Volume 5 — DISEASES OF THE NERVOUS SYSTEM. (continued 19)

The occurrence of intracranial congestions, hemorrhages, and venous thrombosis²¹ will, almost of necessity, render any medication of no value.

²¹ Such as were found upon autopsy in the case reported by Macdonald, and believed by him to be the essential lesions of the disease.

Under all circumstances the PROGNOSIS is exceedingly grave. The mortality-rate of the cases after abortion collected by Garrigues was 92 per cent. (25—23), and of those after labor 84.37 per cent. (32—27).²²

²² As indicating the extreme gravity of tetanus occurring in connection with a wound of the genital tract, it may be noticed that of 17 cases after ovariotomy collected by Parvin, 16 died, 94.1 per cent., and of 24 cases tabulated by Olshausen, 23 died, 95.83 per cent.

Tetanus Neonatorum.

From the earliest times it has been known that newly-born children are occasionally the subjects of trismus and generalized spasms, and that those thus affected usually die.

More common among the darker races²³ and in warm countries (though some of the southern races and tribes are almost or altogether free from it), it has been for years together endemic in places far north (e.g. the islands of Heimacy and St. Kilda), and a veritable scourge in certain lying-in hospitals (e.g. Dublin, Stockholm, St. Petersburg). Occasionally it has prevailed epidemically.

²³ Wallace, however, found that in the Medical College Hospital at Calcutta the disease occurred proportionably more frequently in the children of European than of native mothers, though the actual number of cases among the latter was very much the greater.

Attacking usually the children of the poor, others have not been altogether exempt from it, though unquestionably “it is most often seen where the mothers of the children are very young or very poor or very worthless” (Mosely). Rarely appearing before the third day, it as rarely occurs after the twelfth, generally manifesting itself within the first week.

Its cause has been thought to be navel-string injuries; inflammation of the umbilical arteries or vein; reflected irritation from the skin, the bowels, or the external genitals; uræmic encephalopathy; cold and dampness; defective ventilation; and indirect pressure upon the cerebellum and the medulla.

The supposed causative umbilical lesions have time and again been found in young infants presenting none of the symptoms of the disease; and the same is true of the vessel inflammations²⁴ and of the reflex irritations. Atmospheric and climatic states and the hygienic condition of the child and its surroundings, however much they may contribute to the development of the affection, cannot be regarded as directly producing it; though experience has shown (as in the lying-in hospitals before referred to) that by securing proper care of the children, by improving the ventilation, and by preventing overcrowding, its prevalence may be very greatly diminished.

²⁴ Mildner of Prague reports that in 46 fatal cases of inflammation of the umbilical vein, convulsions occurred in but 5, and in these the spasms were not like those of tetanus.

Forty years ago Marion Sims believed that he had discovered the exciting cause in “pressure exerted on the medulla oblongata and its nerves, the result most generally of an inward displacement of the occipital bone,” occasionally, though rarely, of the parietal. That intracranial pressure may give rise to tetanic symptoms is beyond question, seizures identical with those of tetanus having been observed in connection with tumors of the cerebellum (Hughlings Jackson), as also trismus, confined even to one side (Wernicke).

In some cases without doubt the occipital depression is secondary, the result of intracranial shrinkage; and even if primary, there may be no lockjaw.²⁵

²⁵ H. G. Lyttle of New York recently reported the case of a child two months old whose occipital bone was depressed and overlapped by the parietals, in which there had been no trismus, though the child had slight convulsive movements of the hands and rolling of the eyes.

Parrot regarded the disease as a form of eclampsia, the uræmic encephalopathy manifesting itself as one or other of the three varieties recognized (by Cederschjöld) a half century ago—viz. trismus, tetanus, and ordinary eclampsia. The articular rigidity, especially noticeable in the temporo-maxillary joint, he held to be largely independent of the convulsive tonicity of the muscles, and due in no small measure to induration of the overlying soft parts, such hardening being the result of that loss of fluid which, as it affects the body in general, produces the rapid and extreme emaciation which is so characteristic of the disease.²⁶

²⁶ Parrot adds: “In the new-born in a state of health great difficulty is experienced in separating the jaws, the muscles that bring them together having, relatively, considerable power, and the infants making quite an active resistance when one attempts to separate them. It follows that when a pathological state exaggerates this tendency it may be thought that we have to do with a veritable trismus.”

Though there is at times a prodromal period of restlessness and fretfulness, usually the disease is first indicated by an inability to nurse, the nipple being eagerly seized upon, but quickly dropped—an action that may be regarded as almost pathognomonic. Swallowing, difficult from the first, soon becomes impossible. The lower jaw in the earlier hours in many cases is dropped, but nearly always well-marked trismus is more or less quickly developed, at first intermittent, but later persistent. Opisthotonos in some degree is almost certain to be present, and in a large proportion of cases the tetanic convulsions become generalized, clonic exacerbations occurring as often as every half hour or hour, and capable of being induced at any time by pressure upon the abdomen (Morrison), or indeed by any external irritation, noise, touch, draft of air, etc.

All observers have noticed the peculiar cry, or rather whine, of the little patient. The bowels have in some cases been constipated, in others diarrhœa has been present. The temperature is generally decidedly elevated, and has been known to reach 111.2° F. Usually in from twelve to twenty-four or thirty-six hours collapse occurs, and the child speedily dies; though the fatal result may be deferred for a number of days or suddenly produced at any moment by spasm of the respiratory muscles.

Upon autopsy there has generally been found hyperæmia of the brain and cord with extravasations (commonly perithecal) in the spinal canal, occasionally in the meninges of the brain and in the ventricles. Very probably, as in true tetanus, these vascular conditions are the effect, and not the cause, of the spasms; and sometimes, doubtless, they are hypostatic.

As usually observed and commonly treated, the PROGNOSIS is very bad. Whether occurring in India or in Iceland, in the Rotunda Hospital in Dublin or in the Foundling Hospital in St. Petersburg, in the negro cabins of our Southern States or in New York or Washington, the subjects of it almost always die, generally in from six to forty-eight hours.²⁷ It has been very exceptional to have 20 per cent.²⁸ of recoveries, or even 15;²⁹ and the non-fatal cases have almost invariably been those in which the disease appeared late and in mild form.

²⁷ 80 per cent. of the cases collected by Hartigan (207—165).

²⁸ 8 out of 40 cases tabulated by Smith; 8 out of 42 in the Stockholm Lying-in Hospital in 1834. It is very probable that these latter were cases of infantile meningitis.

²⁹ 5 out of 34 cases reported by Wallace from the Medical College Hospital of Calcutta.

When treated by manipulation and position, as recommended by Marion Sims, the chances of recovery seem to be very much greater. Even in the acute cases under the care of Sims, of Wilhite, and of Hartigan, death occurred only in those seen late, after extravasations had taken place.

The Sims's method consists simply in releasing the overlapped occipital bone by manipulation (or, if that fails, by an operation), and then placing the child so that the head shall rest flat upon its side, the face looking directly toward the horizon. The success attending this postural treatment has been so remarkable that the practitioner cannot be justified in failing to determine the relative positions of the occipital and parietal bones and to keep the head resting upon its side.

Of the medicinal agents that have been administered (the same as those employed in ordinary tetanus), calabar and chloral have of late years been the favorites, chloral to-day standing highest in professional estimation. Calabar is best given hypodermically in doses of from ¹/12 to ¹/6 gr. of eserine; chloral, either by the mouth (½ to 1½ or 2 grs.) or preferably by the rectum (2 to 4 grs.), either drug being pushed until relaxation takes place and sleep is secured, or toxic symptoms become so grave as to compel suspension of the treatment. Though favorable results have rarely followed such medication,³⁰ and (with but few exceptions) only in late-developed and mild cases that very possibly would have gotten well of themselves; yet as recovery from an acute attack has occasionally been reported, at least the chloral treatment should be instituted in every case not found to be promptly relieved by change of position of the head.

³⁰ Monti, however, reported 11 recoveries out of 16 cases treated with calabar (68.75 per cent.), 3 out of 5 in his own practice; and Widerhofer was credited in 1871 with 6 recoveries in the 10 or 12 cases that he treated with chloral.

Whatever views may be entertained as to cause or nature, it is to measures that will prevent development that we must chiefly look for relief from this lockjaw of infants, that even in our own country annually carries off a great number of children—25,000, as estimated by Hartigan. If mechanically produced, its occurrence should be rendered impossible by having the child's head from the time of birth properly placed, and at regular intervals changed in position. If defective hygiene, personal and social, is the one common and constant condition wherever the disease prevails, then due regard should be had to dressing the umbilical (and perhaps the preputial) wound; to bathing, clothing, and keeping quiet³¹ the child; to thoroughly airing,³² warming, and disinfecting the lying-in room; and to overcoming, as far as may be possible, the evil influences of unfavorable atmospheric and climatic conditions.

³¹ In these new-born children, though the reflex irritability is less than in those older, the response to irritation is very much greater, because of the lessened inhibitory power at this age (Soltmann).

³² By increasing the air-supply and lessening the number of beds the mortality at the Rotunda was in seven years reduced from about 1 in 7 to about 1 in 19 of the children born.

