Of these, the latter is the more frequent. Its consideration requires
in this connection very few words. It manifests itself by an
irresistible desire on the part of many insane people for alcohol. It
occurs both in {636} the prodromic and in the fully-established
periods of insanity. It is especially common in various forms of mania
and in the prodromic periods of general paralysis. The dominating
influence in essential dipsomania is heredity. Occasional causes may
bring on particular attacks, but their influence is secondary.
Dipsomania cannot be looked upon as a distinct recurrent affection in
an otherwise healthy person. At some period in their lives, and often
long before the occurrence of characteristic paroxysms, dipsomaniacs
show peculiarities indicating defects of mental organization. Certain
symptoms of dipsomania are often mistaken for its cause. Thus,
dyspepsia is more frequently an effect than a cause of the alcoholic
excesses. The despondency, irritability, restlessness, hysterical
manifestations, and insomnia which precede the attack are not the
cause of it: they are its earliest symptoms.
The affection usually begins insidiously and is progressive. As a
rule, although not always, it begins in early adult life. The
manifestations of this disease are essentially intermittent and
paroxysmal, but the impulse to drink must be regarded as a symptom
which may be replaced by other irresistible desires of an impulsive
kind, such as lead to the commission and repetition of various crimes,
as the gratification of other depraved appetites, robbery, or even
homicide. The paroxysms are at first of short duration, and are
followed by return to the previous regular and decent manner of life.
They become, however, by degrees, more violent and more prolonged. At
first lasting for a few days or a week, by and by they extend to
periods of a month or six weeks, the attack wearing itself out, and
recurring with a periodicity sometimes variable and sometimes
constant. In the intervals of these attacks for a considerable time
the patients very often lead sober, chaste, and useful lives. At
length, however, evidences of permanent mental trouble are manifested,
and the case settles into confirmed insanity. The attack is usually
preceded by evidences of mental derangement; the patient becomes
restless and irritable; sleep is irregular and unrefreshing; he
complains of general malaise, and is anxious, troubled by vague
apprehensions. He presently abandons his usual occupations and gives
himself up to disordered impulses, among which alcoholic excesses are
the most frequent and the most easily gratified. Sometimes the patient
passes his time at taverns drinking with all comers; at others he
shuts himself up in a chamber and gratifies his desire for drink to
the most extreme degree alone. Dipsomaniacs not rarely leave their
homes and associates without warning or explanation, and pass the
period of the paroxysm among associates of the most disreputable
character. The desire for drink is gratified at all costs, and not
infrequently they return to their friends without money and without
sufficient clothing, most of it having been sold or pawned in order to
purchase drink. The paroxysm is succeeded by a period of more or less
marked mental depression, during which the patient not rarely
voluntarily seeks admission to some asylum.
The true nature of dipsomania is frequently overlooked. As a symptom
of hereditary insanity it is in striking contrast with the habitual
propensity to drink which occurs in the ordinary alcoholic subject.
The latter seeks occasions to drink. He renews his excesses not
intermittently, but habitually. If in consequence of disgrace or
misfortune or under strong moral suasion he is for a time abstemious,
it is only to renew and to {637} continue his indulgence upon the
first favorable occasion. On the contrary, the true dipsomaniac
recognizes his malady and struggles against it. Even more: for a time
he shows much skill in concealing it. He avoids occasions to drink,
and, reproaching himself for his mad and unreasonable desire, seeks by
every means to overcome his impulse to it. The ordinary drunkard may
become insane because he drinks; the dipsomaniac drinks because he is
insane.[50]
[Footnote 50: Magnan, _Le Progrès médical_, 1884.]
Dipsomaniacs are apt to manifest precocious or retarded intellectual
development. They are from infancy or childhood especially prone to
convulsive or other paroxysmal nervous phenomena. They are often
choreic, often hysterical. This association with instability of the
nervous system is related to the fact that dipsomania is more common
in women than in men.
