It is now quite generally considered that inebriety is a neurosis and that the alcoholic is a mental defective in some way. White says that the life history of the alcoholic shows him to be an inefficient individual, and continuity of effort, day in and day out, is foreign to his character. In other words, he is a neurotic. The reaction to this inefficiency is an effort to find safety, the state of mind that avoids the thought of responsibility, hence the resort to alcohol. As Walsh says, "alcohol lifts the scare." In other words, alcoholism involves both mental deficiency and access to the drug. It is surprising how little an alcoholic misses his drink when he is completely away from it, as on a long sea-voyage or in an institution.

Inebriates may, for convenience, be divided into three classes, viz., the steady drinkers, the periodic drinkers, and the dipsomaniacs. The steady drinkers are always under the influence of liquor, though not of necessity intoxicated. The periodic drinkers are those who drink to excess at intervals, being started off on the drinking bout by some small provocation or added responsibility which lights up their "fear neurosis." They have little will power. They soon lose their sense of responsibility, and tend to drink larger and larger quantities, though at first attending to business. They may cease drinking if segregated for a single day. Dipsomaniacs are the victims of epileptic insanity (Diefendorf).

In dipsomania the impulse to drink is immediate and irresistible. It comes over the victim like a paroxysm. It may occur in persons who hold positions of responsibility; and these, during the attack, may perform ruinous acts of business, commit social offenses, etc. In the intervals the victims may drink temperately or not at all, and there is no fear that the sight of liquor will bring on a paroxysm. In the attack the drinking may last only a day or two, or may continue in gradually increasing quantities, or with partial remissions, for weeks; it frequently terminates in prostration, failure of the patient's stomach, and nervous breakdown. The patients may be unable to remember where they have been or what they have done. A man who had not drunk for some time was left a fortune on condition that he refrained from drink for a year. This acted as the exciting cause of an attack, and within an hour of the reading of the will he was intoxicated (Crothers).

After drinking for some time, the chronic alcoholic may have various gastro-intestinal disturbances, disgust for food, nausea, retching, vomiting, constipation; and there may be an alcoholic gastritis, with irritability of the stomach, a secretion of large quantities of thick mucus, and a gastric juice of variable quality, sometimes highly acid and sometimes deficient in acid. There may be a swollen, tender liver. The nervous system is severely upset, and there may be mental depression, anxiety, lack of energy, loss of will power, and great general nervousness and restlessness. He doesn't care to go to work, smokes to excess, and has a great thirst for liquors. In some cases there is a peripheral neuritis, usually of hands or feet, but sometimes in other parts of the body, with tingling and numbness or acute tenderness.

The patient may display Korsakoff's psychosis, which is a condition of disorientation with the memory strikingly at fault. The patient may utterly fail to remember what he was doing an hour or a few minutes before, how long ago he came to the hospital, what is his business, or whether he is married or not. He thinks the physician is an old friend, though he really has not seen him before; and, when questioned, will answer with a feeling of absolute certainty what is obviously untrue. This psychosis is usually accompanied by peripheral neuritis.

What brings the patient to the physician is mostly either great nervousness, gastric disturbance, or peripheral neuritis. Some men seem to stand a daily consumption of large quantities of liquor for a very long time without having occasion to visit a physician; others succumb readily to one or other harmful effect of the poison. The typical chronic alcoholic gradually loses his mental and physical vigor, grows careless about his person and his habits, and becomes a relatively useless member of society. The venules of nose and cheek may become visible from chronic dilatation, the eyes are watery, injected, and with a far-away look, there is a tremor of hands, lips, and tongue, the sexual powers are frequently abolished (azoospermia), and the organs of the body show striking pathologic changes.

Treatment Of Chronic Alcoholism

According to the circumstances, the indications for treatment in severe outbreaks are: (1) To check the craving for drink. (2) To allay nervousness and overcome insomnia. (3) To supply nourishment and get the stomach tolerant to food. (4) To promote elimination.

