Chapter M: M——, was a stout Irish woman about forty years of age. She had (7)

Richardson was the first to call attention to the differences in the physiological and pathological action of the members of this series. Other {590} observers, among whom may be named Dujardin-Beaumetz and Andigie,[15] and Rabuteau,[16] have also investigated the subject. The researches of these observers have established the fact that the effects of the different alcohols in depressing the temperature of the body and in paralyzing sensation and motion are exactly the same, but that their narcotic influence upon the nervous system increases, dose for dose, in proportion to the amount of carbon which they contain. Ethyl alcohol is, with the exception of methyl alcohol or wood-spirit, the least rich in carbon and the least dangerous to health.[17] The increased consumption of alcohol, both as a beverage and in the arts, the demand for cheap, coarse spirits producing their primary narcotic effects with promptness, and the cupidity of manufacturers, have led to the almost universal adulteration of the liquors of commerce with the more dangerous alcohols.[18] So extensive has this substitution of the high-carbon alcohols for ethyl or ordinary spirit of wine become that it has been suggested that alcoholism should be divided into ethylism, amylism, propylism, and butylism—not so much for clinical reasons as to direct attention to the composition of alcoholic drinks and to their deleterious properties.[19]

[Footnote 15: _Recherches expérimentales sur la Puissance toxique des Alcools_, Paris, 1879.]

[Footnote 16: “Contributions à l'Étude des Effets physiologiques et therapeutiques d'Alcool,” _Compt. rend. Société de Biologie_, 1870-71.]

[Footnote 17: “Methylic alcohol is the safest of the series of bodies to which it belongs” (B. W. Richardson, _Lectures on Alcohol_).]

[Footnote 18: M. Girard, chief of the municipal laboratory in Paris, has recently called attention to the enormous diminution in the production of alcohol by the natural method—that is to say, by the distillation of wine. The falling off he ascribes to the ravages of the phylloxera. This loss is made up by the substitution of spirits obtained by the distillation of various fermented grains, potatoes, beets, molasses, etc. To give some idea of the extent to which the alcohols of industry at present replace the alcohols of wine, he cites the following figures: From 1840 to 1850 the mean annual production of alcohol in France was 891,500 hectoliters, of which the alcohols of wine amounted to 715,000 hectoliters. In 1883 the product reached 1,997,280 hectoliters, of which alcohols obtained by the distillation of wine amounted to only 14,678 hectoliters.]

[Footnote 19: Peeters, _L'Alcool_, 1885.]

The effects of propyl, butyl, and amyl alcohols upon the nervous system are not only more marked than those of ethyl alcohol, but they are more rapid. The stage of excitement is speedily induced, and its manifestations are intense. Hence the preference often manifested by drunkards for cheap, coarse spirits. On the other hand, the stage of depression quickly follows, and is itself of relatively shorter duration than that induced by ethyl alcohol, probably for the reason that the amount required to bring it about is smaller. Muscular resolution soon becomes general and complete; insensibility speedily succeeds; the fall of temperature is rapid; vomiting, occasionally absent in the intoxication produced by ethyl alcohol, is the rule, and is frequently repeated. Muscular tremor—and especially is this true of amyl alcohol—comes on earlier, is more general and more marked, and lasts longer than that which occurs in consequence of excess in ethyl alcohol. Richardson states that the complex alcohols are more slowly eliminated than ethyl alcohol, but the French observers are of a different opinion.

But these differences in action are probably rather differences in degree than in kind. Peeters says: “Ethyl alcohol is less dangerous than the more complex members of the series. It is less irritating, less charged with carbon, its specific gravity is less, its fumes are less dense and escape {591} more readily from the economy; its action ought to be less profound, less prolonged, than that of butyl, propyl, and amyl alcohol, but it is of the same nature. It is not qualitatively but quantitatively different. I suspect that the effects of liquors containing ethyl alcohol are, as a rule, less decidedly injurious, by reason of the more favorable surroundings of those who can afford to use them.”

