BYEDWARD P. DAVIS, A.M., M.D.
BYEDWARD P. DAVIS, A.M., M.D.
The study of speech, a complex function, enlisting at once the activities of mind and body, invites the physician to enter alike the domains of the psychologist and physiologist.
Distinguishing man from beast, articulate expression has its foundation in purely mental phenomena; its successful accomplishment requires the reflex mechanism common to man and beast.
Let us consider as concisely as possible the physiology of speech.
DEVELOPMENT OFSPEECH IN THEINDIVIDUAL.—The earliest observation has noted in the common name of the new-born child its speechless condition; it is the infant, or not-speaking being. Born with a nervous system in a highly unstable condition, the babe is a most favorable recipient of the many impressions which stream upon it from all sides. With sight and hearing undeveloped, the field of early infantile impressions is limited to hunger, need of sleep, and cutaneous impressions. Speech under such conditions is inarticulate, an animal cry, unconscious and without intelligence. But with the growth of the cerebrum the child's environment suggests to the embryonic intelligence its primal impression. The parental relation is dimly apprehended, and designations of the father and mother are uttered in scarcely articulate sounds.
Sight and hearing open extensive fields of sensation, and with their development begin the primal, physical impressions from which proceed the emotions. The acoustic and optic centres of perception become established, and the mental formation of symbols and signs, an imitative process, marks the stage of childish cerebration, beyond which the savage often does not proceed. The symbolic function is the basis of language and of pictorial representation; as man requires the trade medium of the symbol for the interchange of his ideas, so his legal tender appears with the first emergence of mental enterprise. The hieroglyphic and the onomatopoetic word are as old as humanity.
The co-ordinating mechanism of speech is of equal development. With the growth of the child the varied impressions of education, of surroundings, of heredity, all are influencing speech. With mental growth, stimulated by these numerous impressions, comes the gradual mental habit of forming ideas after certain models—of trading, so to speak, in the coin of the country, of making and using a vocabulary. Intuition,induction, and deduction are established, the general nervous function of memory develops, observations are made, and mind and body, master and instrument, enter upon full activity.
PHYSIOLOGY OFNORMALSPEECH IN THEADULT.—Let us consider normal speech in the adult. From a purely mental aspect speech is not included in the nervous reflexes. The conception before the individual may arise without sight or sound, it may be the object of the mental processes only; but if it is to be communicated, or transferred from the subjective to the objective, it calls into play the denotative faculty or facultas signatrix.
As we are cognizant through the senses of phenomena only, so we communicate only phenomena, or more particularly symbols; the spoken or written word, the gesture, are necessary to make ideas tangible to another mind. The symbolic faculty, then, is the mental faculty most concerned in speech.
Cerebral localization has not included this faculty in its areas; it is assigned to the anterior cortex, which as yet is the indiscriminate site of the formation of ideas. The idea conceived, the symbol formed, the motor area whose integrity is essential, is found in the region commonly known as Broca's convolution, the posterior third of the left third frontal convolution. This region is especially connected with the corona radiata coming from the corpus striatum, with the corpus striatum and the anterior portion of the internal capsule: like the anterior, or motor, cornua of the spinal cord, it possesses giant, or branching, nerve-cells; its anatomy would assign to it a motor function. Its blood-supply is derived through the inferior frontal branch of the Sylvian vessel, whose occlusion in a case cited by Charcot was followed by complete aphasia.
Ferrier distinguishes just adjacent to this centre the motor centres for the tongue and mouth and upper extremities, showing an anatomical association of the processes of articulate and written speech.
But purely motor impulses comprise only a portion of the phenomena of speech. The external world must be brought into relation with the mind, and this is done through the perceptions. We may say that perceptions are apprehended sensations, and this apprehension demands a localized field of cerebral activity, as well as the motor energies. It seems natural enough that experiment should have located (Ferrier) perceptive, visual, and acoustic centres in the posterior cortical areas and temporo-sphenoidal lobes—that the motor and perceptive areas should be contiguous and sharing a common blood-supply.
The perceptive visual centre is found to occupy the occipital lobes, while the acoustic centre occupies the whole length of the first temporo-sphenoidal convolution.
As motor impulses found a path to the motor ganglia, and finally to the cord, so the course of sensory perceptive impressions can be traced back through the posterior internal capsule and through the optic thalami to the sensory columns of the medulla and cord.
Intuitive and sense perception, even when reinforced with motor power, cannot result in articulation. The mechanism of speech requires a co-ordinating centre, and this basal phonic centre of Kussmaul is located in the medulla near the origin of the hypoglossal and facial nerves. From the medulla proceed the nerves supplying the machinery ofphonation, the superior laryngeal nerve to the mucous membrane of the larynx and to the crico-thyroid muscle, the most important muscle of phonation. The remaining laryngeal muscles are supplied by the recurrent laryngeal; the motor processes of articulation are guided by the hypoglossal, facial, and fibres of the glosso-pharyngeal.
