chiefly the extensors of the fingers and toes. The paralysis and
atrophy in some cases come on acutely, in others more slowly. When the
patients come under observation they are usually unable to stand or
walk, and it is therefore not easy to make out whether or not the
paralytic stage has been preceded by a stage of ataxia. As the sensory
phenomena in these cases are the same as in the first group, it is
probable that pseudo-ataxic symptoms have preceded the slowly oncoming
paralysis. Paralysis and atrophy of the extensors of the fingers and
toes, with paresis of the other muscles, are associated with the
sensory phenomena above described. Tendon reflexes are absent; the
superficial reflexes are much diminished. Recovery takes place in a
considerable proportion of the cases upon the withdrawal of alcohol.
The atrophy and paralysis pass away altogether, the tendon reflexes
are restored, and the disturbances of sensation disappear. In the
greater number of these cases persistent delusions are present.
Lancereaux[45] describes alcoholic paralysis as symmetrical, affecting
either the upper or lower extremities and gradually extending toward
the trunk. The lower extremities are invariably more affected than the
upper, and the extensor than the flexor muscles. There is diminished
reaction to electricity, and anæsthesia is present. The brain and
spinal cord are normal, but the peripheral nerves show extensive
degenerative changes.
[Footnote 45: _Gazette des Hôpitaux_, No. 46, 1883.]
4. _Disorders of the Special Senses_.—_a_. The Sight.—Disorders of
vision {623} are among the most frequent and the earliest symptoms of
chronic alcoholism. Phosphenes, scintillations, sensations of
dazzling, muscæ volitantes, and streams of light are often complained
of. These phenomena may be constant or transient. Diplopia and other
visual disturbances of the most irregular and annoying character also
occur. Sometimes there is dyschromatopsia; the colors are confounded:
red appears brown or black, and green appears gray, etc. In the more
advanced stages amblyopia may occur. The acuity of vision rapidly
diminishes, sometimes to the point that the patient with difficulty
distinguishes the largest print. Objects appear as seen through a fog,
and their outlines are distinguished only after repeated and close
effort. Again, blindness almost absolute occurs for the course of some
minutes—passes away rapidly, only to return again at intervals. Not
infrequently the sight is better in the morning and evening than
during the day. Achromatopsia, characterized by enfeeblement, and not
infrequently by the momentary loss of the power to recognize colors,
and particularly the secondary tints, also occurs. Cases of Daltonism
occasionally seem to depend, to some extent at least, upon alcoholic
disturbances of vision. Impairment of the power to distinguish colors
must not, however, be confounded with the difficulty experienced by
many alcoholic subjects in recognizing different colors successively
presented to the eye with some degree of rapidity. Such individuals
are able to distinguish colors when sufficient time is permitted them.
Their difficulty depends upon tardiness of perception, such as is
often experienced by neurasthenic subjects in recognizing faces in a
crowd, rather than upon any failure in the power of recognizing
colors. As a rule, the disorders of vision are not permanent, at least
in the beginning. Later, they are of longer duration, and alcoholic
amblyopia occasionally degenerates into irremediable amaurosis.
Ophthalmoscopic examination reveals at first no appreciable lesion,
and the disturbance of circulation, venous stasis, and peri-papillary
infiltration thus observed appear to be inadequate to explain the
visual disturbance. Atrophy of the optic nerve occasionally occurs as
a direct result of alcoholism. Nystagmus has been frequently observed.
The state of the pupils is variable and without constant relation to
the acuity of vision. The pupils are not infrequently uniformly
dilated, contracting slowly under the influence of light. More rarely
they are permanently contracted; occasionally they are unequal. These
modifications are often without demonstrable relation to anatomical
lesions.[46]
[Footnote 46: Vide this _System of Medicine_, Vol. IV. p. 803.]
