muscles of the whole body. Alcoholic tremor affecting the hands and
arms renders the subject awkward and interferes with his ability to
work; affecting the lower extremities, it gives rise to an
embarrassing, irregular gait; affecting the lips and tongue, it
produces hesitation of speech or stammering, and when it is of a high
degree articulation may be so imperfect that conversation is
impossible; affecting the muscles of the eyes, it gives rise to
nystagmus. Tremor is not infrequently associated with subsultus
tendinum, spasmodic contractions, and cramps. These phenomena are
usually localized, and affect by preference the muscles of the face
and those of the lower extremities.
Loss of muscular power, which may pass, little by little, into
complete palsy, also occurs. It is, however, neither constant nor
proportionate to the gravity of the case in other respects. Whilst, as
a rule, it is developed insidiously, it occasionally shows itself with
suddenness. In the latter {621} case it is usually preceded by some
acute complication, and may disappear as quickly as it came. At first
it is a mere feebleness, which, beginning in the fingers, extends to
the hands and arms. It may after a time manifest itself in the feet.
More or less muscular paresis is invariably associated with the tremor
above described.
Alcoholic Paralysis.—The earliest account of alcoholic paralysis is
that of James Jackson,[42] who designated the disease, from its most
prominent symptom, arthrodynia. He attributes it to ardent spirits,
and chiefly observed it among women. “This arthrodynia comes on
gradually. It commences with pain in the lower limbs, and especially
in the feet, and afterward extends to the hands and arms. The hands
may be affected first in some instances, but in all cases in the
advanced stage of the disease the pain is more severe in the feet and
hands than in the upper limbs. The pain is excruciating, and varies in
degree at different times. It is accompanied by a distressing feeling
of numbness. After the disease has continued a short time there take
place some contraction of the fingers and toes and inability to use
these parts freely. At length the hands and feet become nearly
useless. The flexor muscles manifest, as in other diseases, greater
power than the extensors, and the whole body diminishes in size,
unless it be the abdomen; but the face does not exhibit the appearance
of emaciation common to many visceral diseases. The diminution is
especially observable in the feet and hands. At some time the skin of
these parts acquires a peculiar appearance. The same appearance is
noticed in a slighter degree in the skin of other parts. This
appearance consists in great smoothness and shining, with a sort of
fineness of the skin. The integument looks as if tight and stretched,
without rugæ or wrinkles—somewhat as when adjacent parts are swollen.
The skin is not discolored. In this disease there is not any effusion
under the skin, and the character which it assumes arises from some
change in the organ itself.”
[Footnote 42: _New England Journal of Medicine and Surgery_, vol. xi.,
1822, “On a Peculiar Disease resulting from the Use of Ardent
Spirits.”]
Since Jackson's day, Huss, Lancereaux, Leudet, and others have
described various forms of paralysis due to alcohol. Wilks[43] under
the term alcoholic paraplegia described a form of alcoholic paralysis
of which he had seen numerous cases, especially in women addicted to
alcoholic excesses. The symptoms are severe pain in the limbs,
especially the lower ones, with wasting, numbness, anæsthesia, only
slight power of movement or total inability to stand. The symptoms are
not unlike those of ataxia. Wilks regarded the disease as due to
degeneration of the cord and thickening of the membranes. Several of
the cases terminated in recovery in a comparatively short time after
the abrupt and complete withdrawal of alcohol. Since that time a
number of cases have been reported by various observers.[44]
[Footnote 43: _Lancet_, 1872, vol. i. p. 320.]
[Footnote 44: See, in particular, Hun, _American Journal of the
Medical Sciences_, April, 1885, “Alcoholic Paralysis.” This paper
contains a valuable résumé of the reported cases up to that time.
Consult also Dreschfeld, _Brain_, July, 1884, and January, 1886.]
Hun concludes that alcoholic paralysis may be regarded as a special
form of disease with the following symptoms: “Neuralgic pains and
paræsthesiæ of the legs, gradually extending to the upper extremities,
and accompanied at first by hyperæsthesia, later by anæsthesia, and
{622} in severe cases by retardation of the conduction of pain. Along
with these symptoms appears muscular weakness, which steadily
increases to an extreme degree of paralysis, and is accompanied by
rapid atrophy and great sensibility of the muscles to pressure and to
passive motion. Both the sensory and motor disturbances are
symmetrically distributed. The paralysis attacks especially the
extensor muscles. In addition to these motor and sensory symptoms,
there is also a decided degree of ataxia. The tendon reflexes are
abolished, and vaso-motor symptoms, as œdema, congestion, etc., are
usually present. Symptoms of mental disturbance are always present in
the form of loss of memory or transient delirium.”
Lesions of the cord are absent, but degenerative processes in the
peripheral nerves have been discovered in a number of cases. The
symptoms are those of multiple neuritis, and the essential lesions
consist in degenerative changes in the peripheral nerve-fibres. The
associated mental derangement, tremor, and ataxia have been ascribed
to changes in the cerebral cortex.
Dreschfeld has divided the cases, according to the more prominent
symptoms, into two clinical groups—alcoholic ataxia and alcoholic
paralysis.
The ataxic form represents a milder type. The symptoms are lancinating
and shooting pains in the lower extremities, sometimes in the upper,
with areas of anæsthesia and retarded sensibility. The muscles are
painful upon pressure, and atrophy may be moderate or absent
altogether. Inco-ordination is marked. The tendon reflexes are absent.
Shooting pains down the legs to the toes of a paroxysmal character,
and followed by a sense of numbness, also occur. Eye symptoms are
wanting.