DISORDERS OF SPEECH.

BY EDWARD P. DAVIS, A.M., M.D.

Development of Speech.

The study of speech, a complex function, enlisting at once the activities of mind and body, invites the physician to enter alike the domains of the psychologist and physiologist.

Distinguishing man from beast, articulate expression has its foundation in purely mental phenomena; its successful accomplishment requires the reflex mechanism common to man and beast.

Let us consider as concisely as possible the physiology of speech.

DEVELOPMENT OF SPEECH IN THE INDIVIDUAL.—The earliest observation has noted in the common name of the new-born child its speechless condition; it is the infant, or not-speaking being. Born with a nervous system in a highly unstable condition, the babe is a most favorable recipient of the many impressions which stream upon it from all sides. With sight and hearing undeveloped, the field of early infantile impressions is limited to hunger, need of sleep, and cutaneous impressions. Speech under such conditions is inarticulate, an animal cry, unconscious and without intelligence. But with the growth of the cerebrum the child's environment suggests to the embryonic intelligence its primal impression. The parental relation is dimly apprehended, and designations of the father and mother are uttered in scarcely articulate sounds.

Sight and hearing open extensive fields of sensation, and with their development begin the primal, physical impressions from which proceed the emotions. The acoustic and optic centres of perception become established, and the mental formation of symbols and signs, an imitative process, marks the stage of childish cerebration, beyond which the savage often does not proceed. The symbolic function is the basis of language and of pictorial representation; as man requires the trade medium of the symbol for the interchange of his ideas, so his legal tender appears with the first emergence of mental enterprise. The hieroglyphic and the onomatopoetic word are as old as humanity.

The co-ordinating mechanism of speech is of equal development. With the growth of the child the varied impressions of education, of surroundings, of heredity, all are influencing speech. With mental growth, stimulated by these numerous impressions, comes the gradual mental habit of forming ideas after certain models—of trading, so to speak, in the coin of the country, of making and using a vocabulary. Intuition, induction, and deduction are established, the general nervous function of memory develops, observations are made, and mind and body, master and instrument, enter upon full activity.

PHYSIOLOGY OF NORMAL SPEECH IN THE ADULT.—Let us consider normal speech in the adult. From a purely mental aspect speech is not included in the nervous reflexes. The conception before the individual may arise without sight or sound, it may be the object of the mental processes only; but if it is to be communicated, or transferred from the subjective to the objective, it calls into play the denotative faculty or facultas signatrix.

As we are cognizant through the senses of phenomena only, so we communicate only phenomena, or more particularly symbols; the spoken or written word, the gesture, are necessary to make ideas tangible to another mind. The symbolic faculty, then, is the mental faculty most concerned in speech.

Cerebral localization has not included this faculty in its areas; it is assigned to the anterior cortex, which as yet is the indiscriminate site of the formation of ideas. The idea conceived, the symbol formed, the motor area whose integrity is essential, is found in the region commonly known as Broca's convolution, the posterior third of the left third frontal convolution. This region is especially connected with the corona radiata coming from the corpus striatum, with the corpus striatum and the anterior portion of the internal capsule: like the anterior, or motor, cornua of the spinal cord, it possesses giant, or branching, nerve-cells; its anatomy would assign to it a motor function. Its blood-supply is derived through the inferior frontal branch of the Sylvian vessel, whose occlusion in a case cited by Charcot was followed by complete aphasia.

Ferrier distinguishes just adjacent to this centre the motor centres for the tongue and mouth and upper extremities, showing an anatomical association of the processes of articulate and written speech.

But purely motor impulses comprise only a portion of the phenomena of speech. The external world must be brought into relation with the mind, and this is done through the perceptions. We may say that perceptions are apprehended sensations, and this apprehension demands a localized field of cerebral activity, as well as the motor energies. It seems natural enough that experiment should have located (Ferrier) perceptive, visual, and acoustic centres in the posterior cortical areas and temporo-sphenoidal lobes—that the motor and perceptive areas should be contiguous and sharing a common blood-supply.

The perceptive visual centre is found to occupy the occipital lobes, while the acoustic centre occupies the whole length of the first temporo-sphenoidal convolution.

As motor impulses found a path to the motor ganglia, and finally to the cord, so the course of sensory perceptive impressions can be traced back through the posterior internal capsule and through the optic thalami to the sensory columns of the medulla and cord.

Intuitive and sense perception, even when reinforced with motor power, cannot result in articulation. The mechanism of speech requires a co-ordinating centre, and this basal phonic centre of Kussmaul is located in the medulla near the origin of the hypoglossal and facial nerves. From the medulla proceed the nerves supplying the machinery of phonation, the superior laryngeal nerve to the mucous membrane of the larynx and to the crico-thyroid muscle, the most important muscle of phonation. The remaining laryngeal muscles are supplied by the recurrent laryngeal; the motor processes of articulation are guided by the hypoglossal, facial, and fibres of the glosso-pharyngeal.

The larynx is a reed, with the addition of numerous resonance-cavities producing abundant overtones. It may be considered as a box composed of two segments, the lower of which has vertical motion upon the joint at the posterior junction of the superior and inferior segments. By this motion the tongue of the reed (vocal cords, stretching antero-posteriorly from lower segment to junction with upper segment) is tightened or relaxed, the vibratory blast of air coming through the trachea from the lungs. The superior aperture of the tube is guarded by the epiglottis and false vocal cords. As auxiliaries are the pharyngeal, oral, and nasal cavities, with the associated bony cavities of the skull, the soft palate acting as a movable partition or switch, the hard palate as a sounding-board or resonance-surface. The reed is applicable to the production of musical sounds; the tongue, lips, and teeth are required for the checks in those sounds, constituting the consonants or division utterances.

The curious phenomenon of the falsetto voice is thought by Helmholtz to be produced by the attenuation of the true cords and the vibration of their thinned edges.

DEVELOPMENT OF LANGUAGE.—The study of language demonstrates its origin to have been largely in exclamations and imitative sounds, from which our vowels can easily have arisen. The growth of all synthetic language illustrates the aggregation of accessory sounds about the primitive root-sound, while the common tendency to the insertion of consonants shows their addition to the primitive vowels. That the long vowels should have undergone countless modifications from the physical peculiarities and environment of those speaking them is but natural, for the number of vowels remaining in actual use in any language is not large. Consonants serve to make more clear by their separation of vowel-sounds the meaning to be conveyed; their development resulted from vowel changes, and their number is small.

The written characters of language represent only the usage of the majority. Individual speech and pronunciation vary as greatly as do languages themselves, and it is evident that the speech of any individual is as truly peculiar as his physical conformation.

To recapitulate, we find ideas, the material of speech, formed in the cerebral cortex. Speech-volition becomes motor impulse at Broca's convolution; such impulse passes along the internal capsule to the corpus striatum, where it is co-ordinated probably in the formation of syllables, thence to the medulla, whence the mechanism of the larynx receives its co-ordinated stimulation.

Disorders of Speech.

The classification of the disorders of speech should depend on the anatomical site of the lesions by which they are occasioned. Broadly speaking, speech disorders resolve themselves into those of the formative apparatus for ideas and symbols and those of the purely co-ordinating and conducting mechanism. Abbreviating the schedule of Potter, we may say that the disorders of speech may be included in three classes—alalia, or lack of speech; paralalia, defective speech, the stammering of most observers; and dyslalia, difficult speech or stuttering.

The anatomy of the blood-supply of the speech-centres affords some explanation of alalia. The Sylvian artery will be remembered as the feeder of the speech-centres—an artery often the source of hemorrhage, as Charcot suggests, from the angle at which it leaves the carotid. Ducrot explains the frequency of left-sided softening and hemorrhage from the manner of origin of the left carotid, its axis being more nearly that of the ascending aorta and furnishing a ready channel for cardiac clots. In regard to the relative frequency of peripheral and central hemorrhage, Andral and Durand-Fardel cite 119 cases, of which but 17 were in the anterior or posterior lobes. It is admitted that cerebral lesions are largely those of the circulatory system, and the fact that such lesions result in the suspension of the activity of restricted areas is due to the circumstance that the cerebral arteries are terminal vessels giving off no anastomosing branches and supplying restricted areas only. With blood-supply so arranged it is not difficult to understand how the different portions of the motor centres may be separately involved, and thus the motor functions of speech may become singly at fault.

Inability to remember words and inability to form the motor impulses necessary for speech or writing are the common forms of alalia or aphasia, the former being known as amnesic, the latter as ataxic, alalia. In addition, we may cite the failure of cerebral power occurring in general softening, in microcephalic brains, and the curious instances of voluntary silence from some strong belief or prejudice. Instances of the gradual resumption of cerebral function after its loss are not wanting; and, occurring where subsequent post-mortem examinations reveal a limited area of destruction of brain-tissue, they afford examples of the vicarious performance of cerebral functions by contiguous areas.

The phenomena of amnesic alalia are commonly seen in cases of recovery from cerebral hemorrhage, cerebral injury, and severe febrile affections. Numerous cases are recorded where the memory of things themselves remained, but the faculty of denoting them had been destroyed.