The three principal groups of the alcoholic drinks of commerce produce, independently of the properties of the different kinds of alcohol which they contain, forms of acute alcoholism which differ in important respects.

The intoxication induced by the exclusive use of malt liquors is dull and heavy, slow in coming on, and of long duration. The stage of excitement is relatively brief, not often characterized by gayety, often brutal; drowsiness soon supervenes and deepens slowly into unconsciousness. The after-effects are disagreeable and prolonged. The enormous quantity of fluid and the large amount of malt extractives cause gastro-hepatic derangements of a more or less distressing kind. To the hops must be ascribed the prolonged dulness which is so characteristic of the after-effects of beers and ales. The influence of the various substances used in the adulteration of beers without doubt modifies the symptoms of the alcoholism which these beverages cause when impure. These substances consist of glucose, various vegetable bitters, and salt—articles not necessarily hurtful in small amounts, but capable of exerting deleterious action when taken in excess and in connection with the normal ingredients of beer.

The intoxication produced by pure wines is, as a rule, characterized by a bodily and mental activity strongly in contrast with the drunkenness produced by malt liquors. The drunkard is usually gay and vivacious—at all events, lightly merry or not hopelessly despondent. His mood is variable, changing from grave to gay. The first stage is prolonged, and the manifestations of the later stages less grave, nor are the sequels apt to be so severe. The action is that of ethyl alcohol and certain ethereal substances, the latter being present, however, only in minute amounts. The rapidity of the effects depends upon the proportion of alcohol which the wine contains, which varies from about 7 per cent. in the clarets to 15, to 18, or even to 20 per cent. in port and madeira. The sparkling wines, moselle and champagne, produce more transient effects than the still wines—a fact probably to be explained by their greater and more prompt diuretic action.

The foregoing remarks apply only to pure wines. The intoxication which follows the use of artificial compounds sold in all parts of the world as wines betrays in its course and symptoms the high percentage and toxic characters of the mixed alcohols which form their essential ingredients.

The intoxication which follows excesses in the various spirits of commerce presents no special characters. Its symptoms are determined to a considerable extent by the relative purity—that is, freedom from admixture with the various complex alcohols—of the liquor by which it has been produced. Potato spirit causes drunkenness which is profound, overwhelming, and preceded by a brief period only of excitement.

Even more important than the kind of liquor is its quantity. Here, {592} however, it is impossible to formulate precise statements. A few glasses of wine will produce effects in some persons more decided than much strong spirits in others. Those conditions which favor the absorption of alcohol hasten the production and augment the intensity of alcoholism; and the contrary is true. Thus, alcohol taken while fasting does much more harm than the same amount taken with a meal. Intense excitement, anger, mortification, or other violent emotion is said by Lentz to increase the effects of alcohol. Sudden transition from a warm to a cold atmosphere intensifies the action. That this effect of cold is due to suppression of perspiration, and the consequent interference with one of the elements of elimination, is much less likely than that it is due to the further depressing influence of cold upon the nervous system, already depressed by the alcohol imbibed. Occupation has in an indirect way much to do with the facility with which alcohol is borne. Hard work, requiring great and continuous muscular effort, especially in the open air, diminishes the liability to acute alcoholism, while sedentary occupations and confinement strongly predispose to it. These well-recognized facts are to be accounted for by the influence of different occupations and modes of life upon the elimination of the poison. Persons who are debilitated by chronic disease or are convalescent from acute maladies, and the otherwise feeble and anæmic, are peculiarly obnoxious to the action of alcohol. Previous custom and hereditary peculiarities of organization exert an influence upon the liability of individuals to acute alcoholism, and upon its nature when induced.

Persons of an impressible nervous organization are peculiarly prone to the evil effects of drink. With such persons slight excess is often followed by serious consequences; the intellectual disturbance is early developed and out of proportion to the derangements of motility and sensation. The effects of alcohol are manifested more promptly and more intensely in children and women than in men or in the aged. Drunkenness is induced more rapidly and with smaller quantities of alcohol in summer than in winter, in warm than in cold countries.