The larynx is a reed, with the addition of numerous resonance-cavities producing abundant overtones. It may be considered as a box composed of two segments, the lower of which has vertical motion upon the joint at the posterior junction of the superior and inferior segments. By this motion the tongue of the reed (vocal cords, stretching antero-posteriorly from lower segment to junction with upper segment) is tightened or relaxed, the vibratory blast of air coming through the trachea from the lungs. The superior aperture of the tube is guarded by the epiglottis and false vocal cords. As auxiliaries are the pharyngeal, oral, and nasal cavities, with the associated bony cavities of the skull, the soft palate acting as a movable partition or switch, the hard palate as a sounding-board or resonance-surface. The reed is applicable to the production of musical sounds; the tongue, lips, and teeth are required for the checks in those sounds, constituting the consonants or division utterances.
The curious phenomenon of the falsetto voice is thought by Helmholtz to be produced by the attenuation of the true cords and the vibration of their thinned edges.
DEVELOPMENT OFLANGUAGE.—The study of language demonstrates its origin to have been largely in exclamations and imitative sounds, from which our vowels can easily have arisen. The growth of all synthetic language illustrates the aggregation of accessory sounds about the primitive root-sound, while the common tendency to the insertion of consonants shows their addition to the primitive vowels. That the long vowels should have undergone countless modifications from the physical peculiarities and environment of those speaking them is but natural, for the number of vowels remaining in actual use in any language is not large. Consonants serve to make more clear by their separation of vowel-sounds the meaning to be conveyed; their development resulted from vowel changes, and their number is small.
The written characters of language represent only the usage of the majority. Individual speech and pronunciation vary as greatly as do languages themselves, and it is evident that the speech of any individual is as truly peculiar as his physical conformation.
To recapitulate, we find ideas, the material of speech, formed in the cerebral cortex. Speech-volition becomes motor impulse at Broca's convolution; such impulse passes along the internal capsule to the corpus striatum, where it is co-ordinated probably in the formation of syllables, thence to the medulla, whence the mechanism of the larynx receives its co-ordinated stimulation.
The classification of the disorders of speech should depend on the anatomical site of the lesions by which they are occasioned. Broadlyspeaking, speech disorders resolve themselves into those of the formative apparatus for ideas and symbols and those of the purely co-ordinating and conducting mechanism. Abbreviating the schedule of Potter, we may say that the disorders of speech may be included in three classes—alalia, or lack of speech; paralalia, defective speech, the stammering of most observers; and dyslalia, difficult speech or stuttering.
The anatomy of the blood-supply of the speech-centres affords some explanation of alalia. The Sylvian artery will be remembered as the feeder of the speech-centres—an artery often the source of hemorrhage, as Charcot suggests, from the angle at which it leaves the carotid. Ducrot explains the frequency of left-sided softening and hemorrhage from the manner of origin of the left carotid, its axis being more nearly that of the ascending aorta and furnishing a ready channel for cardiac clots. In regard to the relative frequency of peripheral and central hemorrhage, Andral and Durand-Fardel cite 119 cases, of which but 17 were in the anterior or posterior lobes. It is admitted that cerebral lesions are largely those of the circulatory system, and the fact that such lesions result in the suspension of the activity of restricted areas is due to the circumstance that the cerebral arteries are terminal vessels giving off no anastomosing branches and supplying restricted areas only. With blood-supply so arranged it is not difficult to understand how the different portions of the motor centres may be separately involved, and thus the motor functions of speech may become singly at fault.
Inability to remember words and inability to form the motor impulses necessary for speech or writing are the common forms of alalia or aphasia, the former being known as amnesic, the latter as ataxic, alalia. In addition, we may cite the failure of cerebral power occurring in general softening, in microcephalic brains, and the curious instances of voluntary silence from some strong belief or prejudice. Instances of the gradual resumption of cerebral function after its loss are not wanting; and, occurring where subsequent post-mortem examinations reveal a limited area of destruction of brain-tissue, they afford examples of the vicarious performance of cerebral functions by contiguous areas.
The phenomena of amnesic alalia are commonly seen in cases of recovery from cerebral hemorrhage, cerebral injury, and severe febrile affections. Numerous cases are recorded where the memory of things themselves remained, but the faculty of denoting them had been destroyed.
Kussmaul distinguishes here two conditions: 1st, where the word is entirely effaced from memory, 2d, where it still remains, but its association with that which it represents is suppressed. Cases of the second class are the most frequent, the fundamental part which the association of ideas plays in mental activity and the extent to which memory is dependent on association explaining this fact. A marked example of the failure of the denotative faculty lies in the cases of forgetfulness of one's own name, as described by Crichton in the case of an ambassador at the Russian court, who was obliged to say to his companion, when visitors asked his name, “For Heaven's sake, tell me what I call myself!” Piorry mentions the case of an aged priest who after right-sided paralysis lost entirely the use of substantives; wishing to ask for his hat, the wordhatfailed him utterly, and he was obliged to express himself in the remaining parts of speech: “Give me that which I place upon the——;” but the wordhead, denoting the object most commonly in relation with thehat, was wanting also. When either hat or head was mentioned he spoke the word without difficulty.
Instances of failure in linguistic faculty are not uncommon. Witness a case, reported by Proust, of an Italian who after long residence in France, though understanding his native tongue, could speak only in French. Cases in which after acute disease one language is gone entirely while several others are retained are not wanting. A striking case of amnesic alalia was that of Lordat, a French physician, who thus described his malady: “I find myself deprived of the value of all words. If any words remain to me, they become useless, because I can no longer remember the manner in which I must co-ordinate them to express my thoughts. I am conscious that I recognize all ideas, but my memory does not suggest a word. In losing the memory of the meaning of spoken words I have lost that of their visible signs.”
