On Alcoholism
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YALE UNIVERSITY LIBRARY From the Medical Library of DR. ALEXANDER LAMBERT, B.A. 1884 the gift of DR. ADRIAN LAMBERT, B.A. 193° DR. JOHN T. LAMBERT, B.A, 1935 DR. SAMUEL W. LAMBERT, JR., B.A. 1919 DR. DICKINSON W. RICHARDS, JR., B.A. 1917 TRANSFERRED TO YALE MEDICAL LIBRARY ON ALCOHOLISM ON ALCOHOLISM ITS CLINICAL ASPECTS AND TREATMENT FRANCIS HARE, M.D. MEDICAL SUPERINTENDENT OF THE NORWOOD SANATORIUM, BECKENHAM LONDON J. & A. CHURCHILL 7, GREAT MARLBOROUGH STREET 1912 PRINTED BY ADLARD AND SON, LONDON AND DORKING. 811. VA PREFACE In the middle of 1905, the medical side of the Norwood Sanatorium was taken over by a committee of well-known medical men whose number has since been slightly increased. Since the end of that year the experience gained in the institution has been embodied in quarterly reports, addressed to, and passed by, the Committee at their quarterly meetings. At the end of each year the substance of the quarterly reports has been re-embodied in an annual report, which, after acceptance by the Committee at their annual meeting, has been printed and circulated amongst members of the medical profession. Five such annual reports have now been issued, and, judging by the number applied for and the tone of the acknowledgments received, have met with a measure of appreciation : this applies more especially to the third, fourth and fifth annual reports, which have naturally been longer and more exhaustive than the first and second. Accordingly it has been sug- gested that the time has arrived to collocate and re- arrange the material contained in these annual reports in a form more convenient for reference, and the present volume is the outcome of that sugges- tion. VI PREFACE For the most part alcoholism has been studied clinically under three conditions: (i) In general in licensed practice : (2) in general hospitals ; and (3) retreats. Each of these fields of study provides a somewhat different point of view. The physician in general practice obtains his cases in a comparatively early stage. This is considerably in his favour. On the other hand, he is obliged in most instances to treat his patients in their own homes amongst their accustomed surroundings—surroundings in which the habit has developed. This is not in the physi- cian's favour ; for it is always difficult for him to feel assured that his prescribed treatment is being strictly carried out. The hospital physician sees mainly the advanced cases of alcoholism—cases in which the severity of the ultimate degenerations and physical complications overshadow the earlier and more remediable stages of the affection ; while the physi- cian in charge of a retreat licensed under the Ine- briates Act, armed as he is with no small amount of legal authority, sees his patients in circumstances which are certainly exceptional, if not quite abnormal. Moreover, owing to the natural aversion of patients from signing away their individual freedom even for a time, he can hardly expect to obtain his cases in other than the later stages of alcoholism. All such considerations encourage the hope that the clinical study of alcoholism in a free sanatorium will provide one or two new points of view, and so lead to, if it does not directly promote, an increase in the definite knowledge we now possess of this ubiquitous habit or disease. In works on alcoholism and its treatment it is PREFACE Vll usual to refer also to the management of other drug habits. That course has not here been followed. The subject of morphinism, the only other drug habit at all common in this country, has been thought worthy of a volume to itself, and conse- quently deferred. The first or introductory chapter stands somewhat apart from those which follow. It is theoretical and deductive, and was inspired mainly by the views put forward in the recent report of the Departmental Committee on the law relating to inebriates and their detention. To my mind these views are of extreme interest and even of great practical import- ance. But the chapter is not clinical in its origin, and unlike the remaining eight chapters, does not depend upon the work done at the Norwood Sana- torium. The busy practitioner, therefore, may perhaps elect to omit its perusal. Beckenham, August, 1912. —; CONTENTS CHAPTER I Introductory PAGB Nature of inebriety—Motives for drinking— Generally accepted propositions concerning alcohol—Classifica- tion of population from an alcoholic standpoint Classification of inebriates from a psychological standpoint— Inexpediency of regarding inebriety as a disease i CHAPTER II Exciting, determining, or accentuating factors of alcoho- lism—Extrinsic : grief, worry, boredom, and variations in responsibility ; special occupations ; example, good and bad— Intrinsic, mostly