Kussmaul distinguishes here two conditions: 1st, where the word is entirely effaced from memory, 2d, where it still remains, but its association with that which it represents is suppressed. Cases of the second class are the most frequent, the fundamental part which the association of ideas plays in mental activity and the extent to which memory is dependent on association explaining this fact. A marked example of the failure of the denotative faculty lies in the cases of forgetfulness of one's own name, as described by Crichton in the case of an ambassador at the Russian court, who was obliged to say to his companion, when visitors asked his name, “For Heaven's sake, tell me what I call myself!” Piorry mentions the case of an aged priest who after right-sided paralysis lost entirely the use of substantives; wishing to ask for his hat, the word hat failed him utterly, and he was obliged to express himself in the remaining parts of speech: “Give me that which I place upon the ——;” but the word head, denoting the object most commonly in relation with the hat, was wanting also. When either hat or head was mentioned he spoke the word without difficulty.

Instances of failure in linguistic faculty are not uncommon. Witness a case, reported by Proust, of an Italian who after long residence in France, though understanding his native tongue, could speak only in French. Cases in which after acute disease one language is gone entirely while several others are retained are not wanting. A striking case of amnesic alalia was that of Lordat, a French physician, who thus described his malady: “I find myself deprived of the value of all words. If any words remain to me, they become useless, because I can no longer remember the manner in which I must co-ordinate them to express my thoughts. I am conscious that I recognize all ideas, but my memory does not suggest a word. In losing the memory of the meaning of spoken words I have lost that of their visible signs.”

Fortunately, these cases are among the more tractable of cerebral disorders. Bristowe has reported a case wherein elementary instruction in speech-formation was tried with marked success. The patient, aged thirty-six, after a violent cerebral disturbance without traumatism became paraplegic, speechless, and deaf. Gradual recovery ensued until, seven months after his first illness, he was admitted into St. Thomas's Hospital in the following condition: Numbness and paresis in left leg, less in left arm; special senses healthy; no incontinence; some pain about head and neck; complete loss of speech. It was found that the patient was very intelligent, wrote legibly, could make all kinds of voluntary movements with lips, tongue, and teeth, and was capable of vocal intonation; articulation alone was lacking.

The law of the evolution of language designates as primitive forms of word-signs those words affirming qualities, while those denoting relative positions are of secondary formation (Whitney.) Remembering, also, the fact that amnesia in general “is a regression from the new to the old, from the complex to the simple, from the voluntary to the automatic, from the least organized to the best organized,”¹ we are able to understand the cause of amnesic alalia, and also the steps of the process of recovery, in which the inverse order is observed.

¹ Ribot, Diseases of Memory.

Amnesic alalia can hardly be regarded as susceptible of treatment other than as a general neurasthenia. Though we may develop memory by cultivating the association of ideas and by repetition, yet, regarding it as a general function of the nervous system, it is evident that recovery from its disorders is conditioned by the general vigor of the nervous centres. A partial recovery usually occurs in such cases; complete recovery is more infrequent.

Ataxic alalia, the failure of the motor powers of speech, occurs in all forms of general paralysis, most typically in bulbar paralysis. This disease is fully described in the standard works on neurology. Ataxic alalia will also occur in disseminated sclerosis, posterior spinal sclerosis, dementia paralytica, and cretinism. It forms in general disorders an instructive symptom, and is to be distinguished by a tremulous utterance and by facial spasm from the hesitation of the stammerer and from the convulsive utterance of the stutterer.

Paralalia embraces all abnormalities of speech, from trivial mannerisms to difficulties in the utterance of certain letters, including those painful defects which depend upon physical malformations.

The free discussion of paralalia would cover the domain of elocution; the physician is called upon to advise in those cases only where either a physical malformation is evident or the difficulty experienced by the patient in enunciating certain letters has led to a suspicion of the existence of malformation. The former cases lie in the province of the surgeon; the latter come within the scope of those elocutionists, speech-trainers, and instructors who hope to cure stammering and stuttering.

Discrimination between stammering and stuttering will give the physician a basis for judgment from which he can reasonably offer encouragement in many cases and avoid the creation of false hopes in others. As a cardinal point of difference, it will be remarked that in the case of the stutterer the muscles of phonation are thrown into a state of spasm when speech is attempted, while in the stammerer their movements are merely lacking in proper co-ordination. It may also be observed that the respiration of the stammerer is marked by irregular contractions of the diaphragm, which render the expiratory blast of air irregular in its delivery. In the stutterer the spasm is pronouncedly laryngeal and facial. The nervous embarrassment of the stutterer is proverbial, and is increased by excitement, while a moderate degree of excitement, stimulating respiration, greatly improves the speech of the stammerer.

Whispering, a difficult respiratory act, exaggerates the stammerer's fault, but the spasm of the stutterer is often relaxed by the diminished pressure of whispered breath.

As articulation is effected by the larynx and the oral organs, the stutterer makes his spasmodic articulation particularly noticeable, while the stammerer finds little difficulty in the utterance of words. R, L, S, and other letters whose enunciation demands the continued expiratory blast, are imperfectly uttered by the stammerer, while these letters when joined to a long vowel-sound occasion little or no difficulty for the stutterer.

TREATMENT.—It follows that if stammering is recognized as inco-ordinate enunciation, owing largely to irregular action of the diaphragm, any training of the respiratory muscles which will ensure a regular delivery of the expiratory air will improve this defect. It follows, then, that the treatment of stammering resolves itself into careful attention to general hygiene, associated with such persistent respiratory and vocal gymnastics as shall effectually develop regularity, depth, and co-ordination of action on the part of all the muscles concerned in the act of respiration. Drugs will be of service only as aids to the correction of errors in the essential physiological functions. In the child the powers of imitation may be enlisted to effect a cure, and the familiar fact that the habits of childhood are easily formed would indicate this as the best time for treatment.

Childhood once passed, however, the steadiness of purpose of the adult is requisite to break up a confirmed habit, and active treatment should be deferred until after adolescence. Most important in all cases are judicious moral influences exerted by those about the patient, the ridicule so often visited upon the unfortunate stammerer being most harmful in its consequences. The many tricks and devices so often employed in these cases are of use simply by varying the monotony of vocal drill; they may be employed or abandoned as the judgment of the physician may dictate.

Regarding the prognosis in these cases, it follows that with a fairly developed and healthful nervous system, reinforced by proper mental and physical hygiene, the stammerer's case is far from hopeless in the hands of a patient and intelligent physician.

An unfavorable prognosis would be demanded by hereditary defects and vices of the nervous system, by the lack of general nervous vitality, by enfeeblement of the will and the mental tone of the individual, by advanced age, and by irremediable hygienic conditions. Under favorable conditions recovery should be the rule.

DYSLALIA OR STUTTERING.—Recalling to mind the points of difference between stuttering and stammering, it becomes evident that while the prospect of success in the treatment of the stammerer is often favorable, the case of the stutterer presents such difficulties as render it too frequently hopeless.

We may liken the confirmed stutterer to those rare cases of chorea which defy treatment, and to those cases of hereditary deterioration of the nervous system where the most patient and painstaking care fails to overcome the defect. The laryngeal and facial spasms depend upon no malformation for their exciting cause; hence surgery fails to remedy the defect. Drugs which are given with hope of invigorating the nervous system have only a general tonic influence, while the motor depressants and antispasmodics find but partial success. We must again rely upon hygiene, and also upon those aids to enunciation which come from rhythmical associated movements, such as stamping with the foot, beating time with the hand, the employment of a sing-song tone, or other modes of specially rhythmic enunciation. The sing-song mode of utterance is a familiar resource with parents in attempting to aid a stuttering child, and the measured forms of articulation offer the only vocal drill that possesses any permanent value. It is especially essential in the stutterer's case that the patient be protected from ridicule and from all disturbing emotions: the burden of difficult speech is sufficient to greatly depress the nervous system without the added suffering of emotional distress. It is evident that childhood, characterized as it is by especial instability of the nervous system, is the period when we can hope for the best results from care and training; the long-formed habits of the adult are rarely broken.

We have thus traced the disorders of speech to their origin as symptoms of grave central lesions of the nervous system, as results of heredity or of a general neurasthenic condition; very rarely are they dependent upon malformations of the organs of speech.

The treatment of such malformations, when they occur, is largely unsatisfactory and is seldom curative.

The thorough treatment of those speech disorders that are not susceptible of surgical aid would embrace such mental and physical hygiene and training as should ensure the formation of a thoroughly conceived vocabulary and its co-ordinated expression by words either spoken or written. The study of expression in its highest forms would necessarily conduct the investigator far into the realm of the plastic, harmonic, and literary arts.

ALCOHOLISM.

BY JAMES C. WILSON, M.D.

DEFINITION.—Alcoholism is the term used to designate collectively the morbid phenomena caused by the abuse of alcohol.

SYNONYMS.—Alcoholismus, Ebrietas, Ebriositas, Temulentia, Drunkenness, Delirium potatorium, Mania potatorium, Delirium tremens, Chronic alcoholic intoxication, Dipsomania; Ger. Trunkenheit, Trunksucht; Fr. Ivresse, Ivrognerie.

