Volume 5 — DISEASES OF THE NERVOUS SYSTEM. (continued 21)

⁴⁶ Vide this System of Medicine, Vol. IV. p. 803.

b. The Hearing.—The disturbances of hearing encountered in chronic alcoholism are in many respects analogous to those of sight. Patients complain of curious subjective sensations, which are described as humming or whistling sounds, the ringing of bells, music, or the murmur of a crowd. At times the sense of hearing is so exquisite that the least noise causes pain. On the other hand, hearing may be greatly impaired, diminishing by degrees until it becomes in some cases, without recognizable lesion, almost or completely lost.

c. The Taste.—As a rule, the sense of taste is impaired in chronic alcoholism; occasionally it is wholly lost.

d. The Smell.—The sense of smell is in most cases to some extent, and in many cases greatly, impaired, the most powerful odors being scarcely perceived by old topers.

Alcoholic Epilepsy.—Alcohol, and especially that combination of alcohol with oil of wormwood and aromatics known as absinthe, is capable of producing convulsive seizures resembling epilepsy. Certain forms of alcoholic convulsions can scarcely be distinguished from ordinary epilepsy. Acute alcoholism may be an exciting cause of the convulsive seizures in an epileptic. Alcoholic epilepsy is, however, peculiar to chronic alcoholism, and particularly in individuals in whom there is an hereditary tendency to nervous disorders. Once established, alcoholic epilepsy may continue even after the alcoholic habit has been discontinued. The attack is usually followed by marked mental disturbances. These vary from profound dulness to stupor or mania; they last from some hours to several days, and present the characters of similar conditions following non-alcoholic epileptic paroxysms.

C. PSYCHICAL DERANGEMENTS.—Yet more important than the visceral and nervous lesions of chronic alcoholism are the indications which it affords of a progressive debasing influence upon the mind. The moral sense, the will, and the intellect are involved successively in a process of deterioration, which, manifesting itself only in part and by little at first, becomes after a time general and plain to all the world, and ends at length in ruin more complete and more hopeless than that of the body. Indeed, it not infrequently happens that while the general health appears to be good and the nervous system, save in transient disturbances of function, presents no evidence of the toxic action of alcohol upon its tissues, serious psychical disorders are established. The alcoholic subject develops propensities, otherwise latent, that tend to refer him to the criminal or the insane classes of society. The psychical debasement, of which these propensities are the outcome, is, like the alcohol habit itself, progressive. This fact cannot be too strongly insisted upon. Like the loss of vascular tone, the sclerosis, the steatosis which alcohol induces in the body, this mental deterioration is cumulative and destructive. It is to its psychical manifestations that alcoholism owes its chief importance, not only as a study in pathology, but also as a problem of the gravest moment in social science.

1. The Moral Sense.—Deterioration of the sense of moral obligation is among the earlier of the mental phenomena of alcoholism. The moral sense is perverted and enfeebled. Sentiments of honor, of dignity, of reputation, and of decency are no longer cherished or regarded. The amenities of social life and the proprieties of personal conduct are disregarded or set at naught. He who was punctilious, considerate, and thoughtful becomes negligent, selfish, and indifferent to sentiments of honor and emulation; he gives himself up to indulgences formerly considered unworthy; his reputation and that of his family are no longer matters of concern to him; respect for public opinion is replaced by cynicism. Little by little the conception of duty, of justice, of honor are lost to him, or if he regards them at all it is rather as subjects for idle and purposeless discussion than as motives to regulate his life. These changes are gradual and progressive, their evolution being largely influenced by the hereditary traits and previous moral culture of the individual. The deterioration of the sense of right, and the coincident exaltation of those passions which are normally under its control, lead to the commission of the crimes peculiar to the early period of alcoholism. Indifference is another characteristic of this period—indifference not incompatible with a selfishness of the most intense kind. The sense of obligation to the family is forgotten, and the responsibility of providing for and caring for others is unfelt. If the drunkard's own wants, and especially his craving for drink, are gratified, the necessities of those formerly dear fail to move him. The affections are not only enfeebled, but they are also perverted; not rarely they are replaced by aversion, disdain, and hatred. The individual who has been calm, reasonable, and patient becomes excitable, perverse, and intolerable of contradiction or opposition. Prone to acts of sudden violence, he becomes gloomy, taciturn, and preoccupied. He is disturbed by fixed tormenting ideas or by vague pursuing terrors. He thus becomes self-conscious, irritable, fault-finding, and easily provoked to passion. The character, after a time, undergoes still more decided change: alternations of indifference and irritability characterize his varying moods. After a time the joys and the sorrows of life alike fail to provoke real feeling. At length the confirmed sot manifests moral traits that are simply infantile; he laughs without motive, he weeps without cause.

2. The Will.—At the same time the will undergoes an enfeeblement even more marked. Except in paroxysms of transient excitement it is feeble and uncertain. The subject of chronic alcoholism scarcely knows his own mind under ordinary circumstances. Aware of his duties and his obligations, he is unable to discharge them. Especially does he lack the power to say No. Vacillation, indecision, and dependence upon others become characteristic traits. This loss of moral energy, combined with the loss of physical power brought about by continued and repeated excesses, begets at once a distaste for the ordinary occupations of life and an inability to perform them.

3. The Intellect.—Loss of intellectual power comes last. In some cases it shows itself only after the most prolonged excesses, when the body itself is becoming thoroughly broken down. Exceptionally, fitful intellectual power is curiously sustained to the last. The first evidence of intellectual failure consists in diminution of vivacity and readiness. The intellectual state is marked by apathy, obtuseness, and indifference; mental processes are performed slowly and with difficulty. This is perhaps one of the causes of the mental indolence characteristic of alcoholism. After a time the drunkard becomes timid, loses confidence in himself, and is unwilling to engage in enterprises demanding mental effort. Some tardiness of appreciation then shows itself; conversation becomes difficult; ideas are not spontaneous, but must be sought for; replies are not made with the usual promptness; it is difficult to arouse and fix the attention. The sense of self-respect is now lost, and it is almost impossible to make the subject comprehend his degradation. The intellectual deterioration becomes more and more marked. The memory fails little by little and becomes treacherous. Names and dates are recalled with difficulty. The conversation is interrupted by an inability to choose the proper words with precision, hence hesitancy, interruptions, and various forms of circumlocution. The power of argument and of reasoning is now much impaired, the judgment is uncertain, the association of ideas is inexact, and at length the intellectual degradation attains a degree that unfits the subject for the ordinary relations of life.

The above-described derangements of the viscera, of the nervous system, and of the mind are the morbid phenomena induced by long-continued excesses in alcohol. Whether merely functional or dependent upon recognizable anatomical lesions, they indicate pathological changes in the organism which are radical, and which under the influence of the continuously acting cause are progressive. Taken together, they constitute the condition known as chronic alcoholism. In view of the familiar experiences of every-day life, it is hardly necessary to repeat that these derangements are manifested in all degrees of intensity and in the most variable and complex combinations. The specific nature of chronic alcoholism is, in truth, due not to the derangements themselves, the greater number of which are such as we may encounter in morbid states not occasioned by alcoholic excesses, but to the combinations in which they occur in consequence of the action of the specific cause upon the organism as a whole. The prominence of particular symptoms or groups of symptoms in any given case is to be accounted for largely, if not wholly, by individual peculiarities.

Chronic alcoholism, however latent it may be, however sedulously concealed, warps the life of the individual in all its relations. In its advanced degrees it amounts to mental and physical dyscrasia. Between these extremes is every grade of incapacity and degradation. It is beyond the scope of this article to discuss the moral, social, or medico-legal bearings of this condition. Its purely medical relations are sufficiently obvious from what has gone before. It has been the writer's aim to make clear the existence and nature of the continuing condition.

It remains to describe certain other psychical disturbances which occur in chronic alcoholism, and which require separate consideration for the reason that they are accidental rather than essential, many cases running their course without their manifestation.

4. Alcoholic Delirium in General.—True alcoholic delirium, presenting the traits about to be described, is never the result of the direct primary action of alcohol upon the nervous system. Transient excesses produce acute alcoholism, drunkenness, which, varied as its manifestations are, differs essentially from that peculiar delirium which occurs only in individuals in whom the nervous system has undergone those nutritive changes that are brought about by prolonged alcoholic saturation.

The most striking peculiarity of this delirium relates to the hallucinations which attend it. These are almost invariably visual; occasionally they are also auditory. Their objects, whether men, animals, or things are in constant and unceasing motion, appearing and disappearing, coming and going, and changing from place to place with extreme rapidity. In this respect they differ from the hallucinations of other forms of delirium, of which the objects are fixed and more or less permanent. As a result of this peculiarity, the objects of alcoholic delirium are almost invariably multitudinous, as swarms of vermin, herds of animals, multitudes of demons, and the like.

A second peculiarity is the restlessness of the delirium. The patient is invariably uneasy, apprehensive, always on the alert, declaring that some calamity threatens him or that some evil is about to befall him. In consequence of these apprehensions even momentary repose is wanting. If he lies down for a moment, it is only to rise again and peer under the bed or into the corners, turning his head from side to side in search of some realization of the fears that torment him. This sense of apprehension impels the patient to hurry ever onward from place to place in search of the repose which he nowhere finds. It is increased to positive terror by the ever-varying and constantly-renewed hallucinations which torment him, and from which he seeks to escape, no matter how great the obstacles to be overcome.

A third peculiarity of alcoholic delirium is insomnia. This condition is of the must marked and stubborn character, even continuing for several days in succession.