Fortunately, these cases are among the more tractable of cerebral disorders. Bristowe has reported a case wherein elementary instruction in speech-formation was tried with marked success. The patient, aged thirty-six, after a violent cerebral disturbance without traumatism became paraplegic, speechless, and deaf. Gradual recovery ensued until, seven months after his first illness, he was admitted into St. Thomas's Hospital in the following condition: Numbness and paresis in left leg, less in left arm; special senses healthy; no incontinence; some pain about head and neck; complete loss of speech. It was found that the patient was very intelligent, wrote legibly, could make all kinds of voluntary movements with lips, tongue, and teeth, and was capable of vocal intonation; articulation alone was lacking.
The law of the evolution of language designates as primitive forms of word-signs those words affirming qualities, while those denoting relative positions are of secondary formation (Whitney.) Remembering, also, the fact that amnesia in general “is a regression from the new to the old, from the complex to the simple, from the voluntary to the automatic, from the least organized to the best organized,”1we are able to understand the cause of amnesic alalia, and also the steps of the process of recovery, in which the inverse order is observed.
1Ribot,Diseases of Memory.
Amnesic alalia can hardly be regarded as susceptible of treatment other than as a general neurasthenia. Though we may develop memory by cultivating the association of ideas and by repetition, yet, regarding it as a general function of the nervous system, it is evident that recovery from its disorders is conditioned by the general vigor of the nervous centres. A partial recovery usually occurs in such cases; complete recovery is more infrequent.
Ataxic alalia, the failure of the motor powers of speech, occurs in all forms of general paralysis, most typically in bulbar paralysis. This disease is fully described in the standard works on neurology. Ataxic alalia will also occur in disseminated sclerosis, posterior spinal sclerosis, dementia paralytica, and cretinism. It forms in general disorders an instructive symptom, and is to be distinguished by a tremulous utterance and by facial spasm from the hesitation of the stammerer and from the convulsive utterance of the stutterer.
Paralalia embraces all abnormalities of speech, from trivial mannerisms to difficulties in the utterance of certain letters, including those painful defects which depend upon physical malformations.
The free discussion of paralalia would cover the domain of elocution; the physician is called upon to advise in those cases only where either a physical malformation is evident or the difficulty experienced by the patient in enunciating certain letters has led to a suspicion of the existence of malformation. The former cases lie in the province of the surgeon; the latter come within the scope of those elocutionists, speech-trainers, and instructors who hope to cure stammering and stuttering.
Discrimination between stammering and stuttering will give the physician a basis for judgment from which he can reasonably offer encouragement in many cases and avoid the creation of false hopes in others. As a cardinal point of difference, it will be remarked that in the case of the stutterer the muscles of phonation are thrown into a state of spasm when speech is attempted, while in the stammerer their movements are merely lacking in proper co-ordination. It may also be observed that the respiration of the stammerer is marked by irregular contractions of the diaphragm, which render the expiratory blast of air irregular in its delivery. In the stutterer the spasm is pronouncedly laryngeal and facial. The nervous embarrassment of the stutterer is proverbial, and is increased by excitement, while a moderate degree of excitement, stimulating respiration, greatly improves the speech of the stammerer.
Whispering, a difficult respiratory act, exaggerates the stammerer's fault, but the spasm of the stutterer is often relaxed by the diminished pressure of whispered breath.
As articulation is effected by the larynx and the oral organs, the stutterer makes his spasmodic articulation particularly noticeable, while the stammerer finds little difficulty in the utterance of words.R,L,S, and other letters whose enunciation demands the continued expiratory blast, are imperfectly uttered by the stammerer, while these letters when joined to a long vowel-sound occasion little or no difficulty for the stutterer.
TREATMENT.—It follows that if stammering is recognized as inco-ordinate enunciation, owing largely to irregular action of the diaphragm, any training of the respiratory muscles which will ensure a regular delivery of the expiratory air will improve this defect. It follows, then, that the treatment of stammering resolves itself into careful attention to general hygiene, associated with such persistent respiratory and vocal gymnastics as shall effectually develop regularity, depth, and co-ordination of action on the part of all the muscles concerned in the act of respiration. Drugs will be of service only as aids to the correction of errors in the essential physiological functions. In the child the powers of imitation may be enlisted to effect a cure, and the familiar fact that the habits of childhood are easily formed would indicate this as the best time for treatment.
Childhood once passed, however, the steadiness of purpose of the adult is requisite to break up a confirmed habit, and active treatment should be deferred until after adolescence. Most important in all cases are judicious moral influences exerted by those about the patient, the ridicule so often visited upon the unfortunate stammerer being most harmful in its consequences. The many tricks and devices so often employed in thesecases are of use simply by varying the monotony of vocal drill; they may be employed or abandoned as the judgment of the physician may dictate.
Regarding the prognosis in these cases, it follows that with a fairly developed and healthful nervous system, reinforced by proper mental and physical hygiene, the stammerer's case is far from hopeless in the hands of a patient and intelligent physician.
An unfavorable prognosis would be demanded by hereditary defects and vices of the nervous system, by the lack of general nervous vitality, by enfeeblement of the will and the mental tone of the individual, by advanced age, and by irremediable hygienic conditions. Under favorable conditions recovery should be the rule.
