Acute Alcoholism.—When a large quantity of alcohol is taken, the influence is chiefly on the nervous system, and is manifested in muscular incoordination, mental disturbance, and, finally, narcosis. The individual presents a flushed, sometimes slightly cyanosed face, the pulse is full, respirations deep but rarely stertorous. The pupils are dilated. The temperature is frequently below normal, particularly if the patient has been exposed to cold. Perhaps the lowest reported temperatures have been in cases of this sort. An instance is on record in which the patient on admission to hospital had a temperature of 24̊C. (ca. ̊75̊ degrees F.) and ten hours later the temperature had not risen to 91̊ F. The unconsciousness is rarely so deep that the patient cannot be roused to some extent, and in reply to questions he mutters incoherently. Muscular twitchings may occur, but rarely convulsions. The breath has a heavy alcoholic odor. The respirations may be slow; in one case they were only six in the minute.
The diagnosis is not difficult, yet mistakes are frequently made. Persons are brought to a hospital by the police supposed to be drunk when in reality they are dying from apoplexy. Too great care cannot be exercised, and the patient should receive the benefit of the doubt. In some instances the mistake has arisen from the fact that a person who has been drinking heavily has been stricken with apoplexy. In this condition the coma is usually deeper, stertor is present, and there may be evidence of hemiplegia in the greater flaccidity of the limbs on one side.
Dipsomania is a form of acute alcoholism seen in persons with a strong hereditary tendency to drink. Periodically the victims go "on a spree," but in the intervals they are entirely free from any craving for alcohol.
Chronic Alcoholism.—ln moderation, wine, beer, and spirits may be taken throughout a long life without impairing the general health.
The poisonous effects of alcohol are manifested (1) as a functional poison, as in acute narcosis; (2) as a tissue poison, in which its effects are seen on the parenchymatous elements, particularly epithelium and nerve, producing a slow degeneration, and on the blood vessels, causing thickening and ultimately fibroid changes; and (3) as a checker of tissue oxidation, since the alcohol is consumed in place of the fat. This leads to fatty changes and sometimes to a condition of general steatosis.
The chief effects of chronic alcohol poisoning may be thus summarized:
Nervous System.—Functional disturbance is common. Unsteadiness of the muscles in performing any action is a constant feature. The tremor is best seen in the hands and in the tongue. The mental processes may be dull. particularly in the early morning hours, and the patient is unable to transact any business until he has had his accustomed stimulant, irritability of temper, forgetfulness, and a change in the moral character of the individual gradually come on. The judgment is seriously impaired, the will enfeebled, and in the final stages dementia may supervene. An interesting combination of symptoms in chronic alcoholics is characterized by peripheral neuritis, loss of memory, and pseudo-reminiscences—that is, false notions as to the patient's position in time and space, and fabulous explanations of real occurrences. The peripheral neuritis is not always present ; there may be only tremor and jactitation of the lips, and thickness of the speech, with visual hallucinations. The mental condition was described by Jackson and by hills. Korsakoff speaks of it as a psychosis polyneuritica, and the symptom-complex is sometimes called by his name. The relation of chronic alcoholism to insanity has been much discussed. According to Savage, of 400 patents admitted to the Bethlehem Hospital, 133 gave drink as the cause of their insanity. Chronic alcoholism is certainly one of the important elements in the strain which leads to mental breakdown. Epilepsy may result directly from chronic drinking. It is a hopeful form, and may disappear entirely with a return to habits of temperance.
There is a remarkable condition in chronic alcoholism termed "wet brain:" in which a heavy drinker, who may perhaps have had attacks of delirium tremens, begins to get drowsy or a little more befuddled than usual; gradually the stupor deepens until he becomes comatose, in which state he may remain for weeks. There may be slight fever, but there are no signs of paralysis, and no optic. neuritis. The urine may be normal. The lumbar puncture yields a clear fluid, but under high pressure. in one case, which died at the end of six weeks, there were the anatomical features of a serous meningitis.
No characteristic changes are found in the nervous system. Haemorrhagic pachymeningitis is not very uncommon. There are opacity and thickening of the pia-arachnoid membranes, with more or less wasting of the convolutions. These are in no way peculiar to chronic alcoholism, but are found in old persons and in chronic wasting diseases. In the very protracted cases there may be chronic encephalo-meningitis with adhesions of the membranes. Finer changes in the nerve-cells, their processes, and the neuroglia have been described. By far the most striking effect of alcohol on the nervous system is the production of the alcoholic neuritis.