5. Delirium Tremens.—This is the characteristic form of alcoholic delirium, and, as is indicated by the name, is invariably accompanied by tremor. It must be looked upon as an episode or epiphenomenon of chronic alcoholism. It is rare that even prolonged temporary excesses in persons ordinarily sober are followed by delirium tremens. Such excesses in the subjects of chronic alcoholism are, however, perhaps the most common cause of this condition. Orgies, especially when associated with venereal excesses, very frequently terminate in delirium tremens. Occasionally also, but much less frequently than was formerly supposed, the abrupt discontinuance of alcohol is followed by the outbreak. Other exciting causes are violent emotions, as anger or fright; hardships, such as prolonged hunger, over-exertion, or watching; acute maladies, as pneumonia, dysentery, erysipelas, the exanthemata, or rheumatism; finally, serious traumatisms, with or without great loss of blood. Delirium tremens usually occurs in those addicted to the abuse of spirits, less frequently in beer-drinkers, and comparatively rarely in those whose excesses have been restricted to wine. The attack does not, as a rule, begin abruptly; its prodromes usually consist in an exaggeration of the previously existing symptoms of chronic alcoholism. The patient complains of malaise, restlessness; he becomes depressed, morose, anxious without cause, apprehensive of some calamity, or he is more impatient and choleric than before. The ability to apply himself to his ordinary occupations is lost. He complains of vertigo, ringing in the ears; sleep is disturbed, or there is already insomnia. At the same time the stomach is deranged, appetite is lost, the tongue is covered with a thick yellowish-white fur, and there is constipation or diarrhœa. The period of prodromes may last from a few days to a week.

The outbreak is characterized by delirium, without, at least in the greater number of cases, absolute loss of consciousness. That is to say, it is possible by addressing the patient with energy or by strongly arousing his attention to interrupt the delirium and for a moment recall the patient to himself. In the graver cases, however, loss of consciousness appears to be complete. The subjective impression of the delirium, as recollected at the termination of the attack, is that of a sense of overwhelming confusion and inability to recollect or co-ordinate the ideas that were crowding upon the brain. The hallucinations, as has already been indicated, relate almost exclusively to the organ of sight, more rarely to the hearing; also, and exceptionally, to the other organs of sense. They are almost always either terrifying or repugnant. The objects of the hallucinations of the sight have already been described. They consist of animals, serpents, and monsters, which crowd into the apartment, coming usually toward the patient, disappearing in the walls, in the floor, under the bed, or among the bed-clothing. These visions are usually aggressive, threatening the patient, throwing themselves upon him, striking him, or tearing at his vitals. They are sometimes replaced by phantoms, spectres of the most horrible character, skeletons, death's-heads, or by flames which surround the patient and threaten to consume him. Sometimes the hallucinations relate to the daily occupation of the patient, and he pursues his tasks with a feverish and distressing anxiety. These hallucinations are almost invariably of the most fleeting, incoherent, and variable kind.

Auditory hallucinations occur usually in individuals of marked neurotic tendencies. They are apt to be more coherent than the hallucinations of vision, and are often of the nature of those which occur in the delirium of persecution. Sometimes they consist of cries, of chiding, of menacing voices, of the repetitions of obscene words and suggestions; sometimes they are cries of horror or the roars of animals, sometimes explosions or the discharge of firearms; or, again, they are terrifying threats. Hallucinations of taste and smell are much more rare, and occur in the subacute forms of delirium tremens. The patient complains of annoying odors or disagreeable tastes, either constantly present or upon the taking of food or drink. Disturbances of general sensibility show themselves in hallucinations in regard to sensations of pricking, burning, or tearing of the surface of the body, or of animals or vermin crawling over the patient. Hallucinations relating to the sexual instinct are far from rare. The hallucinations of every form are apt to be more frequent and more troublesome during the night than during the day.

Restlessness, fear, and anxiety are characteristic phenomena of delirium tremens. The patient is not only terrified by the imaginary objects which surround him, but often in their temporary absence he experiences an equal degree of fear for which he can assign no cause. It is to this condition of apprehension that is due the desire to escape from his present surroundings which is so characteristic of the delirium in question. Under its influence the patient occasionally commits acts of violence of the most serious kind. Sometimes the delirium is more quiet: the patient converses with individuals whom he supposes to surround him; he busies himself with his familiar occupations, giving orders, directing work, dictating letters, and arranging his affairs. At other times the delirium takes the form of apprehension of poisoning, and food and medicine are alike stubbornly refused.

The countenance, as a rule, is animated, the eyes brilliant and injected, the look fixed or peering, but always eager, or the expression may be haggard and agitated. The physiognomy, although largely influenced by the character of the delirium, may be said to be in most cases characteristic.

Sensation is usually impaired; especially is this true of sensibility to pain.

Tremor, although occasionally slight, may be said to be never wholly absent. Sometimes it affects the muscles of all parts of the body; more commonly it is limited to the hands, arms, tongue, and lips; less frequently it manifests itself in the lower extremities. Slight tremor may be increased by causing the patient to hold his hands extended with the fingers separated. The movements of the hands consist of rapid rhythmical oscillations of nearly equal extent and duration. The tongue is protruded with a rapid jerking movement, and withdrawn with equal suddenness. It shows fibrillar trembling. The trembling is increased by voluntary movement, and is ordinarily associated with some loss of motor power. The gait is often hesitating and awkward; movements of the upper extremities are executed with difficulty, and speech is irregular and interrupted. The motor disturbances are occasionally associated with choreiform movements or actual epileptic convulsions.

Insomnia is a constant condition. It usually persists throughout the attack, and occasionally proves troublesome for several weeks after convalescence is in other respects complete.

In the absence of pulmonary complications the respiration is not disturbed, save as a result of the restlessness and physical effort which sometimes quicken it. The same statement is true of the pulse. The action of the heart is usually enfeebled, and the first sound weak. The temperature is normal. The skin is frequently bathed in copious perspiration. There is complete loss of appetite, and in most cases inability to retain food. Thirst is constant, often tormenting. The tongue is sometimes moist, and coated with thick white or yellow fur; sometimes hard and dry, sometimes red. The urine is scanty, dark-colored, and sedimentary. It occasionally shows traces of albumen. Constipation is the rule.

The duration of delirium tremens is from three to seven, or even ten or twelve, days. The course of the attack is paroxysmal or remittent. The symptoms usually undergo some improvement during the day, only to become more urgent at night. The periods of remission are occasionally marked by transient slumber; the recovery by prolonged and deep sleep. But this is by no means the rule. Several varieties of delirium tremens have been described by writers upon the subject. These are—the grave form, characterized by violence of the motor disturbances, aggravated delirium, and gravity of the general condition; the febrile form, in which after the third or fourth day the temperature, without pulmonary or other discernible complications, suddenly rises to 104° F. or beyond that point, with great aggravation of the general symptoms; the adynamic form, marked by failing heart-power, feeble or imperceptible pulse, profuse sweats, collapse, stupor, which deepens into coma and ends in death; and finally, the subacute form. Here the patient is quiet, but restless. The delirium scarcely passes beyond the limits of occasional wandering, and relates chiefly to matters connected with the daily interests and occupations of the patient. Tremor is more or less marked, and sleeplessness is stubborn.

The termination of delirium tremens is in—1, recovery; 2, in death; 3, in the chronic form; and 4, in other forms of insanity.

1. Recovery.—Except in the grave forms recovery may be said to be the rule. Occasionally ushered in by a prolonged, almost critical, sleep, more frequently it takes place by gradual improvement. In the latter case the remissions are more and more prolonged, and attended by increasing repose alike of body and of mind, and by tendency to sleep. The hallucinations become feebler and less tormenting, at length recurring only in the evening or at night, and especially as the patient is about falling asleep. The anxiety and restlessness grow less urgent, consciousness becomes more secure, the trembling diminishes, and recovery is slowly established. The tremor is apt to persist some days into convalescence.

2. Death.—This mode of termination is not very common in the ordinary forms of delirium tremens. In the grave forms it is usual, sometimes occurring suddenly, sometimes gradually from intensification of the symptoms and failure of nervous power; or it may occur in consequence of pulmonary, cerebral, or renal complications; finally, the fatal termination is often due to the acute disease or the traumatism by which the delirium tremens has been excited, and of which it is, in fact, a complication.

3. Chronic Delirium Tremens.—This mode of termination, described by Lentz, is rare. The acute phenomena subside; the restlessness and the mental agitation diminish. Insomnia gives place to sleep, which is light and disturbed by dreams and nightmare; most of the hallucinations lose their activity and frequency, and finally disappear. The changing delirium settles into a fixed delirium of persecution; the tremor, while it becomes fainter, persists, and the condition is permanent.

4. Other Forms of Insanity.—This mode of termination has been studied especially by Magnan, who has classified the cases of delirium tremens into three different groups, according to their tendency to recover or to the development of mental alienation. The first group includes those cases which run a favorable course and terminate in complete convalescence; the second group, those cases in which the convalescence is prolonged and characterized by repeated relapses; the third group is composed of cases which likewise show a strong tendency to relapse, but in which the delirium continues after the other active symptoms have subsided. This form shows itself most frequently among the subjects of hereditary alcoholism. After repeated attacks the delirium becomes chronic. Morbid mental phenomena replace or accompany symptoms more directly referable to organic disturbances of the nervous system. Tremor gradually diminishes and disappears, the gastric symptoms subside, insomnia passes away, even hallucinations disappear, or at all events become infrequent; but the delirium which developed coincidently with these symptoms continues, and finally becomes chronic, losing to a great extent its original characteristics and constituting a form of insanity. Finally, dementia constitutes an occasional mode of termination in delirium tremens. It does not often develop immediately, although cases of this kind have been recorded. More commonly, the alcoholic subject, losing little by little his mental activity after each attack of delirium tremens, subsides by degrees into absolute and irremediable dementia. Paretic dementia may also develop after prolonged alcoholic excesses characterized by repeated attacks of delirium tremens.

The anatomical lesions after death from delirium tremens shed no light on the pathogenesis of the condition. Meningeal congestion, œdema of the pia mater and of the cortical substance of the brain, scattered minute extravasations of blood, and some augmentation of the cerebro-spinal fluid have been observed. In the greater number of cases no lesions whatever beyond those characteristic of chronic alcoholism have been discovered.

6. Alcoholic Insanity.—Among the psychical derangements, it remains to notice briefly the more prominent forms of insanity which develop in the course of chronic alcoholism, in consequence either of hereditary or of acquired morbid mental tendencies. These are—a, melancholia; b, mania; c, chronic delirium; d, dementia; e, paretic dementia.