These terms are in common use to describe such conditions and outbreaks in alcoholic individuals as amount to veritable morbid states or attacks of sickness, but they are not interchangeable, nor are they all sufficiently comprehensive to constitute true synonyms. They are names applied to various conditions due to acute or chronic alcohol-poisoning properly and distinctively comprehended under the general term alcoholism.

CLASSIFICATION.—It was formerly the custom to restrict this term to affections of the general nervous system induced by continued excesses in the use of alcoholic drinks.¹ But the nervous system bears the brunt of the attack and suffers beyond all others alike in transient and in continued excesses. The artificial restriction of the term to the cases caused by continued excesses was therefore illogical in itself, and has been productive of much needless difficulty in the treatment of the subject and in the classification of the cases. The use of the term chronic alcoholism to denote an established condition, and of acute alcoholism to describe outbreaks of various kinds which occur in individuals subject to that condition, has also proved a source of embarrassment to the student. Not less vague has been the employment of such terms as delirium tremens, mania-a-potu, and the like, which are unsatisfactory in themselves, and tend to exalt symptoms at the expense of the morbid condition of which they are only in part the manifestation. I am of the opinion—which is at variance with established usage—that the systematic discussion of alcoholism requires that all forms of sickness, including drunkenness, due to that poison must receive due consideration, and that the term acute alcoholism, hitherto used in a sense at once too comprehensive and too variable, should be reserved for those cases in which the sudden energetic action of the poison is the occasion of like sudden and intense manifestations of its effects. Furthermore, the uncertainty and lack of precision in the use of the terms acute and chronic alcoholism are due to errors of theory formerly almost universal in medical writings and popular belief concerning the disease. The chief source of these errors was the recognition only of the more acute nervous affections caused by alcoholic excess—delirium tremens, maniacal excitement, and terrifying hallucinations—and the belief that these conditions occurred only after a temporary abstinence in the course of habitual or prolonged indulgence. It has now long been known that abstinence from drink by no means necessarily precedes the outbreak of mania or delirium, and modern researches have established the existence of a chronic alcoholic intoxication of long duration extending over a period of months or years, in which such outbreaks merely exhibit the full development of symptoms that have already been occasionally and partially recognizable.

¹ Anstie, Reynolds's System of Medicine, vol. ii., 1868.

The following arrangement of the topics will facilitate the discussion of the subject in the present article, and serve, I trust, a useful purpose for the classification of cases in accordance with existing knowledge:²

I. Acute Alcoholism: Drunkenness, Debauch. A. Ordinary or Typical Form. B. Irregular Forms. 1. Maniacal; 2. Convulsive; 3. In persons of unsound mind. C. Acute Poisoning by Alcohol: Lethal doses. II. Chronic Alcoholism. A. Visceral Derangements. 1. Local disorders: a. Of the digestive system; b. Of the liver; c. Of the respiratory system; d. Of the circulatory system; e. Genito-urinary system. 2. Disorders of special structures: a. Of the locomotor apparatus; b. Of the skin. 3. General disorders: a. The blood; b. Obesity; c. Cachexia. B. Derangements of the Nervous System: Cerebro-spinal Disorders. 1. Cerebral disorders. 2. Spinal disorders. 3. Disorders of the peripheral nerves. 4. Disorders of the special senses. C. Psychical Derangements. 1. The moral sense. 2. The will. 3. The intellect. 4. Alcoholic delirium in general. 5. Delirium tremens. 6. Alcoholic insanity: a. Melancholia; b. Mania; c. Chronic delirium; d. Dementia; e. Paretic dementia. III. Hereditary Alcoholism. IV. Dipsomania.

² This classification is in part based upon that of Lentz, De l'Alcoholism et de ses Diverses manifestations, etc., Bruxelles, 1884—a prize essay.

HISTORY.—The history of the abuse of alcohol would be the history of society from the most remote period until the present time, not only among civilized but among barbarous races of men, for the abuse of narcotics, of which alcohol is at once the most important and the most widely used, forms a dark background to the broad picture of healthful human progress. In truth, the most sketchy account of our knowledge of the effects of alcoholic excess, as manifested in the individual and in society at large, interesting as it might prove to the general reader, would be out of place in this article. To be of real value it would necessarily embody a record of experiences so vague, facts so indeterminate, opinions so at variance, and citations so numerous, that they would require for their mere presentation a volume rather than an article. The object of the writer in the following pages shall be, therefore, to present the subject in its present aspect, without reference, beyond that which is absolutely necessary, to considerations of mere historical interest. This being the case, he considers further apology for the lack of laborious historical studies unnecessary.

ETIOLOGY.—A. Predisposing Influences.—We are at this point confronted with a series of problems the complex nature and grave importance of which appeal with peculiar urgency to all thoughtful physicians. Their discussion, however, involving as it does unsettled questions of great moment in social science, is beyond the scope of the present article. A few practical points only can occupy our attention.

The influences which predispose to alcoholism arise from unfavorable moral, social, and personal conditions.

Among the unfavorable moral conditions may be mentioned a want of wholesome public sentiment on the subject in communities. This arises too often, but by no means exclusively, from poverty and its attendant evils ignorance and vice. Rum is at once the refuge and the snare of want, destitution, and sorrow. To the vacant and untrained mind it brings boons not otherwise to be had—excitement and oblivion. That both are brief and bought at a ruinous cost exerts little restraining influence. Of equal if not greater importance are the influences which spring from ill-regulated and demoralizing domestic relations, and the absence of motive and the contentment which properly belong to the family as an organization. Everywhere also do we find in example a potent influence. In the individual, in addition to hereditary propensities, the evil results of a lax, over-indulgent, or vicious early training, as shown in a want of power of application, of moral rectitude, in self-indulgence, craving for excitement, and a weak will, powerfully predispose to the temptations of alcoholic excess.

Among social conditions which must be regarded as predisposing influences occupation takes the first rank. The occupations which render those pursuing them especially liable to alcoholism may be divided into two classes—those in which the temptation to drink is constantly present, and those in which the character of the work begets a desire for stimulation, while the opportunities for the gratification of the desire are but little restricted.

To the first of these groups belong all classes of workmen in distilleries, breweries, and bottling establishments; keepers and clerks of hotels, public houses, and restaurants; the barmen and waiters in the same trades; the salesmen who travel for dealers in wines and spirits. To this group must also be referred the professional politician of the lowest order. These occupations have furnished by far the larger number of cases that have come under my care, both in hospital and in private practice.

To the second class belong occupations involving great exposure to the inclemency of the weather. We frequently find cabmen, expressmen, coal-heavers, hucksters, and street-laborers habitually addicted to excesses in alcohol. The stringent regulations of corporations exert a powerful protective influence in the case of men employed on railways, ferry- and other steamboat service, and in and about dépôts and stations. Exhausting toil under unfavorable circumstances as regards heat and confinement predisposes to drink, as in the case of foundrymen, workers in rolling-mills, stokers, and the like. The men-cooks who work in hotels and restaurants are especially liable to alcoholism. Monotony of occupation, as in the cases of cobblers, tailors, bakers, printers, etc., especially when associated with close, ill-ventilated workrooms and long hours of toil, exerts a strong predisposing influence. Persons following sedentary occupations suffer from excesses sooner than those whose active outdoor life favors elimination. To the monotony of their occupations may be ascribed in part, at least, the disposition of soldiers, ranchmen, sailors, etc. to occasional excesses as opportunities occur. Irregularity of work, especially when much small money is handled, as happens with butchers, marketmen, and hucksters, also often leads to intemperance.

The lack of occupation exerts a baleful influence. Men-about-town, the frequenters of clubs, dawdlers, and quidnuncs often fall victims to a fate from which occupation and the necessity to work would have saved them. In this connection it may be permitted to call attention to the custom of treating as enormously augmenting the dangers to which such persons are habitually exposed in the matter of alcoholic excesses. The occasional moderate use of alcohol in the form of wine with food and as a source of social pleasure is not fraught with the moral or physical evils attributed to it by many earnest and sincere persons. It is, on the contrary, probable that the well-regulated and temperate use of sound wines under proper circumstances and with food is, in a majority of individuals, attended with benefit. Those who suffer from the effects of excesses do not usually reach them by this route, nor would they be saved by any amount of abstinence on the part of temperate and reasonable members of society.

When we turn our attention to the unfavorable personal conditions which predispose to alcoholism, we at once enter upon the familiar field of work of the practical physician. Numerous influences having their origin in the individual himself, some occasional, others constant, all urgent, demand our careful consideration. Some of the conditions out of which these predisposing influences spring are tangible and easy of recognition; others are elusive and uncertain. To point them out is, unfortunately, not to remedy them. As a rule, they have wrought their evil effects long before the individual has cause to regard himself in the light of a patient.