DYSLALIA ORSTUTTERING.—Recalling to mind the points of difference between stuttering and stammering, it becomes evident that while the prospect of success in the treatment of the stammerer is often favorable, the case of the stutterer presents such difficulties as render it too frequently hopeless.
We may liken the confirmed stutterer to those rare cases of chorea which defy treatment, and to those cases of hereditary deterioration of the nervous system where the most patient and painstaking care fails to overcome the defect. The laryngeal and facial spasms depend upon no malformation for their exciting cause; hence surgery fails to remedy the defect. Drugs which are given with hope of invigorating the nervous system have only a general tonic influence, while the motor depressants and antispasmodics find but partial success. We must again rely upon hygiene, and also upon those aids to enunciation which come from rhythmical associated movements, such as stamping with the foot, beating time with the hand, the employment of a sing-song tone, or other modes of specially rhythmic enunciation. The sing-song mode of utterance is a familiar resource with parents in attempting to aid a stuttering child, and the measured forms of articulation offer the only vocal drill that possesses any permanent value. It is especially essential in the stutterer's case that the patient be protected from ridicule and from all disturbing emotions: the burden of difficult speech is sufficient to greatly depress the nervous system without the added suffering of emotional distress. It is evident that childhood, characterized as it is by especial instability of the nervous system, is the period when we can hope for the best results from care and training; the long-formed habits of the adult are rarely broken.
We have thus traced the disorders of speech to their origin as symptoms of grave central lesions of the nervous system, as results of heredity or of a general neurasthenic condition; very rarely are they dependent upon malformations of the organs of speech.
The treatment of such malformations, when they occur, is largely unsatisfactory and is seldom curative.
The thorough treatment of those speech disorders that are not susceptible of surgical aid would embrace such mental and physical hygiene and training as should ensure the formation of a thoroughly conceived vocabulary and its co-ordinated expression by words either spoken or written. The study of expression in its highest forms would necessarily conduct the investigator far into the realm of the plastic, harmonic, and literary arts.
BYJAMES C. WILSON, M.D.
BYJAMES C. WILSON, M.D.
DEFINITION.—Alcoholism is the term used to designate collectively the morbid phenomena caused by the abuse of alcohol.
SYNONYMS.—Alcoholismus, Ebrietas, Ebriositas, Temulentia, Drunkenness, Delirium potatorium, Mania potatorium, Delirium tremens, Chronic alcoholic intoxication, Dipsomania;Ger.Trunkenheit, Trunksucht;Fr.Ivresse, Ivrognerie.
These terms are in common use to describe such conditions and outbreaks in alcoholic individuals as amount to veritable morbid states or attacks of sickness, but they are not interchangeable, nor are they all sufficiently comprehensive to constitute true synonyms. They are names applied to various conditions due to acute or chronic alcohol-poisoning properly and distinctively comprehended under the general term alcoholism.
CLASSIFICATION.—It was formerly the custom to restrict this term to affections of the general nervous system induced by continued excesses in the use of alcoholic drinks.1But the nervous system bears the brunt of the attack and suffers beyond all others alike in transient and in continued excesses. The artificial restriction of the term to the cases caused by continued excesses was therefore illogical in itself, and has been productive of much needless difficulty in the treatment of the subject and in the classification of the cases. The use of the term chronic alcoholism to denote an established condition, and of acute alcoholism to describe outbreaks of various kinds which occur in individuals subject to that condition, has also proved a source of embarrassment to the student. Not less vague has been the employment of such terms as delirium tremens, mania-a-potu, and the like, which are unsatisfactory in themselves, and tend to exalt symptoms at the expense of the morbid condition of which they are only in part the manifestation. I am of the opinion—which is at variance with established usage—that the systematic discussion of alcoholism requires that all forms of sickness, including drunkenness, due to that poison must receive due consideration, and that the term acute alcoholism, hitherto used in a sense at once too comprehensive and too variable, should be reserved for those cases in which the sudden energetic action of the poison is the occasion of like sudden and intense manifestations of its effects. Furthermore, the uncertainty and lack of precision in the use of the terms acute and chronic alcoholism are due to errors of theory formerly almost universal in medicalwritings and popular belief concerning the disease. The chief source of these errors was the recognition only of the more acute nervous affections caused by alcoholic excess—delirium tremens, maniacal excitement, and terrifying hallucinations—and the belief that these conditions occurred only after a temporary abstinence in the course of habitual or prolonged indulgence. It has now long been known that abstinence from drink by no means necessarily precedes the outbreak of mania or delirium, and modern researches have established the existence of a chronic alcoholic intoxication of long duration extending over a period of months or years, in which such outbreaks merely exhibit the full development of symptoms that have already been occasionally and partially recognizable.
1Anstie,Reynolds's System of Medicine, vol. ii., 1868.