Alcohol is the most common of all the causes of insanity. Clouston⁴⁷ estimates that from 15 to 20 per cent. of the cases of mental disease may be put down to alcohol as a cause, wholly or in part. Those forms of insanity in the production of which alcohol is merely an occasional cause are not, however, properly included in the group of alcoholic insanities. Still less are we to include in this group cases of symptomatic dipsomania; that is to say, cases of insanity in which morbid impulse to drink constitutes a prominent symptom of the prodromic or fully-developed periods of various forms of mental disorder.

⁴⁷ Clinical Lectures on Mental Diseases, Am. ed., 1884.

Alcoholic insanity manifests itself as an outcome of chronic alcoholism, just as epileptic and hysterical insanity show themselves as the outcomes of epilepsy and hysteria. This group properly includes various forms of mania-a-potu, especially the maniacal form of acute alcoholism, delirium tremens, and other transitory psychoses which occur in acute and chronic alcoholism.

In truth, the mental derangements of ordinary drunkenness constitute in many cases a form of transient insanity. These forms, have, however, already been considered at sufficient length. Dipsomania, for reasons already stated, cannot be regarded, either in its symptomatic form or in its essential form, as belonging to the group of alcoholic insanities.

a. Melancholia.—Melancholia is the most frequent form of true alcoholic insanity. It may begin abruptly or gradually, with changes of character, vague disquietude, great irritability, and disturbances of sleep amounting in many cases to insomnia. Hallucinations of hearing are characteristic. In this respect the morbid mental condition in question is in strong contrast with delirium tremens, in which the hallucinations are principally visual. The hallucinations of hearing usually consist of accusing or threatening voices. These voices inform the patient that he is to be poisoned, assassinated, murdered, or that outrages of all kinds are to be committed upon him; they accuse him of murder, of robbery, of rape, and of other shameful crimes. Præcordial distress is also apt to be present. In consequence of these hallucinations of hearing the patient falls into a profound melancholia, often characterized by suicidal impulses which are sometimes the direct outcome of hallucination, at other times blind and unreasoning. There is apt to be cephalalgia and insomnia. Trembling is not usually a marked symptom. Local anæsthesia and hyperæsthesia, if they occur, are transient. The ordinary duration of this form of alcoholic melancholia is much longer than that of delirium tremens, sometimes extending throughout several months. The termination usually is in recovery, less frequently in chronic delirium.

b. Mania.—This form of alcoholic insanity is characterized by various hallucinations which present peculiar characters. Thus, the hallucinations of vision commonly relate to supernatural apparitions, attended with luminous phenomena of various kinds. These visions may be occasional or they may be frequently repeated, or the hallucinations may consist of images of emperors, kings, princes, and potentates, or of military chieftains, in the midst of whom the patient passes his existence. Or, again, the hallucinations may be made up of historical scenes, pageants, the movements of armies, battles, and the coronations of kings, or they may be landscapes pleasant to the eye—snow-clad mountains, valleys filled with flowers, magnificent forests, and the like. These phantasmagoria are by no means fixed; on the contrary, they are of the most shifting character.

Auditory hallucinations are even more frequent, and quite as changeable. They bear a more or less well-defined relationship to the hallucinations of vision. They consist not rarely of promises of money, honors, titles, and the like. Sometimes they are voices from heaven, even the voice of God himself, commanding the patients to perform definite acts and promising in return equally definite blessings.

Hallucinations of general sensibility occur much less frequently. When present, they consist of various painful sensations, giving rise to the delusions of blows, stabs, bites of animals, electrical discharges, etc. In consequence of these hallucinations the delusions are often of a grandiose character. Patients believe themselves to be God, the pope, or some great potentate, or enormously rich, etc.

The somatic condition depends upon the degree of chronic alcoholism existing at the time of the manifestation of the mania. There are usually marked tremor, hesitation and uncertainty of speech, stubborn sleeplessness. Acute mania may show itself abruptly, attaining its full development in the course of a few days, or the development may be gradual. The prognosis in alcoholic mania is unfavorable; recoveries are rare. The fatal termination is sometimes the result of the maniacal condition itself, and sometimes the result of visceral complications. This form of insanity occasionally terminates in chronic delirium.

c. Chronic Delirium.—This form of alcoholic insanity is one of the terminations of acute alcoholic melancholia and of acute alcoholic mania. It is also one of the results of repeated attacks of delirium tremens. Finally, it may develop independently of these affections.

Developing independently, chronic delirium is usually of rapid invasion, and is characterized by the prodromes common to the various forms of alcoholic insanity—irritability, headache, vertigo, insomnia, etc. Hallucinations of hearing are very common, and relate principally to the sexual life of the patient. Voices taunt him with the fact that he is maimed or impotent; he hears persons whispering that he is about to be castrated or that he is the subject of loathsome venereal diseases, or they declare that he is known to be addicted to vile crimes and bestiality. Hallucinations of sight are much less common; those of the other special senses occasionally occur. The delirium takes the form of delusion of persecution. The patient believes himself the object of plots and conspiracies; his enemies are seeking to ruin his good name, to tarnish his reputation, to poison him. They put filth in his food or charge him with electricity; they steal away his vital force or his sexual power; they taunt him; they mock him; they beat him and rob him.

A delusion so frequent as to be almost characteristic of chronic alcoholic delirium relates to marital infidelity.⁴⁸ The patients cherish unjust and often absurd suspicions of the virtue of their wives. These delusions arise independently of hallucinations either of sight or hearing, and are of the greatest importance, because they supply logical motives for the most appalling and brutal crimes.

⁴⁸ “The combination of a delusion of mutilation of the sexual organs with the delusion that the patient's food is poisoned, and that his wife is unfaithful to him, may be considered to as nearly demonstrate the existence of alcoholic insanity as any one group of symptoms in mental pathology can prove anything” (Spitzka, Insanity, N. Y., 1883).

Alcoholic delirium differs in the transitory and incoherent character of its delusions from ordinary chronic delirium, in which the delusions are much more apt to be fixed and permanent.

d. Dementia.—This is a common terminal condition of alcoholism. It may develop, without the intervention of other forms of mental disease, in the course of chronic alcoholism as a mere intensification of the intellectual and moral degradation of that condition. This is especially liable to occur in hereditary alcoholism. Dementia also closes the scene in a considerable proportion of cases characterized by repeated attacks of delirium tremens. It likewise constitutes the terminal condition in other forms of alcoholic insanity.

The symptoms are sometimes so slight as to escape ordinary observation. More commonly they are fully developed. As compared with ordinary dementia, they present but little that is characteristic. Alcoholic dements are perhaps more filthy and more difficult to manage, duller and more mischievous, than others. Their somatic disorders are more marked. In them hyperæsthesias are replaced by anæsthesias; sleep is apt to be irregular and disturbed; the hallucinations characteristic of the antecedent alcoholic psychosis now and then reappear. Slowly-developing failure of intellect, forgetfulness, stupor, end in more or less complete loss of mental power. Nevertheless, a small proportion of the milder cases are capable of arrest under treatment.

e. Paretic Dementia.—Alcoholism is an important etiological factor in the production of this condition. The intellectual disorders and motor disturbances which characterize it, varied as they are, are associated with cerebral lesions, and especially with lesions of the cortex equally varied—lesions which are common in chronic alcoholism. These lesions vary from meningeal congestion and inflammation to profound inflammatory and degenerative alterations in the cerebral substance.

Paretic dementia may develop after long-continued excesses without previous appreciable mental or cerebral symptoms. In such cases it presents no specific indications of its alcoholic origin. The difficulty of determining the influence of alcohol in its causation is increased by the fact that alcoholic excesses—symptomatic dipsomania—are frequent in the prodromic and early stages of this form of mental disease. Paretic dementia may also develop after repeated attacks of delirium tremens. Here the early attacks end in recovery apparently complete; later, the convalescence is unsatisfactory and prolonged, leaving some indications of intellectual enfeeblement, which, after renewed attacks, increases, and is accompanied by delusions of grandeur, embarrassment of speech, unequal dilatation of the pupils, and general paresis. The prognosis is practically hopeless.

III. Hereditary Alcoholism.

This term has been used in a somewhat vague manner to designate the morbid tendencies and pathological conditions directly transmitted by alcoholic subjects to their offspring. Chronic alcoholism on the part of one or both parents may be followed by morbid manifestations in the child. The hereditary transmission of the effects of alcoholism has been recognized from remote antiquity. Aristotle believed that a woman given to drunkenness would bear children with the same tendency. Plutarch affirms that the children of drunkards will abandon themselves to the same vice. Hippocrates speaks of the distressing effects of drunkenness upon the product of conception. Bacon states that many idiots and imbeciles are born of drunken parents. In more recent times the fact has been generally recognized that many maladies caused by the abuse of alcohol are liable to be transmitted to succeeding generations, and that alcoholism may in this way, in the course of two or three generations, lead to the complete extinction of families. Alcoholism on the part of the parents certainly exerts an unfavorable influence upon the health of their children, who are especially disposed to cerebral congestion, hypochondriasis, intellectual feebleness, and insanity. Two forms of hereditary alcoholism have been recognized: First, that in which the disease or defect of the parent is transmitted to the offspring; and second, that in which the disease or defect is not directly transmitted to the offspring, but a morbid tendency which manifests itself in diseases or defects of a different kind.⁴⁹

⁴⁹ 1. Heredite de similitude, Alcoolisme hereditaire homotype; 2. Heredite de transformation, Alcoolisme hereditaire heterotype.

1. The appetite for strong drink is frequently transmitted from parents to the children, just as other traits of the mind or body. Sometimes it develops early, sometimes late in life; as a rule, however, this hereditary propensity shows itself at an early age, and is apt to be intensified at the time of puberty and the menopause. Objections have been urged against the theory of hereditary alcoholism. Among these the strongest is perhaps that the taste for drink in the offspring of alcoholic subjects is the result rather of opportunity and example than of heredity. The frequency with which alcoholic tendencies develop themselves in children reared and educated away from their parents, and the number of cases in which these tendencies show themselves only at an advanced period of life, long after the influence of example in childhood has ceased, sufficiently disprove this assumption. The hereditary influence does not, however, invariably manifest itself in the desire for drink. On the contrary, not rarely it consists in feebleness of nervous constitution, characterized by irritability, want of mental repose, or a restless or vicious disposition which demands constant excitement. Hence such individuals, although intellectually well developed, are often scarcely more than moral imbeciles, in whom the passion for drink may be replaced by the opium habit, addiction to gaming and to other vices, and whose career is shaped largely by an inordinate and insatiable craving for excitement of all kinds. Hereditary alcoholism follows the laws of heredity in general. The tendency may be transmitted directly from one generation to another, or may skip one or more generations, taking in the intermediate periods some different form.