_b_. The Hearing.—The disturbances of hearing encountered in chronic
alcoholism are in many respects analogous to those of sight. Patients
complain of curious subjective sensations, which are described as
humming or whistling sounds, the ringing of bells, music, or the
murmur of a crowd. At times the sense of hearing is so exquisite that
the least noise causes pain. On the other hand, hearing may be greatly
impaired, diminishing by degrees until it becomes in some cases,
without recognizable lesion, almost or completely lost.
_c_. The Taste.—As a rule, the sense of taste is impaired in chronic
alcoholism; occasionally it is wholly lost.
_d_. The Smell.—The sense of smell is in most cases to some extent,
and in many cases greatly, impaired, the most powerful odors being
scarcely perceived by old topers.
{624} Alcoholic Epilepsy.—Alcohol, and especially that combination of
alcohol with oil of wormwood and aromatics known as absinthe, is
capable of producing convulsive seizures resembling epilepsy. Certain
forms of alcoholic convulsions can scarcely be distinguished from
ordinary epilepsy. Acute alcoholism may be an exciting cause of the
convulsive seizures in an epileptic. Alcoholic epilepsy is, however,
peculiar to chronic alcoholism, and particularly in individuals in
whom there is an hereditary tendency to nervous disorders. Once
established, alcoholic epilepsy may continue even after the alcoholic
habit has been discontinued. The attack is usually followed by marked
mental disturbances. These vary from profound dulness to stupor or
mania; they last from some hours to several days, and present the
characters of similar conditions following non-alcoholic epileptic
paroxysms.
_C_. PSYCHICAL DERANGEMENTS.—Yet more important than the visceral and
nervous lesions of chronic alcoholism are the indications which it
affords of a progressive debasing influence upon the mind. The moral
sense, the will, and the intellect are involved successively in a
process of deterioration, which, manifesting itself only in part and
by little at first, becomes after a time general and plain to all the
world, and ends at length in ruin more complete and more hopeless than
that of the body. Indeed, it not infrequently happens that while the
general health appears to be good and the nervous system, save in
transient disturbances of function, presents no evidence of the toxic
action of alcohol upon its tissues, serious psychical disorders are
established. The alcoholic subject develops propensities, otherwise
latent, that tend to refer him to the criminal or the insane classes
of society. The psychical debasement, of which these propensities are
the outcome, is, like the alcohol habit itself, progressive. This fact
cannot be too strongly insisted upon. Like the loss of vascular tone,
the sclerosis, the steatosis which alcohol induces in the body, this
mental deterioration is cumulative and destructive. It is to its
psychical manifestations that alcoholism owes its chief importance,
not only as a study in pathology, but also as a problem of the gravest
moment in social science.
1. _The Moral Sense_.—Deterioration of the sense of moral obligation
is among the earlier of the mental phenomena of alcoholism. The moral
sense is perverted and enfeebled. Sentiments of honor, of dignity, of
reputation, and of decency are no longer cherished or regarded. The
amenities of social life and the proprieties of personal conduct are
disregarded or set at naught. He who was punctilious, considerate, and
thoughtful becomes negligent, selfish, and indifferent to sentiments
of honor and emulation; he gives himself up to indulgences formerly
considered unworthy; his reputation and that of his family are no
longer matters of concern to him; respect for public opinion is
replaced by cynicism. Little by little the conception of duty, of
justice, of honor are lost to him, or if he regards them at all it is
rather as subjects for idle and purposeless discussion than as motives
to regulate his life. These changes are gradual and progressive, their
evolution being largely influenced by the hereditary traits and
previous moral culture of the individual. The deterioration of the
sense of right, and the coincident exaltation of those passions which
are normally under its control, lead to the commission of the crimes
peculiar to the early period of alcoholism. {625} Indifference is
another characteristic of this period—indifference not incompatible
with a selfishness of the most intense kind. The sense of obligation
to the family is forgotten, and the responsibility of providing for
and caring for others is unfelt. If the drunkard's own wants, and
especially his craving for drink, are gratified, the necessities of
those formerly dear fail to move him. The affections are not only
enfeebled, but they are also perverted; not rarely they are replaced
by aversion, disdain, and hatred. The individual who has been calm,
reasonable, and patient becomes excitable, perverse, and intolerable
of contradiction or opposition. Prone to acts of sudden violence, he
becomes gloomy, taciturn, and preoccupied. He is disturbed by fixed
tormenting ideas or by vague pursuing terrors. He thus becomes
self-conscious, irritable, fault-finding, and easily provoked to
passion. The character, after a time, undergoes still more decided
change: alternations of indifference and irritability characterize his
varying moods. After a time the joys and the sorrows of life alike
fail to provoke real feeling. At length the confirmed sot manifests
moral traits that are simply infantile; he laughs without motive, he
weeps without cause.