_B_. IRREGULAR FORMS OF ACUTE ALCOHOLISM.[20]—1. _The Maniacal Form_.—The outbreak is usually sudden, sometimes occurring after the ingestion of comparatively small quantities of alcohol; at others after excesses which in a certain proportion of the cases have already ceased. The transition from a condition apparently normal, or marked at most by mental concentration, restlessness, and some degree of irritability, to furious mania is sometimes almost instantaneous, and the subsidence of the latter no less swift. More commonly there are prodromic symptoms, among which are general malaise, præcordial distress, palpitations, flushing of the face, vertigo, tinnitus aurium, phosphenes, and dull, throbbing headache. The attack is characterized by maniacal excitement, usually of a furious kind. The restlessness is, however, far from being aimless and purposeless. On the contrary, impelled by the wildest passions, transported with rage, the patient seeks the destruction of life and property, and wreaks his fury alike upon animate and inanimate objects. So great is his strength for the time being that several strong men may be scarcely able to restrain him. He pours forth a torrent of commingled threats and curses, in which may be heard unintelligible, and often {593} inarticulate, sounds. He is beside himself, yet, so far as can be learned, there are neither hallucinations nor delusions by which his fury can be explained. In this respect the condition is wholly unlike that form of alcoholic mania in which the actions are explained by the imaginary surroundings and circumstances of the patient. In the maniacal form of acute alcoholism the most trifling incident, a word, a look, are sufficient to produce a tempest of rage that may end in scenes of violence. Nevertheless, the patient yet retains for a time some notion of his surroundings. At length, however, he falls into a state of complete unconsciousness, and the delirium is like that of fever, of the delusions of which no recollection afterward remains. This form of acute alcoholism is almost invariably associated with the symptoms of a high degree of cerebral hyperæmia. The hands are hot, the eyes injected, the pupils dilated or contracted, the expression eager. There are abundant secretion of saliva, frequent and irregular respiration, a rapid pulse—often exceeding 100—throbbing arteries, distended veins, and a hot skin, often bathed with sweat. The urine is scanty and constipation usual. There is, as a rule, increased sensibility to light and sound. The attack is liable to come to a tragic close in murder or suicide.

[Footnote 20: Ivresses anormales ou pathologiques of the French writers.]

The termination of the paroxysm is as abrupt as its onset. Some abatement of its violence is quickly followed by signs of mental and bodily exhaustion; this deepens into profound sleep, which often lasts from twelve to twenty-four hours, and from which the patient awakes clear, tranquil, and as if nothing had happened, or dimly recollecting the occurrences that have passed as a hideous dream. In a small proportion of the cases the sleep deepens into coma which ends in death.

2. _The Convulsive Form_.—The analogy to the form just described is very close. Here, however, the morbid manifestations directly relate to the muscular system. The attack is commonly sudden, often abrupt. When prodromes occur, they are such as have been described as preceding the maniacal form—mental irritability, headache, præcordial distress, etc. The attack is thus described by Lentz: “The phenomena consist not in ordinary convulsions, but in convulsiform movements of remarkable disorder, only to be compared with the extraordinary convulsive movements of grave hysteria. We have happened to see several cases during the attack. These patients threw themselves to the ground, giving themselves up to the most irregular and disorderly contortions, rolling from side to side, throwing the body into the air, striking out with the legs and arms, kicking at random, biting at persons and things—now knocking the head against the floor, again rising for a moment, only to fall back and commence again the same contortions. Their movements are energetic and violent. There are madmen whom it is dangerous to approach by reason of the violence of their movements, but they are certainly much less dangerous than those suffering from the maniacal form of acute alcoholism, for their morbid motility has no tendency to take the shape of co-ordinated actions. It is movement wasted in pure loss. Their muscular energy is excessive; it is difficult to restrain them. To resume: the peculiarity of these movements is this, that they are not intentional, but that they are rather purely convulsiform, automatic.