The following arrangement of the topics will facilitate the discussion of the subject in the present article, and serve, I trust, a useful purpose for the classification of cases in accordance with existing knowledge:2
I. Acute Alcoholism: Drunkenness, Debauch.A. Ordinary or Typical Form.B. Irregular Forms.1. Maniacal;2. Convulsive;3. In persons of unsound mind.C. Acute Poisoning by Alcohol: Lethal doses.II. Chronic Alcoholism.A. Visceral Derangements.1. Local disorders:a. Of the digestive system;b. Of the liver;c. Of the respiratory system;d. Of the circulatory system;e. Genito-urinary system.2. Disorders of special structures:a. Of the locomotor apparatus;b. Of the skin.3. General disorders:a. The blood;b. Obesity;c. Cachexia.B. Derangements of the Nervous System: Cerebro-spinal Disorders.1. Cerebral disorders.2. Spinal disorders.3. Disorders of the peripheral nerves.4. Disorders of the special senses.C. Psychical Derangements.1. The moral sense.2. The will.3. The intellect.4. Alcoholic delirium in general.5. Delirium tremens.6. Alcoholic insanity:a. Melancholia;b. Mania;c. Chronic delirium;d. Dementia;e. Paretic dementia.III. Hereditary Alcoholism.IV. Dipsomania.
2This classification is in part based upon that of Lentz,De l'Alcoholism et de ses Diverses manifestations, etc., Bruxelles, 1884—a prize essay.
HISTORY.—The history of the abuse of alcohol would be the history of society from the most remote period until the present time, not only among civilized but among barbarous races of men, for the abuse of narcotics, of which alcohol is at once the most important and the most widely used, forms a dark background to the broad picture of healthful human progress. In truth, the most sketchy account of our knowledge of the effects of alcoholic excess, as manifested in the individual and in society at large, interesting as it might prove to the general reader, would be out of place in this article. To be of realvalue it would necessarily embody a record of experiences so vague, facts so indeterminate, opinions so at variance, and citations so numerous, that they would require for their mere presentation a volume rather than an article. The object of the writer in the following pages shall be, therefore, to present the subject in its present aspect, without reference, beyond that which is absolutely necessary, to considerations of mere historical interest. This being the case, he considers further apology for the lack of laborious historical studies unnecessary.
ETIOLOGY.—A. Predisposing Influences.—We are at this point confronted with a series of problems the complex nature and grave importance of which appeal with peculiar urgency to all thoughtful physicians. Their discussion, however, involving as it does unsettled questions of great moment in social science, is beyond the scope of the present article. A few practical points only can occupy our attention.
The influences which predispose to alcoholism arise from unfavorable moral, social, and personal conditions.
Among the unfavorable moral conditions may be mentioned a want of wholesome public sentiment on the subject in communities. This arises too often, but by no means exclusively, from poverty and its attendant evils ignorance and vice. Rum is at once the refuge and the snare of want, destitution, and sorrow. To the vacant and untrained mind it brings boons not otherwise to be had—excitement and oblivion. That both are brief and bought at a ruinous cost exerts little restraining influence. Of equal if not greater importance are the influences which spring from ill-regulated and demoralizing domestic relations, and the absence of motive and the contentment which properly belong to the family as an organization. Everywhere also do we find in example a potent influence. In the individual, in addition to hereditary propensities, the evil results of a lax, over-indulgent, or vicious early training, as shown in a want of power of application, of moral rectitude, in self-indulgence, craving for excitement, and a weak will, powerfully predispose to the temptations of alcoholic excess.
Among social conditions which must be regarded as predisposing influences occupation takes the first rank. The occupations which render those pursuing them especially liable to alcoholism may be divided into two classes—those in which the temptation to drink is constantly present, and those in which the character of the work begets a desire for stimulation, while the opportunities for the gratification of the desire are but little restricted.
To the first of these groups belong all classes of workmen in distilleries, breweries, and bottling establishments; keepers and clerks of hotels, public houses, and restaurants; the barmen and waiters in the same trades; the salesmen who travel for dealers in wines and spirits. To this group must also be referred the professional politician of the lowest order. These occupations have furnished by far the larger number of cases that have come under my care, both in hospital and in private practice.
To the second class belong occupations involving great exposure to the inclemency of the weather. We frequently find cabmen, expressmen, coal-heavers, hucksters, and street-laborers habitually addicted to excesses in alcohol. The stringent regulations of corporations exert a powerfulprotective influence in the case of men employed on railways, ferry- and other steamboat service, and in and about dépôts and stations. Exhausting toil under unfavorable circumstances as regards heat and confinement predisposes to drink, as in the case of foundrymen, workers in rolling-mills, stokers, and the like. The men-cooks who work in hotels and restaurants are especially liable to alcoholism. Monotony of occupation, as in the cases of cobblers, tailors, bakers, printers, etc., especially when associated with close, ill-ventilated workrooms and long hours of toil, exerts a strong predisposing influence. Persons following sedentary occupations suffer from excesses sooner than those whose active outdoor life favors elimination. To the monotony of their occupations may be ascribed in part, at least, the disposition of soldiers, ranchmen, sailors, etc. to occasional excesses as opportunities occur. Irregularity of work, especially when much small money is handled, as happens with butchers, marketmen, and hucksters, also often leads to intemperance.
The lack of occupation exerts a baleful influence. Men-about-town, the frequenters of clubs, dawdlers, and quidnuncs often fall victims to a fate from which occupation and the necessity to work would have saved them. In this connection it may be permitted to call attention to the custom of treating as enormously augmenting the dangers to which such persons are habitually exposed in the matter of alcoholic excesses. The occasional moderate use of alcohol in the form of wine with food and as a source of social pleasure is not fraught with the moral or physical evils attributed to it by many earnest and sincere persons. It is, on the contrary, probable that the well-regulated and temperate use of sound wines under proper circumstances and with food is, in a majority of individuals, attended with benefit. Those who suffer from the effects of excesses do not usually reach them by this route, nor would they be saved by any amount of abstinence on the part of temperate and reasonable members of society.