1. To check the craving for drink. This requires - (a) Gradual withdrawal of the alcoholic drinks and (b) their replacement by hot, bitter carminatives. (See Acute Alcoholism.) Attempts to withdraw the liquor suddenly result in a rebellious patient, and sometimes in serious mental and nervous manifestations. For the gradual withdrawal of liquor there are two plans in common use, viz.:

(a) Allowing one ounce of whisky for each dose, the interval between the doses is lengthened each time, the second dose being given half an hour after the first, the third one hour later, the fourth two hours later, etc.

(b) Using a bottleful of whisky, a drink is given every half-hour or hour, but after each dose the bottle is refilled with water, so that the liquor becomes more and more diluted. After a time it is practically all water.

2. To allay nervousness and overcome insomnia the favorite remedies are bromides in large doses, morphine sulphate, 1/4 grain (0.015 gm.) by hypodermatic, hyoscine hydrobromide or atropine sulphate, 1/100 grain (0.0006 gm.) by hypodermatic or mouth, paraldehyde 2-4 drams (8-15 c.c.), chloral hydrate, 30 grains (2 gm.). The "narcotic" method of keeping the patient constantly asleep for from twenty-four to thirty-six hours has its strong advocates, and even the rest obtained from a hypodermatic of morphine sulphate, 1/4 grain, and hyoscine hydrobromide, 1/100 grain (0.0006 gm), may be of great benefit. The cold bath and the wet pack may be needed in some cases.

3. To supply food, small quantities of hot milk, koumiss, oyster-stew, junket, calves'-foot jelly, etc., may be administered at frequent intervals. As soon as the stomach becomes tolerant, milk-toast, poached egg on toast, oysters, etc., may be allowed. Carbohydrates are especially recommended to replace the alcohol. Spitzig feeds intensively with sugar.

4. To promote elimination, valuable measures are plenty of fresh air, because of excretion of the alcohol by the lungs, sweating by hot baths, or a Turkish bath if patient is able to stand it, and vigorous catharsis with compound cathartic pills, or calomel followed by citrate of magnesia.

Delirium tremens ("the horrors") is a special manifestation of chronic alcoholism. It rarely occurs except after continued heavy drinking, and in such cases may be brought on by the sudden withdrawal of the alcohol or by a temporary great excess, by pneumonia, or by traumatism, e. g., fracture of a limb. It is characterized by horrible hallucinations of sight and hearing. The hallucinations take the form of snakes, rats, things crawling over the body, or people with harmful intentions. The patient sees them coming or hears voices. He shows intense activity, talking, muttering, crying out, attempting to get out of bed, or perhaps to escape from the attendants. Insomnia is almost complete, and there may be a temperature of 102 ° or 103 ° F. The patient may pass into coma and die with cerebral edema (wet brain), or go into collapse from pneumonia, traumatism, or the excessive activity and struggling.

The treatment is that for chronic alcoholism, and in addition wise restraint and close watching of the circulation because of the tendency to collapse. The withdrawal of liquor must be managed more deliberately. In a study of the treatment in 500 cases Ranson (1909) found ergot apparently the best remedy. The mortality in those getting ergot was 21.6 per cent. below the average. Sceleth and Beifeld, from an experience with 2500 cases a year, state that simple delirium tremens when treated lasts three to eight days, while with wet brain it lasts two to twelve weeks, with a mortality of 75 per cent. They find ergot useful in the asthenic cases, but harmful in wet brain. They recommend hydrotherapy and consider lumbar puncture of no value, though Dana and also Steinebach advocate it. Alcohol has been found in the spinal fluid. Hogan advocates the intravenous use of 1000 c.c. of a solution of sodium chloride 0.58 per cent., sodium bromide 1.02 per cent., and sodium bicarbonate 0.84 per cent., followed by a solution of 80 gm. of glucose in 250 c.c. of water.