“Another phenomenon of this form, one of its characteristic symptoms, is the state of intellectual enfeeblement which accompanies it. The loss {594} of consciousness is complete, and were it not for the movement produced by the convulsions the patient would be plunged into a condition of profound coma. He has not the least knowledge of himself; not even delirium denotes intellectual activity; only an occasional harsh cry or inarticulate sound indicates the existence of mind.”

The other symptoms differ but little from the maniacal form. The duration of the attack varies from a few hours to half a day; its termination is usually abrupt, the patient falling into a condition of extreme exhaustion with stupor, or into a deep and prolonged sleep, from which he awakens without the slightest recollection of the attack through which he has passed.[21]

[Footnote 21: Consult also _Dict. des Sciences méd._, t. xxvi.]

3. _Acute Alcoholism, in Persons of Unsound Mind_.—The insane, imbeciles, epileptics, and persons suffering from nervous diseases are, as a rule, abnormally susceptible to the action of alcohol, and present more or less striking peculiarities in the symptoms which it causes. Brief notice of certain of these peculiarities is in accordance with the scope and plan of this article.

In general paralysis propensity to alcoholic excesses is not rarely an early symptom. The subject is very susceptible to the action of alcohol, and under its influence rapidly passes into a state of intense excitement, characterized by incoherence, delirium, excessive restlessness, and unwillingness to seek repose until exhaustion is complete. It is under the influence of this easily-provoked alcoholic excitement that the vagabondage, quarrels, thefts, robberies, incendiarisms, and other grave crimes observed during the first stage of this form of insanity are often committed.

Imbeciles and idiots are likewise quickly, and often intensely, excited by alcohol. They are then apt to be quarrelsome, perverse, and ungovernable, defiant of authority, and capable of shocking crimes, often evincing latent vicious tendencies previously wholly unsuspected.

Epileptics are easily affected by alcohol, and usually violent in the stage of excitement; not rarely this period terminates in a true epileptic seizure.

The drunkenness of the dipsomaniac is characterized by a prolonged, uninterrupted stage of excitement without the stage of depression. Such individuals are capable of consuming in their periodical excesses large amounts of drink without the evolution of the ordinary successive phenomena of acute alcoholism.

Persons of unsound mind are, as a rule, so susceptible to the influence of alcohol, and suffer so promptly and intensely from its primary effects, that they are rarely able or permitted to consume a sufficient quantity to bring about a comatose state.

The irregular forms of acute alcoholism are only to be explained by the inherited or acquired constitutional peculiarities of individuals. To attempt to explain them in any case by the quality of the alcohol by which they are induced meets with the difficulty indicated in the fact that they are isolated and comparatively rare, even where the coarser spirits are habitually consumed. They occur in individuals who habitually commit excesses, but they cannot be viewed as manifestations of chronic alcoholism, for the reason that they also occasionally occur in those who are {595} not habitual drinkers, and even in persons who have not for a long time previously tasted strong drink. Furthermore, as has been pointed out, they are not only occasionally, but indeed even as a rule, induced by relatively small amounts of alcohol. They are then the manifestations of idiosyncrasy. One of the striking peculiarities of this peculiar bodily organization is this very susceptibility to the action of alcohol in doses smaller than are taken with impunity by ordinary individuals. It is also characterized by a special tendency to delirium in febrile states, to hallucinations, to disturbances from trifling changes in climate, food, or manner of life, to irritability of the nervous system, and in particular of the vaso-motor system, and by a tendency to convulsions. With these tendencies is associated an unstable mental and moral character. Such persons are liable to headaches, vertigo, and epistaxis—signs of cerebral hyperæmia, which is easily induced—and their family histories indicate strong hereditary tendencies to neurotic disorders, and not rarely addiction to alcohol on the part of one or several ancestors.

But this idiosyncrasy is by no means always an inherited one. It is 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.