When we turn our attention to the unfavorable personal conditions which predispose to alcoholism, we at once enter upon the familiar field of work of the practical physician. Numerous influences having their origin in the individual himself, some occasional, others constant, all urgent, demand our careful consideration. Some of the conditions out of which these predisposing influences spring are tangible and easy of recognition; others are elusive and uncertain. To point them out is, unfortunately, not to remedy them. As a rule, they have wrought their evil effects long before the individual has cause to regard himself in the light of a patient.
First in importance is heredity. A peculiar inherited constitution of the nervous system is as influential in leading to alcoholic excess and in aggravating its disastrous effects as any other cause whatsoever. A considerable proportion of individuals who suffer from alcoholism are found upon inquiry to come of parents who have been addicted to drink. A still greater number belong to families in which nervous disorders, and in particular neuralgia, epilepsy, and insanity, have prevailed. Others, again, are the offspring of criminals. It can no longer be doubted that particular causes of nervous degeneration in one or both parents may lead to the hereditary transmission of a feeble nervous organization, which, on the one hand, renders its possessor peculiarly liable to neurosesof every kind, and, on the other hand, an easy prey to the temptation to seek refuge from mental and physical suffering in occasional or habitual narcotic indulgence. Thus, as Anstie pointed out, “the nervous enfeeblement produced in an ancestor by great excesses in drink is reproduced in his various descendants, with the effect of producing insanity in one, epilepsy in another, neuralgia in a third, alcoholic excesses in a fourth, and so on.” When it is possible to obtain fairly complete family histories, covering two or three generations, in grave nervous cases, facts of this kind are elicited with surprising frequency. The part which heredity plays in many of the more inveterate and hopeless cases of alcoholism is wholly out of proportion to the obvious and easily recognizable part played by momentary temptation. To the failure to recognize the real agency at work in such cases must be ascribed the disappointment of too many sanguine and unsuccessful social reformers.
Various forms of disease exert a predisposing influence to alcoholic excesses. In the first place, bodily weakness and inability to cope with the daily tasks imposed by necessity impel great numbers of persons of feeble constitution, especially among the laboring classes, to the abuse of alcohol.
In the second place, many conditions of chronic disease attended by suffering are susceptible of great temporary relief from the taking of alcohol. Especially is this the case in the neuralgias, in phthisis, in dysmenorrhœa and other sexual disorders of women, in the faintness and depression of too-prolonged lactation, in the pains and anxieties of syphilis, and in the malaise of chronic malaria. When the patient has learned that alcohol is capable of affording relief from suffering, it is but a short step through ignorance or recklessness to habitual excess.
The administration of alcohol during convalescence from attacks of illness is not unattended by the danger of subsequent abuse. It is well for the physician to inform himself of the hereditary tendencies and previous habits of the patient before assuming the responsibility of continuing alcohol beyond the period of acute illness under these circumstances; and it is a rule never to be disregarded that the stimulant ordered by the physician is to be regulated by him in amount, and discontinued when the patient passes out of his care.
Irregularities of the sexual functions in both sexes, and especially sexual excesses, strongly predispose to alcoholism. The custom of administering to young women suffering from painful menstruation warming draughts containing gin, brandy, or other alcoholic preparations in excessive amounts is a fertile cause of secret tippling.
The abuse of tobacco, to the depressing effects of which alcohol is a prompt and efficient antidote, must be ranked as an important predisposing influence.
Depressing mental influences of all kinds tend strongly to drinking habits. This is true of persons in all classes of society.
Habit constitutes an influence the importance of which can scarcely be over-estimated. Much of the drinking done by active business-men has no other cause than this. Alcohol, like opium and other narcotics, exerts its most pernicious influence through the periodical craving on the part of the nervous system for the renewal of the stimulating effects which it causes, while it progressively shortens the period and diminishes theeffect by its deteriorating action upon the nutrition of the peripheral and central nervous tissues.
B. The Exciting Cause.—Alcohol, or ethyl hydrate, is the product of the fermentation of solutions which contain glucose or a substance capable of transformation into glucose. Other alcohols, as propyl, butyl, and amyl alcohol, etc., are also formed in small quantity in the fermentation of saccharine liquids. Ethyl alcohol is the type of the series, and forms the normal spirituous ingredient of ordinary alcoholic beverages. The others when present, except in minute quantities, constitute impurities. Their toxic effects are much more pronounced than those of ethyl alcohol.
Alcohol is a colorless mobile liquid having an agreeable spirituous odor and a pungent, caustic taste, becoming fainter upon dilution. It mixes with water and ether in all proportions.
Alcoholic beverages form three principal groups: 1, spirits, or distilled liquors; 2, wines, or fermented liquors; and 3, malt liquors.