2. The second variety is that in which the symptoms of chronic alcoholism are manifested in the offspring in the absence of the direct action of alcohol; that is to say, not the taste for alcohol, but the results of the gratification of that taste are transmitted, just as epileptic or hysterical patients may transmit to their offspring epilepsy or hysteria; thus it is not rare to encounter in the descendants of alcoholic parents perverted sensation, both general and special, hyperæsthesia, anæsthesia, flying neuralgias which do not always follow the course of particular nerves, but frequently affect in a general way the head or the members or manifest themselves as visceral neuralgias. These persons are much troubled with headache from slight causes and with migraine. Nor are disturbances of vision rare, nor vertigo. Insomnia is also frequent in such individuals, and augments the other symptoms. Digestive troubles also frequently occur, notwithstanding a regular and perfectly temperate life. Such persons are often subject to hallucinations of sight and hearing, and are liable to have delirium in trifling illnesses.

The second form of hereditary alcoholism manifests itself in a wholly different manner. The descendants, without a special appetite for strong drink, and in the absence of the special morbid manifestations above described, are singularly liable to mental and nervous diseases of various kinds. Among these convulsions and epilepsy are especially frequent; hysteria and various forms of insanity also occur. In this group of cases we find every degree of arrest of intellectual development, from mere feeble-mindedness to complete idiocy. As manifestations of the influence of alcoholism upon the offspring may be cited certain moral peculiarities otherwise inexplicable, such as are seen in children who at a very tender age show themselves vindictive, passionate, and cruel, to whom the sufferings of others afford pleasure, who torment their companions and torture their pets, and show precocious vicious tendencies of all kinds. Later in life these persons become lazy, intolerant of discipline, vagabonds, unstable of character, without the power of application and without moral sense. Given to drink, defiant of law, they constitute the great body of tramps, paupers, and criminals. The children of alcoholic subjects are often feeble and puny, pale, badly nourished, and curiously subject to morbid influences.

IV. Dipsomania.

Dipsomania, which has also been described under the term oinomania, is rather a form of insanity than of alcoholic disease. The characteristic symptoms are, however, in the greater number of instances, due to indulgence in alcohol. The subjects of this affection usually belong to families in which insanity, and especially this particular form of insanity, is hereditary.

There are two forms of dipsomania—the essential and the symptomatic. Of these, the latter is the more frequent. Its consideration requires in this connection very few words. It manifests itself by an irresistible desire on the part of many insane people for alcohol. It occurs both in the prodromic and in the fully-established periods of insanity. It is especially common in various forms of mania and in the prodromic periods of general paralysis. The dominating influence in essential dipsomania is heredity. Occasional causes may bring on particular attacks, but their influence is secondary. Dipsomania cannot be looked upon as a distinct recurrent affection in an otherwise healthy person. At some period in their lives, and often long before the occurrence of characteristic paroxysms, dipsomaniacs show peculiarities indicating defects of mental organization. Certain symptoms of dipsomania are often mistaken for its cause. Thus, dyspepsia is more frequently an effect than a cause of the alcoholic excesses. The despondency, irritability, restlessness, hysterical manifestations, and insomnia which precede the attack are not the cause of it: they are its earliest symptoms.

The affection usually begins insidiously and is progressive. As a rule, although not always, it begins in early adult life. The manifestations of this disease are essentially intermittent and paroxysmal, but the impulse to drink must be regarded as a symptom which may be replaced by other irresistible desires of an impulsive kind, such as lead to the commission and repetition of various crimes, as the gratification of other depraved appetites, robbery, or even homicide. The paroxysms are at first of short duration, and are followed by return to the previous regular and decent manner of life. They become, however, by degrees, more violent and more prolonged. At first lasting for a few days or a week, by and by they extend to periods of a month or six weeks, the attack wearing itself out, and recurring with a periodicity sometimes variable and sometimes constant. In the intervals of these attacks for a considerable time the patients very often lead sober, chaste, and useful lives. At length, however, evidences of permanent mental trouble are manifested, and the case settles into confirmed insanity. The attack is usually preceded by evidences of mental derangement; the patient becomes restless and irritable; sleep is irregular and unrefreshing; he complains of general malaise, and is anxious, troubled by vague apprehensions. He presently abandons his usual occupations and gives himself up to disordered impulses, among which alcoholic excesses are the most frequent and the most easily gratified. Sometimes the patient passes his time at taverns drinking with all comers; at others he shuts himself up in a chamber and gratifies his desire for drink to the most extreme degree alone. Dipsomaniacs not rarely leave their homes and associates without warning or explanation, and pass the period of the paroxysm among associates of the most disreputable character. The desire for drink is gratified at all costs, and not infrequently they return to their friends without money and without sufficient clothing, most of it having been sold or pawned in order to purchase drink. The paroxysm is succeeded by a period of more or less marked mental depression, during which the patient not rarely voluntarily seeks admission to some asylum.

The true nature of dipsomania is frequently overlooked. As a symptom of hereditary insanity it is in striking contrast with the habitual propensity to drink which occurs in the ordinary alcoholic subject. The latter seeks occasions to drink. He renews his excesses not intermittently, but habitually. If in consequence of disgrace or misfortune or under strong moral suasion he is for a time abstemious, it is only to renew and to continue his indulgence upon the first favorable occasion. On the contrary, the true dipsomaniac recognizes his malady and struggles against it. Even more: for a time he shows much skill in concealing it. He avoids occasions to drink, and, reproaching himself for his mad and unreasonable desire, seeks by every means to overcome his impulse to it. The ordinary drunkard may become insane because he drinks; the dipsomaniac drinks because he is insane.⁵⁰

⁵⁰ Magnan, Le Progrès médical, 1884.

Dipsomaniacs are apt to manifest precocious or retarded intellectual development. They are from infancy or childhood especially prone to convulsive or other paroxysmal nervous phenomena. They are often choreic, often hysterical. This association with instability of the nervous system is related to the fact that dipsomania is more common in women than in men.

DIAGNOSIS.—1. Acute Alcoholism.—The diagnosis of the ordinary form of acute alcoholism, with the exception of alcoholic coma, requires no consideration. The diagnosis of alcoholic coma from profound coma due to other conditions is, in the absence of the previous history of the case, always attended with difficulty, and is in certain cases quite impossible. It is therefore of great practical importance to obtain the history where it is possible to do so. The odor of alcohol upon the breath is of less positive diagnostic value than would at first thought appear. In the first place, sympathetic bystanders may have poured alcoholic drinks down the throat of one found unconscious, or, in the second place, individuals who have taken a certain amount of drink may be, and not unfrequently are, seized with apoplexy in consequence of the excitement thereby induced. The more common conditions with which alcoholic coma is confounded are apoplexy from cerebral hemorrhage and narcotic poisoning, especially opium-poisoning. To these may also be added uræmic coma and, under exceptional circumstances, sunstroke. In all these cases the circumstances under which the individual has been found are of diagnostic importance.

In alcoholic coma the pupils are more commonly dilated than contracted, the heart's action feeble, the respiration shallow, the muscular relaxation symmetrical, and the temperature low. There is a strong odor of alcohol upon the breath.

In apoplexy from cerebral hemorrhage the condition of the pupils will depend upon the location of the clot. They may be moderately dilated, firmly contracted, or unequal. The enfeeblement of the heart's action is, as a rule, less marked than in profound alcoholic coma. The pulse may be small or full and slow or irregular. It is usually slow and full. The respiration is often, although not invariably, slow and stertorous. Not uncommonly, the eyes and also the head deviate from the paralyzed side. If the coma be not absolute, the muscular relaxation is unilateral. The temperature is at first slightly below the normal, but less, as a rule, than in alcoholic coma; after several hours it rises to or above the normal.

In complete opium narcosis the insensibility is profound; the heart's action is slow or rapid, but feeble; the respirations slow and shallow or quiet or stertorous; the face at first flushed, afterward pallid and cyanosed; the pupils minutely contracted or dilated as death approaches; and the muscular relaxation complete, with abolition of reflex movements. In cases of doubt it is important to use the stomach-pump.

Uræmic coma is apt to be preceded by or alternate with convulsions. The pupils are more commonly slightly contracted than dilated, but are without diagnostic significance. The temperature is not elevated; it may even be low. The face may be pallid, pasty, and puffy, and there may be general anasarca if the nephritis be parenchymatous. On the other hand, in interstitial nephritis there is hypertrophy of the heart, without evidence of valvular disease, and some degree of puffiness of the lower extremities. In doubtful cases the urine should be drawn by a catheter and subjected to chemical and microscopical examination.⁵¹ Diabetic coma occurs suddenly without convulsions. This condition may be suspected when the emaciation is extreme or upon the recognition of sugar in the urine.

⁵¹ The following is the method recommended by Green (Medical Chemistry, Philadelphia, 1880) for the detection of alcohol in the urine: If its reaction be acid, the urine is exactly neutralized by potassium acid carbonate. It is then distilled on a water-bath in a flask or retort connected with a condensing apparatus. When about one-sixth of the liquid has passed over the distillate will, if alcohol be present, present the following characteristics: first, the peculiar alcoholic odor; second, a specific gravity lower than water; third, upon being mixed with dilute sulphuric acid and treated with a few drops of potassium bichromate solution the liquid becomes green, owing to the separation of chromic oxide; the odor of aldehyde may at the same time be observed. This reaction is not characteristic, but may serve to confirm other tests. Fourth, if dilute alcohol be shaken with an excess of solid and dry potassium carbonate in a test-tube, the greater part of the water will be appropriated by the potassium carbonate, and two layers of liquid will be formed. The alcohol constitutes the upper layer, and if sufficiently concentrated will burn upon the application of a flame. Finally, a small trace of alcohol may be separated from the urine without difficulty after the ingestion of alcoholic liquids by means of a good fractionating apparatus. Less than 1 per cent. of alcohol cannot be detected.