The Intestines.—Lesions of the small intestine due to alcoholism are {602} extremely rare. Even when simple or ulcerative inflammation of the stomach is localized at, or extends to, the pylorus, it rarely passes any great distance into the gut. The large intestine is, on the contrary, frequently the seat of chronic inflammatory processes. Here we find vascular engorgement, patches of pigmentation, localized thickening of the mucous and submucous tissues, enlargement of the solitary glands, and an excessive secretion of viscid mucus. The tendency to permanent vascular dilatation, which is a characteristic result of alcoholic habits, constitutes a powerful predisposing influence in the causation of hemorrhoids, which are common. Alcohol acts directly upon the hemorrhoidal plexus of veins, and indirectly by causing permanent congestions of more or less intensity in the greater number of the abdominal viscera. When a prolonged course of excesses in alcohol has led to chronic congestion with hypertrophy, cirrhosis, or other structural change in the liver which is capable of causing permanent mechanical obstruction of the portal circulation, hemorrhoids constitute a very common affection in the group of morbid entities secondary to these conditions.

The symptoms of intestinal derangement are in the beginning, as a rule, slight and occasional. They consist of uneasy sensations or colicky pains in the abdomen, a feeling of fulness with or without tympany, and constipation alternating with diarrhœa: in a word, they are the symptoms of acute or subacute intestinal indigestion terminating in an attack of intestinal catarrh. Attacks of this kind repeat themselves in a considerable proportion of the cases with variable but increasing frequency, until at length the conditions of which they are the expression become permanent, and the patient suffers, among other distressing symptoms hereafter to be described, from chronic diarrhœa. The stools are now of the most variable character—occasionally bilious, sometimes containing small dark scybalous masses, rarely formed, but usually containing more or less abnormal mucus, too much fluid, and traces of blood. Indeed, at this stage several causes—among which I may mention visceral congestions, local inflammation of the intestinal mucous membrane, dilatation of the hemorrhoidal veins, and structural changes in the liver—conspire to determine blood toward the interior of the intestinal tube. Traces of blood in the stools are therefore frequent, and actual hemorrhage and the appearance of the dark, tarry, and altered blood formerly described under the term melæna are by no means rare. Colliquative diarrhœa and dysenteric attacks also occur, and at length an intense enteritis with uncontrollable diarrhœa may end the life of the patient. The conditions just described lead to rapid emaciation, and contribute when present to the establishment of the cachexia so marked in many cases of chronic alcoholism.

The Glands.—The salivary glands were found by Lancereaux[32] to have undergone softening, with granulo-fatty changes in their epithelium. If such changes are among the usual effects of alcohol, they are doubtless productive of alterations in the saliva, which explain, in part at least, the dryness of the mouth so frequent among drunkards.

[Footnote 32: _Dictionnaire de Médecine_, art. “Alcoholism.”]

The pancreas is, as the result of interstitial inflammation, the seat of similar changes. It is sometimes enlarged and softened, sometimes atrophied, shrivelled, or cirrhotic. In the latter condition its consistence is {603} firm, its surface uneven, its color deep yellow, brown, or pale. Hyperplasia of the interacinous connective tissue, with subsequent contraction and atrophy and destruction of the glandular tissue, characterizes the more chronic forms of pancreatitis, and the organ is frequently the seat of scattered minute blood-extravasations. I have already alluded to the enlargement of the solitary glands which constitutes a feature of the condition of the large intestine. The solitary glands and Peyer's patches of the small intestine are rarely altered.

_b_. Disorders of the Liver.—Next in order to the stomach, the liver is more directly exposed to the action of alcohol than any other viscus. For this reason lesions of the liver are frequent and grave. It is worthy of note, however, that in a small proportion of cases of chronic alcoholism terminating fatally, with widespread evidences of the destructive action of alcohol upon the other organs of the body, the liver has been found, both in its macroscopic and microscopic appearances, wholly normal. Absorbed by the gastric vessels, alcohol passes directly, by way of the portal vein, into the parenchyma of the liver, there giving rise to various disturbances, the nature of which is determined by the tendencies of the individual on the one hand, and on the other hand by the character of the alcohol consumed. The danger of hepatic disease is in direct proportion to the amount and the concentration of the alcohol habitually taken. The steady drinkers of spirits of whatever kind, whether gin, brandy, whiskey, or rum, present the largest proportion of diseases of the liver. These affections are far less common among beer-drinkers, and infrequent among wine-drinkers in wine-growing countries. In this connection it is to be borne in mind that the presence of food in the stomach retards to some degree the absorption of the alcohol ingested, and to a certain extent constitutes a means of dilution.