1. The various spirituous liquors, as whiskey, gin, rum, brandy, etc., contain, in addition to the ethyl alcohol and water common to them all, varying minute proportions of ethereal and oily substances to which each owes its peculiar taste and odor. These substances are œnanthic, acetic, and valerianic ethers, products of the reaction between the corresponding acids and alcohol, and various essential oils. Traces of the other alcohols are also present. Amyl alcohol, the so-called fusel oil, is present in new and coarse spirit, but especially in that derived from potatoes, in considerable amounts. It is to this ingredient that potato spirit owes its peculiarly deleterious properties. Richardson3experimentally produced with amyl alcohol phenomena analogous to delirium tremens in man. Spirits also frequently contain sugar, caramel, and coloring matters derived from the cask, to which certain products of the still also owe in part their flavor. These liquors are of varying strength, and contain from 45 to 70 per cent. of absolute alcohol by volume.4
3On Alcohol, Lond., 1875.
4Vide Baer,Der Alcoholismus, Berlin, 1878.
Liqueurs (anise, kümmel, curaçoa, Benedictine, etc.) are the products of the distillation of alcohol with various aromatic herbs, sweetened, or of its admixture with ethereal oils and sugar. These compounds contain a very high percentage of alcohol. Two of them, absinthe and kirsch, by reason of their peculiarly dangerous properties deserve especial mention.
Absinthe is an alcoholic distillate of anise, coriander, etc. with the leaves and flowers of theArtemisia absinthium, which yields a greenish essence. This liqueur contains from 60 to 72 per cent. of alcohol, and exerts a specific pernicious effect upon the nervous system, largely due to the aromatic principles which it contains.5Kirsch, which owes itspeculiar flavor to the oil of bitter almonds and hydrocyanic acid which it contains in varying and often relatively large proportions, is still more dangerous. The toxic effects produced by these liqueurs are of a very complex kind, and scarcely fall within the scope of this article.
5As early as 1851, Champouillon (referred to by Husemann,Handbuch der Toxicologie) called attention to the fact that the French soldiers in Algiers, in consequence of excessive indulgence in absinthe, suffered especially from mania and meningitis. Decaisne (La Temperance, 1873, Étude médicale sur les buveurs d'absinthe) found absinthe in equal doses and of the same alcohol concentration to act much more powerfully than ordinary spirits, intoxication being more rapidly induced and the phenomena of chronic alcoholism earlier established. Pupier (Gazette hébdom., 1872) found in those addicted to the use of absinthe marked tendency to emaciation and to cirrhosis of the liver; and Magnan (Archives de Physiol., 1872) asserts that the chronic alcoholism due to this agent is characterized by the frequency and severity of the epileptic seizures which accompany it. There is reason to believe that the consumption of absinthe in the cities of the United States is increasing.
2. Wines are the product of the fermentation of the juice of the grape. Their chemical composition is extremely complex. They owe their general characteristics to constituents developed during fermentation, but their special peculiarities are due to the quality of the grape from which they are produced, the soil and climate in which it is grown, and the method of treatment at the various stages of the wine-making process. So sensitive are the influences that affect the quality of wine that, as is well known, the products of neighboring vineyards in the same region, and of different vintages from the same ground in successive years, very often show wide differences of flavor, delicacy, and strength.
The most important constituent of wine is alcohol. To this agent it owes its stimulating and agreeable effects in small, its narcotic effects in large, amounts. The proportion of alcohol, according to Parkes, Bowditch, Payen, and other investigators, varies from 5 to 20 per cent. by volume, and in some wines even exceeds the latter amount. The process of fermentation, however, yields, at the most, not more than 15 to 17 per cent. of alcohol, and wines that contain any excess of this proportion have been artificially fortified.
Further constituents of wine are sugar, present in widely varying amounts, and always as a mixture of glucose and levulose—inverted sugar; traces of gummy matter, vegetable albumen, coloring matters, free tartaric and malic acid, and various tartrates, chiefly potassium acid tartrate, or cream of tartar. In some wines there are found also traces of fatty matters. Tannin is likewise found. Small quantities of aldehyde and acetic acid are due to the oxidation of alcohol. The acetic acid thus formed further reacts upon the alcohol, forming acetic ether. To the presence of traces of compound ethers, acetic, œnanthic, etc., wines owe their bouquet. Carbon dioxide, produced in the process of fermentation, is retained to some extent in all wines, and is artificially developed in large quantities in champagnes and other sparkling wines.
Much of the stuff sold as wine, even at high prices, in all parts of the world, is simply an artificial admixture of alcohol, sugar, ethereal essences, and water. The wines rich in alcohol are especially liable to imitation.
Wine is the least harmful of alcoholic drinks. In moderate amounts and at proper times its influence upon the organism is favorable. In addition to its transient stimulating properties, it exerts a salutary and lasting influence upon the nutrition of the body. Only after prolonged and extreme abuse, such as is sometimes seen in wine-growing countries, does it lead to alcoholism.
3. Malt liquors—beer, ale, porter, stout, etc.—are fermented beverages made from a wort of germinated barley, and usually rendered slightly aromatic by hops. This process is known as brewing. Malt liquors, of which beer may be taken as the type, contain from 3.75 to 8 per cent. by volume of alcohol, free carbon dioxide, variable quantities of saccharine matters, dextrin, nitrogenized matters, extractive, bitter and coloring matters, essential oil, and various salts. Much importance hasbeen ascribed to the quantity of malt extractive in beer: it has even been seriously spoken of as fluid bread. But, granting the nutritive value of the malt extractives, it is, as compared with the nutritive value of the grain from which they are derived, so small that beer must be regarded as a food of the most expensive kind.