Sunstroke is characterized by dyspnœa, gasping respiration, jactitation, and intense heat of the skin. The pulse varies. It may be full and labored or feeble and frequent. The face is usually flushed. The pupils, at first contracted, are afterward dilated. The coma is apt to be interrupted by transient local or general convulsions.

It is impossible to lay down any rules by which the maniacal form of acute alcoholism may be at once diagnosticated from acute mania from other causes. For the characteristics of the convulsive form of acute alcoholism and those forms which occur in persons of unsound mind the reader is referred to the descriptions of those conditions. The diagnosis of acute poisoning by alcohol in lethal doses can only be established during life by investigation of the history of the case.

II. Chronic Alcoholism.—The lesions of chronic alcoholism, as has already been pointed out, are not in themselves peculiar to that condition. Many of them occur with more or less frequency in morbid states not induced by alcohol. It is their association and progressive character which gives to chronic alcoholism its individuality. The occasional prominence of certain symptoms or groups of symptoms may thus in particular cases lead to some confusion of diagnosis, especially where the history is unknown or the habits of the individual are concealed. In the greater number of cases, however, the association of symptoms is such as to render the diagnosis, even in the absence of a direct history, a comparatively easy one.

Chronic alcoholism is a condition rather than a disease—a condition characterized by varying lesions of the viscera and nervous system, by profound disturbances of nutrition, and by grave mental and moral derangements. This fact being recognized, the cardinal error of diagnosis to be guarded against is that of overlooking the condition upon which the disease itself with which we have to do depends or is associated. Congestion, inflammation, sclerosis, and steatosis affect the various organs of the body and produce their characteristic symptoms. Profound and lasting disturbances of nutrition demand our attention. Psychical derangements of all grades, from mere moodiness to confirmed and hopeless insanity, take place. These affections must be diagnosticated for themselves here as elsewhere in clinical medicine. The recognition of the underlying condition can, however, alone supply the key to their true pathology.

Delirium tremens is occasionally diagnosticated with difficulty from some forms of insanity not caused by drink. Here transitory and fixed delusions, not mere terrors and hallucinations, are of importance, not less than the absence of the varied and complex associations of symptoms which are characteristic of alcoholism. The delirium of the acute infectious diseases may be mistaken for delirium tremens. Pneumonia, typhoid fever, and the exanthemata occasionally begin with delirium resembling in some respects delirium tremens. Here the history of the case, the pyrexia, and the general condition of the patient are sufficient to establish the diagnosis if the danger of error be borne in mind.

III. Hereditary Alcoholism.—The diagnosis of this condition can only be established by careful investigation of the family history and systematic study of the stages of progression by which the morbid condition presented by the patient has been reached.

IV. Dipsomania.—The diagnostic points are the hereditary transmission of this or other forms of insanity—the mental instability of the patient in early life and in the intervals of the paroxysms, the intermittent or cyclical recurrence of the attack, the morbid impulses of a different kind associated with the impulse to drink, and the struggle of the patient against his recurring impulses to uncontrollable excesses.

PROGNOSIS.—The prognosis in acute alcoholism of the ordinary form is favorable, so far as the immediate attack is in question. The prognosis in rapidly-developing, overwhelming coma from enormous doses of alcohol is in the highest degree unfavorable. Acute coma from moderate doses usually passes off in the course of some hours. It occasionally, however, terminates in fatal pneumonia.

The prognosis in delirium tremens of the ordinary form is favorable. It becomes, however, more and more grave with each recurring attack. Delirium tremens in patients suffering from advanced disease of the heart, lungs, liver, or kidneys, or complicated by acute diseases of these organs, is apt to prove fatal.

The prognosis of chronic alcoholism is gloomy. If the lesions be not advanced, permanent discontinuance of alcoholic habits may be followed by restoration of health, but, unfortunately, the discontinuance is too often merely temporary, the habit being too strong to be permanently broken off.

The prognosis in hereditary alcoholism is unfavorable, both as regards the alcoholic habit and as regards the development of serious diseases of the nervous system under adverse circumstances, even in the absence of the direct action of alcohol.

The prognosis in dipsomania is unfavorable. The paroxysm may recur many times without apparent serious result; the patient in the course of some days or weeks recovers, abandons his evil courses, and resumes his usual occupations. After a time, however, the insanity of which the dipsomania is the recurring manifestation declares itself as a more or less permanent state. The outbreaks become more frequent and more prolonged, the mental condition in the intervals progressively more morbid, until the patient lapses by degrees into confirmed insanity.

The prognosis in all forms of alcoholism, both acute and chronic, is rendered in a high degree uncertain by the psychical disorders which characterize so many of its phases. In consequence of some of these conditions the patient loses at once his appreciation of bodily dangers and his power to avoid them; by reason of others, to escape imaginary evils he plunges into real ones; and finally some of them are of such a nature that they impel him to the blind and unreasoning commission of the most grievous crimes, including suicide and homicide.⁵²

⁵² “I believe that more suicides and combined suicides and homicides result in this country from alcoholism in its early stages than from any other cause whatsoever” (T. S. Clouston, Clinical Lectures on Mental Diseases, Am. ed., 1884).

TREATMENT.—The prophylaxis of alcoholism has regard to communities at large and to individuals. The prevention of the evils of excess by the control of the sale of drink constitutes one of the more important objects of state medicine. At the same time, the traffic in alcohol is curiously evasive of legal enactments. The difficulties attending the enforcement of sumptuary laws are well known. Restrictive laws concerning the making and sale of alcoholic drinks, while partaking of the nature of sumptuary laws are of more comprehensive character, being obnoxious to powerful commercial interests and to the sense of personal liberty of large numbers of persons of all classes. As a result of organized opposition and individual violation they are to a great extent inoperative as regards the prevention of alcoholism.

Aside from the question of revenue from taxation, the practical influence of law is in this matter somewhat limited, being confined chiefly to the prevention of the sale of liquors to minors and persons already intoxicated, and to ineffectual attempts in certain countries to regulate the quality of the drink sold. The penalties for personal drunkenness which does not lead to overt acts are, as a rule, wholly inadequate to restrain it. The best results upon anything like an extended scale have been obtained by the co-operative action of philanthropic individuals in endeavoring to influence the moral tone, especially among workingmen, to diminish temptations, and to provide for leisure hours, in the absence of drink, reasonable amusements and occupation to occupy the time ordinarily spent in taverns and similar places.

The decrease in the consumption of alcoholic drinks in the United States within recent years is doubtless due in part to increasing popular knowledge concerning the dangers of alcoholic excess and to the growth of a more wholesome public sentiment. It is, however, in part also due to poor wages among workingmen.

As regards the individual, prophylaxis against alcoholism consists either in total abstinence from, or in the most guarded indulgence in, alcoholic beverages. It is unfortunate that individuals whose moral and physical organization is such as renders them most liable to suffer from the consequences of alcohol are by that very fact most prone to its temptations, and hence contribute largely to the subjects of alcoholism. These individuals are found among the ignorant, the very poor, and especially among neurotic subjects of all classes of society. Due consideration of this fact cannot fail to establish the responsibility of those fortunately not belonging to these classes, in two respects: first, that of example; and second, that of personal restraint from the standpoint of heredity. The influence of heredity among races addicted to alcohol has not yet attracted the attention it deserves. It is probable that much of the tolerance for alcohol exhibited by individuals, families, or even nations, is to be accounted for by heredity. Still more probable is it that most of the evils and crimes that befall alcohol-drinking communities and individuals are due directly or indirectly to the abuse of this agent. No argument against the indulgence in narcotics can be more potent than that derived from a consideration of the laws of heredity.

I. The Treatment of Acute Alcoholism.—The medical treatment of mere drunkenness requires no consideration. The rapid elimination of alcohol, and the transient nature of its pathological effects in excesses which are not repeated or prolonged, explain the spontaneous recovery, which is usually sufficiently prompt and permanent. The physical suffering and mental distress following unaccustomed excesses are of salutary influence. Under certain circumstances a powerful effort of the will is sufficient to control, at all events for a time, the more moderate effects of alcohol. A similar result follows the use of cold douches, the Turkish bath, and full doses of certain preparations of ammonium, particularly the officinal solution of the acetate of ammonium. In alcoholic stupor of an acute kind the patient may be left to himself, care being taken that the clothing is loosened and that the position is such as to prevent local paralysis from the nerve-pressure. Alcoholic coma, if of moderate intensity, may be managed in the same way. Profound alcoholic coma requires, however, more energetic measures. Frictions, artificial warmth, stimulating enemata, as of turpentine or of hot salt and water, an ounce to the pint, hypodermic injections of strychnia or atrophia in minute doses and occasionally repeated, inhalations of ammonia, and occasional cold affusions, followed by brisk frictions with warm flannel and faradism of the respiratory muscles, may be needed to tide over the threatened fatal collapse. The stomach should be at once washed out with hot coffee.

In the convulsive form of acute alcoholism chloral in twenty-grain doses, repeated at intervals until sixty grains have been given, usually serves to arrest, or at all events to moderate, the paroxysm. It may be administered by the mouth or in double doses by the rectum. If chloral be inadmissible by reason of weakness of the circulation, paraldehyde may be substituted in doses of from half a drachm to one drachm, repeated at intervals of from one to two hours until quietude is produced. Where the convulsive paroxysms are of great violence it may be necessary to control them by the cautious administration of ether by inhalation.

The mania of acute alcoholism calls for energetic management. To avert injury to the patient himself or to those about him he must be confined, if practicable, in a suitable apartment in a hospital; if not, in his own house and carefully watched. Here, as a rule, paraldehyde, chloral, or large doses of the bromides constitute our most efficient means of medication.

In all forms of acute alcoholism it is a rule admitting of no exception to at once withhold alcohol in every form and all doses. If, under exceptional circumstances, great nervous depression or flagging circulation seems to call for the use of alcohol in small amounts, it is far better to substitute other drugs. The frequently repeated administration of hot beef-tea or rich broths in small doses, with capsicum and the use of the various preparations of ammonia, or small doses of opium with or without quinia and digitalis, proves useful in proportion to the skill and discrimination with which they are selected and repeated. It is a good plan to commence the treatment with an active purge.