* * * * *
DIAGNOSIS.—1. Acute Alcoholism.—The diagnosis of the ordinary form of
acute alcoholism, with the exception of alcoholic coma, requires no
consideration. The diagnosis of alcoholic coma from profound coma due
to other conditions is, in the absence of the previous history of the
case, always attended with difficulty, and is in certain cases quite
impossible. It is therefore of great practical importance to obtain
the history where it is possible to do so. The odor of alcohol upon
the breath is of less positive diagnostic value than would at first
thought appear. In the first place, sympathetic bystanders may have
poured alcoholic drinks down the throat of one found unconscious, or,
in the second place, individuals who have taken a certain amount of
drink may be, and not unfrequently are, seized with apoplexy in
consequence of the excitement thereby induced. The more common
conditions with which alcoholic coma is confounded are apoplexy from
cerebral hemorrhage and narcotic poisoning, especially
opium-poisoning. To these may also be added uræmic coma and, under
exceptional circumstances, sunstroke. In all these cases the
circumstances under which the individual has been found are of
diagnostic importance.
In alcoholic coma the pupils are more commonly dilated than
contracted, the heart's action feeble, the respiration shallow, the
muscular relaxation symmetrical, and the temperature low. There is a
strong odor of alcohol upon the breath.
In apoplexy from cerebral hemorrhage the condition of the pupils will
depend upon the location of the clot. They may be moderately dilated,
firmly contracted, or unequal. The enfeeblement of the heart's action
is, as a rule, less marked than in profound alcoholic coma. The pulse
may be small or full and slow or irregular. It is usually slow and
full. The respiration is often, although not invariably, slow and
stertorous. Not uncommonly, the eyes and also the head deviate from
the paralyzed side. If the coma be not absolute, the muscular
relaxation is unilateral. The temperature is at first slightly below
the normal, but less, as a rule, than in alcoholic coma; after several
hours it rises to or above the normal.
In complete opium narcosis the insensibility is profound; the heart's
action is slow or rapid, but feeble; the respirations slow and shallow
or quiet or stertorous; the face at first flushed, afterward pallid
and cyanosed; the pupils minutely contracted or dilated as death
approaches; {638} and the muscular relaxation complete, with abolition
of reflex movements. In cases of doubt it is important to use the
stomach-pump.
Uræmic coma is apt to be preceded by or alternate with convulsions.
The pupils are more commonly slightly contracted than dilated, but are
without diagnostic significance. The temperature is not elevated; it
may even be low. The face may be pallid, pasty, and puffy, and there
may be general anasarca if the nephritis be parenchymatous. On the
other hand, in interstitial nephritis there is hypertrophy of the
heart, without evidence of valvular disease, and some degree of
puffiness of the lower extremities. In doubtful cases the urine should
be drawn by a catheter and subjected to chemical and microscopical
examination.[51] Diabetic coma occurs suddenly without convulsions.
This condition may be suspected when the emaciation is extreme or upon
the recognition of sugar in the urine.
[Footnote 51: The following is the method recommended by Green
(_Medical Chemistry_, Philadelphia, 1880) for the detection of alcohol
in the urine: If its reaction be acid, the urine is exactly
neutralized by potassium acid carbonate. It is then distilled on a
water-bath in a flask or retort connected with a condensing apparatus.
When about one-sixth of the liquid has passed over the distillate
will, if alcohol be present, present the following characteristics:
first, the peculiar alcoholic odor; second, a specific gravity lower
than water; third, upon being mixed with dilute sulphuric acid and
treated with a few drops of potassium bichromate solution the liquid
becomes green, owing to the separation of chromic oxide; the odor of
aldehyde may at the same time be observed. This reaction is not
characteristic, but may serve to confirm other tests. Fourth, if
dilute alcohol be shaken with an excess of solid and dry potassium
carbonate in a test-tube, the greater part of the water will be
appropriated by the potassium carbonate, and two layers of liquid will
be formed. The alcohol constitutes the upper layer, and if
sufficiently concentrated will burn upon the application of a flame.