2. _The Will_.—At the same time the will undergoes an enfeeblement
even more marked. Except in paroxysms of transient excitement it is
feeble and uncertain. The subject of chronic alcoholism scarcely knows
his own mind under ordinary circumstances. Aware of his duties and his
obligations, he is unable to discharge them. Especially does he lack
the power to say No. Vacillation, indecision, and dependence upon
others become characteristic traits. This loss of moral energy,
combined with the loss of physical power brought about by continued
and repeated excesses, begets at once a distaste for the ordinary
occupations of life and an inability to perform them.
3. _The Intellect_.—Loss of intellectual power comes last. In some
cases it shows itself only after the most prolonged excesses, when the
body itself is becoming thoroughly broken down. Exceptionally, fitful
intellectual power is curiously sustained to the last. The first
evidence of intellectual failure consists in diminution of vivacity
and readiness. The intellectual state is marked by apathy, obtuseness,
and indifference; mental processes are performed slowly and with
difficulty. This is perhaps one of the causes of the mental indolence
characteristic of alcoholism. After a time the drunkard becomes timid,
loses confidence in himself, and is unwilling to engage in enterprises
demanding mental effort. Some tardiness of appreciation then shows
itself; conversation becomes difficult; ideas are not spontaneous, but
must be sought for; replies are not made with the usual promptness; it
is difficult to arouse and fix the attention. The sense of
self-respect is now lost, and it is almost impossible to make the
subject comprehend his degradation. The intellectual deterioration
becomes more and more marked. The memory fails little by little and
becomes treacherous. Names and dates are recalled with difficulty. The
conversation is interrupted by an inability to choose the proper words
with precision, hence hesitancy, interruptions, and various forms of
circumlocution. The power of argument and of reasoning is now much
impaired, the judgment is uncertain, the association of ideas is
inexact, and at length the intellectual degradation attains a degree
that unfits the subject for the ordinary relations of life.
{626} The above-described derangements of the viscera, of the nervous
system, and of the mind are the morbid phenomena induced by
long-continued excesses in alcohol. Whether merely functional or
dependent upon recognizable anatomical lesions, they indicate
pathological changes in the organism which are radical, and which
under the influence of the continuously acting cause are progressive.
Taken together, they constitute the condition known as chronic
alcoholism. In view of the familiar experiences of every-day life, it
is hardly necessary to repeat that these derangements are manifested
in all degrees of intensity and in the most variable and complex
combinations. The specific nature of chronic alcoholism is, in truth,
due not to the derangements themselves, the greater number of which
are such as we may encounter in morbid states not occasioned by
alcoholic excesses, but to the combinations in which they occur in
consequence of the action of the specific cause upon the organism as a
whole. The prominence of particular symptoms or groups of symptoms in
any given case is to be accounted for largely, if not wholly, by
individual peculiarities.
Chronic alcoholism, however latent it may be, however sedulously
concealed, warps the life of the individual in all its relations. In
its advanced degrees it amounts to mental and physical dyscrasia.
Between these extremes is every grade of incapacity and degradation.
It is beyond the scope of this article to discuss the moral, social,
or medico-legal bearings of this condition. Its purely medical
relations are sufficiently obvious from what has gone before. It has
been the writer's aim to make clear the existence and nature of the
continuing condition.