Digestive System.—Catarrh of the stomach is the most common symptom. The toper has a furred tongue, heavy breath, and in the morning a sensation of sinking at the stomach until he has had his dram. The appetite is usually impaired and the bowels are constipated. In beer-drinkers dilatation of the stomach is common.
Alcohol produces definite changes in the liver, leading ultimately to the various forms of cirrhosis. In Welch's laboratory J. Vriedenwald has caused typical cirrhosis in rabbits by the administratien of alcohol.
A special vulnerability of the liver-cells is necessary in the etiology of alcoholic cirrhosis. There are cases in which comparatively moderate drinking for a few years has been followed by cirrhosis; on the other hand, the livers of persons who have been steady drinkers for thirty or forty years may show only a moderate grade of sclerosis. For years before cirrhosis develops heavy drinkers may present an enlarged and tender liver, with at times swelling of the spleen. With the gastric and hepatic disorders the facies often becomes very characteristic. The venules of the cheeks and nose are dilated; the latter becomes enlarged, red, and may present the condition known as acne rosacea. The eyes are watery, and conjunctivae hyperaemic and sometimes bile-tinged.
The heart and arteries in chronic topers show degenerative changes, and alcoholism is a factor in causing arterio-sclerosis. Steell has pointed out the frequency of cardiac dilatation in these cases.
Kidneys.—The influence of chronic alcoholism upon these organs is by no means so marked. According to Dickinson the total of renal disease is not greater in the drinking class, and he holds that the effect of alcohol on the kidneys has been much overrated. Formad has directed attention to the fact that in a large proportion of chronic alcoholics the kidneys are increased in size. The Guy's Hospital statistics support this statement, and Pitt notes that in 43 per cent. of the bodies of hard drinkers the kidneys were hypertrophied without showing morbid change. A granular kidney may result indirectly through the arterial changes.
It was formerly thought that alcohol was in some way antagonistic to tuberculous disease, but the observations of late years indicate clearly that the reverse is the case and that chronic drinkers are much more liable to both acute and pulmonary tuberculosis. It is probably altogether a question of altered tissue-soil, the alcohol lowering the vitality and enabling the bacilli more readily to develop and grow.
(c) Delirium tremens (mania a potu), an incident in the history of chronic alcoholism, results from the long-continued action of the poison on the brain. The condition was first accurately described early in the 19th century by Sutton, of Greenwich, who had numerous opportunities for studying the different forms among sailors. One of the most careful studies of the disease was made by Ware, of Boston. A spree in a temperate person, no matter how prolonged, is rarely if ever followed by delirium tremens; but in the case of an habitual drinker a temporary excess is apt to bring, on an attack. It sometimes follows in consequence of the sudden withdrawal of the alcohol. An accident, a sudden fright or shock, or an acute inflammation, particularly pneumonia, may determine the onset. It is especially apt to occur in drinkers admitted to hospitals for injuries, especially fractures, and, as this seems most likely to occur when the alcohol is withdrawn, it is well to give such patients a moderate amount of alcohol. At the outset of the attack the patient is restless and depressed and sleeps badly, symptoms which cause him to take alcohol more freely. After a day or two the characteristic delirium sets in. The patient talks constantly and incoherently; he is incessantly in motion, and desires to go out and attend to some imaginary business. Hallucinations of sight and hearing develop. He sees objects in the room, such as rats, mice, or snakes, and fancies that they are crawling over his body. The terror inspired by these imaginary objects is great, and has given the popular name “horrors” to the disease. The patients need to be watched constantly, for in their delusions they may jump out of the window or escape. Auditory hallucinations are not so common, but the patient may complain of hearing the roar of animals or the threats of imaginary enemies. There is much muscular tremor; the tongue is covered with a thick white fur, and when protruded is tremulous. The pulse is soft, rapid, and readily compressed. There is usually fever, but the temperature rarely registers above 102̊ or 103̊. In fatal cases it may be higher. Insomnia is a constant feature. On the third or fourth day in favorable eases the restlessness abates, the patient sleeps, and improvement gradually sets in. The tremor persists for some days, the hallucinations gradually disappear, and the appetite returns. In more serious cases the insomnia persists, the delirium is incessant, the pulse becomes more frequent and feeble, the tongue dry, the prostration extreme, and death takes place from gradual heart-failure.