Finally, a small trace of alcohol may be separated from the urine
without difficulty after the ingestion of alcoholic liquids by means
of a good fractionating apparatus. Less than 1 per cent. of alcohol
cannot be detected.]
Sunstroke is characterized by dyspnœa, gasping respiration,
jactitation, and intense heat of the skin. The pulse varies. It may be
full and labored or feeble and frequent. The face is usually flushed.
The pupils, at first contracted, are afterward dilated. The coma is
apt to be interrupted by transient local or general convulsions.
It is impossible to lay down any rules by which the maniacal form of
acute alcoholism may be at once diagnosticated from acute mania from
other causes. For the characteristics of the convulsive form of acute
alcoholism and those forms which occur in persons of unsound mind the
reader is referred to the descriptions of those conditions. The
diagnosis of acute poisoning by alcohol in lethal doses can only be
established during life by investigation of the history of the case.
II. Chronic Alcoholism.—The lesions of chronic alcoholism, as has
already been pointed out, are not in themselves peculiar to that
condition. Many of them occur with more or less frequency in morbid
states not induced by alcohol. It is their association and progressive
character which gives to chronic alcoholism its individuality. The
occasional prominence of certain symptoms or groups of symptoms may
thus in particular cases lead to some confusion of diagnosis,
especially where the history is unknown or the habits of the
individual are concealed. In the greater number of cases, however, the
association of symptoms is such as to render the diagnosis, even in
the absence of a direct history, a comparatively easy one.
Chronic alcoholism is a condition rather than a disease—a condition
{639} characterized by varying lesions of the viscera and nervous
system, by profound disturbances of nutrition, and by grave mental and
moral derangements. This fact being recognized, the cardinal error of
diagnosis to be guarded against is that of overlooking the condition
upon which the disease itself with which we have to do depends or is
associated. Congestion, inflammation, sclerosis, and steatosis affect
the various organs of the body and produce their characteristic
symptoms. Profound and lasting disturbances of nutrition demand our
attention. Psychical derangements of all grades, from mere moodiness
to confirmed and hopeless insanity, take place. These affections must
be diagnosticated for themselves here as elsewhere in clinical
medicine. The recognition of the underlying condition can, however,
alone supply the key to their true pathology.
Delirium tremens is occasionally diagnosticated with difficulty from
some forms of insanity not caused by drink. Here transitory and fixed
delusions, not mere terrors and hallucinations, are of importance, not
less than the absence of the varied and complex associations of
symptoms which are characteristic of alcoholism. The delirium of the
acute infectious diseases may be mistaken for delirium tremens.
Pneumonia, typhoid fever, and the exanthemata occasionally begin with
delirium resembling in some respects delirium tremens. Here the
history of the case, the pyrexia, and the general condition of the
patient are sufficient to establish the diagnosis if the danger of
error be borne in mind.
III. Hereditary Alcoholism.—The diagnosis of this condition can only
be established by careful investigation of the family history and
systematic study of the stages of progression by which the morbid
condition presented by the patient has been reached.
IV. Dipsomania.—The diagnostic points are the hereditary transmission
of this or other forms of insanity—the mental instability of the
patient in early life and in the intervals of the paroxysms, the
intermittent or cyclical recurrence of the attack, the morbid impulses
of a different kind associated with the impulse to drink, and the
struggle of the patient against his recurring impulses to
uncontrollable excesses.
PROGNOSIS.—The prognosis in acute alcoholism of the ordinary form is
favorable, so far as the immediate attack is in question. The
prognosis in rapidly-developing, overwhelming coma from enormous doses
of alcohol is in the highest degree unfavorable. Acute coma from
moderate doses usually passes off in the course of some hours. It
occasionally, however, terminates in fatal pneumonia.
The prognosis in delirium tremens of the ordinary form is favorable.
It becomes, however, more and more grave with each recurring attack.
Delirium tremens in patients suffering from advanced disease of the
heart, lungs, liver, or kidneys, or complicated by acute diseases of
these organs, is apt to prove fatal.