First in importance is heredity. A peculiar inherited constitution of the nervous system is as influential in leading to alcoholic excess and in aggravating its disastrous effects as any other cause whatsoever. A considerable proportion of individuals who suffer from alcoholism are found upon inquiry to come of parents who have been addicted to drink. A still greater number belong to families in which nervous disorders, and in particular neuralgia, epilepsy, and insanity, have prevailed. Others, again, are the offspring of criminals. It can no longer be doubted that particular causes of nervous degeneration in one or both parents may lead to the hereditary transmission of a feeble nervous organization, which, on the one hand, renders its possessor peculiarly liable to neuroses of every kind, and, on the other hand, an easy prey to the temptation to seek refuge from mental and physical suffering in occasional or habitual narcotic indulgence. Thus, as Anstie pointed out, “the nervous enfeeblement produced in an ancestor by great excesses in drink is reproduced in his various descendants, with the effect of producing insanity in one, epilepsy in another, neuralgia in a third, alcoholic excesses in a fourth, and so on.” When it is possible to obtain fairly complete family histories, covering two or three generations, in grave nervous cases, facts of this kind are elicited with surprising frequency. The part which heredity plays in many of the more inveterate and hopeless cases of alcoholism is wholly out of proportion to the obvious and easily recognizable part played by momentary temptation. To the failure to recognize the real agency at work in such cases must be ascribed the disappointment of too many sanguine and unsuccessful social reformers.

Various forms of disease exert a predisposing influence to alcoholic excesses. In the first place, bodily weakness and inability to cope with the daily tasks imposed by necessity impel great numbers of persons of feeble constitution, especially among the laboring classes, to the abuse of alcohol.

In the second place, many conditions of chronic disease attended by suffering are susceptible of great temporary relief from the taking of alcohol. Especially is this the case in the neuralgias, in phthisis, in dysmenorrhœa and other sexual disorders of women, in the faintness and depression of too-prolonged lactation, in the pains and anxieties of syphilis, and in the malaise of chronic malaria. When the patient has learned that alcohol is capable of affording relief from suffering, it is but a short step through ignorance or recklessness to habitual excess.

The administration of alcohol during convalescence from attacks of illness is not unattended by the danger of subsequent abuse. It is well for the physician to inform himself of the hereditary tendencies and previous habits of the patient before assuming the responsibility of continuing alcohol beyond the period of acute illness under these circumstances; and it is a rule never to be disregarded that the stimulant ordered by the physician is to be regulated by him in amount, and discontinued when the patient passes out of his care.

Irregularities of the sexual functions in both sexes, and especially sexual excesses, strongly predispose to alcoholism. The custom of administering to young women suffering from painful menstruation warming draughts containing gin, brandy, or other alcoholic preparations in excessive amounts is a fertile cause of secret tippling.

The abuse of tobacco, to the depressing effects of which alcohol is a prompt and efficient antidote, must be ranked as an important predisposing influence.

Depressing mental influences of all kinds tend strongly to drinking habits. This is true of persons in all classes of society.

Habit constitutes an influence the importance of which can scarcely be over-estimated. Much of the drinking done by active business-men has no other cause than this. Alcohol, like opium and other narcotics, exerts its most pernicious influence through the periodical craving on the part of the nervous system for the renewal of the stimulating effects which it causes, while it progressively shortens the period and diminishes the effect by its deteriorating action upon the nutrition of the peripheral and central nervous tissues.

B. The Exciting Cause.—Alcohol, or ethyl hydrate, is the product of the fermentation of solutions which contain glucose or a substance capable of transformation into glucose. Other alcohols, as propyl, butyl, and amyl alcohol, etc., are also formed in small quantity in the fermentation of saccharine liquids. Ethyl alcohol is the type of the series, and forms the normal spirituous ingredient of ordinary alcoholic beverages. The others when present, except in minute quantities, constitute impurities. Their toxic effects are much more pronounced than those of ethyl alcohol.

Alcohol is a colorless mobile liquid having an agreeable spirituous odor and a pungent, caustic taste, becoming fainter upon dilution. It mixes with water and ether in all proportions.

Alcoholic beverages form three principal groups: 1, spirits, or distilled liquors; 2, wines, or fermented liquors; and 3, malt liquors.

1. The various spirituous liquors, as whiskey, gin, rum, brandy, etc., contain, in addition to the ethyl alcohol and water common to them all, varying minute proportions of ethereal and oily substances to which each owes its peculiar taste and odor. These substances are œnanthic, acetic, and valerianic ethers, products of the reaction between the corresponding acids and alcohol, and various essential oils. Traces of the other alcohols are also present. Amyl alcohol, the so-called fusel oil, is present in new and coarse spirit, but especially in that derived from potatoes, in considerable amounts. It is to this ingredient that potato spirit owes its peculiarly deleterious properties. Richardson³ experimentally produced with amyl alcohol phenomena analogous to delirium tremens in man. Spirits also frequently contain sugar, caramel, and coloring matters derived from the cask, to which certain products of the still also owe in part their flavor. These liquors are of varying strength, and contain from 45 to 70 per cent. of absolute alcohol by volume.⁴

³ On Alcohol, Lond., 1875.

⁴ Vide Baer, Der Alcoholismus, Berlin, 1878.

Liqueurs (anise, kümmel, curaçoa, Benedictine, etc.) are the products of the distillation of alcohol with various aromatic herbs, sweetened, or of its admixture with ethereal oils and sugar. These compounds contain a very high percentage of alcohol. Two of them, absinthe and kirsch, by reason of their peculiarly dangerous properties deserve especial mention.

Absinthe is an alcoholic distillate of anise, coriander, etc. with the leaves and flowers of the Artemisia absinthium, which yields a greenish essence. This liqueur contains from 60 to 72 per cent. of alcohol, and exerts a specific pernicious effect upon the nervous system, largely due to the aromatic principles which it contains.⁵ Kirsch, which owes its peculiar flavor to the oil of bitter almonds and hydrocyanic acid which it contains in varying and often relatively large proportions, is still more dangerous. The toxic effects produced by these liqueurs are of a very complex kind, and scarcely fall within the scope of this article.

⁵ As early as 1851, Champouillon (referred to by Husemann, Handbuch der Toxicologie) called attention to the fact that the French soldiers in Algiers, in consequence of excessive indulgence in absinthe, suffered especially from mania and meningitis. Decaisne (La Temperance, 1873, Étude médicale sur les buveurs d'absinthe) found absinthe in equal doses and of the same alcohol concentration to act much more powerfully than ordinary spirits, intoxication being more rapidly induced and the phenomena of chronic alcoholism earlier established. Pupier (Gazette hébdom., 1872) found in those addicted to the use of absinthe marked tendency to emaciation and to cirrhosis of the liver; and Magnan (Archives de Physiol., 1872) asserts that the chronic alcoholism due to this agent is characterized by the frequency and severity of the epileptic seizures which accompany it. There is reason to believe that the consumption of absinthe in the cities of the United States is increasing.

2. Wines are the product of the fermentation of the juice of the grape. Their chemical composition is extremely complex. They owe their general characteristics to constituents developed during fermentation, but their special peculiarities are due to the quality of the grape from which they are produced, the soil and climate in which it is grown, and the method of treatment at the various stages of the wine-making process. So sensitive are the influences that affect the quality of wine that, as is well known, the products of neighboring vineyards in the same region, and of different vintages from the same ground in successive years, very often show wide differences of flavor, delicacy, and strength.

The most important constituent of wine is alcohol. To this agent it owes its stimulating and agreeable effects in small, its narcotic effects in large, amounts. The proportion of alcohol, according to Parkes, Bowditch, Payen, and other investigators, varies from 5 to 20 per cent. by volume, and in some wines even exceeds the latter amount. The process of fermentation, however, yields, at the most, not more than 15 to 17 per cent. of alcohol, and wines that contain any excess of this proportion have been artificially fortified.

Further constituents of wine are sugar, present in widely varying amounts, and always as a mixture of glucose and levulose—inverted sugar; traces of gummy matter, vegetable albumen, coloring matters, free tartaric and malic acid, and various tartrates, chiefly potassium acid tartrate, or cream of tartar. In some wines there are found also traces of fatty matters. Tannin is likewise found. Small quantities of aldehyde and acetic acid are due to the oxidation of alcohol. The acetic acid thus formed further reacts upon the alcohol, forming acetic ether. To the presence of traces of compound ethers, acetic, œnanthic, etc., wines owe their bouquet. Carbon dioxide, produced in the process of fermentation, is retained to some extent in all wines, and is artificially developed in large quantities in champagnes and other sparkling wines.

Much of the stuff sold as wine, even at high prices, in all parts of the world, is simply an artificial admixture of alcohol, sugar, ethereal essences, and water. The wines rich in alcohol are especially liable to imitation.

Wine is the least harmful of alcoholic drinks. In moderate amounts and at proper times its influence upon the organism is favorable. In addition to its transient stimulating properties, it exerts a salutary and lasting influence upon the nutrition of the body. Only after prolonged and extreme abuse, such as is sometimes seen in wine-growing countries, does it lead to alcoholism.

3. Malt liquors—beer, ale, porter, stout, etc.—are fermented beverages made from a wort of germinated barley, and usually rendered slightly aromatic by hops. This process is known as brewing. Malt liquors, of which beer may be taken as the type, contain from 3.75 to 8 per cent. by volume of alcohol, free carbon dioxide, variable quantities of saccharine matters, dextrin, nitrogenized matters, extractive, bitter and coloring matters, essential oil, and various salts. Much importance has been ascribed to the quantity of malt extractive in beer: it has even been seriously spoken of as fluid bread. But, granting the nutritive value of the malt extractives, it is, as compared with the nutritive value of the grain from which they are derived, so small that beer must be regarded as a food of the most expensive kind.