In the acute collapse following excessive doses—lethal doses—the stomach is to be immediately emptied by the tube or pump and washed out with warm coffee. In the absence of the stomach-tube emesis may be provoked by the use of mustard or sulphate of zinc or by hypodermic injection of apomorphia. The patient must be placed in the recumbent posture and surrounded with hot blankets. The cold douche may be occasionally applied to the head and face, and the muscles of respiration may be excited to action by faradism. Artificial respiration and friction of the extremities may also be required. Inhalations of ammonia may be used. The flagging heart may be stimulated by occasionally tapping the præcordia with a hot spoon—Corrgan's hammer. Hypodermic injections of digitalis may also be employed. Overwhelming doses of alcohol, leading promptly to collapse, usually prove fatal despite all treatment.

II. The Treatment of Chronic Alcoholism.—Whatever may be the prominence of particular symptoms or groups of symptoms, whether they indicate derangement of the viscera, of the nervous system, or of the mind, whatever their combination, the fundamental therapeutic indication in chronic alcoholism is the withdrawal of the poison. The condition is directly due to the continuous action of a single toxic principle: its relief when practicable, its cure when possible, are only to be obtained by the discontinuance of that poison. This is a matter of great, often of insurmountable, difficulty. The obstacles are always rather moral than physical. Occasional or constant temptation, the iron force of habit, the malaise, the faintness, the craving of the nervous system, and, worse than all, the enfeebled intellectual and moral tone of the confirmed drunkard, stand in the way. Even after success seems to have been attained, and the patient, rejoicing in improved physical health and in the regained companionship and consideration of his family and friends, feels that he is safe, it too often happens that in an unguarded moment he yields to temptation and relapses into his old habits. A patient of the writer, after seven years' abstinence from drink, again became its victim in consequence of the incautious suggestion of a young medical man, met at a summer hotel, to take brandy for some transient disorder, and died after eight months of uncontrollable excesses. It is necessary to guard the patient against the temptation to drink. To secure this he may he sent as a voluntary patient for a length of time to a suitable institution, or, still better, he may place himself under the care of a conscientious, clear-headed country doctor in a sparsely-settled region, preferably in the mountains or at the seaside. The malaise, depression, insomnia, and other nervous symptoms when of moderate degree are best treated by abundance of nutritious and easily-assimilable food, taken often and in moderate amounts. To this end gastro-intestinal disturbances may be practically disregarded, except in so far as they regulate the selection of a highly nutritious diet. As a matter of fact, in the early periods of chronic alcoholism, while visceral lesions of a grave character are yet absent, appetite and digestion alike improve in the majority of cases upon the withdrawal of alcohol, provided a sufficiently abundant and easily assimilable dietary is insisted upon. Grave visceral lesions characterize a more advanced alcoholic cachexia and necessarily complicate the treatment. Nevertheless, even here the indication is the withdrawal of the poison. The nervous symptoms require special medication. The whole group of tonics, from simple bitters to quinia and strychnia, is here available. It is impossible to lay down rules for the treatment of particular cases except in the most general manner. In the absence of conditions calling for special treatment, such as gastritis, hepatic or pulmonary congestion, fatty heart, etc., good results follow the frequent administration of small doses of quinia and strychnia; thus, the patient may take one grain of quinia six or eight times a day, or a little gelatin-coated pill containing ¹/200–¹/100 of a grain of strychnia every hour during the waking day, amounting in all to one-twentieth, one-tenth, or one-fifth of a grain in the course of twenty-four hours. This treatment is often followed by the relief of tremor, the quieting of nervous irritability, and the production of good general results. The malaise, the general depression, and especially the sinking feeling at the pit of the stomach so often complained of by patients, are best relieved by food. Fluid extract of coca is also useful in these conditions. The value of cocaine in the management of the nervous symptoms of chronic alcoholism, and in particular as a temporary substitute for alcohol, is doubtful. The writer, having used it in a number of cases by the mouth and hypodermically in doses of ¼–1 grain, has had variable results. In some cases it temporarily relieved the craving and concomitant symptoms; in others it failed wholly: in one instance one-fourth of a grain was followed by great nervous depression. It is desirable not to inform the patient of the nature of the remedy, especially if its use be followed by good results, lest the cocaine itself supplant alcohol as an habitual narcotic. Cold or tepid sponging, the occasional hot bath at bedtime, and the Turkish bath are useful adjuvants to the treatment. As a rule, opium is contraindicated. Sleep often follows the administration of a cupful of hot broth or milk at bedtime. Lupulin is here useful, and the writer has come to regard an ethereal extract of lupulin in doses of from one to three grains as a valuable and harmless hypnotic. If necessary, hypnotic doses of chloral or paraldehyde may be used, but care is required in their administration, and their early discontinuance is advisable. If anæmia be profound, chalybeate tonics do good, and among the preparations of iron pills of the dried sulphate with carbonate of potassium (Blaud's pills) are especially useful.

The obesity of drunkards, as a rule, diminishes on the withdrawal of alcohol. Under circumstances of partial or complete abstinence from drink measures to reduce the weight of such patients are wholly inadmissible.

In conditions characterized by failure of mental power, in beginning dementia or threatened insanity, the syrup of the hypophosphites, the compound syrup of the phosphates, or cod-liver oil should be administered. These remedies are likewise useful in various forms of alcoholic paralysis, as are also faradism and galvanism employed secundum artem. The various forms of alcoholic insanity require special treatment, only to be had in institutions designed for the care of patients suffering from mental diseases in general.

Whilst it is desirable in the treatment of all forms of chronic alcoholism to secure the permanent discontinuance of the alcoholic habit, the skill, judgment, and experience of the physician must determine the degree of rapidity with which this, when practicable, is to be done. The number of cases in which alcohol can be discontinued at once and finally is limited; those in which it can be wholly given up in the course of a few days constitute the largest proportion of the cases; finally, in a small number of cases alcohol can only be withdrawn cautiously and by degrees.⁵³ Whilst it is in most cases essential to remove the patient from his customary surroundings and companionships, it is in the highest degree important to provide for him mental occupation and amusement. To this end a wholesome open-air life, with sufficient daily exercise to induce fatigue, is highly desirable, as indeed is the companionship of interested and judicious friends.

⁵³ It must be borne in mind that in chronic alcoholism acute maladies of all kinds, including traumatism, both accidental and surgical, act as exciting causes of delirium tremens. The part played by the abrupt diminution or withdrawal of alcohol under such circumstances is often an important one. It is the opinion of the writer that a certain amount of alcohol should be administered for a time at least in the accidental injuries and acute sicknesses of alcoholic subjects, and that the reduction should be gradually made.

The Treatment of Delirium Tremens.—The patient should be confined in a large, well-aired apartment, without furniture except his bed, and when practicable he should have a constant attendant. The favorable influence of a skilful nurse in tranquillizing these patients is very great. The custom of strapping them to the bed by the wrists and ankles is to be deprecated. If the case be a mild one, and especially during convalescence, open-air exercise in the sunshine with an attendant is of benefit; care must, however, be taken to guard against the danger of escape.

Under no circumstances should visitors be permitted to see the patient. In young persons the treatment may be preceded by an active saline or mercurial purge. In elderly persons, those suffering from cachectic conditions, or in cases characterized by marked debility and feeble circulation—conditions frequent in persons who have had repeated attacks—it is not desirable to purge. Alcohol should be either wholly withdrawn or more or less rapidly diminished. It must be replaced by abundant food in the form of concentrated broths or meat-extracts. In cases of vomiting these must be given hot and in small doses frequently repeated. Bitter infusions may also be given, or milk or equal parts of milk and Vichy water. If there be thirst, the effervescent waters may be given freely. Patients often drink with satisfaction and apparent benefit hop tea, which may be made simply with water or with equal parts of water and porter.

The medicinal treatment will depend to a large extent upon the peculiarities of the case. In mild cases a combination of the watery extract of opium in small doses, not exceeding a quarter of a grain, with quinia and digitalis, repeated every four or six hours, is often useful. Although the view once entertained that the graver symptoms were the result of prolonged sleeplessness is no longer tenable, the induction of sleep, or at all events of mental and physical repose, is among the more important therapeutical indications. For this purpose hypnotic doses of opium are not only not desirable, but are even, in the majority of instances, attended with danger. The sleep which follows repeated and increasing doses of opium in delirium tremens has too often terminated in coma deepening into death. As calmatives, extract of cannabis indica, hyoscyamus, or the fluid extract of piscidia are useful. As hypnotics, the bromides, chloral, and paraldehyde yield, in the order here given, the best results. The bromides are better in large single doses than in small doses often repeated, better in combination than singly. Chloral, either by the mouth or by the rectum, in doses of from twenty to forty grains, is often followed by beneficial sleep. It is contraindicated where the heart's action is much enfeebled. Paraldehyde, in doses of half a drachm to one drachm, repeated at intervals of two or three hours until sleep is induced, is still more efficient. This drug may be administered without the fear of its exerting a depressing influence upon the heart. The depression characteristic of grave delirium tremens may be combated by repeated small doses of champagne or by carbonate of ammonium in five- or ten-grain doses; the vomiting, by withholding food and medication by the mouth, and giving them for some hours wholly by the rectum or hypodermically. Excessive restlessness is sometimes favorably influenced by cold affusion, followed by brisk friction and warm blankets with continuous artificial heat. The cold pack has proved useful.

Digitalis may be employed, ex indicatione symptomatica, but the enormous doses of tincture of digitalis used by the late Jones of Jersey and others are here mentioned only to be condemned.

To sum up, the chief indications for treatment are complete isolation, the withdrawal of alcohol, abundant, readily assimilable, nutritious food, and control of the reflex excitability of the nervous system.