The prognosis of chronic alcoholism is gloomy. If the lesions be not
advanced, permanent discontinuance of alcoholic habits may be followed
by restoration of health, but, unfortunately, the discontinuance is
too often merely temporary, the habit being too strong to be
permanently broken off.
The prognosis in hereditary alcoholism is unfavorable, both as regards
the alcoholic habit and as regards the development of serious diseases
of {640} the nervous system under adverse circumstances, even in the
absence of the direct action of alcohol.
The prognosis in dipsomania is unfavorable. The paroxysm may recur
many times without apparent serious result; the patient in the course
of some days or weeks recovers, abandons his evil courses, and resumes
his usual occupations. After a time, however, the insanity of which
the dipsomania is the recurring manifestation declares itself as a
more or less permanent state. The outbreaks become more frequent and
more prolonged, the mental condition in the intervals progressively
more morbid, until the patient lapses by degrees into confirmed
insanity.
The prognosis in all forms of alcoholism, both acute and chronic, is
rendered in a high degree uncertain by the psychical disorders which
characterize so many of its phases. In consequence of some of these
conditions the patient loses at once his appreciation of bodily
dangers and his power to avoid them; by reason of others, to escape
imaginary evils he plunges into real ones; and finally some of them
are of such a nature that they impel him to the blind and unreasoning
commission of the most grievous crimes, including suicide and
homicide.[52]
[Footnote 52: “I believe that more suicides and combined suicides and
homicides result in this country from alcoholism in its early stages
than from any other cause whatsoever” (T. S. Clouston, _Clinical
Lectures on Mental Diseases_, Am. ed., 1884).]
TREATMENT.—The prophylaxis of alcoholism has regard to communities at
large and to individuals. The prevention of the evils of excess by the
control of the sale of drink constitutes one of the more important
objects of state medicine. At the same time, the traffic in alcohol is
curiously evasive of legal enactments. The difficulties attending the
enforcement of sumptuary laws are well known. Restrictive laws
concerning the making and sale of alcoholic drinks, while partaking of
the nature of sumptuary laws are of more comprehensive character,
being obnoxious to powerful commercial interests and to the sense of
personal liberty of large numbers of persons of all classes. As a
result of organized opposition and individual violation they are to a
great extent inoperative as regards the prevention of alcoholism.
Aside from the question of revenue from taxation, the practical
influence of law is in this matter somewhat limited, being confined
chiefly to the prevention of the sale of liquors to minors and persons
already intoxicated, and to ineffectual attempts in certain countries
to regulate the quality of the drink sold. The penalties for personal
drunkenness which does not lead to overt acts are, as a rule, wholly
inadequate to restrain it. The best results upon anything like an
extended scale have been obtained by the co-operative action of
philanthropic individuals in endeavoring to influence the moral tone,
especially among workingmen, to diminish temptations, and to provide
for leisure hours, in the absence of drink, reasonable amusements and
occupation to occupy the time ordinarily spent in taverns and similar
places.
The decrease in the consumption of alcoholic drinks in the United
States within recent years is doubtless due in part to increasing
popular knowledge concerning the dangers of alcoholic excess and to
the growth of a more wholesome public sentiment. It is, however, in
part also due to poor wages among workingmen.
As regards the individual, prophylaxis against alcoholism consists
{641} either in total abstinence from, or in the most guarded
indulgence in, alcoholic beverages. It is unfortunate that individuals
whose moral and physical organization is such as renders them most
liable to suffer from the consequences of alcohol are by that very
fact most prone to its temptations, and hence contribute largely to
the subjects of alcoholism. These individuals are found among the
ignorant, the very poor, and especially among neurotic subjects of all
classes of society. Due consideration of this fact cannot fail to
establish the responsibility of those fortunately not belonging to
these classes, in two respects: first, that of example; and second,
that of personal restraint from the standpoint of heredity. The
influence of heredity among races addicted to alcohol has not yet
attracted the attention it deserves. It is probable that much of the
tolerance for alcohol exhibited by individuals, families, or even
nations, is to be accounted for by heredity. Still more probable is it
that most of the evils and crimes that befall alcohol-drinking
communities and individuals are due directly or indirectly to the
abuse of this agent. No argument against the indulgence in narcotics
can be more potent than that derived from a consideration of the laws
of heredity.