Sound beer is wholesome and nutritious, and serves a useful purpose in the every-day life of a considerable part of the earth's population. But it is wholesome only in moderate amounts. Its excessive consumption results in progressive deterioration of mind and body. Undue accumulation of fat, diminished excretion of urea and carbon dioxide, are followed by disturbances of nutrition. Incomplete oxidation of the products of tissue-waste leads to the abnormal formation of oxalates, urates, etc., to gout, derangements of the liver, and gall-stones. In long-continued excesses in beer one of the effects of the lupulin is to enfeeble the powers of the reproductive organs. The inordinate consumption of beer induces intellectual dulness and bodily inactivity, and lessens the powers of resistance to disease. The dangers of acute and chronic alcoholism are obvious. Five glasses of beer of 5 per cent. alcohol strength contain as much alcohol as half a beer-glassful of spirits of 50 per cent.

The moderate consumption of beer in communities is to some extent a safeguard against alcoholism. To secure this end, however, the beer must be sound and of light quality. The stronger beers, and especially those which are fortified with coarse spirits, besides the direct dangers attending their use, tend rapidly to the formation of spirit-drinking habits.

The action of alcohol varies according to its degree of concentration, the quantity ingested, and its occasional or habitual use. On the one hand, when well diluted, taken in small amount and occasionally only, it may be without permanent effect upon any function or structure of the body; on the other hand, its frequent administration in large doses and but little diluted is, sooner or later, surely followed by widespread tissue-changes of the most serious kind.

The Physiological Action of Alcohol.—Alcohol is very rapidly taken up by absorbent surfaces. According to Doziel,⁶ it has been detected in the venous and arterial blood and in the lymph of the thoracic duct a minute and a half after its ingestion. It is very slightly if at all absorbed by the unbroken skin. Denuded surfaces and extensive wounds permit its absorption, as in the case of surgical dressings, and instances of intoxication from this cause have been recorded. It is also freely absorbed in the form of vapor by the pulmonary mucous surfaces. Some surfaces, as the pleura and peritoneum, absorb it, as has been demonstrated by the effects following its injection into those cavities. Its constitutional effects are also rapidly developed after hypodermic injection. Under ordinary circumstances, however, it is by the way of the absorbents and veins of the gastric mucous membrane that alcohol finds its way into the blood. It is probable that the greater part of the alcohol taken into the stomach undergoes absorption from that organ, and that very little of it reaches the upper bowel. Alcohol is readily absorbed by the rectal mucous membrane. Having entered the blood, it reaches all the organs of the body, and has been recovered by distillation not only from the blood itself, but also from the brain, lungs, liver, spleen, kidneys, and various secretions.⁷

⁶ Pflüger's Archiv für Physiologie, Band viii., 1874.

⁷ Strauch, De demonstratione Spiritus Vini in corpus ingesti, Dorpati, 1862.

Lentz and other observers believe that certain organs have a special affinity for alcohol. The author named and Schulinus place the brain first in this respect, and in the next rank the muscles, lungs, and kidneys. But Lallemand and Perrin regard the liver and the brain as having an equal affinity for alcohol. The opinion of Baer, who rejects the view that alcohol has an especial predilection for particular organs, is more in accordance with known physiological law. This observer holds that alcohol, having found its way into the blood, circulates uniformly throughout the whole organism, and explains the greater amount recoverable from certain organs as due to the fact that these organs contain more blood than others.

The elimination of alcohol is at first rapid, afterward very gradual. It begins shortly after ingestion, and in the course of two or three hours one quarter, and perhaps much more, of the amount passes from the organism. Nevertheless, after the ingestion of large amounts traces of alcohol were discovered on the fifth day in the urine by Parkes and Wollowicz, although the elimination by the lungs had entirely ceased.

Elimination takes place for the most part by way of the kidneys, the lungs, and the skin; alcohol has been recovered also from the bile, saliva, and the milk.

Whatever may be the affinity of certain organs for alcohol, whatever the channels by which it is eliminated, the general belief is that some portion of it undergoes chemical decomposition within the body. The steps of this process and its ultimate results are as yet unknown; nor, indeed, are the proportional amounts decomposed and eliminated established. Some observers regard the amount eliminated as less than that decomposed. Others suppose that the amount consumed within the body is relatively very small as compared with that disposed of by elimination. It is, however, established that the sojourn of alcohol in the body, unlike that of many other toxic substances, is transient, and that in the course of from twenty-four to forty-eight hours after the ingestion of a moderate amount there remain only traces of this substance.

The local action of alcohol upon organic tissues depends upon its volatility, its avidity for water, its power to precipitate albuminous substances from solution and to dissolve fats, and, finally, upon its antiseptic properties.

Applied externally and permitted to evaporate, it produces a fall of temperature and the sensation of cold; if evaporation be prevented, a sensation of warmth is experienced, the skin reddens, and, if the action be prolonged, desquamation results. The sensation produced when diluted alcohol is applied to mucous surfaces is burning and stinging; when concentrated, it may excite inflammation.

Dilute alcohol has been much employed as a surgical dressing for wounds and ulcerated surfaces. Its value for this purpose depends on its stimulating properties, by virtue of which it exerts a favorable influence upon granulating surfaces; and on its antiseptic qualities, which are, however, much inferior to those of salicylic and carbolic acids among organic substances and to the chlorides among the inorganic salts.

The direct action of alcohol upon the mucosa of the digestive system depends upon the quantity ingested and degree of concentration. In moderate amounts and diluted to the extent of 50 per cent. or more, it produces a sensation of warmth in the tissues over which it passes. This sensation is due in part to the impression upon the nerve-endings, and in part to reflex hyperæmia, which is at once excited. In individuals unaccustomed to its use reflex contractions of the constrictor muscles of the pharynx, with gagging, are sometimes provoked. The secretion of saliva and of the gastric juice is increased, diluted alcohol being, in respect to its physiological effect in stimulating the buccal and gastric mucous glands, inferior to no other agent. This action is due as much to reflex as to local action, as has been shown experimentally by the application of a few drops of alcohol to the tongue of a dog with gastric fistula, increased secretion of gastric juice immediately resulting.

It is in consequence of this action that moderate doses of diluted alcohol exert a favorable influence upon the appetite and digestion. Increased amounts of food are well borne; fats especially are more tolerable and better digested; and a more energetic peristalsis favors the absorption of the food solutions. In those habituated to the use of alcohol these effects do not always follow; and if the amount be increased or the repetition become frequent, some part of the alcohol undergoes in the stomach, with the food, acid fermentation, and acid eructations or vomitings occur. With these phenomena is associated gastro-hepatic catarrh with its characteristic symptoms—loss of appetite, feeble digestion, diarrhœa alternating with constipation, sallowness, mental depression, and headache. In still greater amounts and little diluted, alcohol is capable of exciting acute gastritis or congestion and catarrhal inflammation of the liver.

When we come to study the action of alcohol upon the circulatory system, we find that in small doses it has little or no influence either upon the action of the heart or the condition of the vessels. In augmented amounts it increases the action of the heart both in force and frequency, and the arterial blood-pressure. After large doses these effects quickly pass away, and the circulation becomes depressed. The heart's action grows feebler, often slower, the pulse weaker; blood-pressure sinks and arterial tension is diminished. Its physiological action is that of a direct stimulant to the heart and the pneumogastric nerve; its toxic action, that of a depressant. Upon the vaso-motor system the action is from the first that of a depressant. Dilatation of capillary vessels and increased afflux of blood manifest themselves in the flushed face, brilliant eyes, and warmth of surface which are familiar phenomena. Frequent repetition tends to permanently impair the activity of the peripheral circulation. Hence the visible vascular twigs and rubicund nose that characterize the physiognomy of the habitual drinker.

This congestion no less affects the internal organs, setting up, by interference with their functions, chronic derangements of nutritive processes on the one hand, and on the other the liability to acute local diseases and complications.

The reactions which take place between the blood and alcohol remain, notwithstanding the energy devoted to their investigation, among the unsolved problems of physiological chemistry. It were a profitless task to here review the researches into this subject or to set forth their conflicting results. It may be stated that conclusions based upon the reactions between blood drawn from the vessels and tested with alcohol in the laboratory are wholly inapplicable to the inquiry. While it is generally conceded that some part of the alcohol ingested undergoes decomposition within the organism, what the steps of the process are and what the products are have not yet been demonstrated. Rossbach and Nothnagel⁸ state that it has not yet been possible to detect in the organism the products of the oxidation of alcohol—namely, aldehyde, acetic acid, and oxalic acid; nevertheless, acetic acid formed in the economy by the general combustion of alcohol may form acetates, which, undergoing decomposition, are transformed into carbonates and water, and are eliminated as such in the urine.⁹ This view is also held by Parkes.¹⁰

⁸ Cited by Peeters, L'Alcool, physiologie, pathologie, médecine légale, 1885.

⁹ Henri Toffier found in the brain of a man who died of acute poisoning by alcohol not only alcohol, but also aldehyde: Considerations sur l'empoisonment aiqu par Alcohol, Paris, 1880.

