Chronic alcoholism is to be differentiated chiefly from those diseases in which there is mental deterioration: dementia praecox, general paralysis, and senile dementia. The student is referred to the chapters devoted to these diseases for discussions of differential diagnosis.
This is always grave. The symptoms of mental deterioration once established are not likely to become abated. The timely suppression of alcohol prevents their appearance or, if they are already present, arrests their progressive course. Unfortunately this is very difficult to accomplish.
The arterial system is the seat of atheromatous degeneration the intensity and extent of which are variable; it affects especially the arteries of the brain. Atheromatous changes in the arteries at the base are frequent, though not constant. The arterioles and capillaries may present a state of degeneration characterized by the presence of granular masses containing nuclei, which indicate their cellular origin.
The nerve-cells undergo "a certain degree of granulo-pigmentary and fatty degeneration." l The nerve fibers, especially the tangential and commissural fibers, are partially atrophied.
The extent of the lesions in the nervous elements is proportionate to that of the mental deterioration. Therefore it is especially marked in cases of advanced dementia.
The organs of the vegetative functions present the usual lesions of alcoholism: myocarditis, interstitial nephritis, alcoholic gastritis, fatty degeneration of the liver. The hepatic lesions have become of special interest since Klippel has shown that they are the immediate cause of certain deliria occurring in alcoholics.
How does one become an alcoholic? This question resolves itself into two other questions, as follows:
1. Why does a given individual drink alcohol in injurious doses?
2. Why are certain nervous systems more susceptible than others to the poisonous action of alcohol?
It would require a volume to reply fully to the first question; indeed, it would mean a solution of the gigantic problem of alcoholism in its social relations. According to Kraepelin, heredity seems to play a certain role. The tendency to alcoholic excesses is transmitted to descendants. Fere also states that "to become an alcoholic one must be alcoholizable; the mere indulgence in fermented beverages is not in itself sufficient." This factor is of some importance, though slight as compared with social factors. Among the latter the most powerful is undoubtedly the widespread ignorance of the true action of alcohol, as well as the false disastrous notion prevailing among all classes of society that alcohol gives strength and is therefore indispensable to the workingman in the performance of hard labor. Though it is to-day a well-established fact in the medical and scientific world that alcohol produces but an illusion of strength and that the sense of increased energy which it gives is but a morbid subjective phenomenon, this idea is still looked upon by the public as an innovation of doubtful certainty, "an invention of the doctors."
1 Klippel. Dm delire alcoolique. Mercredi medical, Oct., 1893.
To ignorance is joined the element of suggestion. There can be no doubt that many begin to drink by chance or by example. For a laborer in some countries it is almost impossible in his social intercourse to escape alcoholism, even though he may be aware of its dangers. His comrades drag him into the saloons, which constitute perpetual temptations on his way. Refusal to accept their invitations exposes him to their ridicule and ill-treatment, and condemns him to the isolation of a social outcast; here, as everywhere else, "to do as others do " is the great principle that governs the individual and obliges him to conduct himself against his own interest and even against his own inclinations.
Among the social causes there are a great many special factors, one of which deserves special mention, namely, grief. Some alcoholics abandon themselves to drink on account of financial ruin, others because of domestic unhappi-ness, etc. However, it is to be remembered that very often patients claim their misfortunes to have been the cause of their intemperance, while in reality they are the effect. The drunkard pretends that he drinks to find relief from his domestic troubles, while in fact his intemperance has caused them.
We now have to answer the second question: Why does alcohol exert a rapid and intense action upon certain nervous systems, while others resist successfully much greater excesses? - It is here that individual predisposition comes into play.
Like the symptoms of acute alcoholism, those of chronic alcoholism appear chiefly in predisposed individuals; and the greater the predisposition the more rapidly do these symptoms develop. We see daily in general hospitals patients presenting atheroma of the arterial system, alcoholic cirrhosis, etc., and showing but slight if any nervous or mental disorders; while in insane hospitals patients are admitted whose alcoholic excesses have been relatively slight and whose nervous systems have nevertheless already suffered irreparable damage. The quality of the soil is therefore of primary importance.
The pathogenic action of alcohol is also favored by all factors which diminish the resistance of the organism, such as stress, grief, want of sleep, and acute or chronic infectious diseases (tuberculosis). Thus we often encounter, associated in the same subject, the abuse of alcohol, predisposition, and debilitating influences.
It would be useful to know which among the alcoholic beverages produce so great a toxic action as to be particularly responsible for the production of alcoholism. Clinical evidence seems to show that the principal factor in alcoholism is the quantity and not the quality of the beverage ingested. The experiments of Joffroy and Serveaux have shown clearly that alcoholic intoxication is due to ethyl alcohol itself, and not to the impurities often associated with it. Therefore all fermented beverages may cause alcoholism: liquors, alcoholic tonics, wines, beers, ciders, the alcohol of beverages as well as that of substances used in the industries. However, "a given quantity of alcohol is more toxic the more concentrated it is; for this reason the stronger alcoholic beverages play a prominent role in the production of alcoholism." 1
Alcoholism, once established, requires no other treatment than abstinence from alcoholic beverages. Generally this can only be enforced in a hospital for the insane or for inebriates.2 The patient, on being cured of his drinking habit and returned to normal life would do well to join a total abstinence society where he will find the support which his wavering will power is still in need of.
1 Antheaume. De la toxicite des alcools. These de Paris, F. Alcan, 1897. This work contains the results of the experiments of Joffroy and Serveaux.
2 Serieux. Les establissements pour le traitement des buveurs en Angleterre et aux Etats-Unis. Projets de- creation d'asiles d'alcooliques.