I. The Treatment of Acute Alcoholism.—The medical treatment of mere
drunkenness requires no consideration. The rapid elimination of
alcohol, and the transient nature of its pathological effects in
excesses which are not repeated or prolonged, explain the spontaneous
recovery, which is usually sufficiently prompt and permanent. The
physical suffering and mental distress following unaccustomed excesses
are of salutary influence. Under certain circumstances a powerful
effort of the will is sufficient to control, at all events for a time,
the more moderate effects of alcohol. A similar result follows the use
of cold douches, the Turkish bath, and full doses of certain
preparations of ammonium, particularly the officinal solution of the
acetate of ammonium. In alcoholic stupor of an acute kind the patient
may be left to himself, care being taken that the clothing is loosened
and that the position is such as to prevent local paralysis from the
nerve-pressure. Alcoholic coma, if of moderate intensity, may be
managed in the same way. Profound alcoholic coma requires, however,
more energetic measures. Frictions, artificial warmth, stimulating
enemata, as of turpentine or of hot salt and water, an ounce to the
pint, hypodermic injections of strychnia or atrophia in minute doses
and occasionally repeated, inhalations of ammonia, and occasional cold
affusions, followed by brisk frictions with warm flannel and faradism
of the respiratory muscles, may be needed to tide over the threatened
fatal collapse. The stomach should be at once washed out with hot
coffee.
In the convulsive form of acute alcoholism chloral in twenty-grain
doses, repeated at intervals until sixty grains have been given,
usually serves to arrest, or at all events to moderate, the paroxysm.
It may be administered by the mouth or in double doses by the rectum.
If chloral be inadmissible by reason of weakness of the circulation,
paraldehyde may be substituted in doses of from half a drachm to one
drachm, repeated at intervals of from one to two hours until quietude
is produced. Where the convulsive paroxysms are of great violence it
may be necessary to control them by the cautious administration of
ether by inhalation.
The mania of acute alcoholism calls for energetic management. To {642}
avert injury to the patient himself or to those about him he must be
confined, if practicable, in a suitable apartment in a hospital; if
not, in his own house and carefully watched. Here, as a rule,
paraldehyde, chloral, or large doses of the bromides constitute our
most efficient means of medication.
In all forms of acute alcoholism it is a rule admitting of no
exception to at once withhold alcohol in every form and all doses. If,
under exceptional circumstances, great nervous depression or flagging
circulation seems to call for the use of alcohol in small amounts, it
is far better to substitute other drugs. The frequently repeated
administration of hot beef-tea or rich broths in small doses, with
capsicum and the use of the various preparations of ammonia, or small
doses of opium with or without quinia and digitalis, proves useful in
proportion to the skill and discrimination with which they are
selected and repeated. It is a good plan to commence the treatment
with an active purge.
In the acute collapse following excessive doses—lethal doses—the
stomach is to be immediately emptied by the tube or pump and washed
out with warm coffee. In the absence of the stomach-tube emesis may be
provoked by the use of mustard or sulphate of zinc or by hypodermic
injection of apomorphia. The patient must be placed in the recumbent
posture and surrounded with hot blankets. The cold douche may be
occasionally applied to the head and face, and the muscles of
respiration may be excited to action by faradism. Artificial
respiration and friction of the extremities may also be required.
Inhalations of ammonia may be used. The flagging heart may be
stimulated by occasionally tapping the præcordia with a hot
spoon—Corrgan's hammer. Hypodermic injections of digitalis may also be
employed. Overwhelming doses of alcohol, leading promptly to collapse,
usually prove fatal despite all treatment.