¹⁰ Journal of Practical Hygiene, 4th ed., Lond., 1873.

According to Peeters, the action of alcohol upon the blood may be summed up as follows: That portion of the ingested alcohol which undergoes decomposition takes from the blood some part of its oxygen for this purpose, with the result of a diminished amount of oxygen and an increase of carbon dioxide, the blood thus being made to resemble venous blood. A part of the oxygen destined for the oxidation of waste products being thus diverted, these substances are not completely transformed. In this respect also blood charged with alcohol resembles venous blood. Alcohol even when diluted is capable of retarding the combustion of oxidizable organic substances, and there is no reason to doubt that this agent has in the blood the same chemical properties that it elsewhere possesses.

The exhalation of some part of the alcohol circulating in the blood by the way of the pulmonary mucous membrane interferes with the elimination of carbon dioxide, with the result that the latter agent further tends to accumulate in the blood.¹¹

¹¹ David Brodie, Medical Temperance Journal, October, 1880.

Alcohol must act, to some degree at least, directly upon the water of the blood and upon its albuminoid principles. The products of the reactions normally taking place within the corpuscles pass with greater difficulty into serum containing alcohol as the current of osmosis tends rather from the serum to the corpuscles. It is in accord with this fact that the corpuscles of alcoholized animals have been found relatively large.

The blood of individuals who have died in a state of alcoholic intoxication has been frequently found to contain an unusual amount of fatty matter in a fine state of subdivision.

Upon the respiration the influence of alcohol is twofold: it modifies the respiratory movements and the results of the respiratory processes. After moderate doses the movements are accelerated without disturbances of rhythm; after large doses the respiratory acts become embarrassed, feeble, irregular, finally wholly diaphragmatic.

Alcohol modifies the results of respiration in a constant manner and in all doses. This modification consists in a decrease in the amount of oxygen absorbed and carbon dioxide exhaled. This effect is usually more marked when alcohol is taken fasting than during digestion.

The influence of alcohol upon the renal secretion is that of a diuretic, but the fact must not be overlooked that this tendency is much increased by the large amount of water which alcoholic drinks necessarily contain. But that alcohol acts as a diuretic, even in small doses and altogether independently of the water with which it is taken, does not admit of doubt. The changes in the urine are qualitative as well as quantitative. The amount of urea, uric acid, and other solids is always notably diminished. The diminution of the amount of phosphoric acid is even greater than that of the nitrogenized substances, especially during the period of excitation.

The diuretic effect of alcohol is dependent upon its direct action on the parenchyma of the kidneys, the qualitative changes in the urine upon its influence on nutrition.

Upon the temperature of the body alcohol has a marked effect. The sensation of warmth experienced after moderate doses is chiefly subjective, and is accompanied by a very slight actual rise in temperature, amounting to some fraction of a degree Fahrenheit, and of but short duration. This rise is followed by a rapid fall, amounting to a degree or more below the norm. This effect is manifested within the course of an hour after the administration, and is of comparatively brief duration, being largely influenced by the condition of the individual at the time as regards mental or physical exercise, digestion, and the like. It is in part due to the increased loss of heat from the surface of the body, favored by more active cutaneous circulation, but chiefly to the action of alcohol in retarding oxidation and the activity of nutritive changes. Toxic doses are followed by marked fall of temperature. The influence of alcohol upon the temperature is more pronounced in febrile conditions than in health.

The influence of physiological doses of alcohol upon the nervous system is, among all its effects, the most marked and the most difficult to describe with exactitude. It is usual to regard this agent as a stimulant and to separate the period of its direct effects into two stages—that of excitement and that of depression. John Hunter defined stimuli as agents which increase some natural action or tendency, in contradistinction to irritants, which produce actions altogether abnormal. Anstie¹² sought to restrict the use of the term stimulant to agents which by their direct action tend to rectify some deficient or too redundant natural action or tendency. Without entering upon the discussion of the doctrine of stimulation, I may say that the views of Anstie have served a useful purpose in making clear some vexed questions. In accordance with these views, the physiological action of alcohol is followed neither by excitement nor by depression, and when its administration is followed by these conditions, its action is not truly physiological, but narcotic or toxic.

¹² Stimulants and Narcotics, Lond., 1864.

The effects of this agent upon the nervous system vary within very wide limits according to innumerable conditions which relate to the temperament, health, habits, occupation of the individual, season, climate, social circumstances, and the quantity, kind of alcoholic drink, and its mode of administration. Its first action in moderate doses and under circumstances free from complications is to increase the functional activity of the brain: the ideas flow more easily, the senses are more acute, speech is fluent, and movement active. These effects accompany the increase in the heart's action, the slight rise in temperature already described, and increased activity of the organism in general. They appear to be in part due to the direct action of the substance upon the cerebrum, and in part to increased activity of the circulation. The effect upon the nervous system has been compared by Nothnagel to the effect, in a higher sphere, of strong moral impulses. Without otherwise modifying existing traits of character, such impulses call them into action, and lead to the accomplishment of deeds quite impossible under ordinary circumstances. To a man worn out by some prolonged task which from sheer fatigue he despairs of finishing, let there be announced some joyful news; he at once feels refreshed, applies himself with renewed energy to his work, and perhaps finishes it with ease. In kind at least this is the effect also of alcohol.

But the limits of the physiological effects are easily transcended, and the manifestations then become those of its toxic influence, between the slightest grades of which and drunkenness the difference is one rather of degree than of kind. These effects must therefore be described under the heading Acute Alcoholism.

Passing to the influence of alcohol upon nutrition, we recognize two modes of action. Of these the first is direct and in part local, and results from the stimulation of the glandular apparatus of the mucous membrane of the mouth and stomach, from increased activity of the circulation, and from direct stimulation of the pneumogastric nerve. Hence increased secretion of the digestive juices, augmented appetite, more active peristalsis, and improved digestion, to which, indeed, the direct action of alcohol upon the cerebrum doubtless contributes. It is to these effects that the favorable influences of this agent in the extremes of life, when it is so well borne and so useful, must be largely attributed.

The second mode of action is indirect and general. It has been shown that alcohol diminishes the amount of carbon dioxide expired and of oxygen inspired, that it diminishes the quantity of urea excreted, and that it lowers the temperature of the body. It follows that normal oxidation goes on more slowly—that there is diminished tissue-change. Alcohol supports the body, not by nourishing it as a food, but by curtailing waste; it favors nutrition, not by augmenting the receipts, but by cutting down the expenses of the organism. But nutrition and waste are in health correlated and complementary. They are, in fact, essential and associated processes of life, of which one is not more necessary than the other to the maintenance of health. In various pathological states the arrest of waste is a cardinal indication, and for this purpose alcohol holds the first place. But in health this action itself is pathological, and the beginning of evil. The fat accumulation of the drunkard is due in part to the sugar and starchy matter taken in malt liquors, but much more to this control of waste, as is shown by the fact that spirit-drinkers who have sufficient food also often become fat. Alcoholic excesses tend not only to fat accumulation, but also to fatty degeneration of the tissues. The opinion that alcohol in any dose or under any circumstances is a food in the ordinary acceptation of the term is no longer tenable. Chauffard has well said: “Not only is alcohol not an aliment; it is the very reverse. Not only does it not contribute to the nutrition of the body; it opposes it and destroys it little by little.”¹³

¹³ This opinion is at variance with the views generally entertained by English and American writers upon materia medica. T. Lauder Brunton (Textbook of Pharmacology, Therapeutics, and Materia Medica, Am. ed., 1885) regards “all the evidence as pointing to the fact that alcohol is a food, and in certain circumstances, such as febrile conditions, may be a very useful food; but in health, when other kinds of food are abundant, it is unnecessary, and, as it interferes with oxidation, it is an inconvenient form of food.”

THE PATHOLOGICAL ACTION OF ALCOHOL.

I. Acute Alcoholism.

In accordance with the classification laid down at the beginning of this article, the term acute alcoholism is here used to denote the various forms of primary alcoholic intoxication in contradistinction to the conditions which are brought about by the gradual but long-continued action of the poison, and to the violent and sometimes abrupt outbreaks which are secondary to these conditions. From this point of view, which is at variance with the established usage of writers upon alcoholism, but which is here adopted in the hope that it will tend to simplify the treatment of a subject at present in much confusion, acute alcoholism includes all forms of drunkenness, from mere transient derangement of the normal functions of life, scarcely amounting to tipsiness, to profound intoxication. It includes also poisoning by lethal doses. Chronic alcoholism may be the outcome of frequent repetitions of acute alcoholism at short intervals, or it may result from the constant abuse of alcohol in doses so small that the evidences of its poisonous effects are at no time actively manifested. I hope to be able to show that the seemingly acute outbreaks, the symptoms of which chiefly relate to the nervous system, that occur after the condition of chronic alcoholism is fully established, are commonly preceded for a longer or shorter period by imperfectly developed symptoms of an analogous character, and that these outbreaks differ in essential particulars from acute alcoholism in all its forms.