Hepatic disorders due to alcohol may be arranged in two groups: first, congestion and inflammation; second, fatty infiltration or steatosis; and the inflammatory process may affect chiefly the interstitial connective tissue on the one hand, giving rise to sclerosis, or on the other the glandular substance, constituting a true parenchymatous inflammation.

Congestion.—Congestion of the liver is an early lesion. It is brought about by the direct irritant action of the alcohol itself in part, and in part by the extension of inflammation from the stomach by continuous mucous tracts. Its development is insidious. Anatomically, the condition is characterized by vascular dilatation, moderate tumefaction, slight increase in the consistence of the organ; the surface is of a deeper red than normal; on section the color is more intense and the oozing more abundant. At a later period we have, as the result of chronic congestion, the cyanotic liver; the color is brownish or violet, mottled, and on section the surface is granular and the lobules distinct. The organ may now be somewhat diminished in size, but it lacks the firmness of sclerosis and the hobnail appearance due to the contraction of the interlobular connective tissue in that condition.

The symptoms of congestion of the liver are the familiar symptoms of gastro-hepatic catarrh, varying from the transient disturbance known as biliousness to serious sickness, characterized by acute gastro-intestinal phenomena, with vomiting, headache, and other derangements of the nervous system—constipation, succeeded by diarrhœa and by more or less {604} distinct jaundice. The graver forms of hepatic congestion are characterized by intense nausea, frequent vomiting, pain and soreness in the epigastrium and right hypogastrium, the physical signs of augmentation of the volume of the liver, and well-marked yellow discoloration of the conjunctivæ and skin. These attacks are usually afebrile: the pulse is slow; there is considerable nervous and mental depression, a tendency to vertigo, and occasional syncope. The urine is scanty and high-colored, and presents the reactions of bile-pigment. Muscular tremor, especially marked in the extremities and tongue, is often present, but is to be attributed rather to the direct action of alcohol upon the nervous system than to the condition of the liver.

Hepatitis.—There are two principal forms of inflammation of the liver induced by alcohol—parenchymatous hepatitis and interstitial hepatitis or sclerosis.

Several varieties of parenchymatous hepatitis have been described. The anatomical discrimination of these varieties is attended with less difficulty than their clinical diagnosis. One of the more serious is diffused parenchymatous hepatitis or acute yellow atrophy. Alcoholic excesses appear to constitute a predisposing influence to this grave disorder (Lentz). In several cases prolonged and repeated excesses have preceded its development. It is a true parenchymatous inflammation, in which the glandular elements of the organ undergo disintegration. The liver is diminished in volume in all its diameters. It is of a uniform yellow color; its tissue is soft and friable; upon section the hepatic cells are found to be replaced by a granular detritus mingled with globules of coloring matter and a greasy, grayish-yellow liquid exudation.

The symptoms of this affection are those of an acute parenchymatous hepatitis of the gravest kind. In the early stages there is intense jaundice, gastro-intestinal disturbance, and fever, followed by speedy evidences of profound toxæmia. The patient rapidly falls into the so-called typhoid state, with a tendency to coma. The prognosis is, in the greater number or cases, a fatal one. So close is the resemblance between acute yellow atrophy of the liver and the phenomena of acute phosphorus-poisoning that by many observers these two conditions are held to be identical.[33]

[Footnote 33: Consult this _System of Medicine_, Vol. II., article “Acute Yellow Atrophy of the Liver.”]