Sound beer is wholesome and nutritious, and serves a useful purpose in the every-day life of a considerable part of the earth's population. But it is wholesome only in moderate amounts. Its excessive consumption results in progressive deterioration of mind and body. Undue accumulation of fat, diminished excretion of urea and carbon dioxide, are followed by disturbances of nutrition. Incomplete oxidation of the products of tissue-waste leads to the abnormal formation of oxalates, urates, etc., to gout, derangements of the liver, and gall-stones. In long-continued excesses in beer one of the effects of the lupulin is to enfeeble the powers of the reproductive organs. The inordinate consumption of beer induces intellectual dulness and bodily inactivity, and lessens the powers of resistance to disease. The dangers of acute and chronic alcoholism are obvious. Five glasses of beer of 5 per cent. alcohol strength contain as much alcohol as half a beer-glassful of spirits of 50 per cent.
The moderate consumption of beer in communities is to some extent a safeguard against alcoholism. To secure this end, however, the beer must be sound and of light quality. The stronger beers, and especially those which are fortified with coarse spirits, besides the direct dangers attending their use, tend rapidly to the formation of spirit-drinking habits.
The action of alcohol varies according to its degree of concentration, the quantity ingested, and its occasional or habitual use. On the one hand, when well diluted, taken in small amount and occasionally only, it may be without permanent effect upon any function or structure of the body; on the other hand, its frequent administration in large doses and but little diluted is, sooner or later, surely followed by widespread tissue-changes of the most serious kind.
The Physiological Action of Alcohol.—Alcohol is very rapidly taken up by absorbent surfaces. According to Doziel,6it has been detected in the venous and arterial blood and in the lymph of the thoracic duct a minute and a half after its ingestion. It is very slightly if at all absorbed by the unbroken skin. Denuded surfaces and extensive wounds permit its absorption, as in the case of surgical dressings, and instances of intoxication from this cause have been recorded. It is also freely absorbed in the form of vapor by the pulmonary mucous surfaces. Some surfaces, as the pleura and peritoneum, absorb it, as has been demonstrated by the effects following its injection into those cavities. Its constitutional effects are also rapidly developed after hypodermic injection. Under ordinary circumstances, however, it is by the way of the absorbents and veins of the gastric mucous membrane that alcohol finds its way into the blood. It is probable that the greater part of the alcohol taken into the stomach undergoes absorption from that organ, and that very little of it reaches the upper bowel. Alcohol is readily absorbed by the rectal mucous membrane. Having entered the blood,it reaches all the organs of the body, and has been recovered by distillation not only from the blood itself, but also from the brain, lungs, liver, spleen, kidneys, and various secretions.7
6Pflüger's Archiv für Physiologie, Band viii., 1874.
7Strauch,De demonstratione Spiritus Vini in corpus ingesti, Dorpati, 1862.
Lentz and other observers believe that certain organs have a special affinity for alcohol. The author named and Schulinus place the brain first in this respect, and in the next rank the muscles, lungs, and kidneys. But Lallemand and Perrin regard the liver and the brain as having an equal affinity for alcohol. The opinion of Baer, who rejects the view that alcohol has an especial predilection for particular organs, is more in accordance with known physiological law. This observer holds that alcohol, having found its way into the blood, circulates uniformly throughout the whole organism, and explains the greater amount recoverable from certain organs as due to the fact that these organs contain more blood than others.
The elimination of alcohol is at first rapid, afterward very gradual. It begins shortly after ingestion, and in the course of two or three hours one quarter, and perhaps much more, of the amount passes from the organism. Nevertheless, after the ingestion of large amounts traces of alcohol were discovered on the fifth day in the urine by Parkes and Wollowicz, although the elimination by the lungs had entirely ceased.
Elimination takes place for the most part by way of the kidneys, the lungs, and the skin; alcohol has been recovered also from the bile, saliva, and the milk.
Whatever may be the affinity of certain organs for alcohol, whatever the channels by which it is eliminated, the general belief is that some portion of it undergoes chemical decomposition within the body. The steps of this process and its ultimate results are as yet unknown; nor, indeed, are the proportional amounts decomposed and eliminated established. Some observers regard the amount eliminated as less than that decomposed. Others suppose that the amount consumed within the body is relatively very small as compared with that disposed of by elimination. It is, however, established that the sojourn of alcohol in the body, unlike that of many other toxic substances, is transient, and that in the course of from twenty-four to forty-eight hours after the ingestion of a moderate amount there remain only traces of this substance.
The local action of alcohol upon organic tissues depends upon its volatility, its avidity for water, its power to precipitate albuminous substances from solution and to dissolve fats, and, finally, upon its antiseptic properties.
Applied externally and permitted to evaporate, it produces a fall of temperature and the sensation of cold; if evaporation be prevented, a sensation of warmth is experienced, the skin reddens, and, if the action be prolonged, desquamation results. The sensation produced when diluted alcohol is applied to mucous surfaces is burning and stinging; when concentrated, it may excite inflammation.
Dilute alcohol has been much employed as a surgical dressing for wounds and ulcerated surfaces. Its value for this purpose depends on its stimulating properties, by virtue of which it exerts a favorable influence upon granulating surfaces; and on its antiseptic qualities, which are, however, much inferior to those of salicylic and carbolic acids among organic substances and to the chlorides among the inorganic salts.