That persons suffering from some degree of chronic alcoholism may, and as a matter of common occurrence do, after excessive doses suffer from acute alcoholism—in other words, get drunk—is too obvious to demand more than passing consideration at this point; but it is scarcely necessary to point out to those who are familiar with the life-history of such individuals that the time comes when no degree of excess will produce the ordinary manifestations of transient intoxication. It is then that phenomena of another and more serious kind are apt to occur. The difference is that between the reactions of normal or as yet quasi-normal tissues and alcohol on the one hand, and on the other the manifestations induced by the supersaturation of tissues previously alcoholized to the point of an acquired tolerance. This tolerance of the nervous system is in a high degree a pathological condition, and is therefore in an equally high degree unstable and liable to be overthrown by accidents of various kinds as well as by extraordinary excess in alcohol.

The variety of forms and admixtures in which alcohol is taken is so great, and the susceptibility of individuals to its action so different, that it would be a hopeless task to attempt to describe the manifold phases of acute alcoholism. Unfortunately, most of them are too familiar. The following description embraces the more important phenomena, and is intended to serve as a type:

A. THE ORDINARY OR TYPICAL FORM.—The physiological effects of alcohol in moderate doses are followed by no reaction, but they are evanescent. When, however, the dose is repeated at short intervals and the effect is sustained, the condition by its continuance becomes pathological, and the subject enters upon the prodromic period of acute alcoholism. From this condition to that in which the poison manifests its distinctly toxic effects the transition is a speedy one. The face becomes flushed, the eyes brilliant; the heart's action increases in force and frequency; muscular force seems augmented; there is excitation of the mental processes; intelligence seems more active; ideas flow readily; preoccupation ceases; anxieties are forgotten. The future is full of hope, the past has lost its sorrows, its regrets. The powers of expression are brought into fullest play; conversation becomes animated, brilliant, often sparkling and keen. Reason is thrown aside, the judgment relaxed; vanity, pride, rashness, assert themselves. Emotions, sentiments, habitually repressed, are manifested without reserve, often with emphasis and insistance. Hence the proverb, In vino veritas.

Then speech degenerates into loquacity; improper confidences are made, indiscretions committed; the bent of disposition is made clear; he who is by nature sad grows sombre, melancholy; he who is irritable becomes cross and quarrelsome; the generous man grows lavish, and a good-natured fellow is everybody's friend. But this intensification of normal characteristics is by no means invariable. Not seldom do we see the timid man become in his cups violent and aggressive, the refined coarse, and the gay melancholy. The sensation of increase in muscular force manifests itself in unusual activity. Gesticulation is frequent, energetic, and apt; there are bodily restlessness and desire to move about. Shouts of laughter, bursts of song, are followed by a disposition to easily-provoked quarrels. At this stage there are evidences of some degree of cerebral congestion. The temples throb, the heart is full, and dizziness is felt. The skin is moist, the mouth pasty, thirst is experienced, and there is frequent desire to pass water. There yet remains some degree of self-control. The phenomena which characterize this condition are more or less transient, and if alcohol be now discontinued they speedily cease, commonly in sleep, sometimes without it, and are followed by sensations of weariness and fatigue, with headache, gastric disturbances, and temporary loss of appetite.

If, however, the influence of alcohol be pushed beyond this point, the manifestations of mere exaltation of function give place to grave perversion of the processes of life. A gradually increasing vertigo is associated with obscured intelligence, dulled imagination, blunted and confuted perception, disjointed ideation, and incoherent speech. The recollection grows indistinct, the will purposeless. Now the baser passions are aroused; evil impulses and illusions of all kinds sway the drunken man. All control of conversation and action is lost. Reason is replaced by delirium, and he becomes a maniac, dangerous alike to himself and to others, liable upon some sudden impulse to commit the most atrocious crimes.

The countenance betrays the profound disturbance of the intellectual and moral nature: its expression is changed, its lines are blurred; the flush deepens, the veins are distended, the arteries pulsate visibly, the gaze is staring, the pupils contracted. The respiration, at first quickened, becomes irregular. The heart's action is rapid and bounding, and sometimes there is palpitation. Somnolence soon deepens into an invincible desire to sleep. At this point great muscular relaxation not infrequently occurs in connection with vomiting, profuse sweating, and dilatation of the pupils.

Muscular movements are irregular and uncertain, the gait vacillating and staggering; the movements of the superior extremities, wanting in precision, become trembling and awkward. At the same time speech becomes embarrassed. Articulation is difficult and imperfectly executed. At length standing becomes impossible; the drunkard, profoundly poisoned, sinks helplessly to the ground, and not infrequently the control of the sphincters is lost. The development of this condition is accompanied by a gradual perversion of general and special sensibility. Dull headache, ringing in the ears, phosphenes, and other disturbances of vision, hallucinations of taste and smell, are followed by abrogation of the special senses. Loss of cutaneous sensibility, beginning at the extremities, invades the whole body, and finally the subject sinks into more or less profound coma, from which it is no longer possible to arouse him. Muscular resolution is complete, sensation is lost; the face is now bloated, deeply flushed, sometimes livid, sometimes ashy pale; the pupils are dilated; the temperature below normal; the respiration stertorous and accompanied by abundant mucous râles. The pulse is feeble, fluttering, the surface covered with sweat, and involuntary evacuations take place.

VARIETIES.—Three varieties of acute alcoholism are recognized by Lentz—the expansive, the depressive, and the stupid. The first is characterized by gayety, self-satisfaction, and content. The drunkard, smiling and happy, is satisfied with the present and full of hope for the future. The second variety is characterized by sadness and melancholy. The drunkard becomes sombre and taciturn; if he talk at all, it is to bewail his misfortunes and to recount his mishaps. In the third variety the period of excitement is wanting and the drunkard passes rapidly into a condition of stupor.

Great as are the modifications of the course of acute alcoholism under different circumstances and in different individuals, it is evident, upon close investigation, that its phenomena—and especially those which relate to the nervous system—manifest themselves in a progressive series more or less constant in the majority of persons. This series includes three well-characterized periods: 1. The stage of functional exaltation of the nervous system; 2. The stage of functional perversion; 3. The stage of depression.

We may, then, recognize the degrees of acute alcoholism corresponding to these stages.¹⁴ Of these, the first scarcely goes beyond the stage of excitement already described, and if the dose have been moderate or its repetitions not too long continued, the symptoms gradually subside, leaving perhaps no sequels beyond slight headache, tinnitus aurium, some degree of muscular relaxation, and mental depression.

¹⁴ These stages correspond to the three degrees of alcoholic intoxication recognized and described by German writers as Rausch, Betrunkenheit, and Besoffenheit. To these may be added the prodromic period, designated as Weinwarme Zustand. These three degrees are known to the French as l'ivresse légère, l'ivresse grave, and l'ivresse suraiguë.

The second degree is characterized by partial abolition of intelligence, of general and special sensation, and of motor power. Hence incoherent speech, extravagant actions, blunted perceptions, hallucinations and delusions, inco-ordination of movements, a reeling gait, and not rarely vomiting and involuntary discharges of urine and feces. This degree of acute alcoholism usually ends in deep sleep with abundant perspiration, to which succeed great lassitude and depression, accompanied by much gastro-intestinal derangement, of which the symptoms are inability to take food, coated tongue, viscid mouth, foul breath, repeated vomiting, and occasionally diarrhœa. These sequels are less serious in those individuals accustomed to excesses than in others.

In the third degree the subject falls by gradual stages or abruptly into more or less profound coma. The abolition of intelligence, sensation, and motion is complete. The face is now swollen, livid, or pale, the pupils dilated, the respiration stertorous, the pulse feeble, often slow, sometimes imperceptible, the surface cool and often bathed in sweat. The man is dead drunk. The symptoms are now of the gravest kind. It is no uncommon occurrence for this condition to end in death.

Well characterized as these three degrees of alcoholic intoxication are, they are not, when occurring successively in the same individual, separated by abrupt lines of demarcation. On the contrary, the evolution of the symptoms is from the beginning to the close a gradual and progressive one.

While the scope of this article precludes extended discussion of the symptoms of acute alcoholism—which, indeed, present an almost endless variety in their intensity and combination—yet it seems necessary to the elucidation of the subject to point out some of the more prominent modifications due to variations in the conditions under which alcohol acts upon the organism.

First among these are differences in the nature and composition of the drink. Here we have to do not only with the well-known differences in alcoholic beverages, as spirits, wines, and malt liquors, and their quality and grades, but also with differences in the chemical nature of the alcohols themselves which enter into their composition. The principal of these alcohols are—

Methyl alcohol, CH₃OH.

Ethyl alcohol, C₂H₅OH.

Propyl alcohol, C₃H₇OH.

Butyl alcohol, C₄H₉OH.

Amyl alcohol, C₅H₁₁OH.

Richardson was the first to call attention to the differences in the physiological and pathological action of the members of this series. Other 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

¹⁵ Recherches expérimentales sur la Puissance toxique des Alcools, Paris, 1879.

¹⁶ “Contributions à l'Étude des Effets physiologiques et therapeutiques d'Alcool,” Compt. rend. Société de Biologie, 1870-71.

¹⁷ “Methylic alcohol is the safest of the series of bodies to which it belongs” (B. W. Richardson, Lectures on Alcohol).

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.

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 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, 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 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.