There is little doubt that the view now generally held, that acute yellow atrophy is due to the action of some unknown toxic principle, is correct. Alcoholic excess must therefore be regarded merely in the light of a predisposing influence. Acute yellow atrophy of the liver is an exceedingly rare disease.

Suppurative Hepatitis.—Abscess of the liver is in temperate climates infrequent as the direct result of alcoholic excess. It is frequently ascribed, however, to improper alcoholic indulgence, especially when combined with the eating of large quantities of improper food, in tropical and subtropical climates. A form of hepatitis has been described by Leudet under the head of chronic interstitial hepatitis with atrophy. The symptoms are for the most part not very well marked, and consist chiefly in general malnutrition, which may in fact be dependent upon the associated gastric disturbance. Chronic jaundice is usually present.

Interstitial Hepatitis.—Cirrhosis of the liver is in a large proportion of cases directly attributable to alcoholic excess. In this view the greater {605} number of observers coincide. But that alcohol is not the sole cause of chronic interstitial hepatitis has been abundantly established. As long ago as 1868, Anstie[34] wrote as follows: “Considering the enormous quantities of spirituous liquors which are drunk by many of the patients who apply for relief from the consequences of chronic alcoholism, it would be natural for the reader who holds the usual opinion as to the origin of cirrhosis of the liver to expect that serious symptoms produced by the latter disorder must often complicate cases of the former. The case is, however, far otherwise in my own experience. Of the immense number of patients in whom the nervous disorder has been clearly identified, I have only seen thirteen cases in which the symptoms of cirrhotic disease called for any special treatment, although a certain degree of cirrhosis was doubtless present in many of the others; and I cannot avoid the conclusion that some very powerful element over and above the influence of alcoholic excess is needed to produce the severe type of that disease.” Formad[35] states as the result of his investigations as coroner's physician of the city of Philadelphia that cirrhosis of the liver is much less common in alcoholic subjects than has been generally thought. My own experience during eleven years as attending physician at the Philadelphia Hospital leads me to endorse this opinion.

[Footnote 34: _A System of Medicine_, Reynolds, vol. ii. p. 74.]

[Footnote 35: _Proceedings of the Pathological Society of Philadelphia_, Dec., 1885.]

The anatomical lesions of chronic interstitial hepatitis consist essentially in hyperplasia and hypertrophy of the connective tissue of the organ. The progress of the affection is insidious and gradual; some degree of enlargement, due in part to congestion and in part to interstitial exudation, is followed by gradual diminution, with retraction of the new connective tissue. When the connective-tissue new formation is excessive, and retraction fails to take place, the organ remains permanently enlarged (hypertrophic cirrhosis). During the first period the volume of the organ is increased, its consistence is more firm, and its surface is slightly granular. The second period is characterized by induration, with diminution of the volume of the organ and alteration of its form. The surface is uneven, deeply granular, and usually of a mottled yellow color. The tissue is firm, creaking under the knife. The connective tissue is enormously increased, the glandular elements being proportionately atrophied.

The contracting connective tissue exercises at the same time a compressing influence upon the hepatic cells and upon the vascular supply throughout the organ; the radicals of the portal vein and the branches of the hepatic artery are alike compressed, and in part obliterated. The same is true of the bile-ducts. The functional activity of the liver, at first diminished, is finally, to a considerable extent, arrested. In consequence of these physical alterations in the structure of the organ, the symptoms, which are at first insignificant, become progressively more grave, until at length they constitute complications of the most serious kind.

It can be no longer asserted that the interstitial hepatitis produced by alcohol presents specific characters. It nevertheless differs in many respects from that form due to valvular lesions of the heart, in which there are induration, usually augmentation in the volume of the organ, {606} and persistent congestion. Congestion, in truth, is the chief characteristic of the latter form, in which the surface is smooth and glistening, of a deep brown or violet hue, and on section yellowish or brown—a condition which has been well described under the term cyanotic liver.

Sclerotic changes due to alcohol usually affect the organ throughout. In this respect alcoholic cirrhosis differs from that form due to syphilis in which the lesions are irregularly distributed.