It remains to describe certain other psychical disturbances which
occur in chronic alcoholism, and which require separate consideration
for the reason that they are accidental rather than essential, many
cases running their course without their manifestation.
4. _Alcoholic Delirium in General_.—True alcoholic delirium,
presenting the traits about to be described, is never the result of
the direct primary action of alcohol upon the nervous system.
Transient excesses produce acute alcoholism, drunkenness, which,
varied as its manifestations are, differs essentially from that
peculiar delirium which occurs only in individuals in whom the nervous
system has undergone those nutritive changes that are brought about by
prolonged alcoholic saturation.
The most striking peculiarity of this delirium relates to the
hallucinations which attend it. These are almost invariably visual;
occasionally they are also auditory. Their objects, whether men,
animals, or things are in constant and unceasing motion, appearing and
disappearing, coming and going, and changing from place to place with
extreme rapidity. In this respect they differ from the hallucinations
of other forms of delirium, of which the objects are fixed and more or
less permanent. As a result of this peculiarity, the objects of
alcoholic delirium are almost invariably multitudinous, as swarms of
vermin, herds of animals, multitudes of demons, and the like.
A second peculiarity is the restlessness of the delirium. The patient
is invariably uneasy, apprehensive, always on the alert, declaring
that some calamity threatens him or that some evil is about to befall
him. In consequence of these apprehensions even momentary repose is
wanting. If he lies down for a moment, it is only to rise again and
peer under the bed {627} or into the corners, turning his head from
side to side in search of some realization of the fears that torment
him. This sense of apprehension impels the patient to hurry ever
onward from place to place in search of the repose which he nowhere
finds. It is increased to positive terror by the ever-varying and
constantly-renewed hallucinations which torment him, and from which he
seeks to escape, no matter how great the obstacles to be overcome.
A third peculiarity of alcoholic delirium is insomnia. This condition
is of the must marked and stubborn character, even continuing for
several days in succession.
5. _Delirium Tremens_.—This is the characteristic form of alcoholic
delirium, and, as is indicated by the name, is invariably accompanied
by tremor. It must be looked upon as an episode or epiphenomenon of
chronic alcoholism. It is rare that even prolonged temporary excesses
in persons ordinarily sober are followed by delirium tremens. Such
excesses in the subjects of chronic alcoholism are, however, perhaps
the most common cause of this condition. Orgies, especially when
associated with venereal excesses, very frequently terminate in
delirium tremens. Occasionally also, but much less frequently than was
formerly supposed, the abrupt discontinuance of alcohol is followed by
the outbreak. Other exciting causes are violent emotions, as anger or
fright; hardships, such as prolonged hunger, over-exertion, or
watching; acute maladies, as pneumonia, dysentery, erysipelas, the
exanthemata, or rheumatism; finally, serious traumatisms, with or
without great loss of blood. Delirium tremens usually occurs in those
addicted to the abuse of spirits, less frequently in beer-drinkers,
and comparatively rarely in those whose excesses have been restricted
to wine. The attack does not, as a rule, begin abruptly; its prodromes
usually consist in an exaggeration of the previously existing symptoms
of chronic alcoholism. The patient complains of malaise, restlessness;
he becomes depressed, morose, anxious without cause, apprehensive of
some calamity, or he is more impatient and choleric than before. The
ability to apply himself to his ordinary occupations is lost. He
complains of vertigo, ringing in the ears; sleep is disturbed, or
there is already insomnia. At the same time the stomach is deranged,
appetite is lost, the tongue is covered with a thick yellowish-white
fur, and there is constipation or diarrhœa. The period of prodromes
may last from a few days to a week.
The outbreak is characterized by delirium, without, at least in the
greater number of cases, absolute loss of consciousness. That is to
say, it is possible by addressing the patient with energy or by
strongly arousing his attention to interrupt the delirium and for a
moment recall the patient to himself. In the graver cases, however,
loss of consciousness appears to be complete. The subjective
impression of the delirium, as recollected at the termination of the
attack, is that of a sense of overwhelming confusion and inability to
recollect or co-ordinate the ideas that were crowding upon the brain.