III. Hereditary Alcoholism.—The treatment of the vicious propensities of the descendants of alcoholic parents does not fall directly within the province of the physician. It is among the most difficult problems of education. The recognition of the cause of evil traits manifested in childhood and youth may do something to avert dangers commonly unsuspected. All things considered, the outlook is not hopeful. The recognition, on the part of the physician, of the influence of hereditary alcoholism in cases of arrested development, feeble organization, or declared disease of the nervous system will perhaps do less to aid his treatment in many cases than to reconcile him to its want of full success. The cry of warning is to those who are eating sour grapes that the teeth of their children will be set on edge.

IV. Dipsomania.—The general indications for the treatment of dipsomania are two: first, the management of the paroxysm; second, the control of the general condition itself.

First, then, during the paroxysm the patient must be saved, in so far as is possible, from the danger of injuring himself or others and from squandering his property. If the excesses are of such a degree as to render it practicable, the same treatment must be carried out as in cases of acute alcoholic mania and delirium tremens—namely, confinement in a suitable apartment under the care of an experienced nurse and the control of the doctor. Unfortunately, this plan is not always practicable in the early days of the outbreak. Here tonics, coca, and repeated small doses of quinia and strychnia are of advantage. Courses of arsenic at the conclusion of, and in the intervals between, the paroxysms are of use, on account of the excellent influence they exert on the general nutrition. These may be advantageously alternated with iron, cod-liver oil, and the compound syrup of the phosphates or of the hypophosphites. Hydrotherapy may also be used with advantage, and the influences of a well-regulated hydropathic establishment are much more favorable than those of institutions specially devoted to the treatment of alcoholic subjects. In the latter the moral atmosphere is apt to be bad; the patients support each other, and too often conspire to obtain in secret that which is denied them openly, or, if the discipline be too strict for this, they sympathize with each other in their restraint, react unfavorably upon each other in the matter of shame and loss of self-respect, and plot together to secure their liberty.

Few dipsomaniacs in the earlier periods are proper subjects for treatment in hospitals for the insane. If cerebral excitement or sleeplessness persist after the paroxysms, chloral, paraldehyde, or the bromides in large doses may be used to secure sleep. Various combinations of the bromides are often of use where the single salts fail. It must not be forgotten that during the paroxysm there is great danger lest the patient do himself or others harm. When there are indications of an impending attack, and during the period of depression following the attacks, benefit is derived from the daily use of bitter infusions. As a matter of fact, however, the management of these cases is among the most unsatisfactory of medical undertakings. The difficulty is increased by the latent character of the mental disorder in the intervals between the attacks. Even when such patients voluntarily enter hospitals for the insane, they cannot be retained there sufficiently long to derive any permanent benefit. What we want is, in the words of Clouston, “an island where whiskey is unknown; guardianship, combined with authority, firmness, attractiveness, and high, bracing moral tone; work in the open air, a simple natural life, a return to mother Earth and to Nature, a diet of fruits, vegetables, bread, milk, eggs, and fish, no opportunity for one case to corrupt another, and suitable punishments and deprivations for offences against the rules of life laid down. All these continued for several years in each case, and the legal power to send patients to this Utopia for as long a period as medical authority determines, with or without their consent.”

THE OPIUM HABIT AND KINDRED AFFECTIONS.

BY JAMES C. WILSON, M.D.

Next in order to alcohol, opium and morphine are habitually abused to a greater extent than any other narcotic. Chloral is used in the same way by a large number of individuals. Paraldehyde, cannabis indica, ether, chloroform, and cocaine are also used to a less extent. The scope of this article does not include the consideration of acute poisoning by these drugs.

The habit of taking narcotics, whether medicinally or as a mere matter of indulgence, is apt speedily to become confirmed. The physiological dose more or less rapidly loses its power to affect the nervous system in the ordinary way. Tolerance increases with increasing doses, and in a comparatively short space of time poisonous doses are taken with impunity as far as immediate danger to life is concerned. The toxic effects of the poison are shown in characteristic perversion of the functions of the nervous system and of the mind. A condition is established in which the ordinary functions of life are properly performed only under the influence of the habitual narcotic, and in which its absence results in languor, depression, and derangement of bodily and mental processes. The habit, once established, thus makes for itself a constantly recurring plea for its continuance. Especially is this true of opium and morphia.

Opium and Morphine.

Opium-eating is chiefly practised in Asia Minor, Persia, and India. It is also prevalent in Turkey. It has been practised in India from very ancient times. The prevalence of this habit in the East is probably largely due to the restrictions placed upon the use of alcoholic beverages among the Mohammedans, and to some extent also to the long religious fasts observed by the Buddhists, Hindoos, and Moslems, during which opium is often used to allay the pangs of hunger. The prevalence of the opium habit in India is shown by the fact that the license fees for a single year amounted to nearly five hundred thousand pounds sterling. It is stated that in Samarang, a town of 1,254,000 inhabitants, the average quantity of opium consumed monthly is 7980 pounds. The town of Japava, with 671,000 inhabitants, consumed in fifteen days 5389 pounds of opium. In 1850, 576,000 pounds of opium were imported into Java, besides an unknown quantity smuggled.¹

¹ Archiv für Pharmazie, 1873, cited by Von Beck, Ziemssen's Cyclopædia, vol. xvii.

The habit is not confined to Oriental countries, but is also practised in various forms in the West. It is by no means rare on the continent of Europe. In certain districts of England, especially in Lincolnshire and Norfolk, more opium is consumed than in all the rest of the United Kingdom. Shearer² states that the increase in the practice of opium-eating among the workpeople of Manchester is such that on Saturday afternoons the druggists' counters are strewed with pills of opium of one, two, and three grains, in preparation for the known demand of the evening. The immediate occasion is said to be the lowness of wages, opium being used as a cheap substitute for alcohol or as a food substitute, or with the view of removing the effects of disease and depression. According to the same observer, laudanum is more or less in use as a narcotic stimulant in the cotton-spinning towns, where female labor is in requisition and is well paid. Children are accustomed to it from their earliest infancy. Their parents drug them with daily potions of Godfrey's cordial, Dalby's carminative, soothing syrup, and laudanum itself, during the long hours of their absence from home. While the habit of opium-eating cannot be said to be generally prevalent in any part of the United States, instances of it are frequently encountered in all classes of society, and particularly among people of means and refinement. The preparations employed in this country are crude opium, tincture of opium or laudanum, camphorated tincture of opium or paregoric, McMunn's elixir, Dover's powder, and the salts of morphia. All of these preparations are used by the mouth; opium is very frequently, especially among women of the better classes of society, habitually taken in the form of suppositories; finally, the acetate and sulphate of morphine are used by means of the hypodermic syringe. While it will be necessary to point out some differences in the effects of these drugs due to the preparation used or to the method in which it is employed, the distinction between the opium habit and the morphine habit, in itself an artificial one, will not be regarded in the course of the present article.

² Opium-smoking and Opium-eating, their Treatment and Cure, by George Shearer, M.D., F. R. S.

Opium-smoking is chiefly practised by the inhabitants of China and of the islands of the Indian Archipelago. It has been imported into those countries where Chinese labor is largely employed. The Chinese have transmitted it, to an extent which is fortunately very limited, to the inhabitants of certain of our cities. Opium-smoking is habitually practised in this country only among the more debased orders of society.

SYNONYMS.—Opiophagia, Morphiopathy, Morphinism, Morphinomania, Morphiomania, Morpheomania, are terms occasionally employed to designate the opium or morphia habit.³ Landowski, Levinstein, Jouet, and others use the term morphinism to denote the condition of the body; morphinomania, the condition of the mind in chronic morphine-poisoning. This distinction may be misleading. In effect, the pathological condition is complex, including derangements both somatic and psychical.

³ The word morphiomania, used by writers, is contrary to all etymological rule (Zambaco, De la Morphéomania, Paris, 1883).

ETIOLOGY.—A. Predisposing Influences.—Pain holds the chief place among the influences which predispose to the formation of the opium habit. By far the greater number of cases have taken origin either in acute sickness, in which opium administered for the relief of pain has been prolonged into convalescence until the habit has become confirmed, or in chronic sicknesses, in which recurring pain has called for constantly repeated and steadily increasing doses of opiates. In view of the frequency and prominence of pain as a symptom of disease, and the ease and efficiency with which opium and its preparations control it, the remote dangers attending the guarded therapeutic use of these preparations are indeed slight. Were this not so, the number of the victims of the opium habit would be lamentably greater than it is. In a considerable proportion of cases of painful illness the relief afforded by opiates is attended by at least some degree of malaise, nausea, vomiting, and vertigo—symptoms which render the speedy discontinuance of the remedy scarcely less desirable than the control of the pain for which it was administered. Occasionally these symptoms are so distressing as to render opium wholly inadmissible. In other instances each successive dose is attended by an aggravation of the distress. More commonly, especially in acute illnesses, decreasing pain may be controlled by diminishing doses, thus rendering practicable entire discontinuance of the drug before those modifications of the nervous system, and especially before that tolerance for large doses, which constitutes the beginning of the opium habit, are established. For these reasons the use of opiates in acute sickness, if properly regulated, is attended with but little danger. Far different is it, however, in chronic painful illnesses. Here to procure relief by opium is too often to pave the way not only to an aggravation of the existing evils, but also to others which are often of a more serious kind. Opium is at once an anodyne and a stimulant. The temptations to its use are of a most seductive character. To the overworked and underfed mill-operator it is a snare more tempting than alcohol, and less expensive. It allays the pangs of hunger, it increases the power of endurance, it brings forgetfulness and sleep. If there be myalgia or rheumatism or neuralgia, and especially the dispiriting visceral neuralgias so common and so often unrecognized among the poorer classes of workpeople, opium affords temporary relief. The medical man suffering from some painful affection, the worst symptoms of which are relieved by the hypodermic injection of morphine, falls an easy prey to the temptation to continue it—a danger increased by the fact that he is too often obliged to resume his work before convalescence is complete. Indeed, the self-administered daily doses of physicians sometimes reach almost incredible amounts. To women of the higher classes, ennuyée and tormented with neuralgias or the vague pains of hysteria and hypochondriasis, opium brings tranquillity and self-forgetfulness.