There is a condition termed acute hallucinosis. in which auditory hallucinations are marked, orientation is retained, and the mental disturbances are fixed. Ideas of persecution are common. There are intermediate forms between this and the ordinary delirium tremens.
Diagnosis.—The clinical picture of the disease can scarcely be confounded with any other. Cases with fever, however, may be mistaken for meningitis. By far the most common error is to overlook some local disease, such as pneumonia or erysipelas, or an accident, as a fractured rib, which in a chronic drinker may precipitate an attack of delirium tremens. In every instance a careful examination should be made, particularly of the lungs. It is to be remembered that in the severer forms, particularly the febrile cases, congestion of the bases of the lungs is by no means uncommon. Another point to be borne in mind is the fact that pneumonia of the apex is apt to be accompanied by delirium similar to mania a potu.
Prognosis. —Recovery takes place in a large proportion of the cases in private practice. In hospital practice, particularly in the large city hospitals to which the debilitated patients are taken, the death-rate is higher. Gerhard states that of 1,241 cases admitted to the Philadelphia Hospital 121 proved fatal. Recurrence is frequent, almost, indeed, the rule, if the drinking is kept up.
Treatment.—Acute alcoholism rarely requires any special measures, as the patient sleeps off the effects of the debauch. In the case of profound alcoholic coma it may be advisable to wash out the stomach, and if collapse symptoms occur the limbs should be rubbed and hot applications made to the body. Should convulsions supervene, chloroform may be carefully administered. In the acute, violent-alcoholic mania the hypodermic injection of apomorphia, one-eighth or one-sixth of a grain, is usually very effectual, causing nausea and vomiting, and rapid disappearance of the maniacal symptoms.
Chronic alcoholism is a condition very difficult to treat, and once fully established the habit is rarely abandoned. The most obstinate cases are those with marked hereditary tendency. Withdrawal of the alcohol is the first essential. This is most effectually accomplished by placing the patient in an institution, in which he can be carefully watched during the trying period of the first week or ten days of abstention. The absence of temptation in institution life is of special advantage. For the sleeplessness the bromides and hyoscine may be employed. Quinine and strychnine in tonic doses may be given. Cocaine or the fluid extract of coca has been recommended as a substitute for alcohol, but it is not of much service. Prolonged seclusion in a suitable institution is in reality the only elfectual means of cure. When an hereditary tendency exists a lapse into the drinking habit is almost inevitable.
In delirium tremens the patient should, be confined to bed and carefully watched night and day. The danger of escape in these cases is very great, as the patient imagines himself pursued by enemies or demons. Flint mentions the case of a man who escaped in his nightclothes and ran barefooted for fifteen miles on the frozen ground before he was overtaken. The patient should not be strapped in bed, as this aggravates the delirium ; sometimes, however, it may he necessary, in which case a sheet tied across the bed may be sufficient, and this is certainly better than violent restraint by three or four men. Alcohol should be withdrawn at once unless the pulse is feeble.
Delirium tremens is a disease which, in a large majority of cases, runs a course very slightly influenced by medicine. The indications for treatment are to procure sleep and to support the strength. In mild cases half a drachm (2 gm.) of bromide of potassium combined with tincture of capsicum may be given every three hours. Chloral is often of great service, and may be given without hesitation unless the heart's action is feeble. Good results sometimes follow the hypodermic use of hyoscine, one one-hundredth of a grain. Opium must be used cautiously. A special merit of Ware's work was the demonstration that on a rational or expectant plan of treatment the percentage of recoveries was greater than with the indiscriminate use of sedatives, which had been in vogue for many years. When opium is indicated it should be given as morphia, hypodermically. The effect should be carefully watched, and, if after three or four quarter-grain doses have been given the patient is still restless and excited, it is best not to push it farther. Repeated doses of trional (grs. xv-xx) every four hours may be tried. Lambert advises ergotin hypodermically in both the acute and chronic alcoholism. When fever is present the tranquilizing effects of a cold douche or cold bath may be. tried, or the cold or warm packs. The large doses of digitalis formerly employed are not ad visable.
Careful feeding is the most important element in the treatment of these cases. Milk and concentrated broths should be given at stated intervals. if the pulse becomes rapid and shows signs of flagging, alcohol may be given in combination with the aromatic spirits of ammonia.
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