The hallucinations, as has already been indicated, relate almost
exclusively to the organ of sight, more rarely to the hearing; also,
and exceptionally, to the other organs of sense. They are almost
always either terrifying or repugnant. The objects of the
hallucinations of the sight have already been described. They consist
of animals, serpents, and monsters, which crowd into the apartment,
coming {628} usually toward the patient, disappearing in the walls, in
the floor, under the bed, or among the bed-clothing. These visions are
usually aggressive, threatening the patient, throwing themselves upon
him, striking him, or tearing at his vitals. They are sometimes
replaced by phantoms, spectres of the most horrible character,
skeletons, death's-heads, or by flames which surround the patient and
threaten to consume him. Sometimes the hallucinations relate to the
daily occupation of the patient, and he pursues his tasks with a
feverish and distressing anxiety. These hallucinations are almost
invariably of the most fleeting, incoherent, and variable kind.
Auditory hallucinations occur usually in individuals of marked
neurotic tendencies. They are apt to be more coherent than the
hallucinations of vision, and are often of the nature of those which
occur in the delirium of persecution. Sometimes they consist of cries,
of chiding, of menacing voices, of the repetitions of obscene words
and suggestions; sometimes they are cries of horror or the roars of
animals, sometimes explosions or the discharge of firearms; or, again,
they are terrifying threats. Hallucinations of taste and smell are
much more rare, and occur in the subacute forms of delirium tremens.
The patient complains of annoying odors or disagreeable tastes, either
constantly present or upon the taking of food or drink. Disturbances
of general sensibility show themselves in hallucinations in regard to
sensations of pricking, burning, or tearing of the surface of the
body, or of animals or vermin crawling over the patient.
Hallucinations relating to the sexual instinct are far from rare. The
hallucinations of every form are apt to be more frequent and more
troublesome during the night than during the day.
Restlessness, fear, and anxiety are characteristic phenomena of
delirium tremens. The patient is not only terrified by the imaginary
objects which surround him, but often in their temporary absence he
experiences an equal degree of fear for which he can assign no cause.
It is to this condition of apprehension that is due the desire to
escape from his present surroundings which is so characteristic of the
delirium in question. Under its influence the patient occasionally
commits acts of violence of the most serious kind. Sometimes the
delirium is more quiet: the patient converses with individuals whom he
supposes to surround him; he busies himself with his familiar
occupations, giving orders, directing work, dictating letters, and
arranging his affairs. At other times the delirium takes the form of
apprehension of poisoning, and food and medicine are alike stubbornly
refused.
The countenance, as a rule, is animated, the eyes brilliant and
injected, the look fixed or peering, but always eager, or the
expression may be haggard and agitated. The physiognomy, although
largely influenced by the character of the delirium, may be said to be
in most cases characteristic.
Sensation is usually impaired; especially is this true of sensibility
to pain.
Tremor, although occasionally slight, may be said to be never wholly
absent. Sometimes it affects the muscles of all parts of the body;
more commonly it is limited to the hands, arms, tongue, and lips; less
frequently it manifests itself in the lower extremities. Slight tremor
may be increased by causing the patient to hold his hands extended
with the {629} fingers separated. The movements of the hands consist
of rapid rhythmical oscillations of nearly equal extent and duration.
The tongue is protruded with a rapid jerking movement, and withdrawn
with equal suddenness. It shows fibrillar trembling. The trembling is
increased by voluntary movement, and is ordinarily associated with
some loss of motor power. The gait is often hesitating and awkward;
movements of the upper extremities are executed with difficulty, and
speech is irregular and interrupted. The motor disturbances are
occasionally associated with choreiform movements or actual epileptic
convulsions.
Insomnia is a constant condition. It usually persists throughout the
attack, and occasionally proves troublesome for several weeks after
convalescence is in other respects complete.