Of 100 cases collected by Jouet,⁴ the habit followed the therapeutic use of morphine in 32 cases of ataxia, 24 of sciatica and other neuralgias, 8 of asthma, 2 of dyspepsia, 4 of hypochondriasis, 2 of madness, 9 of painful tumors, 2 of prostatic inflammation, 7 of nervous conditions (not specified), 1 of peritonitis, 2 of periostitis, 1 of gastro-enteralgia, 4 of pleuritic pains, 1 of contracture, and 1 case of hæmoptysis.

⁴ Étude sur le Morphinism chemique, Thèse de Paris, 1883.

The responsibility of the physician to his patient becomes apparent when we reflect that with very few exceptions the opium habit is the direct outcome of the use of the drug as a medicine.

The decade of life at which the opium habit is most common is between thirty and forty. But it may be developed at any age. Even infants are not rarely made the subjects of chronic opium narcotism by the use of soothing syrups and other poisonous nostrums.

Sex in itself exerts very little influence as a predisposing cause. Owing to collateral circumstances, the number of women addicted to opium is greater than the number of men. Kane⁵ states that females more frequently fall victims to these drugs than males, in the proportion of three to one, and attributes this excess to the fact that women more often than men are afflicted with diseases of a nervous character in which narcotic remedies are used for long periods. This observer suggests as an additional explanation the occasional preference on the part of women for opium as a stimulant in place of alcohol, its effects being less noticeable and degrading. On the other hand, Levinstein observed in 110 cases 82 men and 28 women. He does not, however, regard the conclusion that the use is more common among men as warranted by these figures. The habit resulted in these 110 cases from the following causes: In 20 men and 6 women after acute affections; in 46 men and 17 women after chronic affections, these diseases being in each instance accompanied by great pain. One man began to use morphine as an antiaphrodisiac. Either to produce mental excitement simply or to cause forgetfulness of the ordinary cares of daily life, 15 men and 5 women indulged to an uncontrollable extent.

⁵ Drugs that Enslave, Philadelphia, 1881. I refer with pleasure to the early labors of this observer. His later publications tell their own story.

Occupation has in some respects much to do in favoring the development of the opium habit. Familiarity with the use of drugs exerts a powerful influence. Of Levinstein's 110 cases, 47 occurred in persons belonging to the medical profession or dependent upon it; thus, 32 physicians, 8 wives of physicians, 1 son of a physician, 4 nurses, 1 midwife, and 1 student of medicine.

A predisposing influence of more importance than would at first sight appear is found in sensational popular writings upon the subject. As Kane has well said, “At the time in which De Quincey, Coleridge, and Southey lived the people and the profession knew little of the opium habit save among foreign nations. The habitués were few in number, and consequently when De Quincey's article appeared it created a most decided impression upon the popular mind—an impression not yet effaced, and one which bore with it an incalculable amount of harm. Men and women who had never heard of such a thing, stimulated by curiosity, their minds filled with the vivid pictures of a state of dreamy bliss and feeling of full content with the world and all about, tried the experiment, and gradually wound themselves in the silken meshes of the fascinating net, which only too soon proved too strong to admit of breaking.” There can be no question that a percentage of cases of the opium habit, small though it be, is even in our day to be attributed to this cause.

Somewhat analogous in its etiological importance is the influence of example upon persons of idle and luxurious habits. Nowhere in Western countries, with the exception of the opium-smoking dens of the Chinese and their depraved associates, are there public places of resort devoted to the practice of the opium and morphine habits, as there are in Turkey and the East. According to Jouet—whose statements are corroborated by occasional statements in French newspapers—the habitual injection of morphine is to-day, in France at least, almost a matter of fashion. Landowski states that friendship is occasionally pushed to the extent of the exchange of pretty syringes in silver cases as presents, and that a patient received upon his birthday a hypodermic syringe as a present from his sister. Zambaco, whose observations were made at Constantinople, states that among the Moslems the opium habitués prefer the crude drug, either alone or associated with certain aromatic substances, such as ambergris, canella, or saffron, which are used for their aphrodisiac effect. These mixtures are prepared openly in the family, and carried upon the person in the form of pills in rich boxes of gold and enamel among the better classes. This observer further says that the ladies of the better classes carry jewelled cases containing hypodermic syringes and artistic flaçons for the seductive solution, and that they avail themselves of favorable opportunities to take an injection of morphine even when together.

In addition to the predisposing influences already mentioned, it has been customary to regard insanity as a cause of the opium habit. Laehr⁶ and Fidler⁷ have gone so far as to class the morphine habit among the psychoses. This view appears to be no longer tenable. The opium habit must be classed with the taste for alcohol, gambling, avarice, and lust as among human passions. That nervous subjects, invalids, and individuals wanting in moral and physical tone are specially prone to it is obvious. It constitutes in these cases, however, an expression of the morbid constitution rather than a substantive affection in itself. In the same manner, the opium habit in insane persons must be looked upon as an epiphenomenon of the morbid mental condition.

⁶ Allgemeine Zeitschrift für Psychiatrie, 1872.

⁷ Jahresb. der Gesellschaft für Natur und Heilkunde, Dresden, 1876.

Levinstein has with reason insisted upon the essential difference between the disturbances resulting from chronic poisoning by alcohol, lead, arsenic, etc., and that produced by morphine. In the former group the mental conditions are expressions of physical and chemical alterations of the central nervous system, which, once established, persist for an indefinite period, whereas in morphinomania the troubles of the nervous system are chiefly functional and of a transitory character. He regards the nervous disorders developed from the prolonged use of morphine as the result simply of depression of the nervous system, and the extreme suffering experienced on the withdrawal of the regular dose to which the subject has been accustomed as a trouble of innervation rather than as a psychical derangement. This physical suffering and the mental depression which accompanies it have their analogues in the angina occasionally seen in paroxysmal affections of the heart, the blood-vessels, and the respiratory organs. Certain it is that individuals addicted to opium and morphine excesses in a high degree not only frequently retain full possession of their intellect, but occasionally achieve and maintain great distinction in professional and scientific life. Furthermore, subjects of the opium habit, notwithstanding the gravest mental disturbance manifested during the continuance or upon the cessation of the habit, usually exhibit when cured no further indication of mental disorder.

B. The Exciting Cause.—In addition to the usual constituents of vegetable substances, mucilage, albumen, proteids, fat, volatile substances, and salts of ammonium, calcium, and magnesium, opium contains a number of alkaloids, two neutral substances, and meconic acid. Some of the alkaloids are probably derivatives from morphia. The three most important alkaloids are morphine, codeine, and thebaine. The neutral substances are meconin and meconiasin. Morphinæ hydrochloras, acetas, and sulphas, codeina, and apomorphinæ hydrochloras are officinal in the United States Pharmacopœia. Opium and its alkaloids act principally on the central nervous system, and in mammals on the brain. The functions of the nervous system, as Brunton has pointed out, are abolished in the order of their development, the highest centres being the first affected. In man the action of opium is chiefly manifested upon the brain. With small doses a stage of excitement, attended by increased activity of the circulation, augmented nervous energy, and under favorable circumstances an agreeable languor, followed by quiet sleep, constitute the effects of the drug; with larger doses, of from one to two grains, the transient stage of excitement is followed by deep sleep, the awakening from which is marked by headache, nausea, and evidences of gastro-intestinal catarrh; with still larger doses, of three grains or more, deep sleep is produced, which speedily passes into coma. The drug has an especial action on the vaso-motor system, which is manifested in its power to diminish congestion and relieve inflammation. With the exception of the urine and the sweat, the secretions of the body are diminished by opium. The action of the drug upon the intestines varies with the dose. In moderate doses it diminishes peristalsis and causes constipation; in very small doses it increases peristalsis; in large doses peristaltic action ceases. Morphine is eliminated unchanged by the kidneys. It is eliminated also by the gastro-intestinal mucous membrane, having been found in the stomach after hypodermic injection. The action of opium and its derivatives, as that of other narcotics, is much influenced by habit. In those accustomed to the drug large (and sometimes enormous) quantities are required to induce the characteristic manifestations. Not rarely these manifestations are much retarded. The enormous amount of two pints of tincture of opium has been taken in the course of a day; a female patient afterward successfully treated by the writer took habitually for a long period of time from ten to twelve grains of morphine per diem, hypodermically. Diedriech⁸ assumes that a portion of the morphine introduced into the organism is converted into oxydimorphine or other analogous substances which have the property of counteracting to some extent the toxic effects of the morphine.

⁸ Ueber oxydimorphine, Inaug. Diss., Göttingen, 1883.

Levinstein concludes as a result of experiments upon animals that morphine, besides its influence upon the nervous system, exerts an especial action upon two sets of organs: first, upon the digestive tube; and second, upon the sudoriferous glands. Taken by the mouth, it irritated the gastric mucous membrane. Whether taken by the mouth or hypodermically, it diminishes the secretion of gastric juice and the peristaltic movements of the intestine. These disturbances serve to explain not only certain of the phenomena of the opium habit itself, but even more fully some of the symptoms manifested upon its discontinuance. The nausea, vomiting, and constipation occurring during the continuance of the habit must be looked upon as a result of the derangement of function of the gastro-intestinal glandular apparatus and the chronic catarrh which accompanies it. The abrupt discontinuance of the drug is followed by the sudden return of functional activity, hence salivation, persistent vomiting, anorexia, and diarrhœa.

The effects of habitual excesses in opium and morphine upon the nervous system are in essential particulars the same. Upon the functions of the digestive system and upon nutrition they differ to a considerable extent. Opium, as a rule, soon produces gastro-intestinal derangements of a marked kind. These derangements consist in loss of appetite, enfeebled digestion, nausea, vomiting, and constipation alternating with occasional diarrhœa. The anorexia is usually persistent and of a high degree, and has much to do with the development of the wasting which is so common and so marked. The occasional excessive appetite for food manifested by opium-eaters is of brief duration. Its gratification aggravates the functional disturbances, provokes gastro-intestinal catarrh, and thus tends to increase the general malnutrition. On the other hand, morphine is much better borne. At the present time almost all morphine habitués use the hypodermic syringe, and, notwithstanding the elimination of the drug in part by the gastric mucous membrane, thus escape in part its evil effects upon the organs of digestion, and remain for a long time, often despite enormous excesses, free from the nutritive disturbances which are almost characteristic of the habitual abuse of crude opium.