pathological : pyrexial conditions and convalescence therefrom ; insanity ; abnormal mental conditions not amounting to insanity mental depression ; insomnia ; debilitating condi- tions ; dysmenorrhcea ; asthma ; recurrent neuralgic and allied painful conditions ; paroxysmal tachy- cardia ; eye-strain ; morphinism gout 14 ; ... CHAPTER III Clinical classification of alcoholism : recurrent, or inter-— mittent ; chronic, or continuous — Dipsomania Pseudo-dipsomania— Chronic or continuous alcoho- lism, inebriate and sober — Intermediate cases; absence of sharp lines of demarcation between the four varieties of alcoholism ; consequent difficulty of classification — Dipsomaniac craving and alcoholic craving • • • 59 ; CONTENTS CHAPTER IV Symptoms and complications — Acute complications, mental and other—Chronic mental complications- Alcoholic peripheral neuritis—Alcoholic albuminuria —Hepatic complications —Gastric catarrh and vomit- ing 92 CHAPTER V Abstinence phenomena of alcoholism— Natural tolerance tolerance —Acquired tolerance : alcoholic insomnia ; of morphine ; tolerance of chloral ; tolerance of tole- veronal ; tolerance of cocaine—Loss of acquired rance— Intolerance : pathological drunkenness ; mania a potu—Affections arising during and after convales- cence from alcoholism : recurrent or periodic ano- rexia ; recurrent or periodic "bilious" attacks; re- current sick headache ; recurrent or periodic diarrhcea recurrent or periodic migraine ; morning headaches ; persistent high blood-pressure; acute articular gout 113 CHAPTER VI Alcoholic epilepsy and delirium tremens—Alcoholic epi- lepsy : cases occurring in sanatorium ; cases which occurred before admission ; conclusions— Delirium tremens : cases occurring in sanatorium ; cases which occurred before admission ; conclusions, special and general ; differences in incidence between alcoholic epilepsy and delirium tremens—Alcoholic epilepsy and delirium tremens combined—Abortive treat- mentof delirium tremens—Somefallacies regardingthe pathology of delirium tremens—Theories of delirium tremens— Prognosis of delirium tremens and alcoholic epilepsy —Treatment of delirium tremens and alco- holic epilepsy 140 CHAPTER VII Treatment—Compulsion and moral tone—Voluntary re- strictions—Policy in free sanatorium—Diet—Tobacco 178 CONTENTS XI CHAPTER VIII PAOR Treatment (continued)—The withdrawal of alcohol : cases suited for sudden withdrawal ; cases suited for taper- tapering Special drugs ing ; principles of successful — used : apomorphine hydrochloride ; sodium bromide ; special hypnotics ; strychnine, atropine, cinchona rubra, and gentian ; morphine tartrate ; rationale of action of drugs used in alcoholism—Duration of treat- . ment ; after-treatment ; parting advice 208 CHAPTER IX : of results General results—Fallacies incomparability ; incomparability of data—Statistics : percentage of relapses, of cases stated to be improved, and of abstainers ; known duration of abstinence following treatment ; results in individual patients — Some factors bearing on prognosis : heredity ; sex ; age ; form of alcoholism 244 INDEX . .263 — ON ALCOHOLISM CHAPTER I INTRODUCTORY Nature of inebriety— Motives for drinking— Generally accepted propositions concerning alcohol—Classification of population from an alcoholic standpoint—Classification of inebriates from a psychological standpoint — Inexpediency of regarding in- ebriety as a disease. Is inebriety a disease? This is one of the com- monest questions put to the physician who devotes his attention mainly to alcoholism. Unfortunately no straightforward answer can be made. In the first place the term " disease " has never been clearly and comprehensively defined. We might, of course, beg the latter question to some extent and define disease as unphysiological action. Then, however, we should have to admit that there is no clear line of demarcation between physiological and unphysio- logical, or pathological, action. And it is equally certain that there is no clear line of demarcation between strictly moderate drinking and drinking to excess. There are, it is true, some who regard all consumption of alcohol, in whatever form, as patho- logical, and these certainly gain the advantage of evading a difficulty. But in the present state of public opinion, the advancement of such a view — 2 ON ALCOHOLISM whether it prove eventually right or wrong—is, for the practical physician, at any rate, to be avoided. It is for him a heavy handicap in seeking to gain the confidence of the ordinary alcoholic patient with whom he has to deal. I do not deny that the con- stant ventilation of views in advance of the average opinion of the public may have been an efficient agent in bringing about the present very general reaction against the use and abuse of alcohol in daily life.